Benzodiazepines are some of the most commonly prescribed medications in the world. These sedative-hypnotics can provide rapid relief for symptoms like anxiety and insomnia, but are also linked to a variety of adverse effects (whether used long-term, short-term, or as needed). Many patients take benzodiazepines long-term without ever receiving evidence-based first-line treatments (e.g., psychotherapy, relaxation techniques, sleep hygiene education, serotonergic agents). This review discusses the risks and benefits of, and alternatives to benzodiazepines. We discuss evidence-based indications and contraindications, and the theoretical biopsychosocial bases for effectiveness, ineffectiveness and harm. Potential adverse effects and drug-drug interactions are summarized. Finally, both fast-acting/acute and delayed-action/chronic alternative treatments for anxiety and/or insomnia are discussed. Response to treatment—whether benzodiazepines, other pharmacological agents, or psychotherapy—should be determined based on functional recovery and not merely sedation.
This review discusses risks, benefits, and alternatives in patients already taking benzodiazepines when care transfers to a new clinician. Prescribers have the decision—sometimes mutually agreed-upon and sometimes unilateral—to continue, discontinue, or change treatment. This decision should be made based on evidence-based indications (conditions and timeframes), comorbidities, potential drug-drug interactions, and evidence of adverse effects, misuse, abuse, dependence, or diversion. We discuss management tools involved in continuation (e.g., monitoring symptoms, laboratory testing, prescribing contracts, state prescription databases, stages of change) and discontinuation (e.g., tapering, psychotherapeutic interventions, education, handouts, reassurance, medications to assist with discontinuation, and alternative treatments).
Background Molecular imaging of dopaminergic parameters has contributed to the dopamine hypothesis of schizophrenia, expanding our understanding of pathophysiology, clinical phenomenology and treatment. Our aim in this study was to compare 18F-fallypride binding potential BPND in a group of patients with schizophrenia-spectrum illness vs. controls, with a particular focus on the cortex and thalamus. Methods We acquired 18F-fallypride positron emission tomography images on 33 patients with schizophrenia spectrum disorder (28 with schizophrenia; 5 with schizoaffective disorder) and 18 normal controls. Twenty-four patients were absolutely neuroleptic naïve and nine were previously medicated, although only four had a lifetime neuroleptic exposure of greater than two weeks. Parametric images of 18F-fallypride BPND were calculated to compare binding across subjects. Results Decreased BPND was observed in the medial dorsal nucleus of the thalamus, prefrontal cortex, lateral temporal lobe and primary auditory cortex. These findings were most marked in subjects who had never previously received medication. Conclusions The regions with decreased BPND tend to match brain regions previously reported to show alterations in metabolic activity and blood flow and areas associated with the symptoms of schizophrenia.
individuals at clinical high risk (CHR) for developing schizophrenia is not well characterized. Methods: We studied youth (ages 11-30) meeting CHR for psychosis criteria (n = 30), individuals early in their schizophrenia illness (ESZ; n = 22), and healthy adolescents and young adults (HC; n = 72). Functional magnetic resonance imaging was collected during Go/NoGo response inhibition task performance. Voxelwise main effects of Group (p<.001 height threshold, family-wise error corrected P < .05) for incorrect NoGo versus correct Go activations were examined, and correlated with the signal detection measure d'. Results: Error rates and error-related activations in anterior cingulate and dorsolateral prefrontal cortex were equivalent across the three groups. A significant main effect of Group for the contrast of NoGo errors relative to correct Go responses was detected in the left cerebellum. This main effect of Group was explained by the ESZ group showing significantly less errorrelated activation, relative to the HC group (with the CHR group differing from neither). In HC individuals, higher error-related contrast values in this cerebellar region significantly related to better d', a relationship that was not present in either of the clinical groups (group slopes difference, P < .05). Conclusion: ESZ patients showed significantly less cerebellar activation during error processing, relative to HC participants. In HCs, cerebellar activation in this region was significantly related to better signal detection. A role for the cerebellum in performance monitoring is increasingly recognized, and these data suggest that the normal relationship between cerebellar error-related responses and task performance breaks down in both CHR and ESZ groups. Background: Schizophrenia has been associated with thalamic hyperconnectivity with sensory regions, including the middle and superior temporal gyrus, and hypoconnectivity with cerebellar and prefrontal regions. While thalamic dysconnectivity has been consistently replicated in chronic schizophrenia samples, less is known about when these abnormalities emerge in the illness course and if they are present prior to illness onset. Methods: Resting-state fMRI data were collected from clinical high-risk youth (n = 45; CHR), early illness schizophrenia (n = 74; ESZ) patients, and healthy controls (n = 85; HC). Age-adjusted whole-brain functional connectivity, seeded from the thalamus, was compared among the three groups. Main effects of group (FDR-corrected, p = .01) were followed up with Tukey-corrected pairwise comparisons. Results: Significant main effects of group were observed in 8 regions: 2 left middle temporal regions, 2 right middle temporal regions, a left superior temporal region, a right superior temporal region, a left cerebellar region, and a bilateral thalamic region. Pairwise follow-up tests (P < .05) conducted on extracted mean connectivity values revealed that, consistent with data comparing chronic schizophrenia patients to HCs, ESZ patients demonstrated greater thalam...
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