Risk of Attempted or Completed Suicide in Borderline Personality Disorder: Reduced with ADHD meds; Increased with Benzodiazepines
Johannes Lieslehto et al 2023 reported in JAMA New. Open on the comparative effectiveness in 22,601 individuals with BPD that “ADHD medication was the only pharmacological treatment associated with reduced risk of suicidal behavior among patients with BPD. Conversely, the findings suggest that benzodiazepines should be used with care among patients with BPD due to their association with increased risk of suicide.” Mood stabilizers had no effect while antipsychotics minimally and antidepressants moderately increased risk of suicide attempts or completed suicide.
No Association of Benzodiazepines, Z Drugs and Other Anxiolytics with Dementia
Benzodiazepines, so-called Z-drugs (such as zolpidem, zopiclone, and zaleplon), and other anxiolytics are commonly prescribed drugs that have some cognitive side effects. For this reason, there has been concern that the drugs may increase risk of dementia, and small studies had suggested that this might be the case. However, a new large study found no subsequent dementia risk after taking these drugs.
In a 2020 article in the American Journal of Psychiatry, researchers Merete Osler and Martin Balslev Jørgensen described a cohort and nested case-control study of 235,465 adult patients in Denmark in which they found no association of benzodiazepines, Z-drugs, or other anxiolytics with a subsequent diagnosis of dementia. Participants were patients over the age of 20 who were hospitalized for an affective disorder. Of these, 75.9% had been prescribed one of the drugs in question, and 4.2% went on to be diagnosed with dementia.
While participants in this study who had the lowest use of benzodiazepines or Z drugs showed a minimal increased risk of dementia compared to those who took none of these drugs, those who had the highest use of benzodiazepines and Z drugs actually had the lowest incidence of dementia in the study.
The previous studies may have been “confounded by indication” meaning they did not take the underlying psychiatric condition for which the drugs were prescribed into account.
Multiple Risks of Benzodiazepine Use
Benzodiazepines are a class of drugs that became widely used in the 1970s for their ability to reduce panic, anxiety, and insomnia. Some also functioned as anticonvulsants, reducing seizures. They are considered “downers,” with sedating qualities.
New research shows that benzodiazepine use, particularly long-term use, comes with risks such as increased mortality and mood instability.
At a 2015 scientific meeting, researcher Jari Tiihonen reported that among 21,492 patients with schizophrenia in Sweden, benzodiazepine use was associated with increased mortality, while antidepressant and antipsychotic use decreased mortality.
At the same meeting, researcher Cristina Albott reported that benzodiazepines may interfere with the rapid onset of antidepressant effects usually brought about by intravenous treatment with the drug ketamine.
In 2010, researcher Roy Perlis reported in the Journal of Clinical Psychiatry that in STEP-BD, a large study of people with bipolar disorder, benzodiazepine use was associated with an increased risk of recurrence of mood episodes.
Editor’s Note: Benzodiazepines can also exacerbate symptoms of post-traumatic stress disorder (PTSD) and regular use can lead to a decrease in lifespan. It now seems as though there are many reasons to exercise caution in the use of these drugs.
Opiate and Alcohol Abuse
Deaths from opiate abuse are occurring in the US at about the same rate as automobile fatalities. At a recent talk, researcher Richard Ries discussed treatment of opiate addictions and the current epidemic of unintended opiate overdoses. Most opiates being abused come from other people’s leftover prescriptions. The best way to prevent opiate abuse is to throw out unused painkillers when they are no longer needed.
Many overdoses from opiates also involve alcohol and benzodiazepines, which can contribute to breathing difficulties.
There are several treatments available that can help patients abstain from using opiates. Treatment with opioid receptor antagonists (such as naltrexone (Rivia or long-acting Vivitrol, which is taken as an injection and lasts for 1 month), partial agonists (like buprenorphine), or full agonists (like methadone) results in, on average, an 80% decrease in the rate of hospitalization and an 80% reduction in crime, as well as a marked decrease in AIDS transmission. Without treatment, it is very difficult for people with opiate addictions to maintain abstinence, and relapse rates are extraordinarily high.
Treatment of Alcohol Abuse and Benzodiazepines
Ries also discussed data on treatment of alcohol abuse. He emphasizes that some aspects of withdrawal, such as sleep disturbance, can last a month or more after a parient’s last drink, putting the patient at high risk for relapse. Gabapentin, which is most often prescribed to prevent seizures, helps patients with this phase. Ries endorsed the combination of gabapentin and naltrexone as especially helpful. Carbamazepine is widely used in Europe for the treatment of alcohol abuse, and Ries also strongly endorsed the drug as another way of avoiding benzodiazepines. Several large placebo-controlled trials suggest that the anticonvulsant topiramate is also effective for long-term alcohol avoidance.
Editor’s Note: Another researcher, Mark Frye, found that women with bipolar disorder are more than seven times more likely than women in the general population to abuse alcohol, often in an attempt to self medicate their residual anxiety and depression. Excellent treatment of mood in bipolar disorder may have the double benefit of helping patients avoid alcohol abuse. The nutritional supplement n-acetylcysteine (NAC) also helps improve mood in bipolar disorder and has positive placebo-controlled data in heroin, cocaine, and alcohol avoidance.
