Mitchell B. Balter

Cross-national study of the extent of anti-anxiety-sedative drug use.

Abstract National samples of respondents in nine Western European countries were asked identical questions about their use of anti-anxiety/sedative drugs during the past year and about their general attitude toward tranquilizers. The proportion of persons who used anti-anxiety/sedative drugs on one or more occasions varied from 17 per cent in Belgium and France to 10 per cent in Spain. In almost every country the percentage of females who had used anti-anxiety/sedative drugs was approximately twice that of males. Persons 45 years of age and over were over-represented among drug users in all countries in relation to their presence in the national population. The rank order of the countries on attitude toward tranquilizers was poorly correlated with rank order on use rates. However, within each country there was a sharp difference in attitude between users and nonusers. Independent data place the United States in a middle position among the nine countries surveyed on use of anti-anxiety/sedative drugs. (N E...

Risks and benefits of long-term benzodiazepine use.

Despite a sharp decline in the prescription of benzodiazepines during the past decade, reservations about their use have continued to escalate. This article presents converging data from three diverse sources: national survey data from consumers, laboratory data on the drug preferences of normal subjects, and a controlled clinical study of long-term diazepam treatment and withdrawal. These data suggest that (1) the risks of overuse, dependence, and addiction with benzodiazepines are low in relation to the massive exposure in our society; (2) benzodiazepine addiction can occur when doses within the clinical range are taken regularly over about 6 months; (3) many patients continue to derive benefit from long-term treatment with benzodiazepines; and (4) attitudes strongly against the use of these drugs may be depriving many anxious patients of appropriate treatment. (J Clin Psychopharmacol 1988;8:161–167)

Marijuana use among urban adults.

A relatively high proportion of young adults in San Francisco have used marijuana one or more times. The proportion in this age group who have used marijuana is as great among nonstudents as among students.

International study of expert judgement on therapeutic use of benzodiazepines and other psychotherapeutic medications: II. Pharmacotherapy of anxiety disorders

OBJECTIVE To assemble expert clinical experience and judgement in the treatment of anxiety and related disorders in a systematic, quantitative manner. METHODS A panel of internationally recognized Experts in treating anxiety and depression was constituted by multistage peer nomination. 90% completed a questionnaire. This report focuses on case vignettes of 7 anxiety disorders followed by questions about relevant therapeutic options. RESULTS Panelists usually recommended both psychological and pharmacological interventions. Most favored antidepressants, usually tricyclic, for agoraphobia, panic and OCD; beta-blockers for specific social phobia; and benzodiazepines for GAD and adjustment disorder. Some Experts favored polypharmacy, usually an antidepressant and a benzodiazepine. The majority usually advocated pharmacotherapy for 6 months or more. They recommended the same duration of treatment with benzodiazepines and other medications, except for GAD. CONCLUSIONS The responses of the Expert Panel imply that; (1) most anxiety disorders are serious and merit vigorous, prolonged pharmacotherapy; and (2) antidepressants and benzodiazepines are effective and safe for long-term treatment of these conditions. This outcome contrasts with the widespread apprehension about long-term pharmacotherapy, especially with benzodiazepines, and some regulatory views.

Evaluating a household survey measure of psychic distress

This paper describes a study to assess the validity of a brief household survey measure of psychic distress (PSYDIS). The measure classifies persons according to their pattern of scores on four dimensions, including anxiety and depression. Study subjects were interviewed first as respondents from the general population in a cross-sectional household survey. Then, according to their ratings on PSYDIS, subsamples were selected for psychiatric evaluation in a clinic a few weeks later. The survey ratings of 287 persons were compared with evaluations of the same persons by experienced psychiatrists. Overall levels of concordance ranged from 76% to 80%, depending on the psychiatric criterion used. Concordance was very high for women; it was lower for men and for persons classified as High on PSYDIS. We than applied two analytic strategies for increasing agreement between the clinical judgements and the clinical ratings. Strategy number I augmented the symptom checklist data with additional survey data on the subjects history of episodes of distress. Strategy II revised procedures for constructing the PSYDIS typology by (1) using more rigorous cutting point scores on the component scales, and (2) using a non-typological method of classification. The first strategy improved agreement between the clinic and survey measures; the second did not. The paper also compares PSYDIS with other brief symptom checklist measures.

Trends in recommendations for the pharmacotherapy of anxiety disorders by an international expert panel, 1992-1997.

Abstract A follow-up survey in 1997 to a 1992 study of the recommendations of an international expert panel on the use of benzodiazepines (BZDs) and other psychotherapeutic medications in the treatment of anxiety disorders suggests that the BZDs remain a mainstay of pharmacotherapy for most of these conditions. BZDs were mentioned more often than any other class of drugs as preferred first-line therapy for anxiety disorders, except obsessive compulsive disorder. The introduction of the selective serotonin reuptake inhibitors (SSRIs) did not significantly affect the experts’ recommendations for the use of BZDs as first-line pharmacotherapy. Rather, the SSRIs displaced the tricyclic antidepressants. Some implications of the continuing recommendations for the use of BZDs in anxiety disorders are discussed.

International study of expert judgment on therapeutic use of benzodiazepines and other psychotherapeutic medications : V. Treatment strategies in panic disorder, 1992-1997

Our objective was to assemble expert clinical experience and judgment in the treatment of anxiety and related disorders in a systematic, quantitative manner. This article reports on some clinical features apart from diagnosis that may affect choice of strategy in the pharmacotherapy of anxiety disorders. A panel of internationally recognized experts in treating anxiety and depression was constituted by multistage peer nomination. Ninety percent (66 of 73) completed an extensive questionnaire. This report focuses on the expert panels responses to questions on therapeutic options, based on multi-part case vignettes of several anxiety disorders presenting clinical variations within the same diagnosis. In the presence of higher levels of functional impairment, the experts more often recommended formal psychosocial procedures for adjustment disorder; medication for agoraphobia, social phobia, obsessive-compulsive disorder, and adjustment disorder; and polypharmacy for agoraphobia. Their therapeutic recommendations were not materially affected by chronicity in the case of panic disorder. Under the condition of heavy use of alcohol in the case of generalized anxiety disorder, the experts avoided benzodiazepines in favor of various other medications. In the presence of a serious cardiac conduction defect in the case of obsessive-compulsive disorder, they less often recommended medication. Those who did recommend medication changed their preference from tricyclic antidepressants (clomipramine) to selective serotonin reuptake inhibitors. Under the condition of a more severe precipitating event in the case of adjustment disorder, the experts were more likely to recommend both formal psychosocial intervention and medication.(ABSTRACT TRUNCATED AT 250 WORDS)

Assessing Comprehension in a Survey of Public Reactions to Complex Issues

This paper reports results of research to develop household interview procedures for obtaining reasonably informed public judgements about ethical issues in biomedical research. We describe (1) an interviewing strategy designed to enhance comprehension among survey respondents, and (2) a composite comprehension index based on three types of information from the interview. Using data from a cross-section sample, we identify subgroups that differ significantly with respect to scores on the comprehension index, and we then describe the observed levels of comprehension in terms of the operations defining the index. The results demonstrate both the feasibility and limits of obtaining informed rather than naive judgements about complex issues from lay respondents.

Clinical variables in pharmacoepidemiology

Pharmacoepidemiology traditionally concerns itself with the rates at which drugs are prescribed and used in the general population. Interpretations of these data frequently assume that the rates--for psychotropic drugs--reflect primarily the reinforcing properties of the drugs. This paper, in contrast, focuses on the influence of certain clinical characteristics of consumers on patterns of psychotherapeutic drug use. The data are from a nationwide (US) probability sample of 3,161 persons aged 18-79 years surveyed in 1979. One-year prevalence rates of use and the longest period of regular daily use serve as indices of drug consumption. Scores on a 43-item checklist of psychological symptoms were used to compute two clinical descriptors of the respondents--a quantitative index of the level of psychic distress and a qualitative syndromal classification including depression, agoraphobia/panic, other phobias, and generalized anxiety. The data showed that, although anxiolytics and antidepressants have characteristic patterns of prevalence and duration of use, the clinical characteristics of users (severity and pattern of symptoms) strongly influence these patterns. Prevalence and duration of drug use alone do not suffice to illuminate the social functions and significance of psychotherapeutic agents, to provide a basis for value judgments about the use of such compounds, and to guide medical decision-making. Since clinical variables play such a major role in the consumption of these agents, it is crucial to include information about these variables in the analysis and interpretation of patterns of psychotherapeutic drug use.

Survey method for post-marketing drug surveillance: a demonstration.

Distinguishing characteristics of a community survey method for post-marketing drug monitoring are described, as are results of a pilot study of the method. Representative samples of outpatients treated with tricyclic antidepressants or benzodiazepine anxiolytics were identified in a clinic or pharmacy and interviewed at baseline and specified intervals thereafter in the home or by telephone. Data were collected by lay interviewers trained to use a detailed interview schedule designed with input from experts in pharmacology, relevant clinical disciplines, and survey research. The critical validity question was the degree to which predicted outcomes for the two well-studied drug classes matched observed outcomes. The analytic design involved two contrast groups, three measurement periods, and six key symptom measures. The latter were specific to the disorder (anxiety and depression), to the medications, or to neither the disorders nor the medication (neutral symptoms). Predictions took account of degree and direction of change, as well as differences in profile levels over time. Results conformed precisely to expectations. As one component of a comprehensive system, the method provides an opportunity to examine efficacy as well as safety under conditions that are typically absent or excluded in clinical trials. Data on patterns of prescribing by physicians and use by patients are valuable byproducts that are immediately relevant for professional education and product liability. Advantages and limitations of the method are discussed. (J Clin Psychopharmacol 1988;8:168–176)