Talk:Benzodiazepine

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Lots of Misinformation in this Article (Reads like a Drug-Company Sales Pamphlet)

Citations do not by themselves a neutral article make. There is a lot of legitimate controversy (at the professional level) about benzodiazapines, their safety and side effects. Really there should be a controversy section in this article.

There are also plenty of citations available that counter some of the claims made in the article. It should be noted that there are major efforts in several countries to ban benzodiazapine use altogether, and that a number of these efforts are being spearheaded by Medical Doctors.

I encourage anyone with the time and knowledge to follow wiki guidelines while posting numerous alternative citations to the blatant drug company propaganda in this article.

69.171.160.51 (talk) 22:31, 3 February 2010 (UTC)

I also encourage people not to be shy about appealing to Wikipedia administrators over the heads of anyone who reverts legitimate additions or changes to the article--

Automatically reverting changes that you don't like (or that you are being paid not to like) without justification is considered vandalism by Wikipedia standards and will usually be dealt with if reported often enough to Wikipedia administrators.

You also have the right to appeal to more than one administrator.

69.171.160.51 (talk) 22:46, 3 February 2010 (UTC)

What is wrong with this paragraph

WhatIamdoing insisted that I accept abuse from LG as given and get on with the program. So, what is wrong with this paragraph? LG reverted it three times, after each sentence as I was writing it. (Note for LG: Mind WP:TLDR and AGF. I will stop reading your argument beyond ten sentences and at the first word of abuse. Note for Eubulides and everyone: "Please ignore for a second style problems with the last view and some other grammar and style problems and concentrate on the content.")

SUGGESTED: "The data on the The effects of long-term use is contradictory. One interpretation of this data, exemplified by Ashton maintain that benzodiazepines have all the characteristic of drugs of dependence and result "in the insidious development of increasing psychological and physical symptoms." On the prolonged exposure they may worsen anxiety and cause depression, and deficits of learning, memory and attention. Another view counters that "despite considerable scientific evidence that the risk of drug abuse with benzodiazepines is low, there is tremendous prejudice against their use in many individuals, in certain treatment settings, and even countries (e.g., United Kingdom)." This view argues that the short-term treatment for generalized anxiety disorder and panic disorder makes no sense as these disorders continue long-term. Its proponents assert that the current practice is to "continue treatment for 6 to 18 months before tapering and attempting discontinuation." An intermediate, empirical, position advocates careful and limited use of benzodiazepines. In this view, if the prolonged treatment is necessary, the patient reports sustained benefits from a benzodiazepine and no signs of misuse are visible, there is no harm from this practice."

On the other hand, the current version (below) exaggerates side effects, and does not represent other points of view. IMHO, the majority view is the balanced third view in the suggested version. The Sceptical Chymist (talk) 19:12, 25 June 2009 (UTC)

CURRENT:"The long-term adverse effects of benzodiazepines include a general deterioration in physical and mental health and tend to increase with time. Not everyone however, experiences problems with long-term use. The adverse effects can include cognitive impairments and affective and behavioural problems. Feelings of turmoil, difficulty in thinking constructively, loss of sex-drive, agoraphobia and social phobia, increasing anxiety and depression, loss of interest in leasure persuits and interests, an inabilty to experience or express feelings also occurs. Additionally an altered perception of self, environment and relationships may occur.

Refs

Discussion

I've fixed the refs. Please place any comments below. WhatamIdoing (talk) 18:15, 25 June 2009 (UTC)

Discussion on text in above section

Ref is not discussing long-term effects so ref is being misused to say things that aren't in citation. The statement "data is conflicting" is opinion by Sceptical Chymist and is therefore original research. I cannot agree with this original research and misuse of refs. They are only discussing long-term use. It is fine to discuss the fact other doctors believe in long-term use. This is represented in the article already and I don't oppose this. As far as the UK being "extreme" I think that it is only fair to then state how some countries eg hong kong have benzos listed as dangerous drugs and countries like Holland and several other european countries have stronger stances against benzos and then cite how America's health body publishes research connecting benzos to cancer and there is a team of doctors in America who campaign against benzos whereas this is not the case in the UK, gotta keep things in perspective. To be honest though, I think pitting America against the UK is going to lead issues unless we put it in balance by listing other countries which have stronger stances than the UK. I also think that it would worsen the article.--Literaturegeek | T@1k? 19:41, 25 June 2009 (UTC)

You are welcome to provide citations saying that the long term effects are exagerated. I intentionally added the statement that "not everyone is effected by adverse long-term effects" one because it puts it into context, does not exagerate it and 2 because it is true. One tip as well, all of the studies into benzos which follow people up for 6 - 12 months show improvements in some measure, physical, mental health. The drug companies and regulatory bodies don't challenge this data, they just ignor it so I think it is unlikely that you will find a source that challenges it but if you find one I am not opposed to you using it. just opposed to using irrelevant refs to do a synthesis and original research is all. There are lots of good psychiatry and addiction books which discuss these long-term effects. I can provide more citations if you like.--Literaturegeek | T@1k? 19:47, 25 June 2009 (UTC)

The problem as I see it is that Sceptical feels that NPOV policy means that refs can be misused and original research is allowed in these cases to achieve neutrality. I cannot agree to this editing practice.--Literaturegeek | T@1k? 19:50, 25 June 2009 (UTC)

The "intermediate" position is original research and implies that clinical guidelines and systematic reviews are "extremist" thus I feel it is not me who is breaking NPOV but you. We must stick to refs and no original research. Hope this helps clarify my position.--Literaturegeek | T@1k? 19:53, 25 June 2009 (UTC)

P.S. thanks to those who are trying to resolve this. I believe it is impossible to resolve this without outside eyes so your help is much appreciated.--Literaturegeek | T@1k? 19:55, 25 June 2009 (UTC)

The evidence based truth is the abuse potential of benzos is "moderate" or intermediate. The abuse potential is not high and it is not low. I dunno where authors got the low stat from, never seen a review of animal and human studies which came to that conclusion. They are still commonly abused by drug misusers.--Literaturegeek | T@1k? 21:01, 25 June 2009 (UTC)

Here we ago again with TLDR. Is that too hard to get to the point in the first paragraph? I read the first 10 sentences as promised. Which "Ref is not discussing long-term effects"? -- please specify, and I will answer. "Not everyone is effected by adverse long-term effects" is true but vague, and may create an impression that 90% of the people get addicted, for example. "Data is conflicting" is not OR, see for example ref 6 :" The literature is divided, however, on the persistence of cognitive effects in patients taking benzodiazepines long-term." What are you other arguments against the suggested paragraph? Try to be concise. Bulletize the points. Start with the most important point and with the most important idea in each point. The Sceptical Chymist (talk) 21:25, 25 June 2009 (UTC)

Oh you mean conflicting with cognition, the review author in ref 6 concluded that impaired cognition did occur, so you are using primary sources within a review to come up with your own conclusions,,, but,,, this is already discussed in the cognitive section Benzodiazepine#Cognitive_effects, which I still don't fully agree with. What I am looking for is a long term follow-up study say 6 - 12 months post withdrawal which finds no improvements in physical or mental health. Do you have any refs which says data is conflicting in this regard? Reference two does not say that the data is conflicting and does not discuss long-term effects so thus I feel is original research and a misuse of a ref. I find your approach to discussing references remains combative.--Literaturegeek | T@1k? 22:08, 25 June 2009 (UTC)

• This is a simple question and requires only a "Yes" or "No" answer: Do we have a high-quality reliable source that directly says that there are disagreements about the long-term effects of this drug? If yes, please give me the PMID or ISBN. If no, please just say no. Note that "Here are six sources, all of which say different things," is not what I'm after. I'm after a source that directly says, with little or no beating about the bush, "There are disagreements about the long-term effects of this drug." WhatamIdoing (talk) 00:10, 26 June 2009 (UTC)

"While the recent NICE guidelines suggest that long term use is contraindicated (NICE, 2004), others suggest that fears about abuse are exaggerated and may limit use of these medications to the disadvantage of patients who would otherwise benefit (APA, 1998)."Cambridge textbook of effective treatments in psychiatry" ISBN-10: 052184228X, p. 546. The Sceptical Chymist (talk) 00:33, 26 June 2009 (UTC)

"The major controversy surrounding the use of benzodiazepines has concerned the risks of long-term treatment, specifically tolerance, abuse, dependence and withdrawal effects." Anxiety and Anxiolytic Drugs, p.474, ISBN-10 3-540-22568-4 The Sceptical Chymist (talk) 00:45, 26 June 2009 (UTC)

From the same book, "it being argued that some patients who respond well to benzodiazepines have chronic disorders for whom continued treatment is desirable and justifiable, but this remains a minority view." Page 532

Your second comment, not sure what you are implying. If you are implying that that statement means that the existance of tolerance and withdrawal doesn't occur or is debated and controversial then I think you are taking that quote out of context.

I am not opposed to the inclusion that there are doctors who believe in long term use but I don't feel that it should be given undue weight. It is a notable enough viewpoint to include but should not be used in the article text to minimise or even ridicule the NICE clinical guidelines or systematic reviews as "extremist".

I don't believe the quotes are related to long-term effects.

Here is a good ref to use.[1] It discussed some of the long-term effects as well as evidence of long-term effectiveness.--Literaturegeek | T@1k? 01:19, 26 June 2009 (UTC)

1. LG, are you saying that a sentence that includes the words "risks of long-term treatment" does not say anything about "long-term effects"? As I understand it, SC is writing about adverse effects in people that take these drugs for years. This is not the same subject as adverse effects that last for years after you've taken the drug.
2. ISBN 103540225684 (the second source) clearly and directly seems to agree with the first sentence in SC's proposal ("The data on the The effects of long-term use is contradictory"). It mentions a "major controversy" over "risks of long-term treatment". I think that fully addresses LG's concern above about whether this sentence represents impermissible original research. It's not original research if a reliable source plainly states the fact. LG, are you prepared to withdraw your objection in the face of this evidence? WhatamIdoing (talk) 01:34, 26 June 2009 (UTC)

I can't access that page of the book on google books but no I am not saying that. I am saying that it means the use of the drugs is controversial because of their adverse effect profile with differing opinions on the risk-benefit ratio but equally I found a page where the author clarified his views on the controversy where he said those advocating long term use for anxiety are a minority view in the literature (he cited some authors promoting the view so he was referring to literature). Also the quote is not directly relevant to dispute long-term adverse effects of benzodiazepines on physical and mental health and whether improvements occur after withdrawal from long term use. If you disagree, I am open to how it could be used in the benzo article. I am not opposed to compromising. Let me know your thoughts. Perhaps we could add a sentence before the long-term effects saying "their is major controversy surrounding the risk benefit ratio and the incidence of long-term adverse effects of benzodiazepines." Whilst it is not discussing the long-term effects on physical mental health and whether people improve after withdrawal,,, I think it might be a borderline case of using common sense and bending the rules a little but if that is what is needed, I happy to come up with a compromise.--Literaturegeek | T@1k? 01:54, 26 June 2009 (UTC)

It does not back up the view the "data is contradictory" but does back up the viewpoint that there is controversy over opinions of the risk benefit ratio.--Literaturegeek | T@1k? 02:01, 26 June 2009 (UTC)

Zero adverse effects

• W! This is a simple question and requires only a "Yes" or "No" answer: Do we have a high-quality reliable source that directly says that "Not everyone however, experiences problems with long-term use". Do not insult my intelligence by saying that the source that states "The abuse in the therapeutic users of BDz is rare" supports LG's statement. If yes, please give me the PMID or ISBN. If no, please just say no. Note that I'm after a source that directly says, with little or no beating about the bush, "Not everyone however, experiences problems with long-term use".The Sceptical Chymist (talk) 00:20, 26 June 2009 (UTC)
  • I interpret the statement as requiring a source that states that at least one long-term user has experienced zero adverse effects, whether perceived or unperceived by the user, and regardless of whether the user considers the adverse effect to be important (since the word "problems" is not qualified by words like "significant"). I'm not aware of any such source, and thus I'm skeptical of this being an appropriate claim for a Wikipedia article to make. My lack of awareness of such a source should not be taken as proof that no such source exists. WhatamIdoing (talk) 01:29, 26 June 2009 (UTC)

I don't really want to get involved here as both sides seem quite worked up about this, but there are certainly references that show long-term use of benzodiazepines without causing harm if you would accept older reviews or primary studies. The problem with only relying on these big meta-review papers is that they tend to presume that things which are statistically true for the majority of patients will therefore be true for every single patient, even though this is clearly not the case. Sure perhaps 80% of patients prescribed benzodiazepines long term will suffer declining efficacy and side effects which eventually outweigh the benefits of treatment, but that still leaves a substantial minority of patients who do not suffer these side effects and still find the treatment effective even after many years. I tend to agree with Sceptical Chymist in this respect, there is not a universal consensus on this even though the politically correct view seems to be that benzos are bad and should never be prescribed long term. However I deplore the name-calling and negative attitude on both sides, lets please just work on improving the article! Meodipt (talk) 01:43, 26 June 2009 (UTC)

We need up-to-date evidence, but as far as I'm concerned, this claim only requires proof that one person used this drug for a long time and experienced no adverse effects. If we can't find a single report of any individual that experienced no adverse effects, then either we're not trying very hard, or we shouldn't be making the claim. WhatamIdoing (talk) 01:53, 26 June 2009 (UTC)

That was not a single-word answer from W. It was weaseling. No, we just need a respectable author who would say with a straight face "Not everyone however, experiences problems with long-term use" of benzodiazepines. The Sceptical Chymist (talk) 02:30, 26 June 2009 (UTC)

I absolutely deplore name-calling. Is there a single instance where I did it to LG? The Sceptical Chymist (talk) 02:19, 26 June 2009 (UTC)

I think a compromise can be reached, see above. All I want is the sources to be accurate represented, undue weight is not used etc.--Literaturegeek | T@1k? 02:04, 26 June 2009 (UTC)

Yeah I think there is clearly scope for compromise here. Just say the majority view is that long-term benzo presciption is not appropriate but it may still be suitable in a minority of patients, should be easy enough finding refs for both those statements. Meodipt (talk) 02:09, 26 June 2009 (UTC)

[Edit conflict with Meodipt] I know people who use benzos and are not suffering mental or physical adverse effects from it so I admit and know for a fact that people do exist who do not suffer adverse effects due to long-term use. They may be "functionally" dependent on the drug but it does them no psychological or physical harm. The main thing though is to focus on reliable sources. I am not opposed to older sources if newer sources don't exist but not a fan of debunking new research with old research. Thanks for your views Meodipt. I do appolgise for losing my cool.--Literaturegeek | T@1k? 02:16, 26 June 2009 (UTC)

Good idea on long-term use, how about this citation. Quote, "Long term prescription is occasionally required for certain patients."--Literaturegeek | T@1k? 02:16, 26 June 2009 (UTC)

I do not know how we can say which view is majority or which minority without doing original research. Guidelines appear to disagree -- that is NICE vs. APA. Textbook authors pipe in with their disparate comments. That is why I tried to present the spectrum of the views without being judgmental AND without saying which view is more prevalent. In that I followed WP:NPOV to the letter. The Sceptical Chymist (talk) 02:23, 26 June 2009 (UTC)

I think that we go by what the best quality sources say. A non-systematic review of a few uncontrolled clinical trials would not be superior to a systematic review of the literature. I don't see a big conflict between NICE and the APA when the author says this. "it being argued that some patients who respond well to benzodiazepines have chronic disorders for whom continued treatment is desirable and justifiable, but this remains a minority view." Page 532--Literaturegeek | T@1k? 02:31, 26 June 2009 (UTC)

I think that we're confusing "do adverse effects happen" with "should this be prescribed". 100% of patients receiving cisplatin-containing chemotherapy regimens experience undesirable adverse effects. That is an entirely different question from whether or not the drug is justifiable. This section, as I understand it, attempts to identify the adverse effects that appear in long-term users of this drug -- not whether or not the drug is helpful to long-term users. WhatamIdoing (talk) 02:48, 26 June 2009 (UTC)

Side effects of the long-term use of benzodiazepines

How representative of the consensus view of the professionals is this sample of the long-term side effects from the current version of the article?

The [long-term] adverse effects can include cognitive impairments and affective and behavioural problems. Feelings of turmoil, difficulty in thinking constructively, loss of sex-drive, agoraphobia and social phobia, increasing anxiety and depression, loss of interest in leasure persuits and interests, an inabilty to experience or express feelings also occurs.

Below I will try to present a random sampling of psychiatric textbooks from my shelf, warts and all. The Sceptical Chymist (talk) 02:39, 26 June 2009 (UTC)

• Side effects include sedation, fatigue, and memory impairment. Although these medications carry a potential risk of abuse, the risk is felt to be overestimated in patients with anxiety disorders (Uhlenhuth, et al., 1989). Avoidance of these medications out of fear of abuse may be more problematic than the risk of abuse. If benzodiazepines are employed over an extended period of time, patients are at risk for recurrence of symptoms when they are tapered. (ISBN 0-471-43478-7, p 356) The Sceptical Chymist (talk) 02:48, 26 June 2009 (UTC)

Those side effects are acute side effects. Tolerance to the hypnotic effect occurs in days or weeks so it is definitely not referring to long-term effects. It is not discussing adverse effects which may result from long-term use. I am not trying to be antagonistic but this is why editing beside you led to dispute because I felt you were misrepresenting refs to delete or challenge facts you didn't like.--Literaturegeek | T@1k? 02:54, 26 June 2009 (UTC)

No, you got it right. Those are the short-term effects. I was just trying to show that I am not concealing anything. So the only long-term effect is recurrence of symptoms, according to that textbook. The Sceptical Chymist (talk) 02:59, 26 June 2009 (UTC)

No, it is just saying when people stop their medication their symptoms may return either I assume beccause the drug was alleivating the symptoms or as a rebound withdrawal effect. You are adding to what they say. I could find a book which discusses George Bush but never mentions his wife, then could I claim he was never married? It is still claiming a citation says something when it doesn't in my opinion.--Literaturegeek | T@1k? 03:09, 26 June 2009 (UTC)

I said "warts and all". This was the only place in the book where long term side effects of BDs were mentioned. Do not blame me, blame the authors. I just quote them. The Sceptical Chymist (talk) 03:22, 26 June 2009 (UTC)

Okie dokie, understood, we shall blame the authors then. :)--Literaturegeek | T@1k? 03:25, 26 June 2009 (UTC)

• Like the barbiturates, long-term use of benzodiazepines can lead to physical dependence, and abrupt discontinuation can produce an unpleasant, or even dangerous, withdrawal syndrome. (ISBN-10: 0-471-25401-0, p 132) The Sceptical Chymist (talk) 02:59, 26 June 2009 (UTC)

• Probably more important are the observations that long-term benzodiazepine therapy interferes with concentration and memory of new material. However, it does appear that the ability to remember and recall information learned prior to benzodiazepine therapy is not compromised. Although this can be a particular problem in elderly patients and may even lead to confusional, delirious, and even pseudodementia-type pictures, these effects on memory are generally subtle. These adverse effects, in particular, must be monitored with each individual patient to balance these relatively minor memory disturbances (if they occur) with clinical efficacy.(Chapter 31.10, Kaplan & Sadock’s) The Sceptical Chymist (talk) 03:06, 26 June 2009 (UTC)

• The role of benzodiazepines in brain damage has been reviewed (SEDA-14, 36). Cognitive impairment in longterm users can be detected in up to half of the subjects, compared with 16% of controls, but the issue of reversibility with prolonged abstinence is unresolved. Cognitive toxicity is more common with benzodiazepines than other anticonvulsants, with the possible exception of phenobarbital (84)....These findings suggest that long-term use of benzodiazepines is a risk factor for increased cognitive decline in elderly people...Withdrawal symptoms occur in at least one-third of long-term users (over 1 year), even if the dose is gradually tapered (111). (Meyler's side effects of drugs) The Sceptical Chymist (talk) 03:17, 26 June 2009 (UTC)

• After long-term administration (weeks to months) tolerance develops. While most patients rapidly become tolerant to the sedative side effects of these drugs, some patients, particularly the elderly, experience excessive sedation, poor memory and concentration, motor incoordination and muscle weakness. In extreme cases in the elderly, an acute confusional state may arise which simulates dementia... In addition to the tolerance that occurs following the long-term treatment of a patient with a benzodiazepine, dependence also arises... It has been estimated that 15–30% of patients on benzodiazepines for longer than a year may encounter problems in trying to discontinue their medication. (ISBN 0 471 52178 7, p 236)

• However, benzodiazepines are associated with risk of dependence after long-term usage (Tyrer et al., 1983; Rickels et al., 1988) and, although there may sometimes be withdrawal problems (‘discontinuation symptoms’) with antidepressants (Haddad, 1997), they are less likely to lead to persistent consumption than benzodiazepines. Because of this, the general guidance is to give benzodiazepines only for short-term treatment up to 4 weeks (Priest & Montgomery, 1988; Ballenger et al., 2001; NICE, 2004; Baldwin et al., 2005). Although this statement is frequently repeated, it is often ignored by many who prescribe in general practice. It is also worth adding that, as both generalised anxiety disorder and somatoform disorders are chronic conditions, it is highly unlikely that less than 4 weeks treatment would be of value. In practice, because both patients and practitioners find benzodiazepines to be of some value, they continue to be prescribed, either regularly or intermittently, over long periods and this applies even when the risks of dependence are known and explained. Short-term regular prescriptions of benzodiazepines are often of limited benefit and if followed by immediate withdrawal this benefit disappears (Tyrer et al., 1988) and so intermittent irregular but long-term use becomes the norm, even when patients are fully aware of the risk of dependence (Holton & Tyrer, 1990). (p 531,ISBN-13 978-0-521-84228-0,)

The above quote really sums it up I think. While it is important to note the clinical prescribing guidelines in the page, it is even more important to say why despite these guidelines warning against long-term use, benzodiazepines nevertheless still are often prescribed for long periods of time. If both sides aren't noted the page doesn't really explain why such long-term prescription would happen, if the adverse effects are inevitably so bad. Meodipt (talk) 06:15, 27 June 2009 (UTC)

• Around 80% of all such prescriptions [for BD hypnotics] in England are for those aged 65 years or over (Curran et al., 2003), and many patients remain on the drugs for months or years (Taylor et al., 1998). This prescribing is likely to lead to development of dependence and many other adverse effects on health (Ashton 1995). All currently marketed hypnotics have been associated with at least some features of dependence and have demonstrated a potential for misuse and dose escalation in at least a minority of patients (Ashton, 1995; Hajak et al., 2003; Lader, 1999). (p 402, ISBN-13 978-0-521-84228-0,) The Sceptical Chymist (talk) 03:36, 26 June 2009 (UTC)

• Unfortunately, although needed, effective and reasonably safe long-term BZD therapy for anxiety disorders has had various problems associated with it, especially in the elderly, including: Excessive daytime drowsiness; Cognitive impairment and confusion sychomotor impairment and a risk of falls; Paradoxical reactions and depression; Intoxication, even on therapeutic dosages; Amnestic syndromes; Respiratory problems; Abuse and dependence; Breakthrough withdrawal reactions (Principles & Practice of Psychopharmacotherapy, 4th Edition Copyright ©2006 Lippincott Williams & Wilkins > Table of Contents > Chapter 12) The Sceptical Chymist (talk) 03:43, 26 June 2009 (UTC)

Hi meodipt, the article already mentions that large amounts of people are still prescribed these drugs long-term (unless it got deleted and I didn't realise). Sceptical Chymist has used that paragraph out of context and misused the ref to make this change which he intends inserting into the main article I presume. If you read the tyrer book, he clarifies his opinion of what the evidence based literature says by saying this From the same book and on the next page ""it being argued that some patients who respond well to benzodiazepines have chronic disorders for whom continued treatment is desirable and justifiable, but this remains a minority view." Page 532 I feel that this type of editing is harmful to wikipedia and this article and is original research and misuse of references and I cannot compromise and accept misrepresented references. Presumably Tyrer believes that long-term use for anxiety is ineffective from reviewing the evidence and the risks outweigh the benefits.--Literaturegeek | T@1k? 12:46, 27 June 2009 (UTC)

We should stick to the conclusions of the authors and minority viewpoints should not be given undue weight and should not be used to delete or minmise majority evidence based viewpoints.--Literaturegeek | T@1k? 12:55, 27 June 2009 (UTC)

First, these excerpts are about long-term effects not prescribing. Second, the above sampling of textbooks shows that the current description of the long-term side effects in the article written by LG does represent only minority view. Third, it is LG who takes quotes out of context. I shall address this below. The Sceptical Chymist (talk) 15:32, 27 June 2009 (UTC)

Of course short-term therapy would be ineffective for a long-term disorder but the authors views are that it is a minority view that long-term use of benzos is effective. You need to quote him in context. Your suggested edits are misleading as they imply long-term effectiveness and imply that the author believes long-term use is effective. Are you happy enough to quote the source in its correct context? Will you add to the quote that it is a minority view that long-term use is effective?--Literaturegeek | T@1k? 16:05, 27 June 2009 (UTC)

I addressed the alleged "reference misuse" below [2] The Sceptical Chymist (talk) 16:09, 27 June 2009 (UTC)

Questions about U Sheffield paper

I have a few questions about this U Sheffield paper, which is used several times in the article: <ref name=cgftmamoa2004>{{cite web|author=McIntosh A, Cohen A, Turnbull N ''et al.''|title=Clinical guidelines and evidence review for panic disorder and generalised anxiety disorder|url=http://www.nice.org.uk/nicemedia/pdf/cg022fullguideline.pdf|publisher=National Collaborating Centre for Primary Care|format=PDF|year=2004|accessdate=2009-06-16}}</ref>.

1. The paper proclaims itself to be a "guideline"; however, it contains the following caveat on p 2: "The views expressed in this Publication are those of the authors and not necessarily those of either the Royal College of General Practitioners or the National Institute for Clinical Excellence." I wonder if using a real NICE guideline would be better.

2. This paper is 165 pages long. I believe that for each citation a page number should be provided. At the very least, a shorter range of pages could be given, if all citations are from the same part or chapter. For example, it would be nice to have numbers/range for the pages that confirm the bold parts in this sentence: "Their use beyond two to four weeks is not recommended in clinical guidelines, as tolerance and a physical dependence develops rapidly, with withdrawal symptoms including rebound anxiety occurring after six weeks or more of use.<ref name=cgftmamoa2004>" (bold mine, TSC).

3. This paper is used to support the following statement: "Psychological therapies such as cognitive behavioural therapy are recommended as a first line therapy; benzodiazepine use has been found to interfere with therapeutic gains from these therapies."(emphasis mine, TSC). LG reverted my failed verification tag with the following edit summary: "Page six Sceptical. I don't fake refs."[3]. I look at page 6 and still cannot find support for the bold part of this statement. The Sceptical Chymist (talk) 00:46, 27 June 2009 (UTC)

I don't see anything in that reference to support the bolded statement in (3), although I just used a keyword search rather than reading all 165 pages! My understanding was that a combination of psychotherapy and pharmacotherapy is usually more effective than either treatment alone, although this has been better established with SSRIs than with benzos The most recent review I could find specifically about benzos vs CBT vs both failed to find a statistically significant trend in either direction and concludes there is inadequate evidence at this point to say for sure which is better. (PMID 19160253) Meodipt (talk) 04:40, 27 June 2009 (UTC)

Meodipt, the keyword search may not work because the concept could have different wording in the source. So, to be fair, I skimmed through all 165 pages (!) before inserting the failed verification tag. And LG had the gut to revert the tag and claim that he "don't fake refs." Thank you for finding the Cochrane review that directly disproves the questionable sentence in the text; I was not aware of it. The Sceptical Chymist (talk) 11:25, 27 June 2009 (UTC)

Hi, hope these replies address your points.

Point 1.

That is just a routine legal disclaimer which you will often see in publications. It is still a systematic review of the peer reviewed literature so I think it is irrelevant. NICE would have peer reviewed it before publishing it on their website.--Literaturegeek | T@1k? 14:23, 27 June 2009 (UTC)

Point 2.

I can do this, but will need time.

Point 3.

I thought you were talking about the cited sentence before that which is on page 6.[4] See page 76 for this statement.--Literaturegeek | T@1k? 14:23, 27 June 2009 (UTC)

RE: Point 1. That little "routine legal disclaimer" means that this is not a NICE guideline and that it has not been officially reviewed and approved by NICE. Is there an official NICE guideline? - that is the question. The Sceptical Chymist (talk) 15:33, 27 June 2009 (UTC)

It is an official guidance, it is listed under their guidance sub domain, so they must have reviewed it and accepted it before they placed it on there as that is used for national prescribing guidelines.[5] There is no way they would publish a systematic review on their national guidance subdomain if they didn't approve it or even review it.--Literaturegeek | T@1k? 15:39, 27 June 2009 (UTC)

That section of their website is used by all National Heealth Trusts when forming policy so it is not possible they would publish something there without NICE reviewing it first.--Literaturegeek | T@1k? 15:50, 27 June 2009 (UTC)

I marvel at the LG's denial of the facts. The paper says: "The views expressed in this Publication are those of the authors and not necessarily those of either the Royal College of General Practitioners or the National Institute for Clinical Excellence." Please answer this question, are there NICE guidelines which say that they are NICE guidelines? The Sceptical Chymist (talk) 16:13, 27 June 2009 (UTC)

RE: Point 2. Accepted.

RE: Point 3. What statement on p 76? The Sceptical Chymist (talk) 16:19, 27 June 2009 (UTC)

I have spent a month answering your questions. Everytime I ask a question you ignor it or dart around it. Can you explain to me why almost 100% of your edits have been demonising antidepressants on wikipedia? This is against the evidence base and mainstream consensus that antidepressants do more good than harm when used correctly and are effective in the long-term. Are your edits to benzo articles a way of promoting an alternative? If it is, bad move because benzos long-term cause depression and would get people onto antidepressants quicker than it would stop people getting antidepressants. About half the people on benzos I have met are on antidepressants as well and many don't need them after they get off of benzos. :)--Literaturegeek | T@1k? 02:11, 28 June 2009 (UTC)

Please be more clear and address the issue not the personality. I asked you about what statement I have to find on p 76 because there appear to be no relevant statements. The Sceptical Chymist (talk) 12:10, 28 June 2009 (UTC)

Try page 81 as well.--Literaturegeek | T@1k? 13:34, 28 June 2009 (UTC)

This is a real, official NICE guideline. It is Clinical guideline 22 (CG22, "Anxiety"), as shown here. Pages 75 and 76 summarize the findings of PMID 8596113 and PMID 12214810. The statement on page 81 is "There is some evidence that prior long term use of benzodiazepines is associated with a poorer response to subsequent psychological therapies." Fvasconcellos (t·c) 02:14, 29 June 2009 (UTC)

See How NICE clinical guidelines are developed (e.g. page 8). Technically, what has been linked to is the "Full guideline", which contains all the background evidence for the guideline, as well as the recommendations. The "NICE guideline" contains only the recommendations from the full guideline, without the information on methods and evidence. If you read the process you see the "full guideline" is fully reviewed to the point of issuing the guideline, and the "NICE guideline" is effectively a mechanically edited version of that. Note, that NICE have amended the "NICE guideline" for Anxiety[6] but not the "Full guideline"[7]. But that appears to be a minor change regarding "prescribing advice for venlafaxine".

So which should we cite? Well, NICE tell us in their FAQ:

• How do I reference NICE guidance? Please cite and quote from the full version of the guidance. You can find full versions of our guidance on the NICE website.

Colin°^Talk 12:11, 29 June 2009 (UTC)

Thank you Colin for your detailed and definitive answer and finding the real NICE guideline at [8]. As I understand it, LG was quoting a supporting document. The real NICE guideline states that it is a NICE guideline and does not have that "little insignificant" legal disclaimer. It has only 54 pages making it much easier to read than the U Sheffield supporting document, which has 165 pages. To everybody: please, let's quote the real guideline with the page numbers. The Sceptical Chymist (talk) 12:28, 29 June 2009 (UTC)

No, what you call "U Sheffield supporting document" is the real full NICE guideline, it is what is reviewed at endless meetings, and was finally approved by NICE. The shorter guideline document with the methods and evidence removed is the for the benefit of clinicians who don't need to read all that stuff. Which part of "Please cite and quote from the full version of the guidance" do you have difficulty understanding? Colin°^Talk 13:50, 29 June 2009 (UTC)

Colin, which part of this caveat in the U Sheffield supporting document -- "The views expressed in this Publication are those of the authors and not necessarily those of either the Royal College of General Practitioners or the National Institute for Clinical Excellence." -- do you not understand? The PDF of the NICE guideline here[9] says "This document, which contains the Institute's full guidance on Anxiety: management of anxiety (panic disorder, with or without agoraphobia, and generalised anxiety disorder) in adults in primary, secondary and community care, is available from the NICE website (www.nice.org.uk/CG022NICEguideline)". It is different from the abridged NICE guideline, which is "available from the NICE website (www.nice.org.uk/CG022quickrefguide)."

I think you got confused by the NICE wording. I quote from the brochure you kindly provided [10]:

"The full guideline contains all the background details and evidence for the guideline, as well as the recommendations. This document is produced by the National Collaborating Centre that is responsible for the guideline (see pages O-11 to O-12)." Please note that the "full guideline" is not produced by NICE, and is not called "NICE guideline". Accordingly, we have a legal disclaimer on the supporting document.

"The ‘NICE guideline’ contains only the recommendations from the full guideline, without the information on methods and evidence." That is the real full "NICE guideline", which excludes the supporting material.

Regardless, the recommendation sections of both documents say the same. In my opinion, it would be more convenient to use the "NICE guideline" than the National Collaborating Centre "full guideline", because NICE guideline is shorter. I hope, you could agree with that. It is a chore to read the 165 pages of the NCC document.The Sceptical Chymist (talk) 17:06, 29 June 2009 (UTC)

You hyperlinked the wrong version but yes, the "NICE Guideline" does say "This document, which contains the Institute's full guidance on..." but that is not the same as saying it is the full version of the guideline. Have a read of The guidelines manual 2009:

• "Four versions of each standard clinical guideline are published:

The full guideline contains all the background details and evidence for the guideline, as well as the recommendations. This document is produced by the NCC.

The NICE guideline contains only the recommendations from the full guideline, without the information on methods and evidence.

The quick reference guide summarises the recommendations in an easy-to-use format for healthcare professionals.

'Understanding NICE guidance' summarises the recommendations in the NICE guideline in everyday language for patients and carers."

• "The National Collaborating Centre (NCC) (with the Guideline Development Group [GDG]) writes the full guideline and the NICE guideline."
• "Agreed changes to recommendation wording [in the NICE guideline] are transferred to the full guideline."
• "the NCC is responsible for ensuring that the wording of the recommendations in the full guideline matches that in the final NICE guideline"
• ""The full guideline is signed off by NICE’s Guidance Executive on advice from the GRP. The NICE guideline is also signed off by NICE’s Guidance Executive, but only when the full guideline has been finally signed off by NICE."
• "The NICE guideline presents the recommendations from the full guideline in a format that focuses on implementation by healthcare professionals and NHS organisations."
• "The full guideline and the NICE guideline should be written in a style that can be understood by the non-specialist healthcare practitioner and by anyone who has a good knowledge of the area but is not a trained clinician (for example, a patient with the condition who has in-depth knowledge of the disease and treatment options). Plain English should be used, and unnecessary jargon avoided as much as possible."

So NICE produce four "versions" of the same guideline (e.g. CG22 Anxiety). The "full version" is the one they call the "full guideline", not the one they call the "NICE guideline". I really don't see how "the full version of the guidance" could be confused with anything else. One version gets the 'NICE Guideline' branding and is published in a nice font. The "full guideline" is the serious publication for use by researchers and encyclopaedia editors, and is what NICE say we should cite and quote from. Provided the page number is given, the "full guideline" is no more onerous that the "NICE guideline" version. And the former contains much more that may be of interest to the reader. Both documents are designed to be readable by our readers. Colin°^Talk 18:07, 29 June 2009 (UTC)

Please take a closer look at the 165-page NCC "full guideline". It is not an easy read even for somebody with my experience reading long government documents. The recommendations are not highlighted and dispersed with many pages of lit review. It is going to be completely unreadable to an average educated person. And the references given in the BD article are without pages. The Sceptical Chymist (talk) 10:26, 30 June 2009 (UTC)

In my opinion, if one must choose one citation over another, the authoritative citation should always be used in preference to a less authoritative citation which might be more accessible to the general reader. The primary purpose of a Wikipedia citation is for verification and a secondary purpose is to provide a link for more details/deeper understanding. But why not cite both documents? This dispute could easily have been solved if there were laysummary and laysource parameters in the {{cite web}} template like there are in the {{cite journal}} template. Even without this option, both web citations could easily be included in the same footnote. Am I missing something? Boghog2 (talk) 17:32, 30 June 2009 (UTC)

Yes, this would be an excellent opportunity to use the |laysummary= parameter. WhatamIdoing (talk) 18:01, 30 June 2009 (UTC)

Benzodiazepines and worsening of sleep quality

I have questions about this sentence: "Drawbacks of benzodiazepines including worsening of sleep quality such as increased light sleep, decreased deep sleep as well as tolerance, dependence and rebound effects[38][39]"

1. The abstract of reference [38] PMID 18824834 only states: "The longer-acting benzodiazepines are associated with next-day "hangover" effects and, as a result, have been largely replaced by agents in the nonbenzodiazepine class, which typically have shorter half-lives.". Perhaps, there is something in the full text that supports the worsening of sleep quality. Would it be possible to quote it?

2. Reference [39] PMID 7525193 (Ashton, 1994) has three problems.

a) It does not support the purported "worsening of sleep quality". To the contrary, it states "Benzodiazepines in general hasten sleep onset, decrease nocturnal awakenings, increase total sleeping time and often impart a sense of deep, refreshing sleep."

b) It is 15 years old, and was written before the introduction of many non-benzodiazepines. It states, for example, that "Benzodiazepines and related drugs are probably the best (as well as the most widely used) hypnotics at present available."

c) Ashton does not, generally, represent the mainstream medical views. In various publications, she advocated the views that BDz have "all the characteristics of drugs of dependence", result "in the insidious development of increasing psychological and physical symptoms" and cause "neurological damage" when taken long-term in therapeutic doses.

If possible, we should find a better reference. The Sceptical Chymist (talk) 01:45, 27 June 2009 (UTC)

You are quoting sources out of context by only quoting one or two sentences. Benzos do promote a "sense" of a deep sleep, i.e. patients think they are getting a good sleep when they are actually getting a light sleep. There is really no dispute in the literature that benzodiazepines cause a worse sleep profile and even the drug companies highlight this themselves to promote the likes of zaleplon and zolpidem. The 1994 ref says this, "Benzodiazepines in general hasten sleep onset, decrease nocturnal awakenings, increase total sleeping time and often impart a sense of deep, refreshing sleep. However, they alter the normal sleep pattern: Stage 2 (light sleep) is prolonged and mainly accounts for the increased sleeping time, while the duration of slow wave sleep (SWS) and rapid eye movement sleep (REMS) may be considerably reduced."

Point B is irrelevant because that sentence is not cited in the article, however, it was correct at the time. Other hypnotic agents eg antihistamines, antipsychotics, alcohol, opiates have too many side effects or are even worse in promoting sleep than benzos. There is eveidence that zolpidem and zaleplon are more effective than benzos in promoting a more natural sleep.

C. Ashton does not say they cause neurological damage, she says it is possible and one of your psychiatric text books quoted a review saying pretty much the same that data is conflicting on whether benzos cause brain damage so her views are in keeping with the evidence base. The world health organisation. Again one of your psychiatric text books which you want to quote, I looked it up and it reviewed the evidence that benzos cause increasing psychological and physical symptoms and concluded that they did and recommended that most long-term users of benzos be withdrawn from long-term use. Benzos would have to have the characteristics of drugs of dependence otherwise the world health organisation would not have listed them as Schedule IV controlled drugs.

I wouldn't mind using the psychiatric text books that you suggested to cite about brain damage, increasing mental and physical health problems if you want newer and better refs.--Literaturegeek | T@1k? 14:44, 27 June 2009 (UTC)

2A. In the psychiatric context "quality" as in "quality of life" and, similarly, "quality of sleep" means subjectively rated quality. That is what patient feels about the effects of the drug. For example, sometimes antidepressants may "objectively" improve depression but not improve "quality of life". Similarly, however "unnatural" the objective structure of BD-induced sleep is, BDs do improve "quality of sleep" even according to Ashton The sentence you inserted contradicts the source. Psychiatrists here, please correct me if I am wrong. The Sceptical Chymist (talk) 15:07, 27 June 2009 (UTC)

2B and C. Your arguments do not obviate the need of a better and newer source. And Ashton is not mainstream. Quoting Ashton about side effects of BDs is like quoting David Healy on the antidepressant suicidality. Both Ashton and Healy have been correct in many things but they also sometimes exaggerated their case. They are not mainstream. The Sceptical Chymist (talk) 15:07, 27 June 2009 (UTC)

I did say we could use your psychiatric text books which say that long-term use being effective is a minority view and use them for the discussion about brain damage and long-term effects. David Healy is into the media campaigning side of things. Ashton is an academic who has published more on benzos than most others and is one of the most quoted peer reviewed researchers. She is not controversial so it is an unfair comparison.--Literaturegeek | T@1k? 15:16, 27 June 2009 (UTC)

Ok, I have been answering loads and loads of your questions now where you attack any source that you don't like. I would like to know your motives for investing an immense amount of time and effort resorting to quoting sources out of context to make them say the opposite which today you have been continuing to do. Why are you doing it? Why are you determined to make according to one of your own sources which you misused on the talk page says is a minority view and you want to make it a majority view and downplay or eliminate the majority view of peer reviewed researchers?--Literaturegeek | T@1k? 15:19, 27 June 2009 (UTC)

Because you are trying to present what is, arguably, a minority view as the only truth. The Sceptical Chymist (talk) 16:15, 27 June 2009 (UTC)

But your source says it is a minority view and the majority view is in keeping with evidence based clinical guidelines. I know it is "arguable" in the sense that you can fill the talk page up with misrepresented facts and all sorts of original research claims and weak sources. That is why we are in a dispute. Anything can be argued, what we need to stick with is what the best quality sources say giving the due weight and minority views lower weight.--Literaturegeek | T@1k? 16:22, 27 June 2009 (UTC)

• IMO, the 1994 paper is too old and should be dropped per WP:MEDRS. WhatamIdoing (talk) 00:22, 29 June 2009 (UTC)

Miscellaneous style comment(s)

• This sentence is confusing: "However, even in those without impaired liver functioning, the shorter acting drugs may be less effective in reducing the symptoms of alcohol withdrawal and may lead to break through seizures, and thus are not recommended for outpatient detoxification.[47][48]" There are four negatives, which makes it hard to follow: without (1) impaired (2) less (3) in reducing (4). The Sceptical Chymist (talk) 02:32, 27 June 2009 (UTC)
  • Pure copy editing, without even looking at the sources: "Regardless of liver function, short-acting benzodiazepines may be inferior to longer-acting ones in reducing the symptoms of alcohol withdrawal. Short-acting BZDs may also lead to breakthrough seizures, and are therefore not recommended for detoxification in an outpatient setting." Fvasconcellos (t·c) 02:19, 29 June 2009 (UTC)

Yeah that looks better, incorporated into article. Meodipt (talk) 02:39, 29 June 2009 (UTC)

I'd also replace reference 47 with PMID 15249349, which is (a) more recent, (b) an official, evidence-based clinical guideline, and (c) not limited to elderly populations. Reference 47 really isn't what I'd call a good source for this section (or this statement). Fvasconcellos (t·c) 02:49, 29 June 2009 (UTC)

PMID 16034964 seems relevant as well. Meodipt (talk) 03:02, 29 June 2009 (UTC)

Indeed. Fvasconcellos (t·c) 03:08, 29 June 2009 (UTC)

Thank you, guys, for addressing this. The Sceptical Chymist (talk) 12:11, 29 June 2009 (UTC)

Re-write of Anxiety, panic and agitation

I extensively re-wrote the Benzodiazepine#Anxiety, panic and agitation chapter. This re-write (below) separates anxiety disorders from other indications, removes multiple redundancies and acknowledges the existence of a controversy about their long-term efficacy. Is there anyone who opposes to this version? The Sceptical Chymist (talk) 03:09, 27 June 2009 (UTC)

Anxiety, panic and agitation

Because of their effectiveness, tolerability and rapid onset of anxiolytic action, benzodiazepines are frequently used for the short-term treatment of anxiety. Their use beyond two to four weeks is not licensed and is not recommended in evidence based clinical guidelines, as tolerance and physical dependence may develop rapidly. The guidelines recommend antidepressants, the anticonvulsant drug pregabalin and cognitive behavioural therapy as the first line treatment options. In addition, benzodiazepine use has been found to interfere with therapeutic gains from psychotherapy.<ref name=cgftmamoa2004 /better reference needed> Deleted per comment [11]. These clinical guidelines are often ignored in general practice because GAD and PD are chronic conditions, and it is "highly unlikely that less than 4 weeks treatment would be of value". In practice, if the patient and the physician find the treatment useful, the benzodiazepine may get continuously or intermittently prescribed over the long-term, even when the risks of dependence are known and explained. added per comment[12]

There has been a controversy as to whether the benzodiazepines maintain their anti-anxiety action long-term, and the issue still remains undecided. A majority of the follow-up studies do not suggest a significant loss of therapeutic effect over time. Furthermore, they do not provide evidence that the increase of dose is necessary to maintain the anxiolytic action. A recent review on clonazepam notes that some longitudinal data "suggest an ability to maintain improvement without tolerance for up to three years"; however, long-term controlled studies in panic disorder are lacking. Another review of longitudinal studies notes that the improvement is maintained in 30–60% of patients with panic disorder on the same or lowered dose and suggests that there is not "significant development of therapeutic tolerance" to benzodiazepines.

Benzodiazepines are usually administered orally; however, very occasionally lorazepam or diazepam may be given intravenously for the treatment of panic attacks. They are also used to treat the acute panic caused by hallucinogen intoxication. Benzodiazepines are also used to calm the acutely agitated individual and can, if required, be given via an intramuscular injection. They can sometimes be effective in the short-term treatment of psychiatric emergencies such as acute psychosis as in schizophrenia or mania, bringing about rapid tranquillization and sedation until the effects of lithium or neuroleptics (antipsychotics) take effect. Lorazepam is most commonly used but clonazepam is sometimes prescribed for acute psychosis or mania.

The Sceptical Chymist (talk) 03:09, 27 June 2009 (UTC)

I oppose it because you misrepresented the author by quoting him out of context to make him say the opposite of what he said. See this section above for my problems with this.Talk:Benzodiazepine#Side_effects_of_the_long-term_use_of_benzodiazepines--Literaturegeek | T@1k? 14:47, 27 June 2009 (UTC)

LG also alleges the same above [13]. As a proof that I misinterpreted the reference isbn0-521-84228-X he quotes the following short excerpt from p 532: "it being argued that some patients who respond well to benzodiazepines have chronic disorders for whom continued treatment is desirable and justifiable, but this remains a minority view.". In reality, it is LG who misinterprets the authors conclusions. The full paragraph from which he quotes is concerned with a relative efficacy of BDz and antidepressants. And the snippet he gave is about poor efficacy of benzodiazepines in comorbid anxiety and depression. Below is the full paragraph with the LG's selective quotation italicized. The important part he omitted is in bold. Let the reader judge for himself. The Sceptical Chymist (talk) 16:02, 27 June 2009 (UTC)

Psychological symptoms of anxiety may respond better to antidepressant drugs than to benzodiazepines, but there have been few comparator-controlled studies, and most reveal no significant differences in efficacy between active compounds (Mitte et al., 2005). Benzodiazepines have only limited efficacy against depressive symptoms, and given the comorbidity of GAD with depression and potential hazards associated with prolonged use of benzodiazepines, antidepressant treatment is preferable to prescription of benzodiazepine anxiolytics in ‘cothymia’ and other mixed conditions (Ballenger et al., 2001; Baldwin et al., 2005; Mitte et al., 2005). There has been some reaction against the general advice that benzodiazepines should only be prescribed for up to 4 weeks in regular dosage and then tapered off as this can be less efficacious than taking a placebo (Tyrer et al., 1988); it being argued that some patients who respond well to benzodiazepines have chronic disorders for whom continued treatment is desirable and justifiable (Taylor, 1989; Romach et al., 1995), but this remains a minority view.

The Sceptical Chymist (talk) 16:02, 27 June 2009 (UTC)

Nice try but the section of that book is about generalised anxiety disorder. It can be read online. Proof that he was not talking about people with depression when he made that statement is to look up his cited sources that he used as examples and you will see that they were talking about the 4 week guidelines in general or for anxiety, NOT in regard to anxiety and depression.--Literaturegeek | T@1k? 16:13, 27 June 2009 (UTC)

I don't expect you to type out the whole section but you know that section is about generalised anxiety disorder so quoting the one paragraph is misleading but like I say won't hold that against you as typing the whole section could be quite time consuming. He just mentioned within a paragraph about anxiety and depression. Also he says general advice, so obviously he is talking about benzos for all indications including anxiety, "There has been some reaction against the general advice that benzodiazepines should only be prescribed for up to 4 weeks in regular dosage and then tapered off as this can be less efficacious than taking a placebo (Tyrer et al., 1988)" How else can general advice be taken? Why would he cite a source about anxiety and a source about benzos for all indications if he was only talking about those with "depression"? It is obvious what he means.--Literaturegeek | T@1k? 16:19, 27 June 2009 (UTC)

Here we go again denying evident facts and obscuring them by TLDR. LG, please let readers judge. Please be merciful to the reader and use colons to indent your replies. The Sceptical Chymist (talk) 16:24, 27 June 2009 (UTC)

You failed to reply to my points and cited a wiki policy instead but ok. I want readers to judge. They can read page 532 online of that book.--Literaturegeek | T@1k? 16:35, 27 June 2009 (UTC)

• Question to LG. What would you add to make this more balanced in your view. We do need to address the issue of off-label prescribing, which is rampant. Even Ashton decries it. Please no TLDR. The Sceptical Chymist (talk) 16:45, 27 June 2009 (UTC)

Arbitrary break

Look guys this arguing over what constitutes the truth is really not helpful. Both of your versions are too POV, LG's has an anti-benzo slant and SC's is correspondingly pro-benzo, neither of which is suitable for the "finished" article. Clearly there is not a consensus among experts in the field regarding a number of these issues, so both of you stop trying to prove that there is and attacking each other over minor details! I don't see why you can't just acknowledge the disputes in the sources and explain both viewpoints instead of each trying to delete the others work so it only shows the view of the experts you agree with.

For each of these issues why don't you each just write your own version one after the other, i.e.

anti Clinical guidelines say CBT and antidepressants should be first-line treatment for anxiety because when effective, the benefits of these treatments tend to be more sustained over time, whereas benzos often produce rebound anxiety and recurrence of symptoms following cessation of use. Where benzos are appropriate, clinical guidelines recommend only prescribing for 2-4 weeks max because of development of tolerance and declining efficacy along with risk of dependence and side effects.

pro However benzodiazepines tend to produce faster relief of symptoms, and so may be more appropriate in some instances, especially in treating actute anxiety conditions such as panic attacks. Also since anxiety disorders are often chronic, long-term conditions for which it is "highly unlikely that less than 4 weeks treatment would be of value" the prescribing guidelines are often ignored in practice; if the patient and the physician find the treatment useful, the benzodiazepine may get continuously or intermittently prescribed over the long-term, even when the risks of dependence are known and explained.

Both those statements are supported by the references you have provided, and show both sides of the argument. Now you guys do the same for all the other paragraphs under dispute... Meodipt (talk) 22:24, 27 June 2009 (UTC)

Why is the majority viewpoint too POV? See WP:UNDUE. I can include those viewpoints without a problem but it mustn't be given undue weight or written in a way to ridicule the mainstream consensus and it must say that it is a minority viewpoint. Trust me if the peer reviewed literature was in favour of benzos long-term they would be approved overnight, Roche would make sure of that! One thing I fully support is that people on long-term benzos should not be forced to withdraw against their wishes.

Can you imagine what would happen if I went and started editing into the main HIV article loads of conspiracy theories about how it isn't HIV that causes HIV and ridiculed and/or cast doubt on the mainstream science? Fair enough a small mention of a minority viewpoint is fine. You cannot violate WP:UNDUE to achieve WP:NPOV. :) I wish Sceptical Chymist would accept this.--Literaturegeek | T@1k? 02:01, 28 June 2009 (UTC)

Meodipt the above post is not meant to criticise you, I really appreciate your knowledge and time and effort in this dispute resolution and respect that and hope you stick around. I think that you are genuinely trying to resolve this dispute and be fair but I feel that you are saying we should minimise majority viewpoints and promote minority viewpoints with equal presidence and cast doubt on the peer reviewed literature. We need to follow the evidence base and mainstream viewpoints. :-)--Literaturegeek | T@1k? 02:03, 28 June 2009 (UTC)

A necessary explanation. I am not "pro-benzo". It is LG's radical position on the risk-benefit balance of benzodiazepines, exaggeration of their side effects and lax approach to the references that forced me to be the devil's advocate. In fact, I agree with every word Meodipt written. My position, I believe, is the position of the majority. That is, BDz should be relegated to the second line treatment when the first line (SSRIs) does not work. However, they could be used, if necessary, long-term. For example, if their withdrawal causes an unnecessary trouble to the patient, and there is nothing to replace them with (remember, first line did not work). The Sceptical Chymist (talk) 12:36, 28 June 2009 (UTC)

I'm not disputing that the majority view should be given more prominence, but per WP:UNDUE viewpoints held by a "significant minority" need to at least be mentioned. The prescribing guidelines certainly represent the majority consensus view of the medical establishment as per the latest research etc, but the fact is there are still thousands of doctors who do continue to prescribe benzos on a long-term basis. Perhaps those doctors are from the older generation and qualified in the 70s and 80s when benzos were more fashionable than they are now, and perhaps they don't keep up with the current research as much as they should, but still the article needs to explain why some doctors continue to hold these "pro-benzo" views and base their prescribing practices accordingly. Meodipt (talk) 02:20, 28 June 2009 (UTC)

Meodipt, I applaud you! Thank you for stepping in when the supposed many experienced editors who supposedly closely watch this dispute do nothing. "For each of these issues why don't you each just write your own version one after the other" -- actually I suggested something like that awhile ago[14] and was ignored by LG. In fact I would go further and suggest simply taking what you wrote and adorning it with references. The Sceptical Chymist (talk) 12:27, 28 June 2009 (UTC)

You two managed to stay on task for more than one entire day, so there was no need for any intervention. Now there's more commenting on the contributor than on the content again. Take a break if you need to, but whatever you post on this page should be solely about improving the article, not complaining about the other editor. WhatamIdoing (talk) 00:33, 29 June 2009 (UTC)

You are wrong, W. I was explaining my view about the BDz, which is very relevant to the article. This is the most appropriate forum to do that. I was contrasting mine with LG's views, which is also appropriate.The Sceptical Chymist (talk) 12:10, 29 June 2009 (UTC)

80% of benzo users are elderly according to two sources I have seen so this would show most people who are on benzos long-term are on them before the prescribing guidelines came into effect. I would submit that those elderly people many of them were on benzos from the 1970's. I have a source but it is primary source which interviewed GPs and they said that it was usually them that suggested benzos in the first place for short-term use but for long-term use it is not the doctor's will but pressure from the patient to get repeat prescriptions. So long-term use is mostly patient driven rather than doctor driven.--Literaturegeek | T@1k? 13:03, 28 June 2009 (UTC)

Actually I did reply to Sceptical's diff up there as I always did. He is just playing dirty trying to smear me. More combative editing. Since you agree with Meodipt regarding minority views not being given undue weight are you happy to acknowledge your own source that says long-term use being effective is a minority viewpoint?--Literaturegeek | T@1k? 13:05, 28 June 2009 (UTC)

LG, you're complaining about SC again, which is unproductive. Please stop.

Please also remember that the current NICE guideline does not tell us anything at all about the rest of the world. "Mainstream consensus" is not represented by a single country's current rules. It seems to me that NICE is leading the curve here -- probably a good thing, in terms of public health, but not exactly synonymous with actual mainstream medical practice (because they wouldn't be marshaling evidence to justify a change to mainstream medical practice if their view already matched mainstream practice). WhatamIdoing (talk) 00:33, 29 June 2009 (UTC)

SC attacked me by saying that I ignored him when I replied to him and responded to his points. My "attack" was in defense of his attack. I was only defending myself. I feel he should have been criticised for attacking me unprovoked but water under the bridge now.--Literaturegeek | T@1k? 03:19, 29 June 2009 (UTC)

Criticizing people does not improve the article. That's why Wikipedia has rules like "comment on the content, not the contributor". WhatamIdoing (talk) 19:48, 29 June 2009 (UTC)

May I also step in and remind everyone that if the current state of the art is controversy or a lack of consensus among experts in the literature, then that is what the article should report? Fvasconcellos (t·c) 02:52, 29 June 2009 (UTC)

I am happy to mention the controversy but sources I have seen say that it is a minority view amongst experts. I am still waiting for a reference that says that the majority view is tolerance doesn't occur. I have provided about 7 or 8 recent secondary sources so far, could provide probably another 20 or 30 recent secondary souurces. Sceptical's psychiatry text book source even says it is a minority view that tolerance does not occur to anxiolytic effect. I have another source by same psychiatrist in a different psychiatrist text book which says that some doctors believe in long-term use but it is very hard to find any data to support their beliefs. Sceptical wants to quote from one of these sources but quote the author out of context to make him say almost the opposite. This kind of misuse of sources willl destroy the FA. I see boghog and Eubulides still working away at the article so obviously want the article to go to FA but if we misuse refs it will only fail. Minority views can't be made to look like majority views.--Literaturegeek | T@1k? 03:11, 29 June 2009 (UTC)

My edits reflect high quality sources and evidence based clinical trials and systematic reviews. He has not provided any high quality sources to show the clinical guidelines and systematic reviews are "radical".--Literaturegeek | T@1k? 03:20, 29 June 2009 (UTC)

No-one is denying that tolerance occurs, but it is important to note that some doctors continue to prescribe benzos long-term as even though they get less effective with time, the patient may still find them effective enough to be worth continuing. Also it is important to note that long-term use does not neccesarily mean daily use, as the Holton & Tyrer ref above states, "intermittent irregular but long-term use becomes the norm". Patients are usually well aware that benzos quickly lose their effectiveness when taken every day, and so long as they are not actually dependent they will often restrict their use accordingly. Meodipt (talk) 03:27, 29 June 2009 (UTC)

A little amendment to Meodipt's comment. No-one denies that dependence and withdrawal syndrome often occurs. The consensus is that tolerance occurs to anti-seizure, sedative, muscle-relaxing and hypnotic effects. The consensus on the tolerance to the anxiolytic effects is that it is unclear. The main reason for that is the practical difficulty of conducting longitudinal controlled studies. I addressed the issue in a paragraph in the first version of this chapter, but I did not include it into the second take hoping that it would be easier to agree if I simply copy-paste Meodipt's version. Would Meodipt be willing to re-write the following paragraph including Ashton/LG's view and paste it into take 2? Sorry to exploit you :), but you seem to be the only person offering a well articulated compromise.

There has been a controversy as to whether the benzodiazepines maintain their anti-anxiety action long-term, and the issue still remains undecided. A majority of the follow-up studies do not suggest a significant loss of therapeutic effect over time. Furthermore, they do not provide evidence that the increase of dose is necessary to maintain the anxiolytic action. A recent review on clonazepam notes that some longitudinal data "suggest an ability to maintain improvement without tolerance for up to three years"; however, long-term controlled studies in panic disorder are lacking. Another review of longitudinal studies notes that the improvement is maintained in 30–60% of patients with panic disorder on the same or lowered dose and suggests that there is not "significant development of therapeutic tolerance" to benzodiazepines.

The Sceptical Chymist (talk) 12:52, 29 June 2009 (UTC)

Your own psychiatric text books say that this is a minority view. I can provide many other recent secondary sources which say the same thing. Do you have any sources that say that the viewpoint that tolerance occurs is a minority or fringe viewpoint? Any sources to say that clinical guidelines are minority or extremist? Are you willing to correctly quote your sources? The controversy is mentioned in the article already,Benzodiazepine#Tolerance.2C_dependence_and_withdrawal but what you want to do is rubbish the NICE and other citations with weak sources and misrepresented/misused sources. I cannot support this. Please demonstrate without using original research how NICE and other systematic reviews are minority or fringe viewpoints and why we should minmise them?--Literaturegeek | T@1k? 14:20, 30 June 2009 (UTC)

Anxiety, panic and agitation (take 2)

I suggest pasting this version of the section written by Meodipt into the article and then adding references, editing for style, expanding, working out bugs etc.

Clinical guidelines say CBT and antidepressants should be first-line treatment for anxiety because when effective, the benefits of these treatments tend to be more sustained over time, whereas benzos often produce rebound anxiety and recurrence of symptoms following cessation of use. Where benzos are appropriate, clinical guidelines recommend only prescribing for 2-4 weeks max because of development of tolerance and declining efficacy along with risk of dependence and side effects.

However benzodiazepines tend to produce faster relief of symptoms, and so may be more appropriate in some instances, especially in treating acute anxiety conditions such as panic attacks. Also since anxiety disorders are often chronic, long-term conditions for which it is "highly unlikely that less than 4 weeks treatment would be of value" the prescribing guidelines are often ignored in practice; if the patient and the physician find the treatment useful, the benzodiazepine may get continuously or intermittently prescribed over the long-term, even when the risks of dependence are known and explained.

Benzodiazepines are usually administered orally; however, very occasionally lorazepam or diazepam may be given intravenously for the treatment of panic attacks. They are also used to treat the acute panic caused by hallucinogen intoxication. Benzodiazepines are also used to calm the acutely agitated individual and can, if required, be given via an intramuscular injection. They can sometimes be effective in the short-term treatment of psychiatric emergencies such as acute psychosis as in schizophrenia or mania, bringing about rapid tranquillization and sedation until the effects of lithium or neuroleptics (antipsychotics) take effect. Lorazepam is most commonly used but clonazepam is sometimes prescribed for acute psychosis or mania.

The Sceptical Chymist (talk) 12:46, 28 June 2009 (UTC)

Your source also says this is a minority view. This must be included before I could accept it. It must be put into context. Also I do not generally like "quoting" a sentence and copying and pasting it. It should be reworded in your own words. You know I honestly think that I could write something up which you would see as neutral but it will have to wait until tomorrow.--Literaturegeek | T@1k? 12:59, 28 June 2009 (UTC)

Do I correctly understand that the intention is for this to replace Benzodiazepine#Anxiety.2C_panic_and_agitation, a subsection of #Therapeutic uses? WhatamIdoing (talk) 00:36, 29 June 2009 (UTC)

That does seem to be the intention. I think we should be able to come up with a version everyone can agree on. LG, your turn to write a neutral version, then we can combine the three drafts as appropriate and copy it into the article. Meodipt (talk) 00:49, 29 June 2009 (UTC)

Some useful PMID reference

I am just a research who likes dig deeper in to issues just for the fun of it. You may find the following PMID links useful.

Knock-out drugs: their prevalence, modes of action, and means of detection.

• PMID 19547737

The association between dementia and long-term use of benzodiazepine in the elderly: nested case-control study using claims data.

• PMID 19546656

LC-MS-(TOF) analysis method for benzodiazepines in urine samples from alleged drug-facilitated sexual assault victims.

• PMID 17132247

Prevalence of drugs used in cases of alleged sexual assault.

• PMID 10369321

Pictures in clinical medicines. Recovery of cerebral blood perfusion from transient hypo-perfusion due to acute benzodiazepine poisoning coinciding with generalized convulsion as withdrawal syndrome.

• PMID 19443987

Abuse of alcohol and benzodiazepine during substitution therapy in heroin addicts: A review of the literature.

• PMID 19540407

Comparison of five benzodiazepine-receptor agonists on buprenorphine-induced mu-opioid receptor regulation.

• PMID 19443999

Use of psychotropic substances by the elderly and driving accidents.

• PMID 19562427

Illicit drugs, medications and traffic accidents

• PMID 18847565

Benzodiazepine withdrawal in subjects on opiate substitution treatmen

• PMID 16614601

Pattern of benzodiazepine use in psychiatric outpatients in Pakistan: a cross-sectional survey

• PMID 19400933

Fatal drug poisonings in a Swedish general population

• PMID 19397805

Memory function in opioid-dependent patients treated with methadone or buprenorphine along with benzodiazepine: longitudinal change in comparison to healthy individuals

• PMID 19374740

dolfrog (talk) 01:10, 1 July 2009 (UTC)

Therapeutic Use

Shouldn't Veterinary use be moved to the Therapeutic section of the article, instead of being tacked on to the very bottom? —Preceding unsigned comment added by Edwinhenryjr (talk • contribs) 19:24, 27 January 2010 (UTC)