Neuroscwnce. 1978. Vol. 3. pp. 159-165.
PergamonPress.Printedm GreatBritain.
COMMENTARY BENZODIAZEPINES-THE
OPIUM
OF THE MASSES?
M. LADER Inslitute of Psychiatry (University of London), De Crespigny Park Denmark Hill, London SE5 8AF, U.K. CONTENTS
Historical introduction Extent of usage Extent of anxiety Anxiety in general practice Anxiety in the community Tranquillizers and anxiety Dependence Some implications
HISTORICAL
INTRODUCTION
MANKIND has used drugs affecting the mind for the whole of recorded history and probably for many preceding millenia. In Europe, alcohol, tobacco and caffeine are widely used and in other continents cannabis, cocaine and mescaline have been employed. Some of the drugs used have been highly dependenceproducing, for example, the opiates, narcotics; others such as alcohol have proved disastrous for a vulnerable minority of the population. Social attitudes to such drugs have varied widely from time to time and from place to place. Thus, opium, dubbed by De Quincey ‘dread agent of unimaginable pleasure and pain’, was widely taken for minor ailments by nineteenth-century society and its use was condoned. Indeed, opium and its derivatives were freely available into this century. Even now, public attitudes to narcotic addiction vary from an acknowledgement in the U.K. that it is a disease, best dealt with medically, to a moral censure in the U.S.A. with addicts regarded as criminals. The twentieth century has witnessed a rapid growth of organic chemistry culminating in the introduction of many series of drugs with profound effects on behaviour and emotions. Among these medical compounds the most widely used have been the barbiturates and their successors, the benzodiazepines. Barbituric acid was prepared in 1862 by Adolf von Baeyer working in Kekult’s laboratory. The first hypnotic barbiturate, barbitone (Veronal), was introduced by Fischer and von Mering in 1903, and still survives. Next was phenobarbitone (Luminal) which was intro-
Abbreoiation:
by
MAI, morbid anxiety inventory (as defined
SALKIND, 1973).
duced in 1912, followed by amylobarbitone in 1923. These two are still among the most widely used compounds of this class. About 2500 barbiturate compounds were synthesized over the succeeding years and approximately 50 marketed, of which about a dozen are still available. The dependence-producing potential of these compounds became increasingly clear and together with the introduction of ‘safer’ drugs has led to an official campaign in the U.K. to discourage the prescription of barbiturates. The first replacement was meprobamate (Miltown, Equanil). Developed as a muscle relaxant and sedative and widely promoted and prescribed for a while, it was made obsolescent by the introduction of the benzodiazepines. The story of the benzodiazepines starts in the 1930s with their synthesis but it was not until the late 1950s that their potential as sedatives and hypnotics became appreciated. The first clinical tests led to the prototype chlordiazepoxide (Librium) almost being discarded because it was given in too large a dose to elderly patients, making them ataxic and dysarthric. Soon, however, its clinical effectiveness in anxiety was established. It was introduced in 1960 and was followed by its even more successful congener, diazepam (Valium), in 1963. In the 15 yr or so since the appearance of the benzodiazepines on the medical scene, thousands of different members of this class have been synthesized and their pharmacology worked out in detail. Throughout the world about ten of these drugs have been marketed but several others are at an advanced stage of development. The benzodiazepines are steadily ousting the barbiturates because: (1) they are more effective in alleviating anxiety and stress responses, (2) they are safer in overdose, (3) they are
159 lis(‘ 3’2--*
160
M.
LAUtK
less liable to induce dependence, and (4) they have less effect on liver microsomal oxidizing enzymes. The prescription of benzodiazepines has been increasing steadily almost everywhere they have been made cheaply available. Backed by lavish advertising campaigns they are now among the most widely prescribed of all drugs, more than one-billion-dollarsworth being sold worldwide annually. The widespread acceptance of these drugs by the public, general practice and hospital doctors and by psychiatrists bears witness to the intolerance of present-day society to its anxiety and reactions to stress. Further, the indications for these drugs are being insidiously widened and the boundary between normality and illness increasingly blurred. The extent of this usage of benzodiazepines has become apparent recently following several surveys. However, there have been few attempts to relate the prescription of these drugs to the symptoms of individuals or to the mass of minor psychiatric morbidity in the population. The lack of data makes it diffcult to be categorical about the factors operating, but the extent of the problem presents major scientific, moral, economic and political issues, which are usually avoided both by the experts and by the lay public. EXTENT OF USAGE Interviews with a representative sample of adults in San Francisco revealed that a third of men and nearly a half of women had used psychotropic drugs during the previous year (MELLINGER,BALTER & MANHEIMER, 1971). Stimulants, sedatives and hypnotics formed the bulk of this usage. Most people taking
these drugs (18% of the total male sample; 32% of women) had them prescribed by their doctor. Between a quarter and a third of those admitting to taking psychotropic drugs had done so for 6 months or more. Put another way, about 1 in 10 adults in San Francisco had taken psychotropic drugs chronically during the course of 1yr. according to their own admissions. An extension to 2554 persons aged 18-74 TAKE
1. PERCENTAGE
Age
(YV Males.
OF ADULT
Belgium
POPULATION BY AGE AND SEX ADMITTING ro THE USE OF SEDATIVE DRUGS PREVIOUS YEAR (DATA FROM BALTER et al.. 1974)
Denmark
FWW
1
h
I2 9 I4 17
6 9 17 13
Allmales
12
10
8 9 I1 19 13 12
Females: 15-24 25-34 35-44 4S.54 55+ Allfemales
lb 21 21 I9 2s 21
14 8 29 24 23 20
13 21 20 20 28 ?I
All persons
17
I5
17
!5-24 S.34 35-44 45..54 s5+
living in the contiguous United States yieIded sun&u figures--t3% of men and 29’0 of women had used prescribed psychotropic drugs during the previous year (PARRY, BALTER,MELLINGER.C‘ISIN & MAX-HEIMER,1973). A further extension to Europe focusstd on sedative drug usage (BALTZR,LEVINE& MANHEIMER.1974). National samples of individuals in nine Western Eur. opean countries were asked about sedative drug usage and also their attitudes to these drugs. Numbers interviewed ranged from IO00 to 2377 in the various countries. The drug-use rates for any period during the year before interview varied from 100,: in Spain to 17% in Belgium and France with Germany and the United Kingdom falling at the median of 140;. Parallel data from the U.S.A. were similar to the Li.K. figures. Breakdown by age and sex is shown in Table 1. It is apparent that the male rates are lower than the female rates in every country. Higher usage tends to occur in age groups over 35 but there is no clear relation with age. Regular daily use for I month or more showed somewhat different patterns among the European countries. The U.K., Denmark, Netherlands and Belgium were at the top with approximately 8:;/, of the adult population using sedative drugs; France at 7% and Germany at 6% were followed by Sweden at 57,;; Spain (4’+
11 IO
9 I‘i
I? 20
14
24
lb
I5 14 13
21 31 22
24 IQ I9
IO
lb
i4
161
The opium of the masses confirm that anxiolytic drugs are by far the most extensively used of the psychotropic drugs (HEsBACHER, RICKELS, REAL,SEGAL& ZAM~JSTIEN, 1976). In the U.K. the number of prescriptions for psychotropic drugs rose from 38.5 million in 1965 to 48.0 million in 1971. More striking still, psychotropic drugs as a percentage of the total rose from 15.8 to 18.0 over these 7 yr (COOPERSTOCK, 1974). A recent survey of the prescription of medicines in general practice revealed that psychotropic drugs were prescribed more often than any other group, accounting for 17% of prescriptions (SKEGG,D0r.t 82 PERRY, 1977). Diazepam was the most frequently prescribed of all drugs-4.3% of all prescriptions. During 1 yr 9.7% of the adult male population and 21.0% of females received a prescription for at least one psychotropic drug. Nor do these figures include ‘hidden psychotropics’, preparations cont~ning sedatives or stimulants combined with more important amounts of other agents for treating conditions such as dyspepsia or asthma. Psychotropic drug prescription was commoner for females than for males and increased sharply with age. The extent of chronic drug usage can be estimated from figures for repeat prescriptions. Again psychotropic drugs head the list, comprising a quarter of all medicines taken for a year or more (Du~EL~ 1973). The commonest complaints for which these drugs were administered were sleeplessness, nerves and depression. EXTENT OF ANXIETY The prescribing of sedative drugs, in particular the benz~i~epines, is obviously very extensive. Does this reflect genuine symptomatic distress in the recipients or are the drugs being used in a much wider context? The following section reviews the prevalence of anxiety and stress responses in general practice and in the community. Anxiety in general practice Studies of minimal psychiatric morbidity in the community vary widely in their estimates. A 1-yr morbidity study by eight general practitioners scattered throughout the UK. concluded that psychiatric illness was responsible for less than 4y0 of all consultations (LOGAN,1953). However, a group of six practitioners collaborating with a psychiatrist estimated that about one-fifth of patients seen in any one day in an urban practice suffered from ‘stress disorders’ (FINLAY, GILLISON, HART, MASON, MOND, PAGE & Q’NEILL, 1954). Quite clearly, such figures depend crucially on the definition of and the criteria for the condition under study. As an example, the figures of k.SSEL (1960) from one London general practice can be instanced. Using criteria based on the International Classification of Diseases (ICD), SO/l000 of the population were diagnosed as suffering from a formal psychiatric illness. If the criteria were widened to in-
clude all patients .who showed signs of psychological disturba~,i~r~~tive of formal diagnosis, the prevalence rate rose to 90,/1000. If patients presenting with physical symptoms for which no organic cause was detectable were added, the figure attained 380/1000. In a careful and extensive study, SHEPHERD, COOPER,BROWN & KALTON (1966) scrutinized the case-records of general practitioners in London. The prevalence-rate over 1 yr of adults consulting for psychiatric problems was the statistic of interest, but problems stemmed from the difficulty of defining mental illness as seen in general practice and in differences among individual practitioners in their criteria for diagnosing such illnesses. Psychiatric morbidity was one of the commoner reasons for consultation: among females it ranked second after respiratory diseases. It was less common in males, coming after respiratory, orthopaedic and g~tro-intesti~l conditions. The data by diagnosis and sex are set out in Table 2. Most patients with formal psychiatric illness fell into the neurotic category, mainly anxiety states. The mean of 139/1000 for total morbidity prevalence conceals a range from 26/lOOOto 3OO/lOOOat risk. True differences in prevalence related to social class and mobility were discerned but the most important factor was the attitude of the general practitioner, those sympathetic to emotional problems having a high prevalence rate. Not only did emotionally disturbed people tend to gravitate to such doctors but also these doctors were more ready to diagnose psychiatric problems. Anxiety in the community A large-scale study, germane to an ex~ination of anxiety in the community is that of TAYLOR& CHAVE (1964). The prevalences of various types of mental illness in the community-at-large+ in general practice and in hospital practice in a satellite New Town were recorded, and compared with data for a dormitory suburb and for a decaying inner area of London, The New Town was a socially planned community with full local work oppo~uniti~; the dormitory housing estate (‘Outlands’) had good living accommodation but poor social planning and no local work-places; the old area (‘Oldfield’) had poor housing usually with shared bathrooms, multiple occupancy and a somewhat above-average number of elderly women. The purpose of the survey was to elucidate the influence of environment on mental health. Does a ‘good community’ promote mental well-being or are TABLE2. PATIENT CONSULTING Diagnostic
group
Psychoses NtllKlS~ Psychosomatic Others Total psychiatric
morbidity
OVER1 yr/f OCKJ AT et ai., 1966)
RATES
RISK (FROM SHEPHERD Male
Female
Both
3 56 25 14 98
9 117 35 14 175
6 89 30 14 139
162
hl. LADI K
genetic and constitutional factors more important‘! In the field survey, a I in 14 random sample of households in Newtown was selected and 1422 interviews were obtained. In Outlands a survey had been carried out a few years before in which 1485 people were interviewed. In Oldfield. a pilot study was carried out on 218 people. The salient points with regard to anxiety and anxiety states were as shown in Table 3. Nervous symptoms were reported by about a third of the subjects, the same proportion for the three samples. The percentage of females reporting such symptoms was about twice that of the males: the percentage of positive responders tended to be highest in the lowest social class. This group of positive responders was regarded by Taylor and Chave as suffering from a condition they termed the ‘sub-clinical neurosis syndrome’. Hire-purchase commitments and short-time working were particular sources of anxiety. Nearly 20”/, of both men and women described themselves as life-long ‘natural worriers’. All the doctors in Newtown participated in a yearlong survey of general practice. The authors concluded ‘that between 7 and 8% of adults in the new town were treated for neurosis during the year. and this took the form mainly of anxiety and tension states’. Anxiety states were more prevalent in women than in men, and in the over-45s than the younger groups. In women aged 45-65, the I-yr prevalence rate was 83/1GOO, similar to that in the study of SHLPHERD et ul. (1966). As well as these formally diagnosed psychoneuroses, milder conditions were classified by the general practitioners among the group of psychiatric symptomatic conditions. However. in general, the more a practitioner was prepared to make a formal diagnosis. the lower was the figure for these vaguer conditions, and vice versa. Only 4% of the patients with neurosis were referred to a psychiatrist. TAYLOR & CHAVE (1964) were themselves surprised that the incidence of subclinical neurosis ‘would be virtually the same in a decaying London borough, in an out-country estate without local work or social life, and in a planned new town’. They conclude that this minor disease entity must presumably stem from the constitutional factors in the individual. ‘in the sense that it represents a deeply embedded pattern within the nervous system’. The step from this subclinical syndrome to overt neurosis occurs when the patient takes note of the subjective symptoms and consults a doctor. This overt neurotic group varies TABLE
3.
PREVALENCI:
OF NERVOUS
I-OR &
CNAVE,
SYMPTOMS
(FROM
TAY-
1964)
I? I0 ti II -
in
size according
general
practice
to
and
the
quantit!
specialist
and
qki;ii~~!
psychi,\tric
concerning various aspects of anxiety to be an\wcrcd by the subject. The inventory was shown to hc sensltive to changes in anxiety level and to be an t’ll‘cctivc: instrument in screening subjects for anxict). (‘linical validation studies suggested that a score of 14 adcquately separated calm from anxi0u.s subjects. The range 14 17 was a ‘twilight zone’ in which thcrc was difficulty in deciding whether an individual wab anxious or calm. With scores of IX and above the few misdiagnoscs wcrc almost all false negatitcs. due to denial of symptoms by obviously anxious patients. Armed with these clinical data. Salkind commissioned a quota sampling of the population of Great Britain by the Gallup Poll organization. Reprcsentative samples with respect to age. sex. social class .ind employment were sought in all 12 of the RegistrarGeneral’s Demographic Regions. Forty-four intcrviewers were used and obtained full data on 420 ~cL)ple. Sub.jects were directly questioned regarding treatment for ‘worry. depression or any other nervous complaint’: 29”,, answered positively, and about half of this group had received treatment in the previous year. Hospital treatment accounted for a quarter-. Taking an MAI score of 14 as the criterion. no less than 44”,, of the adult population were anxious. If one uses the more conservative criterion 01 I ,Ythen 31’:,, fall into the anxious group, a figure very close to that of TAYLOR & CHAVE (1964) for ‘sub-clinical neurosis’. Women tended to have higher MAI scores than men, the means being 15.0 and 12.7 rcspectivcly. Scores increased with advancing age and in the lower social groups. The anxiety levels of the urban and the rural population samples did not differ but baffling regional variations were found. the highest values being obtained from East Anglia. West Midlands and South Wales.
TRANQUILLIZERS
AND ANXIET\I
Recently, a pilot study was carried out to try and link together self-reports of anxiety levels and tranquillizer use in the adult population (K. STOLL.& M. LAWR, unpublished observations). A representative stratified sample of just over 1000 adults was interviewed in the Borough of Southwark in South-East London. About 650 completed the Salkind Morbid Anxiety Inventory and almost all gave information regarding psychotropic drug usage. Neither sex nor age were related to MAI scores but manual workers tended to be most anxious, followed by professional workers. Self-rating of anxiety on a seven-point scale correlated highly with MA1 scores. Neither marital status nor social mobility
163
The opium of the masses related to MA1 scores but Catholics and Jews tended to be more anxious than average. Male smokers tended to be more anxious than non-smokers. Alcohol intake was not related to anxiety levels. About a third of the females and a fifth of males had had recourse to tranquillizers at some time. Eight per cent of males and 14% of females had taken tranquillizers in the previous year; 3% of males and SO,:, of females had used them for more than 6 months during the previous year. Use of tranquill~ers was clearly related to MAI scores, especially in women. Tranquillizer usage was greatest in women aged 25-44-nearly half the sample had taken these drugs. Drug usage in males was not age-related. Among social classes, professional and managerial workers were most likely to have taken tranquillizers, manual workers least likely. Among the tranquillizers, the benz~i~epines, especially diazepam, were most widely used. Barbiturate usage comprised less than lo:,;. The use of tranquillizers was not related to smoking or alcohol ingestion. Questions were asked concerning consultations with general practitioners about anxiety problems. As expected, the higher the MA1 score, the more likely were people to consult their doctor. Nevertheless, in those subjects with MAI scores over 17, i.e. in the clinical range, less than half had sought advice. This was particularly marked in males, with 707; coping without help. Of the total sample, a third of the females and a fifth of the males had talked to their doctors about anxiety-related topics. Respondents were asked what problems contributed to their anxiety and whether they had then discussed these problems with their doctors. Health worries were the major items in both males and females. Females but not males Iisted marital and sexual problems as important consultant topics. A fifth of patients claimed that their doctors had spent over half-an-hour discussing their problems but about a half of consultations lasted 6-l 5 min. Consultation time was not related to anxiety level but the mode of management was. Highly anxious patients tended to be referred to psychiatrists, but this happened in less than 107; of consultations. Drugs were prescribed in a further 7.5%. leaving less than 1 in 6 patients dealt with by reassurance and support alone. Nevertheless, the time spent with the patient did not depend on whether a prescription was offered. In other words, the patients did not feel that writing the prescription was being used to terminate the inter-. view. However, consultations tended to be short if the patient was referred for a specialist opinion. About a third of patients would have preferred to spend longer with their doctors, in particular the very anxious patients. A quarter of patients thought their doctors had been of no help to them, another quarter that they had received some help, and the remaining half that they had been greatly helped. Satisfaction with the doctor’s handling of their problems was not related to the measures the doctor took. Prescribing
tranquillizers was generaliy regarded as a legitimate way for the doctor to act. DEPENDENCE Dependence occurs with the benzodiazepines as with all drugs of this class but it is less severe and less of a hazard than with the barbiturates. High doses (e.g. more than 60mg/day of diazepam) have to be given before marked withdrawal symptoms including fits appear. Withdrawal phenomena-insomnia, restlessness, anxiety and tension-are delayed for up to several days after the abrupt cessation of most benzodiazepines because of the long half-life of the metabolite, desmethyldiazepam. major common Tolerance may be also noted in some patients who tend to gradually escalate the dose. Mild psychological dependence is probably very common but is dithcult to document. The anxiety symptoms which supervene on cessation of chronic benzodiazepine administration may be due to either mild withdrawal effects or to a recrudescence of the anxiety which led to the prescription of the drug initially or to both. SOME IMPLICATIONS
The use of tranquillizers to lessen emotional reactions is itself an emotional topic. People’s views range from regarding these drugs as useful panaceas to abhorring them as undermining civilization. The implications of their widespread usage have numerous ramifications and the following points are just a selection of those deemed most salient. Mood-altering drugs have been resorted to for many millenia but the scientific revolution of the past 1OOyr has led to a systematization of the use of increasingly powerful and effective agents. Compounded with vast social changes and alterations in public attitudes to psychotropic drugs, the products of the pharmaceutical industry are now widely available and, indeed, sought by the general public. As noted earlier, one in ten men and one in five women takes tranquiIlizers during the course of a year. Many agencies are involved: the pharmaceutical industry produces and promotes its drugs; the government exercises some control over this, especially with regard to safety; the doctor, mainly the general practitioner, prescribes the drugs; the drugs are dispensed by pharmacists; the patient consumes the medications; and, in the U.K., the tax-payer pays to a very large extent. The doctor is the most crucial link in this chain. He orders the sale of the drug but does not pay. He is the recipient of the drug company’s promotional efforts and he is the person the government relies on to withstand unwarranted or exaggerated claims. He is also the person on whom the public exert pressure in order to get the drugs they feel will relieve their symptoms. Now that diseases arising from infection and from nutritional inadequacies have been largely contained,
164
M.
the doctor is left stru~1ing with the degenerative diseases such as heart disease and cancer. He is also confronted, as the data presented earlier showed, with mental conditions such as anxiety or depression. The doctor is enjoined by specialists to remember that many physical symptoms may be aggravated by or be a direct reflection of psychological problems. The patient comes to his general practitioner with symptoms which can be the result of stress. The doctor ‘medicalizes’ the problem by concentrating on the symptom rather than the cause. He writes a prescription because by training and inclination he is accustomed to dealing with symptoms rather than predominantly social factors. The prescription reinforces the patient’s belief that he has something ‘medically’ wrong with him and the process is set in train which culminates in a chronically ‘ill’ patient receiving repeat prescriptions for years on end. The political and economic aspects of health care delivery services do not seem to materially affect the usage of tranquillizers. Prescribing figures are not dissimilar whether the drugs are free to the patient, covered by insurance or have to be paid for. Also, the cost of the ~nzodi~epines varies substantially from country to country (they are cheap in the U.K.), but do not seem to influence consumption. The most persistent criticisms of the widespread use of tranquillizers have concerned their effectiveness, their safety, their liability to induce dependence, and their social implications. The general consensus among psychiatrists and general practitioners is that the benzodiazepines provide worthwhile but by no means total symptomatic relief. The ineffable feeling of chronic foreboding is lessened and the patient can turn his mind to other matters, including his own general problems. Symptomatic relief is attainable without the torpor and oversedation so characteristic of the barbiturates. To date, the benzodiazepines seem safe drugs. In overdose they are astonishingly non-toxic, which is an important consideration with the present pandemic of suicidal attempts. Drug overdoses have risen ten-fold in 20 yr. However, the drugs have only been available 15 yr or so and many of the dangers of the
LAfEK
bromides, barbiturates and amphetamines were not appreciated for several decades. Although less likely to induce physical dependence than the barbiturates. the modern tranquillizers arc associated with long-term usage. Whatever the pharmacological processes involved, it is often difficult to wean patients off benzodiazepines. The social implications concern the consequences of treating symptomatically stress reactions to social problems. It could be argued that the appropriate treatment is to lessen the social problems by social reforms. Instead, the individual is persuaded to tolerate his conditions. With pharmacological help his responses are attenuated. The Orwellian spectre of chemical manipulation of the populace can be seen to be uncomfortably real in view of the usage of tranquillizers outlined earlier. Instead of retigion being the ‘opium of the masses’ as Marx opined, is opium the opium of the masses, or at least the twentieth-century equivalent of opium? In cost-effectiveness terms, tranquillizers are cheap. It is much cheaper to tranquillize distraught housewives living in isolation in tower-blocks with nowhere for their children to play than to demolish these blocks and to rebuild on a human scale, or even to provide play-groups. The drug industry, the government, the pharmacist, the tax-payer and the doctor all have vested interests in ‘medicalizing socially determined stress responses. As the doctor is crucial to this process. he is the point at which reform is most appropriate. He must be re-educated in the use of drugs, in realizing that counselling is not really more tie-consuming than repeat prescriptions and that good medicine is not merely the choice of an apparently appropriate remedy. The medical profession is now beginning to realize the extent and the depth of the problem. The recent campaign to phase out the barbiturates was a step in the right direction. An educational campaign to make doctors appreciate the more nebulous dangers of our present scale of usage of the benzodiazepines is urgently needed. Tranqui1lizers should be reserved for the severely anxious who really need them, and less specific stress responses managed by non-pharmacological means such as adequate and experienced counselling.
REFERENCES BALTER M.
B., LEVINE J. & MANH~ER D. I. (1974) Cross-national study of the extent of anti-anxiety/~t~ve drug use. New Engt. J. Med. 290, X9-774. CCXIPERSTOCK R. (Ed.) (1974) Social Aspects of the Medical Use of Psychotropic Drugs. Alcoholism and Drug Addiction Research Foundation of Ontario, Toronto. DUNNELLK. (1973)Medicine takers and hoarders. J. R. Co/l. Gen. Pratt. Suppl. 2 (23), 2-8. FINLAY B., GILLEON K., HART D., MEN R. W. T., MOND N. C., PAGE L. & O’NEILL D. (1954) Stress and distress in general practice. Practitioner 172, 183. HFSBACHERP., RICICEI~K., RUL W. Y., SEGAL A. & ZAMOSTIEXB. B, (1976) Psychotropic drug prescription in family practice. Comp. Psyc~iutry 17, 407-415. KWEL W. I. N. (1960) Psychiatric morbidity in a Loadon general practice. Br. J. preu, sot. &fed. 14, 1622. LOGAN W. P. D. (1953) General Practitioners’ Records: AR analysis of eight practices during the period April 1951 to March 1952. Studies on Medical and Population Subjects. No. 7, H.M.S.O., London.
The opium of the masses
165
MELLINGERG. D., BALTERM. B. & MANHEIMERD. I. (1971) Patterns of psychotherapeutic drug use among adults in San Francisco. Archs Gen. Psychiatry 2!5, 385-394. PARRYH. J., BALTERM. B., MELLINGERG. D., CISIN I. H. & MANHEIMER D. I. (1973) National patterns of psychotherapeutic drug use. Archs Gen. Psychiatry 28, 769-783. SALKINDM. R. (1973) The construction and validation of a self-rating anxiety inventory. Ph.D. Thesis, University of London. SHEPHERDM., CARPERB., BROWNA. C. & KALTONG. W. (1966) Psychiatric Illness in General Practice. Oxford University Press, London. SKEGGD. C. G., DOLL R. & PERRY J. (1977) Use of medicines in general practice. Brir. med. J. 2, 1561-1563. TAYLOR LORD & CHAVE, S. (1964) Mental Health and Environment. Longmans, London. (Accepted 21 October 1977)
PergamonPress.Printedm GreatBritain.
COMMENTARY BENZODIAZEPINES-THE
OPIUM
OF THE MASSES?
M. LADER Inslitute of Psychiatry (University of London), De Crespigny Park Denmark Hill, London SE5 8AF, U.K. CONTENTS
Historical introduction Extent of usage Extent of anxiety Anxiety in general practice Anxiety in the community Tranquillizers and anxiety Dependence Some implications
HISTORICAL
INTRODUCTION
MANKIND has used drugs affecting the mind for the whole of recorded history and probably for many preceding millenia. In Europe, alcohol, tobacco and caffeine are widely used and in other continents cannabis, cocaine and mescaline have been employed. Some of the drugs used have been highly dependenceproducing, for example, the opiates, narcotics; others such as alcohol have proved disastrous for a vulnerable minority of the population. Social attitudes to such drugs have varied widely from time to time and from place to place. Thus, opium, dubbed by De Quincey ‘dread agent of unimaginable pleasure and pain’, was widely taken for minor ailments by nineteenth-century society and its use was condoned. Indeed, opium and its derivatives were freely available into this century. Even now, public attitudes to narcotic addiction vary from an acknowledgement in the U.K. that it is a disease, best dealt with medically, to a moral censure in the U.S.A. with addicts regarded as criminals. The twentieth century has witnessed a rapid growth of organic chemistry culminating in the introduction of many series of drugs with profound effects on behaviour and emotions. Among these medical compounds the most widely used have been the barbiturates and their successors, the benzodiazepines. Barbituric acid was prepared in 1862 by Adolf von Baeyer working in Kekult’s laboratory. The first hypnotic barbiturate, barbitone (Veronal), was introduced by Fischer and von Mering in 1903, and still survives. Next was phenobarbitone (Luminal) which was intro-
Abbreoiation:
by
MAI, morbid anxiety inventory (as defined
SALKIND, 1973).
duced in 1912, followed by amylobarbitone in 1923. These two are still among the most widely used compounds of this class. About 2500 barbiturate compounds were synthesized over the succeeding years and approximately 50 marketed, of which about a dozen are still available. The dependence-producing potential of these compounds became increasingly clear and together with the introduction of ‘safer’ drugs has led to an official campaign in the U.K. to discourage the prescription of barbiturates. The first replacement was meprobamate (Miltown, Equanil). Developed as a muscle relaxant and sedative and widely promoted and prescribed for a while, it was made obsolescent by the introduction of the benzodiazepines. The story of the benzodiazepines starts in the 1930s with their synthesis but it was not until the late 1950s that their potential as sedatives and hypnotics became appreciated. The first clinical tests led to the prototype chlordiazepoxide (Librium) almost being discarded because it was given in too large a dose to elderly patients, making them ataxic and dysarthric. Soon, however, its clinical effectiveness in anxiety was established. It was introduced in 1960 and was followed by its even more successful congener, diazepam (Valium), in 1963. In the 15 yr or so since the appearance of the benzodiazepines on the medical scene, thousands of different members of this class have been synthesized and their pharmacology worked out in detail. Throughout the world about ten of these drugs have been marketed but several others are at an advanced stage of development. The benzodiazepines are steadily ousting the barbiturates because: (1) they are more effective in alleviating anxiety and stress responses, (2) they are safer in overdose, (3) they are
159 lis(‘ 3’2--*
160
M.
LAUtK
less liable to induce dependence, and (4) they have less effect on liver microsomal oxidizing enzymes. The prescription of benzodiazepines has been increasing steadily almost everywhere they have been made cheaply available. Backed by lavish advertising campaigns they are now among the most widely prescribed of all drugs, more than one-billion-dollarsworth being sold worldwide annually. The widespread acceptance of these drugs by the public, general practice and hospital doctors and by psychiatrists bears witness to the intolerance of present-day society to its anxiety and reactions to stress. Further, the indications for these drugs are being insidiously widened and the boundary between normality and illness increasingly blurred. The extent of this usage of benzodiazepines has become apparent recently following several surveys. However, there have been few attempts to relate the prescription of these drugs to the symptoms of individuals or to the mass of minor psychiatric morbidity in the population. The lack of data makes it diffcult to be categorical about the factors operating, but the extent of the problem presents major scientific, moral, economic and political issues, which are usually avoided both by the experts and by the lay public. EXTENT OF USAGE Interviews with a representative sample of adults in San Francisco revealed that a third of men and nearly a half of women had used psychotropic drugs during the previous year (MELLINGER,BALTER & MANHEIMER, 1971). Stimulants, sedatives and hypnotics formed the bulk of this usage. Most people taking
these drugs (18% of the total male sample; 32% of women) had them prescribed by their doctor. Between a quarter and a third of those admitting to taking psychotropic drugs had done so for 6 months or more. Put another way, about 1 in 10 adults in San Francisco had taken psychotropic drugs chronically during the course of 1yr. according to their own admissions. An extension to 2554 persons aged 18-74 TAKE
1. PERCENTAGE
Age
(YV Males.
OF ADULT
Belgium
POPULATION BY AGE AND SEX ADMITTING ro THE USE OF SEDATIVE DRUGS PREVIOUS YEAR (DATA FROM BALTER et al.. 1974)
Denmark
FWW
1
h
I2 9 I4 17
6 9 17 13
Allmales
12
10
8 9 I1 19 13 12
Females: 15-24 25-34 35-44 4S.54 55+ Allfemales
lb 21 21 I9 2s 21
14 8 29 24 23 20
13 21 20 20 28 ?I
All persons
17
I5
17
!5-24 S.34 35-44 45..54 s5+
living in the contiguous United States yieIded sun&u figures--t3% of men and 29’0 of women had used prescribed psychotropic drugs during the previous year (PARRY, BALTER,MELLINGER.C‘ISIN & MAX-HEIMER,1973). A further extension to Europe focusstd on sedative drug usage (BALTZR,LEVINE& MANHEIMER.1974). National samples of individuals in nine Western Eur. opean countries were asked about sedative drug usage and also their attitudes to these drugs. Numbers interviewed ranged from IO00 to 2377 in the various countries. The drug-use rates for any period during the year before interview varied from 100,: in Spain to 17% in Belgium and France with Germany and the United Kingdom falling at the median of 140;. Parallel data from the U.S.A. were similar to the Li.K. figures. Breakdown by age and sex is shown in Table 1. It is apparent that the male rates are lower than the female rates in every country. Higher usage tends to occur in age groups over 35 but there is no clear relation with age. Regular daily use for I month or more showed somewhat different patterns among the European countries. The U.K., Denmark, Netherlands and Belgium were at the top with approximately 8:;/, of the adult population using sedative drugs; France at 7% and Germany at 6% were followed by Sweden at 57,;; Spain (4’+
11 IO
9 I‘i
I? 20
14
24
lb
I5 14 13
21 31 22
24 IQ I9
IO
lb
i4
161
The opium of the masses confirm that anxiolytic drugs are by far the most extensively used of the psychotropic drugs (HEsBACHER, RICKELS, REAL,SEGAL& ZAM~JSTIEN, 1976). In the U.K. the number of prescriptions for psychotropic drugs rose from 38.5 million in 1965 to 48.0 million in 1971. More striking still, psychotropic drugs as a percentage of the total rose from 15.8 to 18.0 over these 7 yr (COOPERSTOCK, 1974). A recent survey of the prescription of medicines in general practice revealed that psychotropic drugs were prescribed more often than any other group, accounting for 17% of prescriptions (SKEGG,D0r.t 82 PERRY, 1977). Diazepam was the most frequently prescribed of all drugs-4.3% of all prescriptions. During 1 yr 9.7% of the adult male population and 21.0% of females received a prescription for at least one psychotropic drug. Nor do these figures include ‘hidden psychotropics’, preparations cont~ning sedatives or stimulants combined with more important amounts of other agents for treating conditions such as dyspepsia or asthma. Psychotropic drug prescription was commoner for females than for males and increased sharply with age. The extent of chronic drug usage can be estimated from figures for repeat prescriptions. Again psychotropic drugs head the list, comprising a quarter of all medicines taken for a year or more (Du~EL~ 1973). The commonest complaints for which these drugs were administered were sleeplessness, nerves and depression. EXTENT OF ANXIETY The prescribing of sedative drugs, in particular the benz~i~epines, is obviously very extensive. Does this reflect genuine symptomatic distress in the recipients or are the drugs being used in a much wider context? The following section reviews the prevalence of anxiety and stress responses in general practice and in the community. Anxiety in general practice Studies of minimal psychiatric morbidity in the community vary widely in their estimates. A 1-yr morbidity study by eight general practitioners scattered throughout the UK. concluded that psychiatric illness was responsible for less than 4y0 of all consultations (LOGAN,1953). However, a group of six practitioners collaborating with a psychiatrist estimated that about one-fifth of patients seen in any one day in an urban practice suffered from ‘stress disorders’ (FINLAY, GILLISON, HART, MASON, MOND, PAGE & Q’NEILL, 1954). Quite clearly, such figures depend crucially on the definition of and the criteria for the condition under study. As an example, the figures of k.SSEL (1960) from one London general practice can be instanced. Using criteria based on the International Classification of Diseases (ICD), SO/l000 of the population were diagnosed as suffering from a formal psychiatric illness. If the criteria were widened to in-
clude all patients .who showed signs of psychological disturba~,i~r~~tive of formal diagnosis, the prevalence rate rose to 90,/1000. If patients presenting with physical symptoms for which no organic cause was detectable were added, the figure attained 380/1000. In a careful and extensive study, SHEPHERD, COOPER,BROWN & KALTON (1966) scrutinized the case-records of general practitioners in London. The prevalence-rate over 1 yr of adults consulting for psychiatric problems was the statistic of interest, but problems stemmed from the difficulty of defining mental illness as seen in general practice and in differences among individual practitioners in their criteria for diagnosing such illnesses. Psychiatric morbidity was one of the commoner reasons for consultation: among females it ranked second after respiratory diseases. It was less common in males, coming after respiratory, orthopaedic and g~tro-intesti~l conditions. The data by diagnosis and sex are set out in Table 2. Most patients with formal psychiatric illness fell into the neurotic category, mainly anxiety states. The mean of 139/1000 for total morbidity prevalence conceals a range from 26/lOOOto 3OO/lOOOat risk. True differences in prevalence related to social class and mobility were discerned but the most important factor was the attitude of the general practitioner, those sympathetic to emotional problems having a high prevalence rate. Not only did emotionally disturbed people tend to gravitate to such doctors but also these doctors were more ready to diagnose psychiatric problems. Anxiety in the community A large-scale study, germane to an ex~ination of anxiety in the community is that of TAYLOR& CHAVE (1964). The prevalences of various types of mental illness in the community-at-large+ in general practice and in hospital practice in a satellite New Town were recorded, and compared with data for a dormitory suburb and for a decaying inner area of London, The New Town was a socially planned community with full local work oppo~uniti~; the dormitory housing estate (‘Outlands’) had good living accommodation but poor social planning and no local work-places; the old area (‘Oldfield’) had poor housing usually with shared bathrooms, multiple occupancy and a somewhat above-average number of elderly women. The purpose of the survey was to elucidate the influence of environment on mental health. Does a ‘good community’ promote mental well-being or are TABLE2. PATIENT CONSULTING Diagnostic
group
Psychoses NtllKlS~ Psychosomatic Others Total psychiatric
morbidity
OVER1 yr/f OCKJ AT et ai., 1966)
RATES
RISK (FROM SHEPHERD Male
Female
Both
3 56 25 14 98
9 117 35 14 175
6 89 30 14 139
162
hl. LADI K
genetic and constitutional factors more important‘! In the field survey, a I in 14 random sample of households in Newtown was selected and 1422 interviews were obtained. In Outlands a survey had been carried out a few years before in which 1485 people were interviewed. In Oldfield. a pilot study was carried out on 218 people. The salient points with regard to anxiety and anxiety states were as shown in Table 3. Nervous symptoms were reported by about a third of the subjects, the same proportion for the three samples. The percentage of females reporting such symptoms was about twice that of the males: the percentage of positive responders tended to be highest in the lowest social class. This group of positive responders was regarded by Taylor and Chave as suffering from a condition they termed the ‘sub-clinical neurosis syndrome’. Hire-purchase commitments and short-time working were particular sources of anxiety. Nearly 20”/, of both men and women described themselves as life-long ‘natural worriers’. All the doctors in Newtown participated in a yearlong survey of general practice. The authors concluded ‘that between 7 and 8% of adults in the new town were treated for neurosis during the year. and this took the form mainly of anxiety and tension states’. Anxiety states were more prevalent in women than in men, and in the over-45s than the younger groups. In women aged 45-65, the I-yr prevalence rate was 83/1GOO, similar to that in the study of SHLPHERD et ul. (1966). As well as these formally diagnosed psychoneuroses, milder conditions were classified by the general practitioners among the group of psychiatric symptomatic conditions. However. in general, the more a practitioner was prepared to make a formal diagnosis. the lower was the figure for these vaguer conditions, and vice versa. Only 4% of the patients with neurosis were referred to a psychiatrist. TAYLOR & CHAVE (1964) were themselves surprised that the incidence of subclinical neurosis ‘would be virtually the same in a decaying London borough, in an out-country estate without local work or social life, and in a planned new town’. They conclude that this minor disease entity must presumably stem from the constitutional factors in the individual. ‘in the sense that it represents a deeply embedded pattern within the nervous system’. The step from this subclinical syndrome to overt neurosis occurs when the patient takes note of the subjective symptoms and consults a doctor. This overt neurotic group varies TABLE
3.
PREVALENCI:
OF NERVOUS
I-OR &
CNAVE,
SYMPTOMS
(FROM
TAY-
1964)
I? I0 ti II -
in
size according
general
practice
to
and
the
quantit!
specialist
and
qki;ii~~!
psychi,\tric
concerning various aspects of anxiety to be an\wcrcd by the subject. The inventory was shown to hc sensltive to changes in anxiety level and to be an t’ll‘cctivc: instrument in screening subjects for anxict). (‘linical validation studies suggested that a score of 14 adcquately separated calm from anxi0u.s subjects. The range 14 17 was a ‘twilight zone’ in which thcrc was difficulty in deciding whether an individual wab anxious or calm. With scores of IX and above the few misdiagnoscs wcrc almost all false negatitcs. due to denial of symptoms by obviously anxious patients. Armed with these clinical data. Salkind commissioned a quota sampling of the population of Great Britain by the Gallup Poll organization. Reprcsentative samples with respect to age. sex. social class .ind employment were sought in all 12 of the RegistrarGeneral’s Demographic Regions. Forty-four intcrviewers were used and obtained full data on 420 ~cL)ple. Sub.jects were directly questioned regarding treatment for ‘worry. depression or any other nervous complaint’: 29”,, answered positively, and about half of this group had received treatment in the previous year. Hospital treatment accounted for a quarter-. Taking an MAI score of 14 as the criterion. no less than 44”,, of the adult population were anxious. If one uses the more conservative criterion 01 I ,Ythen 31’:,, fall into the anxious group, a figure very close to that of TAYLOR & CHAVE (1964) for ‘sub-clinical neurosis’. Women tended to have higher MAI scores than men, the means being 15.0 and 12.7 rcspectivcly. Scores increased with advancing age and in the lower social groups. The anxiety levels of the urban and the rural population samples did not differ but baffling regional variations were found. the highest values being obtained from East Anglia. West Midlands and South Wales.
TRANQUILLIZERS
AND ANXIET\I
Recently, a pilot study was carried out to try and link together self-reports of anxiety levels and tranquillizer use in the adult population (K. STOLL.& M. LAWR, unpublished observations). A representative stratified sample of just over 1000 adults was interviewed in the Borough of Southwark in South-East London. About 650 completed the Salkind Morbid Anxiety Inventory and almost all gave information regarding psychotropic drug usage. Neither sex nor age were related to MAI scores but manual workers tended to be most anxious, followed by professional workers. Self-rating of anxiety on a seven-point scale correlated highly with MA1 scores. Neither marital status nor social mobility
163
The opium of the masses related to MA1 scores but Catholics and Jews tended to be more anxious than average. Male smokers tended to be more anxious than non-smokers. Alcohol intake was not related to anxiety levels. About a third of the females and a fifth of males had had recourse to tranquillizers at some time. Eight per cent of males and 14% of females had taken tranquillizers in the previous year; 3% of males and SO,:, of females had used them for more than 6 months during the previous year. Use of tranquill~ers was clearly related to MAI scores, especially in women. Tranquillizer usage was greatest in women aged 25-44-nearly half the sample had taken these drugs. Drug usage in males was not age-related. Among social classes, professional and managerial workers were most likely to have taken tranquillizers, manual workers least likely. Among the tranquillizers, the benz~i~epines, especially diazepam, were most widely used. Barbiturate usage comprised less than lo:,;. The use of tranquillizers was not related to smoking or alcohol ingestion. Questions were asked concerning consultations with general practitioners about anxiety problems. As expected, the higher the MA1 score, the more likely were people to consult their doctor. Nevertheless, in those subjects with MAI scores over 17, i.e. in the clinical range, less than half had sought advice. This was particularly marked in males, with 707; coping without help. Of the total sample, a third of the females and a fifth of the males had talked to their doctors about anxiety-related topics. Respondents were asked what problems contributed to their anxiety and whether they had then discussed these problems with their doctors. Health worries were the major items in both males and females. Females but not males Iisted marital and sexual problems as important consultant topics. A fifth of patients claimed that their doctors had spent over half-an-hour discussing their problems but about a half of consultations lasted 6-l 5 min. Consultation time was not related to anxiety level but the mode of management was. Highly anxious patients tended to be referred to psychiatrists, but this happened in less than 107; of consultations. Drugs were prescribed in a further 7.5%. leaving less than 1 in 6 patients dealt with by reassurance and support alone. Nevertheless, the time spent with the patient did not depend on whether a prescription was offered. In other words, the patients did not feel that writing the prescription was being used to terminate the inter-. view. However, consultations tended to be short if the patient was referred for a specialist opinion. About a third of patients would have preferred to spend longer with their doctors, in particular the very anxious patients. A quarter of patients thought their doctors had been of no help to them, another quarter that they had received some help, and the remaining half that they had been greatly helped. Satisfaction with the doctor’s handling of their problems was not related to the measures the doctor took. Prescribing
tranquillizers was generaliy regarded as a legitimate way for the doctor to act. DEPENDENCE Dependence occurs with the benzodiazepines as with all drugs of this class but it is less severe and less of a hazard than with the barbiturates. High doses (e.g. more than 60mg/day of diazepam) have to be given before marked withdrawal symptoms including fits appear. Withdrawal phenomena-insomnia, restlessness, anxiety and tension-are delayed for up to several days after the abrupt cessation of most benzodiazepines because of the long half-life of the metabolite, desmethyldiazepam. major common Tolerance may be also noted in some patients who tend to gradually escalate the dose. Mild psychological dependence is probably very common but is dithcult to document. The anxiety symptoms which supervene on cessation of chronic benzodiazepine administration may be due to either mild withdrawal effects or to a recrudescence of the anxiety which led to the prescription of the drug initially or to both. SOME IMPLICATIONS
The use of tranquillizers to lessen emotional reactions is itself an emotional topic. People’s views range from regarding these drugs as useful panaceas to abhorring them as undermining civilization. The implications of their widespread usage have numerous ramifications and the following points are just a selection of those deemed most salient. Mood-altering drugs have been resorted to for many millenia but the scientific revolution of the past 1OOyr has led to a systematization of the use of increasingly powerful and effective agents. Compounded with vast social changes and alterations in public attitudes to psychotropic drugs, the products of the pharmaceutical industry are now widely available and, indeed, sought by the general public. As noted earlier, one in ten men and one in five women takes tranquiIlizers during the course of a year. Many agencies are involved: the pharmaceutical industry produces and promotes its drugs; the government exercises some control over this, especially with regard to safety; the doctor, mainly the general practitioner, prescribes the drugs; the drugs are dispensed by pharmacists; the patient consumes the medications; and, in the U.K., the tax-payer pays to a very large extent. The doctor is the most crucial link in this chain. He orders the sale of the drug but does not pay. He is the recipient of the drug company’s promotional efforts and he is the person the government relies on to withstand unwarranted or exaggerated claims. He is also the person on whom the public exert pressure in order to get the drugs they feel will relieve their symptoms. Now that diseases arising from infection and from nutritional inadequacies have been largely contained,
164
M.
the doctor is left stru~1ing with the degenerative diseases such as heart disease and cancer. He is also confronted, as the data presented earlier showed, with mental conditions such as anxiety or depression. The doctor is enjoined by specialists to remember that many physical symptoms may be aggravated by or be a direct reflection of psychological problems. The patient comes to his general practitioner with symptoms which can be the result of stress. The doctor ‘medicalizes’ the problem by concentrating on the symptom rather than the cause. He writes a prescription because by training and inclination he is accustomed to dealing with symptoms rather than predominantly social factors. The prescription reinforces the patient’s belief that he has something ‘medically’ wrong with him and the process is set in train which culminates in a chronically ‘ill’ patient receiving repeat prescriptions for years on end. The political and economic aspects of health care delivery services do not seem to materially affect the usage of tranquillizers. Prescribing figures are not dissimilar whether the drugs are free to the patient, covered by insurance or have to be paid for. Also, the cost of the ~nzodi~epines varies substantially from country to country (they are cheap in the U.K.), but do not seem to influence consumption. The most persistent criticisms of the widespread use of tranquillizers have concerned their effectiveness, their safety, their liability to induce dependence, and their social implications. The general consensus among psychiatrists and general practitioners is that the benzodiazepines provide worthwhile but by no means total symptomatic relief. The ineffable feeling of chronic foreboding is lessened and the patient can turn his mind to other matters, including his own general problems. Symptomatic relief is attainable without the torpor and oversedation so characteristic of the barbiturates. To date, the benzodiazepines seem safe drugs. In overdose they are astonishingly non-toxic, which is an important consideration with the present pandemic of suicidal attempts. Drug overdoses have risen ten-fold in 20 yr. However, the drugs have only been available 15 yr or so and many of the dangers of the
LAfEK
bromides, barbiturates and amphetamines were not appreciated for several decades. Although less likely to induce physical dependence than the barbiturates. the modern tranquillizers arc associated with long-term usage. Whatever the pharmacological processes involved, it is often difficult to wean patients off benzodiazepines. The social implications concern the consequences of treating symptomatically stress reactions to social problems. It could be argued that the appropriate treatment is to lessen the social problems by social reforms. Instead, the individual is persuaded to tolerate his conditions. With pharmacological help his responses are attenuated. The Orwellian spectre of chemical manipulation of the populace can be seen to be uncomfortably real in view of the usage of tranquillizers outlined earlier. Instead of retigion being the ‘opium of the masses’ as Marx opined, is opium the opium of the masses, or at least the twentieth-century equivalent of opium? In cost-effectiveness terms, tranquillizers are cheap. It is much cheaper to tranquillize distraught housewives living in isolation in tower-blocks with nowhere for their children to play than to demolish these blocks and to rebuild on a human scale, or even to provide play-groups. The drug industry, the government, the pharmacist, the tax-payer and the doctor all have vested interests in ‘medicalizing socially determined stress responses. As the doctor is crucial to this process. he is the point at which reform is most appropriate. He must be re-educated in the use of drugs, in realizing that counselling is not really more tie-consuming than repeat prescriptions and that good medicine is not merely the choice of an apparently appropriate remedy. The medical profession is now beginning to realize the extent and the depth of the problem. The recent campaign to phase out the barbiturates was a step in the right direction. An educational campaign to make doctors appreciate the more nebulous dangers of our present scale of usage of the benzodiazepines is urgently needed. Tranqui1lizers should be reserved for the severely anxious who really need them, and less specific stress responses managed by non-pharmacological means such as adequate and experienced counselling.
REFERENCES BALTER M.
B., LEVINE J. & MANH~ER D. I. (1974) Cross-national study of the extent of anti-anxiety/~t~ve drug use. New Engt. J. Med. 290, X9-774. CCXIPERSTOCK R. (Ed.) (1974) Social Aspects of the Medical Use of Psychotropic Drugs. Alcoholism and Drug Addiction Research Foundation of Ontario, Toronto. DUNNELLK. (1973)Medicine takers and hoarders. J. R. Co/l. Gen. Pratt. Suppl. 2 (23), 2-8. FINLAY B., GILLEON K., HART D., MEN R. W. T., MOND N. C., PAGE L. & O’NEILL D. (1954) Stress and distress in general practice. Practitioner 172, 183. HFSBACHERP., RICICEI~K., RUL W. Y., SEGAL A. & ZAMOSTIEXB. B, (1976) Psychotropic drug prescription in family practice. Comp. Psyc~iutry 17, 407-415. KWEL W. I. N. (1960) Psychiatric morbidity in a Loadon general practice. Br. J. preu, sot. &fed. 14, 1622. LOGAN W. P. D. (1953) General Practitioners’ Records: AR analysis of eight practices during the period April 1951 to March 1952. Studies on Medical and Population Subjects. No. 7, H.M.S.O., London.
The opium of the masses
165
MELLINGERG. D., BALTERM. B. & MANHEIMERD. I. (1971) Patterns of psychotherapeutic drug use among adults in San Francisco. Archs Gen. Psychiatry 2!5, 385-394. PARRYH. J., BALTERM. B., MELLINGERG. D., CISIN I. H. & MANHEIMER D. I. (1973) National patterns of psychotherapeutic drug use. Archs Gen. Psychiatry 28, 769-783. SALKINDM. R. (1973) The construction and validation of a self-rating anxiety inventory. Ph.D. Thesis, University of London. SHEPHERDM., CARPERB., BROWNA. C. & KALTONG. W. (1966) Psychiatric Illness in General Practice. Oxford University Press, London. SKEGGD. C. G., DOLL R. & PERRY J. (1977) Use of medicines in general practice. Brir. med. J. 2, 1561-1563. TAYLOR LORD & CHAVE, S. (1964) Mental Health and Environment. Longmans, London. (Accepted 21 October 1977)
