ABSTRACT
Introduction Inappropriate use and dependence to prescription drugs has been considered as a growing health problem in recent years. It has been recognized that benzodiazepines (BZD) are one of the most commonly prescribed drugs due to their rapid therapeutic effect, high efficacy and favorable side effect profile when compared to other psychotropic medications. Despite the desirable therapeutic actions of BZD, mainly for the treatment of anxiety disorders, concerns about the dependence producing or addictive nature of these drugs have been expressed for decades. BZD dependence, unlike dependence to other substances, is a condition generally circumscribed to a therapeutic framework. It is well known that BZD use generally starts legitimately by a medical prescription for the treatment of anxiety symptoms or insomnia. Persons with psychiatric disorders are at a greater health risk for BZD dependence than other groups as BZD are highly used for the treatment of several psychiatric symptoms. BZD dependence in these patients may have a negative clinical impact in the medical treatment of the primary psychiatric disorder and may also affect patients' quality of life as the BZD dependence is added as a comorbid diagnosis that also requires clinical management. In this way, the need for clinical useful information for the prevention or early detection of BZD dependence emerges. Although inconsistent associations have been encountered in the scientific literature, some sociodemographic variables, such as gender and level of education, as well as the characteristics of BZD use, have been identified as potential risk factors for the development of BZD dependence. This information is of easy access for the mental health professional during the initial or subsequent clinical interview with patients, and if significant findings are obtained in Mexican psychiatric patients, these variables may become useful clinical tools for a closer follow-up of those patients with high risk of presenting BZD dependence. Objective To determine sociodemographic variables and characteristics of BZD use that may be risk factors for the development of BZD dependence in a sample of psychiatric patients from Mexico City. Method Subjects. Subjects were consecutively recruited at the outpatient services of the Instituto Nacional de Psiquiatría Ramón de la Fuente (INPRF) in Mexico City. All patients with BZD consumptions were included indistinctly of their psychiatric diagnosis of attendance in the institution. All patients gave their written informed consent after receiving a comprehensive explanation of the nature of the study. The Ethics Review Board of the INPRF approved the study. Assessment procedure Psychiatric diagnoses were made with the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) and BZD dependence was determined with an adapted version of the substance dependence section of the SCID-I designed to assess BZD use exclusively. Sociodemographic features and characteristics of BZD use were registered in a previously designed format and information was obtained by a personal interview with each patient and main caregiver. The Benzodiazepine Dependence Questionnaire in its Mexican version (BDEPQ-MX) is a self-administered questionnaire used to assess the subjective experience with BZD in the last month in three main areas: perceived dependence, BZD pleasant effects and perceived need of BZD consumption. Results The sample comprised 150 psychiatric patients. A total of 70.0% (n=105) were women and 30.0% (n = 45) were men. Their mean age was 45.9±14.1 with a mean educational level of 11.6±3.9 years. Diagnoses of the sample were mainly anxiety disorders (n = 76, 50.7%) and affective disorders (38.0%). According to the SCID-I, a total of 73 (48.7%) patients met the diagnostic criteria for BZD dependence. Sixty seven percent of the men included in the study reported BZD dependence in contrast to 41.0% of the women. Also, patients with BZD dependence exhibited a higher level of education and a longer time consumption of BZD. A longer duration of BZD consumptions was the main indicator for BZD dependence conferring a risk 10.4 higher for its development. Male gender and psychiatric diagnoses different to anxiety and affective disorders were also significant predictors for BZD dependence. Discussion Numerous potential risk factors relating to BZD dependence have been found and our results support the influence of sociodemographic features and characteristics of BZD consumption for dependence development in a Mexican sample of psychiatric patients. In general, it has been described that men are more prone to substance abuse and dependence and our results showed this same pattern. Nevertheless, this result must be replicated in future studies as for BZD dependence men and women may exhibit similar patterns of consumption and dependence. High rates of BZD prescription, coupled with an elevated risk of substance dependence in diagnoses different to anxiety disorders, highlight the need for a careful review of the costs-benefits of BZD use for the treatment of anxiety emergent symptoms, as other additional medications with lower dependence effect can be used to minimize the potential risk of BZD dependence in these patients. One of the biggest controversies surrounding BZD use has been its long-term use, which has been reported and replicated in our studies as the main indicator for BZD dependence development. Treatment with BZD may be useful for short-term periods of time, and specific goals and objectives of their therapeutic benefits must be established since the initial treatment plans for each patient. The clinical relevance of the present study relies in standing out the high prevalence of BZD dependence found in patients treated with BZD and had not been treated for this comorbid condition. It is important to promote in the mental health professional attendance team strategies for the prevention and early detection of BZD dependence in psychiatric patients.
Introducción El uso inapropiado de los fármacos de prescripción y la dependencia a ellos conforman un problema de salud que va en aumento en la actualidad. A diferencia de la dependencia a otras sustancias, la dependencia a BZD es una condición generalmente circunscrita a un marco terapéutico, ya que el primer contacto frecuentemente se presenta en un contexto clínico. Por el es necesario contar con información que pudiera ser de utilidad clínica para prevenir o detectar de forma oportuna la dependencia en pacientes tratados con BZD. Objetivo Determinar las variables sociodemográficas relacionadas con el patrón de consumo de BZD que pudieran ser predictoras de dependencia a BZD en una muestra de pacientes psiquiátricos de la Ciudad de México. Método Sujetos. Se reclutó a los pacientes que acudieron de forma consecutiva al servicio de Consulta Externa del Instituto Nacional de Psiquiatría Ramón de la Fuente (INPRF) que presentaron uso de BZD, indistintamente del diagnóstico psiquiátrico por el que acudieron a recibir atención especializada. Instrumentos El diagnóstico psiquiátrico y de dependencia a BZD de los pacientes se realizó mediante la entrevista SCID-I. Los principales datos sociodemográficos y las características del consumo de BZD fueron registrados en un formato diseñado ad hoc. El Cuestionario de Dependencia a Benzodiazepinas en su versión para México (BDEPQ-MX) se utilizó para evaluar la experiencia subjetiva del consumo de BZD. Resultados Se incluyó a un total de 150 pacientes con una edad promedio de 45.9±14.1 años. El 48.7% de los pacientes presentaron dependencia a BZD. Los pacientes con dependencia a BZD fueron con mayor frecuencia hombres, con una mayor escolaridad y presentaron un mayor tiempo de consumo. El ser hombre, presentar un diagnóstico distinto a un trastorno de ansiedad o afectivo y tener un mayor tiempo de consumo de BZD fueron los principales factores predictores de dependencia en el presente estudio. Discusión Los hallazgos del presente estudio sustentan la influencia de variables demográficas y del consumo de BZD en el riesgo para desarrollar dependencia. Se observa un mayor riesgo para el desarrollo de dependencia en los hombres. Para los pacientes con diagnósticos distintos a los trastornos de ansiedad es necesario evaluar el costo-beneficio de utilizar las BZD como parte del tratamiento para el manejo de síntomas relacionados con la ansiedad. El uso crónico de BZD fue el principal predictor de dependencia en la presente investigación, lo que pone de manifiesto la importancia de restringir el uso de BZD a periodos cortos de tiempo, estableciendo metas y objetivos claros de sus beneficios terapéuticos. Es fundamental fomentar en el personal médico y paramédico la prevención y detección oportuna de la dependencia a BZD en pacientes psiquiátricos.
ABSTRACT
Misuse and potential abuse of prescription drugs are growing problems in elderly people over 65 years old. Although the prevalence of this condition is difficult to estimate, drug misuse is most common in elderly women. A great proportion of the psychoactive prescriptions in old people include tranquilizers and hypnotics. There are several risk factors related to increased risk misuse, abuse, and dependence of prescription drugs. The following are among these risk factors: the female gender, social isolation, history of substance abuse or dependence, history of mental illness and medical exposure to prescription drugs with abuse potential. Also, BDZ consumption for a period longer than four weeks has also been associated to BDZ dependence, even at therapeutic doses. Until now, BDZ dependence in the elderly has been poorly studied, so the present study may increase our knowledge of this complex phenomenon. Objective The aim of the present study was to describe and compare sociodemographic and clinical features related to the prescription and benzodiazepines use in old people with and without dependence to these drugs in an outpatients psychogeriatric service. Method A total of 39 patients from the outpatients service at the psychogeriatric clinic of the National Institute of Psychiatry Ramón de la Fuente in Mexico City were recruited. All of the participants signed an informed consent to be included in the study. Several assessments were performed to determine the psycho-pathological status. Diagnosis of BDZ dependence was obtained with the SCID-I Interview, the severity of depression and anxiety symptoms were evaluated through the Montgomery & Asberg Scale (MADRS) and the Hamilton Anxiety Scale, respectively. For the evaluation of the functionality level, the Katz Index and GAF were used. Results No significant differences were found between patients with and without BDZ dependence in terms of social and demographic characteristics and medical comorbidity. The main Axis I diagnoses of the patients were depressive disorder or anxiety disorders. The first medical prescription of BDZ in patients with BDZ dependence was the presence of anxiety symptoms, while for patients without BDZ dependence the aim of BDZ prescription was the treatment of insomnia. The mean age of BDZ use onset and the time of consumption were 57.5 years and 675.2 weeks, respectively. The average dose of BDZ used by the patients was 14.4mg of diazepam equivalents. Significant differences were found between groups in terms of BDZ consumption features. Patients with BDZ dependence exhibited more drug seeking behavior, more abandonment of daily activities, and more tolerance and abstinence symptoms. Patients with BDZ dependence exhibited more prominent symptoms of anxiety and depression than patients without BDZ dependence. Also, these patients had a poorer cognitive performance and lower psychosocial functioning. Discussion BDZ dependence is a complex phenomenon related to the severity of depressive and anxiety symptoms. These symptoms were the main reason for the medical prescription of BDZ. Although BDZ use was indicated for the treatment of anxiety disorders, the use of BDZ in the elderly has been contraindicated for the treatment of depression with anxiety features. The potential risk to develop BDZ dependence in elderly patients can be related to pharmacological variations due to changes in the metabolism process of aging and the interactions with other drugs. Both factors could increase half life of BDZ and their pharmacological effect in the organism. There were statistical differences in the drug-taking pattern of BDZ consumption in the patients. Patients with BDZ dependence had an earlier onset of BDZ consumption and longer use. The chronic use of BDZ is one of the most important risk factors for dependence development. For the present study, BDZ dependence was clinically defined in terms of tolerance and abstinence symptoms. This definition is in accordance to what has been described in international scientific literature as BDZ physiologic dependence. In this way, tolerance and abstinence symptoms might be the main reason why patients with BDZ dependence needed higher BDZ dosages for the treatment of anxiety symptoms. Sociodemographic characteristics in this sample were not related to the presence of BDZ dependence; nevertheless, it has been reported that the female gender and the presence of chronic pain are risk factors for BDZ abuse and dependence. Future longitudinal studies with an increased number of patients should assess the effect of these variables in BDZ dependence development in the elderly. Differences found in terms of cognitive performance may be related to the psychomotor retardation conferred by the use of BDZ, which may in turn have a direct impact on the velocity of mental performance in the patients. Also, the presence and severity of depressive and anxiety symptoms may also have a negative impact on cognitive performance. Generalization of the findings of the present research is limited by sample size. Nevertheless, the relevance of the present results highlight the importance of the careful prescription and inherent risks related to potentially addictive medications. Increasing our knowledge in the prescription of these medications will improve our medical attention and our patients' quality of life.
El abuso potencial y el uso inapropiado de fármacos de prescripción en adultos mayores de 65 años o más está en aumento. Aunque la prevalencia de esta condición es difícil de estimar, se sabe que es más frecuente en mujeres. Una gran proporción de los tranquilizantes e hipnóticos son prescritos a adultos mayores. El género femenino, el aislamiento social y una historia de abuso de sustancias y de trastornos mentales son los principales factores de riesgo asociados al uso inapropiado de fármacos. Por otro lado, el uso prolongado de benzodiazepinas (BDZ) -mayor a cuatro semanas- también se ha asociado al desarrollo de dependencia, aun cuando las BDZ se utilicen a dosis terapéuticas Objetivo El objetivo del presente estudio es describir y comparar las características sociodemográficas y clínicas relacionadas con la prescripción y el uso de benzodiazepinas en adultos mayores con y sin dependencia a las mismas en un servicio especializado de psicogeriatría. Método Se reclutó un total de 39 pacientes de la Clínica de Psicogeriatría del Instituto Nacional de Psiquiatría Ramón de la Fuente en la Ciudad de México. Todos los participantes consintieron por escrito su participación en el estudio. El diagnóstico de dependencia a BDZ se realizó a partir del SCID-I; la gravedad de los síntomas de depresión se evaluó mediante la Escala de Montgomery y Asberg (MADRS); los síntomas de ansiedad, con la Escala de Ansiedad de Hamilton (HAM-A), y el nivel de funcionalidad, mediante el Índice de Katz y el GAF. Resultados No se encontraron diferencias significativas entre los grupos en las variables sociodemográficas y la comorbilidad médica. Los pacientes incluidos cursaron en su mayoría con un cuadro depresivo o algún trastorno de ansiedad como diagnóstico principal. La indicación médica inicial para el consumo de BDZ fue el tratamiento de la ansiedad para los pacientes con dependencia y del insomnio para los no dependientes. La edad de inicio del consumo de las BDZ y el tiempo de consumo fue de 57.5 años y 675.2 semanas en promedio, respectivamente. La dosis promedio utilizada por los pacientes fue de 1 4.4mg en equivalentes de diazepam. Los pacientes con dependencia a las BDZ mostraron una mayor gravedad de los síntomas de depresión y ansiedad, menor desempeño cognoscitivo y menor funcionamiento psicosocial, así como conductas de búsqueda y abandono de actividades relacionadas con el consumo y mayores síntomas de tolerancia y abstinencia a las BDZ. Discusión La dependencia a las BDZ se presentó como un fenómeno complejo relacionado con la intensidad de los síntomas de depresión y ansiedad, un consumo crónico y una mayor dosificación. La depresión con síntomas de ansiedad en el adulto mayor no debería tratarse con BDZ, ya que, además del riesgo de desarrollar dependencia, éstas pueden efectuar negativamente el desempeño cognoscitivo y el funcionamiento global de los pacientes. Al momento de prescribir una BDZ a la población geriátrica se deben tomar en consideración variables sociodemográficas y clínicas de los pacientes. De la misma forma, será necesario evaluar en futuros estudios la influencia de la personalidad y otras variables clínicas sobre el desarrollo de esta dependencia.
ABSTRACT
Unipolar depression is considered as one of the main psychiatric diagnosis related to psychosocial functioning impairment. It has been documented that personality features exert a direct influence on how people with depression cope and adapt to the disorder. The relationship between personality traits and depression has been studied in several models. As depressed patients usually exhibit several personality features of more than one personality disorder, a multidimensional theoretical perspective may increase the clinical description of prototypical diagnosis provided by current categorical criteria. The psychobiological model of personality proposed by Cloninger takes into account the respective contribution of neurobiologically-based mechanisms related to adaptative behaviors in response to danger, avoidance and reward, formulating four main temperamental dimensions and three characterological dimensions centered in conscious learning about self-concepts. The four temperament dimensions are: Novelty Seeking (NS) is thought to be related to the behavioral activation system; Harm Avoidance (HA) to the behavioral inhibition system; Reward Dependence (RD) is defined as a bias toward the maintenance of ongoing behaviors; and Persistence (PE) is defined as a tendency to perseverance despite frustration and fatigue. The character dimensions are: Self-directedness (SD) refers to the ability of an individual to control, regulate and adapt behavior to fit the situation in accordance with personal goals and values; Cooperativeness (CO), account for individual differences in identification with and acceptance of other people; and Self-transcendence (ST) refers to spiritual maturity, transpersonal identification and creativity. Several studies that used the psychobiological model or personality reported that personality differences are detectable among persons with a current major depressive disorder when compared to non-depressed. The most frequent finding reported is the association between higher scores in harm avoidance (HA) and depression. Nevertheless, other studies have found that depression is also related with high scores in the temperamental dimension: reward dependence (RD). In terms of character dimensions, it has been reported that depressed patients exhibit low self-directedness (SD) and low cooperativeness (CO). Objetive The aims of the present study were to determine the reliability of the Temperament and Character Inventory (TCI) in a sample of Mexican depressed patients and healthy controls and to compare TCI dimensions between both groups. Method A total of 40 first-episode depressed patients and 40 healthy controls matched by gender, age and length of education were recruited. All patients were recruited from the outpatient service at the Instituto Nacional de Psiquiatría Ramón de la Fuente. Patients were excluded if they had received any psychotropic medication for the treatment of depression, if they had concomitant medical or neurological illness, current substance abuse or a history of substance dependence, history of bipolar disorder; high risk for suicide or were agitated. Healthy controls were recruited from a public university and were not enrolled if they presented any psychiatric disorder or scored ≥ 2 points in any SCL-90 subscale, or verbally reported any aggressive behavior in the week prior to the assessment. Diagnosis of depression was done according to DSM-IV criteria and confirmed by clinical consensus. The Montgomery & Asberg Depression Rating Scale (MADRS) was used to measure depressive symptom severity. Personality dimensions were assessed using the Temperament and Character Inventory (TCI). Results Personality dimensions of the TCI showed moderate to high reliability. Internal consistency was higher for the character dimensions than for the temperament dimensions in both groups. Patients with major depression showed higher scores in the temperament dimension harm avoidance when compared to healthy controls. No significant differences emerged between groups in the dimensions: novelty seeking, reward dependence and persistence. Significant differences emerged between groups in terms of character dimensions. Depressed patients exhibit: lower self-directedness, lower cooperativeness and lower self-transcendence when compared to healthy controls. Discussion Personality assessment in patients with their first depressive episode offers the advantage of reducing biases secondary to the falsification of retrospective report, the effects of illness chronicity and pharmacological treatment on personality. Our results support the idea that the temperament dimension harm avoidance can be consider as an intermediate phenotype for major depression, as it can be a risk factor or may have a direct influence in the way depression is manifest. In terms of character dimensions, lower scores of self-direct edness may be reflected in patients lack of control responses in situations where mature and effectives responses are required. In this way, patients with low self-direct edness may exhibit irresponsible behaviors and a poor impulse control. Low cooperativeness in patients with depression may represent a state characterized by a limited empathy and can be reflected as social intolerance or social isolation. These behavioural changes are frequent depressive symptoms that can be observed by persons that share the environment with the patient. The result of a low self-transcendence in patients with depression raises the possibility that certain beliefs can modify patients' behavior when they cannot conceive their existence as a part of a unified whole. This, in conjunction with lack of transpersonal identification may explain the presence of self-destructive thoughts and behaviors, such as suicide ideation, frequent symptoms observed in patients with depression. In conclusion, our results show that the temperament dimension HA can be associated with vulnerability to depression, while severity of depression may lay in the interaction between constitutional factors and the subjectivity of illness experience conferred by character.
La depresión unipolar se ha considerado como uno de los trastornos mentales que tiene un mayor impacto en el funcionamiento psicosocial de los individuos. Se ha documentado que los rasgos de la personalidad influyen directamente sobre la forma en como las personas con depresión mayor se adaptan y enfrentan este padecimiento. Diversos estudios que han empleado el abordaje multidimensional de la personalidad mediante el modelo psicobiológico de la personalidad de Cloninger, han considerado que la personalidad es un constructo que diferencia a los sujetos que cursan con un trastorno depresivo mayor de los sujetos sin esta patología. El hallazgo más reportado en la bibliografía ha mostrado que una elevada Evitación al Daño (HA) se asocia con la depresión. Sin embargo, otras investigaciones han encontrado que la depresión mayor también se asocia con una mayor Dependencia a la Recompensa (RD). En cuanto a las dimensiones de carácter, se ha encontrado que los pacientes con depresión muestran una Baja Autodirección (SD) y una Baja Cooperatividad (CO). Objetivo Los objetivos del presente estudio fueron determinar la confiabilidad del Inventario de Temperamento y Carácter (ITC) en una muestra mexicana de pacientes con trastorno depresivo mayor y sujetos control, y comparar las dimensiones del ITC entre ambos grupos. Método Se incluyeron 40 pacientes que estuvieran cursando con su primer episodio de depresión mayor y 40 sujetos controles comparados por el método de pares por género, edad y nivel de escolaridad. Los pacientes fueron reclutados del servicio de consulta externa del Instituto Nacional de Psiquiatría Ramón de la Fuente. Los sujetos control fueron reclutados de una universidad pública de la Ciudad de México. El diagnóstico de los pacientes se realizó a partir de los criterios del DSM-IV y fue confirmado mediante consenso clínico. La severidad de los síntomas de depresión fue evaluada mediante la Escala de Depresión de Montgomery & Asberg (MADRS). Las dimensiones de la personalidad en pacientes y controles fue evaluada mediante el Inventario de Temperamento y Carácter (ITC). Resultados Las dimensiones del ITC mostraron una confiabilidad de moderada a alta. Se observaron diferencias significativas entre grupos en la dimensión de temperamento: Evitación al Daño (HA) y en las dimensiones de carácter Autotrascendencia (ST), Cooperatividad (CO) y Autodirección (SD). Discusión La evaluación de la personalidad en pacientes con un primer episodio de depresión permite excluir la falsificación del reporte retrospectivo así como los efectos que la cronicidad del padecimiento o el tratamiento farmacológico tienen sobre la personalidad. La dimensión de temperamento HA puede ser considerada un factor de vulnerabilidad en el desarrollo de la depresión, mientras que la severidad de la depresión podría estar relacionada con la interacción de los factores constitucionales del sujeto y la subjetividad de la experiencia del padecimiento a partir de la conformación del carácter.