James Davies

Long-term benzodiazepine and Z-drugs use in England: a survey of general practice

BACKGROUND Current British National Formulary (BNF) guidelines state that benzodiazepines and zolpidem, zopiclone, and zaleplon, commonly known as Z-drugs (BZD), be prescribed for no more than 4 weeks, although anecdotal data suggest that many patients are prescribed BZDs for much longer. As there are no recent, evidence-based estimates of long-term (>12 months) BZD use in the UK, the scale of this potential problem is unknown. AIM To produce the first reliable, evidence-based estimate of long-term BZD use in the UK. DESIGN AND SETTING Estimates of UK long-term BZD use were projected from data obtained from a survey conducted in 2014-2015 by the Bridge Project, a prescribed-drug withdrawal support charity in the North of England (Bradford). METHOD Percentages of long-term users of BZD were derived from the survey, by sampling primary care GP surgeries with around 100 000 registered patients, and these were applied to UK-wide NHS patient numbers. The data were filtered to exclude the very young and old, and those with other health issues. RESULTS The mean percentage of registered patients prescribed BZDs for more than a year in the survey sample is 0.69% (95% confidence interval [CI] = 0.54 to 0.84). Applying this value to national patient numbers yields a mean projection of 296 929 (95% CI = 232 553 to 361 305) long-term users of BZD in the UK. The data also suggest that as many as 119 165 of these patients may be willing to accept prescribed drug dependency withdrawal services. CONCLUSION More than a quarter of a million people in the UK are likely to be taking highly dependency-forming hypnotic medication far beyond the recommended time scales. As there is evidence that long-term use of BZDs causes adverse physiological and neurological effects, and protracted withdrawal (with associated complications), this represents a serious public health problem.

How Voting and Consensus Created the Diagnostic and Statistical Manual of Mental Disorders (DSM-III)

ABSTRACT This paper examines how Task Force votes were central to the development of Diagnostic and Statistical Manual of Mental Disorders (DSM-III and DSM-III-R). Data were obtained through a literature review, investigation of DSM archival material housed at the American Psychiatric Association (APA), and interviews with key Task Force members of DSM-III and DSM-III-R. Such data indicate that Task Force votes played a central role in the making of DSM-III, from establishing diagnostic criteria and diagnostic definitions to settling questions about the inclusion or removal of diagnostic categories. The paper concludes that while the APA represented DSM-III, and the return to descriptive psychiatry it inaugurated, as a triumph of empirically based decision-making, the evidence presented here fails to support that view. Since the DSM is a cumulative project, and as DSM-III lives on through subsequent editions, this paper calls for a more socio-historically informed understanding of DSMs construction to be deployed in how the DSM is taught and implemented in training and clinical settings.

Political Pills: Psychopharmaceuticals and Neoliberalism as Mutually Supporting

This chapter argues that a core explanatory variable in the spread of psychopharmaceuticals has been the ability of such products since the 1980s to serve key aims of the neoliberal political economy. Thus to understand the expansion of psychopharmaceutical consumption since the 1980s, we must go beyond the machinations of the pharmaceutical industry and psychiatric profession, to inspect the deeper neoliberal interests, aims and logics to which both profession and industry have been responsive and beholden. Psychopharmaceuticals, in other words, have enjoyed rapid ascent by being configured as consistent with key neoliberal aims of increasing ‘labour productivity’ and of furthering ‘commodification’ while themselves benefitting from ‘deregulation’. While reform of psychiatric and pharmaceutical practices certainly is long overdue, unless political will grows sufficiently to tackle systemic corruptions and excesses in the research, regulation and distribution of psychopharmaceuticals, little may transpire in the form of tangible change.

Why full disclosure is healthy

Do British people know enough about the financial interests of those writing health articles? Time to toughen editorial codes, asks James Davies

Psychotherapy and the third wave of professionalisation

I write this response to balance the papers set down in this current edition. For although these papers have provided us with much valuable historical knowledge about how the professionalisation of psychotherapy has unfolded in a number of different countries, what they have not revealed are some of the more shrouded problems with which professionalisation may burden the therapeutic community in the near future. As the task of indentifying these possible perils of professionalisation has thus far been neglected, let me take up the duty of identifying some of them here, so far as it is advantageous and informative to do so. But before I proceed, allow me to first make some preliminary comments in order to clarify my position – both ideologically and methodologically. The first thing to note is that by advancing the following reflections I do not mean to set myself entirely against the process of professionalisation. My intention is rather to articulate certain dangers that the current wave of professionalisation may bring in its wake; dangers that are often more mutely sensed than overtly apprehended or robustly declared; dangers that will not simply evaporate due to our ignoring them. Secondly, I wish to reveal these dangers by undertaking an anthropologically guided analysis. The advantage of anthropology, of course, being that it is primarily interested in social and institutional systems, not individual, intra-psychic or inter-personal systems. And as the process of professionalisation is, by all accounts, a social phenomenon (even if it prompts both psychological and social effects), I shall address it from this socio/cultural standpoint. Of course psychotherapy has been subject to forces of professionalisation since its very inception, insofar as we define professionalisation as the process by which an occupation transforms itself into a profession by way of establishing acceptable qualifications (distinguishing the qualified from the unqualified) and by contriving a professional association to oversee the conduct of its members. In the light of this definition, it is important to stress that three waves of professionalisation have swept our community’s shore during psychotherapy’s institutional history: the first wave arrived with the founding of the training institutes in the first three-quarters of the twentieth

First Indications for Long-Term Benzodiazepine and Z-drugs use in the United Kingdom

Benzodiazepines and Z-drugs (BZDs), hypnotic drugs used for insomnia and anxiety, are prescribed millions of times a year in the UK. Although guidance from the relevant regulatory authorities (NICE and BNF) indicates them only for short-term use, the evidence suggests that many patients have been taking these drugs for much longer, often for decades. At present, there are no up-to-date, evidence-based estimates of the scale of long-term BZD use in the UK, which has prevented making a strong case for the need for withdrawal services. However, data obtained recently on BZD use from a number of GP surgeries (covering nearly 100,000 registered patients) in the North of England, allow such projections to be calculated. Scaling the results to a national level suggests that there are over a quarter of a million patients in the UK using BZDs for periods far longer than recommended. The projections also suggest that nearly half this number may be willing to accept help to stop their dependency on BZDs. These results indicate a serious problem, which should be addressed by more research into the harms associated with long-term BZD use, the provision of withdrawal services, and a national helpline to support patients with BZD dependency.

Psychoanalytic practice and state regulation

‘Educate yourself, my friends, a great threat approaches!’. Such were the alleged words of Abraham Lincoln to those too blind to sense the coming Civil War. Why, you might ask, do I use these words to open a book review on therapy regulation? Well, if you are unable to answer, then this might be a book for you. For rarely have so few political words been so apposite for so many therapists working across Britain today. Before I explain to you why, let us first ask: ‘what is this threat that approaches?’ – What bleak cloud blows in from the horizon? The answer: the state’s regulation of psychotherapy in Britain. The purpose of this book is to articulate exactly why state regulation should be seen as a threat and not as a salvation. It aims to show what precisely is at stake if the psychoanalytic community hands over its autonomy to an untested authority, in the hope that some of this authority’s legitimacy and security will be transferred. By offering its predictions about where such subservience would leave us, this book aims to shake the current political apathy out of our profession’s apolitical bones, and possibly for the first time in our profession’s history pull us together as a political unit to fight for our right to practice in accordance with our own professional conscience, rather than in concurrence with the unyielding edicts and expectations of the state. The question the book asks, therefore, is whether by submitting to state control we will place psychotherapy in safe hands. The book’s answer is an unequivocal ‘no’. It justifies this position over a series of chapters (written by many notable figures in the field of therapy), which very effectively outline what forms this threat could be said to take. In short, it holds that our profession is on the brink of being colonized by an external power, more dominant than ourselves, hostile to and uncomprehending of our values; a power less with our best interests in mind, than with an eye to expanding its own authority and jurisdiction in the name of ‘protecting’ the public. This book traces the clash of two very different cultures – that of the Whitehall bureaucracy and that of psychoanalysis or psychoanalytic psychotherapy. Each speaks its own language, understands reality in its own terms, neither shares the other’s idiosyncrasies, aims or aspirations; one honours order, the predictable, the measurable and ‘provable’ – in short, what is ‘useful’, Psychodynamic Practice Vol. 15, No. 3, August 2009, 311–335

The unanimity of purpose: Some anthropological reflections

One aim of writing a ‘response’ is to tease from the event reviewed its less explicit aspects, to render implied themes overtly declared and thus, in short, with the benefit of hindsight, to uncover that which was too ‘close up’ at the time to be clearly discussed and examined. A response is therefore usually less a summary or descriptive account than an exposé of an event, one that should aspire to reveal from the observed event dimensions that would otherwise remain concealed. It was with this thought in mind that the present editorial committee considered whether an anthropological assessment of the symposium might yield some novel reflections. Since I am both a social anthropologist and a psychotherapist I was therefore asked, and, while due to my dual position I claim neither any special impartiality nor any special ability to achieve this task, I do admit to a certain desire to perform it, such was the importance of the symposium’s theme and the thoughtfulness and ingenuity of many of those who addressed it. I only hope what little I have to say might be of some use. Anyone who reads this current issue will quickly surmise that the conference constituted one of the most comprehensive gatherings of different therapeutic traditions assembled in recent years. And yet, as can be expected from the meeting of such diverse representatives, enough themes emerged for consideration to intimidate anyone who attempts in a short space a general appraisal. Therefore, to avoid overwhelming both myself and my readers, let me focus intimately on one theme alone, rather than pass cursorily over many. The theme I have chosen, or, as I should say, the theme that has