Thomas A. M. Kramer, MD



The following is dialogue with a colleague who is a child psychiatrist and who has recently expanded her practice to treat more adults.

Dr K: When do you actually use benzodiazepines to treat anxiety? I mean, how many other drugs will the patient actually have to fail before you would prescribe them?

Dr. F: Well, sometimes none. A lot of the time, I would use them right away. First-line.

Dr K: Really?

Dr. F: Sure. It wasn't that long ago that benzos were used routinely as first-line treatment for generalized anxiety. It's only fairly recently that they've been supplanted by SSRIs and SNRIs.

Dr K: And aren't those drugs better? Don't benzos tend to make patients sleepy, stupid, and addicted? I mean, not using benzos as first-line treatment is a step forward, right?

Dr F: Certainly, SSRIs and SNRIs are important treatment options. But benzos have their virtues, too. They work right away; antidepressants in general take a few weeks to work. When dosed appropriately, they don't make people sleepy or stupid. As far as addiction goes, that's pretty controversial, but my feeling is that the risk of addiction for benzos is grossly overstated. Certainly, in a vulnerable population, like people with substance abuse history or strong family histories of substance abuse, tolerance and dependence can be a problem. But that is a very small percentage of patients who present for treatment for anxiety. I've seen a lot of patients who have taken 10 mg a day of Valium for years with good result. They don't escalate the dose, and if they try to come off it or miss a few doses, all that happens is that they get anxious again. Benzos don't really have very many side effects besides the ones you mentioned, and since antidepressants have side effects of their own, there are some patients who can tolerate benzos who cannot tolerate antidepressants.

Dr K: So why don't we use them any more?

Dr F: I do. But the sense I get, in what little adult work I do, is that they have really fallen out of favor.

Dr K: You're right, but I don't think that's for good reason. I think that's basically a function of marketing.

Dr F: You mean, drug companies are trying to get us to write for their SSRIs and SNRIs for anxiety as opposed to benzos?

Dr K: Exactly. The other side of that coin is that nobody is marketing benzos at the moment. That may change soon with the launch and subsequent marketing of rapidly dissolving Klonopin and Xanax XR, but for the time being, all of the marketing efforts of the pharmas for anxiety treatments are focused on antidepressants.

Dr F: So you are saying that we all are really controlled by the pharmaceutical industry? That their marketing efforts really do control our behavior?

Dr K: Well, no. I do think that at least some of us are capable of independent thought. The problem, I think, has more to do with sources of information. So much research and educational programming is funded by pharmas that they have an enormous amount of influence over what is defined as the state of the art. While they may not have direct control over the results of published research, or the content of educational programs at meetings, or the information that is sent to us in the mail, they have enough influence to determine a lot of what it is you are going to see when you go to "read the literature." You end up thinking that the treatments for which they choose to fund research and programs are indeed the state of the art. After all, you read all of these advantages of these new treatments. No one's putting material in front of you telling you about the advantages of the older treatments.

Dr F: And no one is funding head-to-head studies between the new and the old treatments, either.

Dr K: Exactly. Why should they? The only people who fund clinical trials these days are pharmas -- although that has changed a little bit with some new NIMH studies that are actually comparing different treatments without any pharma funding -- and pharmas are certainly not going to fund such a study because it may not look so good for them. Look, I have nothing against marketing. I think that the pharma industry, like any other industry, is entitled to promote its products. I am also sympathetic to the fact that is not easy for them to do this. It is hard to get the attention of busy physicians. My concern is that some things are marketing that aren't labeled as such. I am tired of hearing the words "unrestricted educational grant." There ain't no such animal. Simply deciding what it is you're going to fund with such an unrestricted educational grant gives you a fair amount of discretion as to what clinicians will hear about and know. And as far as research is concerned, it seems to me that the results of studies sponsored by pharmas seem to almost always be good news for the company actually doing the sponsoring. I'm not saying that they manipulate the data, but I am saying that they have a fair amount of control over what data you see and what data never sees the light of day.

Dr F: I can see a little bit of this happening now with ADHD treatments. While stimulants can have bad side effects, particularly weight loss and insomnia, they do work for most kids, and as we start to get alternatives to stimulant medications for ADHD, some materials and programs I've seen are starting to imply that stimulants may become obsolete. Immediate-release stimulants are a very good example of what you're talking about. They're treated in current discussion as if they're obsolete, but they can have a great deal of clinical utility, particularly as augmenting medications.

Dr K: I think the best example of this phenomenon is lithium. Lithium is a fabulous drug. Unfortunately, nobody is marketing it presently, and there's a lot of aggressive marketing of other medications for bipolar disorder. As a result, I think a lot of clinicians are becoming convinced that lithium is an inferior drug. There have even been a few papers written by old-timer psychopharmacologists defending lithium as a treatment of choice, particularly for classic, nonrapid cycling bipolar I disorder. I have even seen things written saying that lithium has become less effective over time. That's crazy. Lithium may have been used less than successfully for bipolar subtypes for which it is less effective, such as rapid cycling or mixed dysphoric states, but for classic mania it really works, and these days clinicians really need to be reminded of that fact. This kind of marketing has almost relegated a useful medication to the status of historical artifact.

Dr F: Interesting.

Dr K: Yeah, and you know what else? I think we just wrote my next column.


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