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Background: Depressive and anxiety disorders contribute to a high disease burden. This paper investigates whether concise formats of cognitive behavioral- and/or pharmacotherapy are equivalent with longer standard care in the treatment of depressive and/or anxiety disorders in secondary mental health care., Methods: A pragmatic randomized controlled equivalence trial was conducted at five Dutch outpatient Mental Healthcare Centers (MHCs) of the Regional Mental Health Provider (RMHP) 'Rivierduinen'. Patients (aged 18-65 years) with a mild to moderate anxiety and/or depressive disorder, were randomly allocated to concise or standard care. Data were collected at baseline, 3, 6 and 12 months by Routine Outcome Monitoring (ROM). Primary outcomes were the Brief Symptom Inventory (BSI) and the Web Screening Questionnaire (WSQ). We used Generalized Estimating Equations (GEE) to assess outcomes., Results: Between March 2010 and December 2012, 182 patients, were enrolled (n=89 standard care; n=93 concise care). Both intention-to-treat and per-protocol analyses demonstrated equivalence of concise care and standard care at all time points. Severity of illness reduced, and both treatments improved patient's general health status and subdomains of quality of life. Moreover, in concise care, the beneficial effects started earlier., Discussion: Concise care has the potential to be a feasible and promising alternative to longer standard secondary mental health care in the treatment of outpatients with a mild to moderate depressive and/or anxiety disorder. For future research, we recommend adhering more strictly to the concise treatment protocols to further explore the beneficial effects of the concise treatment. The study is registered in the Netherlands Trial Register, number NTR2590. Clinicaltrials.gov identifier: NCT01643642., (Copyright © 2015 Elsevier Inc. All rights reserved.)

About two-thirds of long-term users of benzodiazepines in the population are able to discontinue this drug with the aid of supervised programmes for tapering off. Little is known about the long-term outcome of such programmes, and they have never been compared with usual care. After a 15-month follow-up of a randomised controlled trial comparing such a programme with and without psychotherapy with usual care, we found significantly higher longitudinal abstinence rates in long-term benzodiazepine users who received a benzodiazepine tapering-off programme without psychotherapy (25 out of 69, 36%) compared with those who received usual care (5 out of 33,15%; P=0.03).

Background: Predictors of benzodiazepine discontinuation after sending a discontinuation letter by the family practitioner have not been established sufficiently., Objective: To identify predictors of short- and long-term discontinuation of benzodiazepine use and relapse in use after a minimal intervention with a discontinuation letter followed by an offer for an evaluation consultation., Methods: Predictors of benzodiazepine discontinuation and relapse in use were studied by logistic regression analysis and survival analysis within a family practice population of long-term benzodiazepine users (n = 1707) addressed by a discontinuation letter and followed for 21 months., Results: A lower baseline prescription, a shorter duration of use, male gender and use of an agent with a half-life time <24 hours were predictive of complete discontinuation in the short (6 months) and long term (21 months). Multiple agent use at baseline, use of antidepressants at 6 months and benzodiazepine type (anxiolytic/hypnotic) at baseline predicted relapse. Attendance at an evaluation consultation 3 months after the letter was sent was not predictive of discontinuation or relapse., Conclusions: Amount of baseline use and duration of use are the main determinative characteristics of successful discontinuation. The discontinuation letter intervention is suitable for use with a broad group of long-term benzodiazepine users in family practice and can be used as a first step within a stepped care approach to decrease long-term benzodiazepine use.

This study aimed to assess benzodiazepine craving longitudinally and to describe its time course by means of the Benzodiazepine Craving Questionnaire (BCQ). Subjects were long-term benzodiazepine users participating in a two-part treatment intervention aimed to reduce long-term benzodiazepine use in general practice in The Netherlands. Four repeated measurements of benzodiazepine craving were taken over a 21-month follow-up period. Results indicated that (1) benzodiazepine craving severity decreased over time, (2) patients still using benzodiazepines experienced significantly more severe craving than patients who had quit their use after one of the two interventions, and (3) the way in which patients had attempted to quit did not influence the experienced craving severity over time, however, (4) patients who had received additional tapering off, on average, reported significantly more severe craving than patients who had only received a letter as an incentive to quit. Although benzodiazepine craving is prevalent among (former) long-term benzodiazepine users during and after discontinuation, craving severity decreases over time to negligible proportions. Self-reported craving can be longitudinally monitored and quantified by means of the BCQ.

Aim: To assess the scalability, reliability and validity of a newly constructed self-report questionnaire on craving for benzodiazepines (BZs), the Benzodiazepine Craving Questionnaire (BCQ)., Setting and Participants: The BCQ was administered once to a sample of 113 long-term and 80 former long-term general practice BZ users participating in a large BZ reduction trial in general practice., Measurements: (1) Unidimensionality of the BCQ was tested by means of the Rasch model. (2) The Rasch-homogeneous BCQ items were assessed for subject and item discriminability. (3) Discriminative and construct validity were assessed., Findings: The BCQ met the requirements for Rasch homogeneity, i.e. BZ craving as assessed by the scale can be regarded as a unidimensional construct. Subject and item discriminability were good. Construct validity was modest. Highest significant associations were found with POMS depression (Kendall's tau-c = 0.15) and Dutch Shortened MMPI negativism (Kendall's tau-c = 0.14). Discriminative validity was satisfactory. Highest discriminative power was found for a subset of eight items (Mann-Whitney U Z = - 3.6, P = 0.000). The first signs of craving are represented by the acknowledgement of expectations of positive outcome, whereas high craving is characterized by direct intention to use., Conclusions: The BCQ proved to be a reliable and psychometrically sound self-report instrument to assess BZ craving in a general practice sample of long-term BZ users.

Background: Long-term results of minimal intervention strategies to cut down benzodiazepine use are not available., Objective: To evaluate the relapse rate over a two-year period and to search for predictors of relapse among patients who quit benzodiazepine use after receiving a discontinuation letter., Methods: Baseline assessment and prospective monitoring of the medical records of 109 patients who quit long-term benzodiazepine use after a minimal intervention strategy in general practice., Results: After 819 +/- 100 days of follow-up, 53 (49%) patients had remained completely abstinent. Two independent predictors of relapse were identified by Cox regression analysis: use of more than 10 mg diazepam equivalent (RR = 2.4 [1.2 - 4.7]) and poor general health perception (RR = 0.98 [0.97 - 0.99])., Conclusion: Short-term success rates after a minimal intervention were maintained well during long-term follow-up. High-dose users have the highest risk of relapse.

Background: Benzodiazepine withdrawal programmes have never been experimentally compared with a nonintervention control condition., Aims: To evaluate the efficacy and feasibility of tapering off long-term benzodiazepine use in general practice, and to evaluate the value of additional group cognitive-behavioural therapy (CBT)., Method: A 3-month randomised, 3-month controlled trial was conducted in which 180 people attempting to discontinue long-term benzodiazepine use were assigned to tapering off plus group CBT, tapering off alone or usual care., Results: Tapering off led to a significantly higher proportion of successful discontinuations than usual care (62% nu. 21%). Adding group CBT did not increase the success rate (58% v. 62%). Neither successful discontinuation nor intervention type affected psychological functioning. Both tapering strategies showed good feasibilityin general practice., Conclusions: Tapering off is a feasible and effective way of discontinuing long-term benzodiazepine use in general practice. The addition of group CBT is of limited value.

Background: Despite generally accepted advice to keep treatment short, benzodiazepines are often prescibed for more than six months. Prevention of long-term benzodiazepine use could be facilitated by the utilisation of risk indicators for long-term use. However, the characteristics of long-term benzodiazepine users described in the literature are based on studies in which long-term users were compared with non-users. Thus these characteristics may be imprecise., Aim: To study the characteristics of long-term benzodiazepine users by comparing their demographic data and health status (mental and physical) with those of short-term users., Design of Study: Cross-sectional comparison of short-term and long-term benzodiazepine users., Setting: Patients from 32 GP practices of the Nijmegen Health Area, The Netherlands., Method: The characteristics of 164 short-term and 158 long-term benzodiazepine users in general practice were compared, using interview data and morbidity referral and prescription data from GP records., Results: Long-term benzodiazepine users were (a) older, (b) had a more severe history of mental health problems for which they had received more serious treatment, (c) used more psychotropic drugs, (d) had a higher hospital specialist consultation frequency, (e) had more diagnoses of the following: diabetes, asthma, chronic obstructive pulmonary disease, hypertension a serious skin disorder, and (f) reported a lower perceived general health status. There were no sex differences., Conclusion: Specific risk characteristics of long-term benzodiazepine users can be used to develop a risk profile for the management of benzodiazepines in general practice. We believe that (somatic) secondary care also contributes to benzodiazepine use. It may be worthwhile to coordinate care for benzodiazepine users between GPs and hospital specialists.

Background: Different prevalences of benzodiazepine (BZ) use are described in the literature. The present study assessed the effects of employing various definitions of BZ use and various observation periods on the prevalence rate of BZ use in an open population aged 18-74 years., Method: In a literature review, prevalence studies were systematically compared. In a second stage, a descriptive cross-sectional multipractice study was analysed using 48,046 prescriptions of BZ in the past year given to a population of 80,315 patients at 31 general practices in the Nijmegen Health Area. From this database, prevalence rates were calculated applying different definitions of BZ use and different observation periods., Results: In the literature, prevalence rates varied between 2.2 and 17.6%. There was wide variation in definitions of BZ use and observation period. In our prescription database, depending on the definitions of BZ use and observation period, prevalence rates ranged from 0.2% to 8.9%. The ratio of female:male (2:1) remained constant irrespective of the prevalence rate. Age distribution varied according to the duration of use: among long-term BZ users, approximately 80% were older than 45 years; among short-term BZ users, approximately 55% were older than 45 years., Conclusions: The wide variation in prevalence rates of BZ use reported in the literature can largely be explained by differences in definitions of BZ use and observation period. This affected the distribution of some BZ-use-related variables such as age. For reliable comparisons of BZ use, standardisation of the definition of BZ use is required. A proposal for standardising methodology is presented.

The aim of the present study was to obtain standardized scores that correspond with the raw scores on the four Rasch scales of the Benzodiazepine Dependence-Self Report Questionnaire (Bendep-SRQ). The eligible normative group for standardization of the Bendep-SRQ scales consisted of 217 general practice (GP) patients, all using benzodiazepines. Two standardization methods were used and compared: "classical standardization," which transforms raw scores into standard scores on the unit normal distribution, and "latent trait standardization," which transforms raw scores into latent trait scores. The latter requires the Rasch model with the additional assumption of a normally distributed latent trait, which held true for the scales "problematic use," "lack of compliance," and "withdrawal," but not for "preoccupation." The observed unequal item spacing on the "preoccupation" scale was hypothesized to induce a response tendency of nondeviation, causing a local violation of the assumption of a normally distributed latent trait. Nevertheless, comparison of the results of the two standardization methods revealed such a high degree of resemblance, that latent trait standardization could be used for "preoccupation" just as well as classical standardization. The presented standard scores and corresponding percentile ranks make raw Bendep-SRQ scores clinically interpretable in relation to the normative GP sample. Incorporation of the Rasch scaling methodology into the development of the Bendep-SRQ marks the adoption of the item response theory in the field of applied test methodology. In this process, it appears that equal item spacing has to be taken into account to prevent local violations of the Rasch model with the additional assumption of a normally distributed latent trait., (Copyright 2001 by W.B. Saunders Company)

The aim of this study was to cross-validate the Benzodiazepine Dependence Self-Report Questionnaire (Bendep-SRQ), which reflects the severity of benzodiazepine (BZD) dependence. The Bendep-SRQ, Symptom Checklist-90 (SCL-90) Schedules for Clinical Assessments in Neuropsychiatry (SCAN), and Addiction Severity Index-Revised (ASI-R) were administered to 102 general practice (GP) patients and 126 psychiatric outpatients who were using BZDs. The scalability and reliability of the Bendep-SRQ scales were reassessed in terms of Rasch homogeneity, subject discriminability, item discriminability, and test-retest stability. Present and original Rasch item orders were compared to evaluate construct validity. A matrix of all measures was factor-analyzed to assess concurrent and discriminant validity. The scalability of the Bendep-SRQ scales was confirmed. The reliability results were fairly good. Present and original Rasch item orders corresponded. The Bendep-SRQ scales and concurrent measures had high loadings on one factor, the discriminant measures on two other factors. In spite of some differences with respect to sociodemographic characteristics and pattern of BZD use, the cross-validation results agreed well with the results of the original study on the Bendep-SRQ. The Bendep-SRQ has presently acquired enough support of favorable and consistent results for clinical and scientific use., (Copyright 2001 by W.B. Saunders Company)

Benzodiazepines are the most prescribed drugs in the Netherlands. There is scarcely an indication for long-term benzodiazepine use. Long-term use may lead to dependency and is associated with an increased risk of accidents/falls and cognitive function impairment. Therefore national and international guidelines advocate a conservative prescription policy, especially with respect to long-term prescription. It appears that these guidelines are not followed in practice. A standard sized general practice in the Netherlands contains, on average, 75 long-term benzodiazepine users. There appear to be both patient and GP related factors which influence the maintenance of this long-term use of benzodiazepines.

Treatment strategies for discontinuing long-term benzodiazepine usage can be divided into minimal interventions and gradual discontinuation programs. Minimal interventions invite patients to quit their long-term benzodiazepine usage on their own by making them aware of the adverse effects. This type of intervention is successful in about one fifth of patients. Gradual discontinuation programs are more extensive interventions in order to help those patients who are unable to discontinue benzodiazepine use on their own. These programs are successful in two-thirds of the patients and can be combined with additional pharmacological or psychological treatment. Once the withdrawal symptoms have diminished, most patients have an improved psychological functioning compared to when they were using benzodiazepines. Furthermore, no increase in medical consumption has been found.

In this study on 99 outpatients who were being treated for alcohol and/or drug dependence and also using benzodiazepines (BZDs), prevalence rates of DSM-III-R and ICD-10 substance dependence diagnoses were ascertained and scalability, reliability and validity of the scales of the Benzodiaepine Dependence Self-Report Questionnaire (Bendep-SRQ) were assessed. The latter properties were investigated by Rasch analyses, discriminability coefficients, test-retest coefficients and factor analyses. BZD dependence was found to be a prevalent additional diagnosis. The psychometric findings appear to support the use of the Bendep-SRQ at outpatient addiction centers, which could contribute to a more differentiated treatment for poly-substance dependence.

Background: Many patients with depression take benzodiazepine drugs long term despite the absence of continuing therapeutic value., Aims: To evaluate a treatment programme involving gradual discontinuation with or without simultaneous selective serotonin reuptake inhibitor (SSRI) prescribing and to determine the long-term outcome after benzodiazepine withdrawal., Method: Patients went through three phases - change to an equivalent dose of diazepam; subsequent randomisation to either 20 mg of paroxetine or placebo; and gradual reduction of diazepam in depression-free patients - with a follow-up after 2 or 3 years., Results: A total of 230 patients were recruited and 75% in the paroxetine group and 61% in the placebo group were successfully treated after 6 weeks (P:=0.067). After 2 or 3 years 13% of patients were still benzodiazepine free: 26% of those who had successfully tapered off benzodiazepine and 6% of the total group., Conclusions: Transfer to diazepam followed by gradual withdrawal is an effective way of discontinuing chronic benzodiazepine use. The addition of SSRI treatment is of limited value.