Is the need for medications with calming effects ever going to disappear?

To the Editor

A recent article on utilization of psychotropic medications in Australia since 2000 reveals that the use of benzodiazepines (BDZ) has not increased while the use of second-generation antipsychotics has risen by 217.7% (Stephenson et al., 2013). Of the latter class, olanzapine and quetiapine have been the most commonly prescribed agents; both have prominent calming effects.

Data from other countries and clinical observation in Australia suggest that quetiapine is increasingly used to replace BDZ for anxiety disorders. This pattern of prescribing quetiapine is usually off-label, although quetiapine is licensed for generalized anxiety disorder in Australia. One US study of veterans with posttraumatic stress disorder reported a decreased use of BDZ between 1999 and 2009 and the largest increase for quetiapine in the number of prescriptions filled (Bernardy et al., 2012). In New Zealand, quetiapine seems to be prescribed frequently by general practitioners and off-label (Monasterio and McKean, 2013).

These trends are hardly surprising. Relief from anxiety, tension, and distress often occurs through the calming effects of BDZ and other medications. When calming effects are absent, as with most selective serotonin reuptake inhibitors, a number of people with anxiety disorders do not experience an appreciable relief from their anxiety or distress and some also have difficulty tolerating these agents. Although calming effects may not always be implicated in producing anxiolysis, they seem to temporarily help people feel less troubled by their anxiety. From a historical perspective, substances such as alcohol have been used for calming purposes throughout centuries. A need for substances with calming effects may accompany human predicament, as people rely on them when dealing with challenges of everyday life. If this need for calming substances is indeed persistent and universal, it is not likely to go away and then the question becomes how it can best be met.

BDZ represented not only a huge improvement over alcohol, but also over calming medications previously used for anxiety and insomnia (i.e. barbiturates and meprobamate). As BDZ are associated with dependence and potentially troublesome side effects, clinicians have been under pressure to avoid prescribing them. It is now realized that the push to abandon BDZ and replace them with selective serotonin reuptake inhibitors in the treatment of anxiety disorders was premature and not well founded (Berney et al., 2008; Starcevic, 2012; Tyrer, 2012). Many clinicians have already learnt this and either continue to prescribe BDZ for anxiety disorders or have switched to other medications with calming and sleep-promoting effects. These include quetiapine and, to a seemingly lesser extent, olanzapine and antidepressants such as mirtazapine, trazodone, and amitriptyline.

An increased use of quetiapine and other calming medications may thus be related to an apparently perennial need for calming substances, which is nowadays somewhat less often met with BDZ. However, both the effectiveness and safety of this change remain to be established. Comparative studies of BDZ and “calming alternatives” in people with anxiety and other disorders should be conducted to ascertain whether this shift in prescribing patterns is justified.