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Benzodiazepine prescribing behaviour and attitudes: a survey among general practitioners practicing in northern Thailand

Benzodiazepine prescribing behaviour and attitudes: a survey among general practitioners... Background: Over-prescribing of benzodiazepines appears common in many countries, a better understanding of prescribing practices and attitudes may help develop strategies to reduce prescribing. This study aimed to evaluate benzodiazepine prescribing behaviour and attitudes in general practitioners practising in Chiang Mai and Lampoon, Thailand. Methods: Questionnaire survey of general practitioners in community hospitals, to estimate: i) use of benzodiazepines for anxiety/insomnia, panic disorder, depression, essential hypertension, and uncomplicated low back pain and ii) views on the optimal duration of benzodiazepine use. Results: Fifty-five of 100 general practitioners returned the completed questionnaires. They reported use of benzodiazepines for anxiety/insomnia (n = 51, 93%), panic disorder (n = 43, 78%), depression (n = 26, 43%), essential hypertension (n = 15, 27 %) and uncomplicated low back pain (n = 10, 18%). Twenty-eight general practitioners would prescribe benzodiazepines for non- psychiatric conditions, 17 for use as muscle relaxants. Seventy-five per cent, 62% and 29% of the general practitioners agreed or totally agreed with the use of benzodiazepines for insomnia, anxiety and depression, respectively. Practitioners agreed that prescribing should be less than one week (80%); or from 1 week to 1 month (47%); or 1 to 4 months (16%); or 4 to 6 months (5%) or more than 6 months (2%). Twenty-five general practitioners (45%) accepted that they used benzodiazepines excessively in the past year. Conclusion: A considerable proportion of general practitioners in Chiang Mai and Lampoon, Thailand inappropriately use benzodiazepines for physical illnesses, especially essential hypertension and uncomplicated low back pain. However, almost half of them thought that they overused benzodiazepines. General practitioner's lack of time, knowledge and skills should be taken into account in improving prescribing behaviour and attitudes. cally significant anxiety and insomnia. They have a better Background Benzodiazepines (BZDs) are approved for treating clini- safety profile in comparison to barbiturates – their Page 1 of 5 (page number not for citation purposes) BMC Family Practice 2005, 6:27 http://www.biomedcentral.com/1471-2296/6/27 predecessors, and many physicians have overestimated scribing. We therefore proposed to evaluate the prescrib- their safety. It is now widely accepted that BZD prescribing ing behaviour and attitudes of GPs practicing in Northern has many risks, including tolerance, dependence and mis- Thailand. Two major foci of the survey were the indica- use, as well as BZD-induced depression, cognitive impair- tions for and appropriate duration of BZD treatment. ment, disinhibition and psychomotor impairment [1]. Because most GPs in developing countries are overloaded BZD has become more restricted recently. The UK data by a large number of patients in their everyday practice, sheets for diazepam and temazepam recommend that patient medical records, e.g. diagnosis, are usually not BZD should be used for short-term (2 – 4 weeks) manage- completed or inaccurate. We therefore decided to conduct ment. They are unlikely to be efficacious in the treatment a survey using mailed questionnaires. of anxiety after 4 months [2]. BZD addiction can occur when doses within the clinical range are taken regularly This survey concerned only the GPs' practice at public set- over about 6 months [3]. In addition, a recent review sug- tings, where pharmacists take a role in dispensing the pre- gests that, even in general anxiety disorder – a major indi- scribed drugs, and GPs practice as non-dispensing cation for BZDs – this treatment may do more harm than physicians. This decision was made because most Thai good [4]. physicians have their own private practice and are allowed to dispense almost all prescribed drugs, including BZDs, BZD use has been studied in high income countries, and in their private settings. The results of a previous study it appears that prescribing levels have come down as the have shown that dispensing and non-dispensing physi- risks of addiction and adverse effects have become more cians have different patterns of prescribing [13]. widely publicised [5]. However, little research has been carried out in developing countries. Limited evidence sug- Methods Study population gests that BZD use is common in these countries. A recent community survey in Lebanon found that 9.6% (N = Questionnaire survey to all 100 general practitioners 1000) of the population had taken BZD in the previous working in community hospitals located in Chiang Mai month [6]. This study also found that approximately 30% and Lampoon, Northern Thailand. of BZD users took these medications for more than 12 months. Although many developing countries allow Questionnaire BZDs to be sold over-the-counter in pharmacies, a litera- The questionnaire for this study included four parts: ture review of BZD use in Brazil found that the vast major- ity of BZD consumption was due to medical prescription i) GP's were asked to say whether they would prescribe [7]. BZDs and/or brief (3–5 minutes) supportive psychother- apy/advice for five case vignettes of anxiety/insomnia fol- While psychiatrists are specialised in caring for people lowing a stressful life event, panic disorder, depression, with mental health and substance use problems, their essential hypertension and uncomplicated low back pain numbers are very limited, especially in developing coun- (see Annex). Brief supportive psychotherapy/advice could tries. Therefore, GPs play an important role in prescribing be given by the GPs or other medical professionals in the BZDs. For example, a survey in Chile found that 69% of community hospitals. those taking BZDs received the medications from commu- nity clinics [8]. A cross-sectional study of prescriptions in ii) GPs were asked whether they agreed with the use of 3,368 patients visiting a primary health unit in Brazil also BZDs for clinically significant insomnia, anxiety and showed that 20.6% of prescriptions included BZDs [9]. A depression, as well as non-psychiatric illnesses, by using a survey of community hospitals in a rural area of Thailand 10 cm line of visual analogue scale (VAS) ranging from demonstrated that 15% of all adult outpatients received totally disagree to totally agree. A VAS score of 0.00–1.9, benzodiazepines [10]. These results seem to agree with a 2.0–3.9, 4.0–6.0, 6.1–8.0, and 8.1–10.0 were classified as previous questionnaire survey among Thai GPs, which totally disagree, disagree, neutral, agree and totally agree, found that approximately 50% of them prescribed BZDs respectively. for more than 25% of their patients [11]. As there is a trend to increase the provision of mental health care at the iii) the same VAS and its scoring system were used to ask primary care level [12], GPs may prescribe more BZDs in the GPs whether they agreed with the regular use of BZDs the future. for less than 1 week, 1 week to 1 month, more than 1 month to 4 months, more than 4 months to 6 months A survey of BZD prescribing practice and attitudes would and more than 6 months. increase understanding of BZD prescribing problems, important in developing a strategy to reduce BZD pre- Page 2 of 5 (page number not for citation purposes) BMC Family Practice 2005, 6:27 http://www.biomedcentral.com/1471-2296/6/27 Table 1: Number of GPs giving BZDs and brief supportive psychotherapy or medical advices for the 5 case vignettes (N = 55) Clinical conditions No. of GPs (%) giving BZDs No. of GPs (%) giving brief supportive psychotherapy or advice 1. Stressful life event and anxiety and insomnia 51 (92.7) 39 (70.9) 2. Panic disorder 43 (78.2) 35 (63.6) 3. Depression 26 (47.2) 29 (52.7) 4. Essential hypertension 15 (27.3) 46 (83.6) 5. Uncomplicated low back pain 10 (18.2) 38 (69.1) iv) finally, GPs were asked if they thought they over-pre- numbers of GPs giving brief supportive psychotherapy/ scribed BZDs and if so why (more than one reason could advice for anxiety/insomnia and panic disorder were be chosen). lower (22% and 15%, respectively). While 47% of the GPs would give BZDs for depression, 27% and 18% would Procedures give BZDs for essential hypertension and uncomplicated The GPs were informed that the survey did not intend to lower back pain, respectively. Of 26 GPs (47% of the GPs) assess their knowledge but wished to understand their who gave BZDs for depression, 16 of them would admin- practice. The answers should be based on their everyday ister antidepressants concurrently. practice in public settings only (mainly community hospi- tals). The GPs were also asked to return the questionnaires Agreement on the indications and durations of BZD use with no answer if: i) they did not wish to respond or ii) are shown in Table 2. In respect to indications, 75%, 62% they saw less than five adult out-patients per week. and 29% of the GPs agreed or totally agreed with the use of BZD for insomnia, anxiety, and depression, respec- To maximize responses, 6 weeks after the first mailing, we tively. Twenty-eight GPs specified the use of BZDs for sent the questionnaire to all GPs who had not replied. Six nonpsychiatric illnesses, especially the use of BZDs as weeks after the second mailing, we sent the questionnaire muscle relaxants in 17 GPs. Eighty percent, 47%, 16%, 5% for the third (and last) time to GPs who had still not and 2% of the GPs agreed or totally agreed with the regu- responded. The survey was carried out between July and lar treatment of BZD for less than 1 week, 1 week – 1 November 2003. month, more than 1 month – 4 month, more than 4 months – 6 months and more than 6 months, Statistical analysis respectively. Descriptive statistics (percentages, means and standard deviations) were calculated. Twenty-five GPs (45.5%) accepted that they excessively used BZDs in the past year. The reasons for the over-pre- scribing were lack of time (17 responses), lack of knowl- Results Fifty-eight of 100 GPs (58%) returned the questionnaires edge and skills (14 responses), intention to keep doctor- to us. Three were excluded; two GPs refused to answer the patient relationship (i.e., patient demand -13 responses), questionnaire, and another one saw less than five adult lack of alternative treatment to BZDs (12 responses) and patients per week. Questionnaires from 55 GPs (32 males saving costs (10 responses). and 23 females) were subsequently analyzed. The GPs mean (SD) age in years was 31.6 (7.1), with a mean of 6.7 Discussion (5.8) years in practice and working for an average of 38.7 This survey was conducted in young Thai GPs practicing (18.2) hours per week. The mean number of patients seen in community hospitals. One of the surprising findings per week (SD) was 392.8 (243.9). Of 13 GPs who had spe- was these doctors reported that they would use BZDs for cial training, four were paediatricians, three were essential hypertension and uncomplicated low back pain, internists, two each were surgeons and orthopaedists, and as well as the use as muscle relaxants. Almost half of the there was one family practitioner and one obstetrician/ GPs agree that they over-prescribe BZDs. gynaecologist. BZD prescribing for essential hypertension and low back Table 1 shows the number of GPs giving BZDs and brief pain is relatively common in developing countries [10]. supportive psychotherapy/advice for the 5 case vignettes. Although there is some evidence supporting the benefits The majority of GPs would give BZDs for anxiety/insom- of BZDs for these conditions [14-16], the administration nia following a stressful life event and panic disorder. The of these drugs may be detrimental [17]. This practice Page 3 of 5 (page number not for citation purposes) BMC Family Practice 2005, 6:27 http://www.biomedcentral.com/1471-2296/6/27 Table 2: Agreement on the use of BZD assessed by using a 10 cm line of visual analogue scale from totally disagree to totally agree* Issues Totally disagree, n (%) Disagree, n (%) Neutral, n (%) Agree, n (%) Totally agree, n (%) 1. For clinically significant insomnia 2 (3.6) 1 (1.8) 11 (20.0) 14 (25.5) 27 (49.1) 2. For clinically significant anxiety 7 (12.7) 4 (7.3) 10 (18.2) 15 (27.3) 19 (34.5) 3. For clinically significant depression 16 (29.1) 11 (20.0) 12 (21.8) 5 (9.1) 11 (20.0) 4. For regular use of less than 1 week 2 (3.6) 1 (1.8) 8 (14.5) 13 (23.6) 31 (56.4) 5. For regular use of 1 week – 1 month 15 (27.3) 2 (3.6) 12 (21.8) 15 (27.3) 11 (20.0) 6. For regular use of more than 1 month – 4 28 (50.9) 10 (18.2) 8 (14.5) 5 (9.1) 4 (7.3) months 7. For regular use of more than 4 months – 6 39 (70.9) 9 (16.4) 4 (7.3) 1 (1.8) 2 (3.6) months 8. For regular use of more than 6 months 47 (85.5) 4 (7.3) 3 (5.5) 0 (0.0) 1 (1.8) *A VAS score of 0.00–1.9, 2.0–3.9, 4.0–6.0, 6.1–8.0, and 8.1–10.0 were classified as totally disagree, disagree, neutral, agree, and totally agree should be obsolete as a number of inexpensive drugs with reflect the 'real world' practice. As most physicians have preferred risk/benefit profiles are widely available, e.g., realized the detrimental effects of BZDs, the answers of propanolol, orphenadrine citrate. many respondents may be based on their knowledge, or what they perceive to be 'best practice', but not their actual The results of this and previous studies [18] demonstrate practice. Due to this limitation, we focus our interpreta- that BZD prescribing is a dilemma for GPs. Many of them tion and discussion only on outstanding findings, e.g., the realize the harmful effects of BZDs, but cannot control use of BZDs for physical illnesses, the acceptance of BZD their prescribing. Improvement of knowledge and skills over-prescribing. Second, the moderate response rate alone may not solve the problem. GPs in this survey have (58%) of this survey may have some impact on the valid- to see approximately 10 patients per hour, and this time ity of this study. Third, the results of present study may pressure should be taken into account in developing any not be widely applicable because the GPs in Thailand may strategy to solve the problem. have different backgrounds from those in other parts of the world, e.g., culture, education, health care systems. The findings of this survey are helpful in developing a However, the findings may provide insight for further strategy to reduce BZD use, especially among GPs practic- studies elsewhere particularly developing countries. Last, ing in developing countries. Because almost half of the most (16 of 26) GPs who gave BZDs for treating depres- GPs have already identified BZD prescribing as a problem, sion would also administer antidepressants concurrently. a simple and practical strategy to reduce prescribing BZDs and anti-depressants should not be co-prescribed would be welcomed. As lack of knowledge and skills con- for longer than four weeks [20]. As the survey did not tributes to the problem, an educational programme assess duration of BZD co-prescribing in depressed should be a part of the strategy. Firm evidence showing patients, we cannot determine the appropriateness of that fluoxetine can be used to treat patients with anxiety these co-prescriptions. and/or depression safely and cost-effectively in primary care settings of low-income countries [19] should be pre- Conclusion sented to the GPs. GPs perceived causes of BZD over-pre- This survey found that a considerable proportion of GPs scribing, e.g., lack of knowledge and skills, lack of in Chiang Mai and Lampoon, Thailand inappropriately alternative treatment to BZDs and saving cost of treat- use BZDs for physical illnesses, especially essential hyper- ment, could be solved. Improving GPs' communication tension and uncomplicated low back pain. However, and training other health professionals, e.g., nurses, to many GPs are aware that they over-prescribe BZDs. The provide brief supportive psychotherapy/advice may be problems of lack of time, knowledge and skills should be also helpful, especially, in maintaining health profes- taken into account in improving the prescribing behav- sional-patient relationship. In addition, this can be used iour and attitude. as an alternative or an adjunct to BZD treatment. Because sufficient consultation time is a key for quality patient List of abbreviations care, it should be kept in mind that the impact of any strat- BZD = benzodiazepine egy may be reduced if this problem cannot be mitigated. GP = general practitioner Some limitations should be considered in interpreting the study findings. First, a questionnaire survey may not VAS = visual analog scale Page 4 of 5 (page number not for citation purposes) BMC Family Practice 2005, 6:27 http://www.biomedcentral.com/1471-2296/6/27 13. Trap B, Hansen EH, Hogerzeil HV: Prescription habits of dispens- Competing interests ing and non-dispensing doctors in Zimbabwe. Health Policy Plan The author(s) declare that they have no competing 2002, 17:288-295. interests. 14. Pozenel H, Buckert A, Amrein R: The antihypertensive effect of lexotan (bromazepam) – a new benzodiazepine derivative. Int J Clin Pharmacol Biopharm 1977, 15:31-39. Authors' contributions 15. Lasagna L: The role of benzodiazepines in nonpsychiatric med- ical practice. Am J Psychiatry 1977, 134:656-658. MS conceived and initiated the study, conducted the sur- 16. Van Tulder MW, Touray T, Furlan AD, Solway S, Bouter LM: Muscle vey and analyzed the data. PG and JC conceived and initi- relaxants for nonspecific low back pain: a systematic review ated the study. NW conducted the survey. All authors within the framework of the Cochrane Collaboration. Spine 2003, 28:1978-1992. participated in the writing of successive drafts of the man- 17. Krogh C, McLean WM, LaPierre YD: Minor transquillizers in uscript and all have read and approved the final somatic disorders. Can Med Assoc J 1978, 118:1097-1108. manuscript. 18. Bendtsen P, Hensing G, McKenzie L, Stridsman AK: Prescribing benzodiazepines – a critical incident study of a physician dilemma. Soc Sci Med 1999, 49:459-467. Additional material 19. Patel V, Chisholm D, Rabe-Hesketh S, Dias-Saxena F, Andrew G, Mann A: Efficacy and cost-effectiveness of drug and psycho- logical treatments for common mental disorders in general health care in Goa, India: a randomised, controlled trial. Lan- Additional File 1 cet 2003, 361:33-39. Five case vignettes used in the survey. 20. Furukawa TA, Streiner DL, Young LT: Is antidepressant-benzodi- Click here for file azepine combination therapy clinically more useful? A meta- [http://www.biomedcentral.com/content/supplementary/1471- analytic study. J Affect Disord 2001, 65:173-177. 2296-6-27-S1.pdf] Pre-publication history The pre-publication history for this paper can be accessed here: Acknowledgements This study was supported by a grant from Effective Health Care Programme http://www.biomedcentral.com/1471-2296/6/27/prepub Alliance, International Health Research Group, Liverpool School of Tropi- cal Medicine, Liverpool, U.K. The authors would like to thank the 58 general practitioners who responded to our mailed questionnaires. References 1. Royal College of Psychiatrists: Benzodiazepines: risks, benefits or dependence – a re-evaluation (Council Report CR 59) London: Royal Col- lege of Psychiatrists; 1997. 2. Committee on the review of medicines: Systematic review of the benzodiazepines. BMJ 1980, 280:910-912. 3. Uhlenhuth BH, DeWit H, Balter MB, Johanson CE, Mellinger GD: Risks and benefits of long-term benzodiazepine use. J Clin Psychopharmacol 1988, 8:161-167. 4. Tonks A: Extracts from "Best Treatments": treating general- ized anxiety disorder. BMJ 2003, 326:700-702. 5. van Hulten R, Leufkens HG, Bakker A: Usage patterns of benzo- diazepines in a Dutch community: a 10 year follow up. Pharm World Sci 1998, 20:78-82. 6. Naja WJ, Pelissolo A, Haddad RS, Baddoura R, Baddoura C: A gen- eral population survey on patterns of benzodiazepine use and dependence in Lebanon. Acta Psychiatr Scand 2000, 102:429-431. 7. Kapczinski F, Amaral OB, Madruga M, Quevedo J, Busnello JV, de Lima MS: Use and misuse of benzodiazepines in Brazil: a review. Publish with Bio Med Central and every Subst Use Misuse 2001, 36:1053-1069. scientist can read your work free of charge 8. Busto UE, Ruiz I, Busto M, Gacitua A: Benzodiazepine use in Chile: impact of availability on use, abuse, and dependence. "BioMed Central will be the most significant development for J Clin Psychopharmacol 1996, 16:363-372. disseminating the results of biomedical researc h in our lifetime." 9. Horta BL, de Lima MS, Faleiros JJ, Weiderpass E, Horta RL: Benzo- diazepines: prescription study in a primary health care unit. Sir Paul Nurse, Cancer Research UK Revista da Associacao Medica Brasileira 1994, 40:262-264. Your research papers will be: 10. Chuyana N, Garner P: Primary care nurses using guidelines in Thailand: a randomised controlled trial. . in submission available free of charge to the entire biomedical community 11. Saipanish R, Zartrungpak S, Silpakit C: A survey of psychotropic peer reviewed and published immediately upon acceptance drug prescription of general practitioners in primary care settings. Journal of the Psychiatric Association of Thailand 1998, cited in PubMed and archived on PubMed Central 43:316-324. in Thai yours — you keep the copyright 12. World Health Organization: World Health Report 2001 Geneva: World Health Organization; 2001. 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Benzodiazepine prescribing behaviour and attitudes: a survey among general practitioners practicing in northern Thailand

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Springer Journals
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Copyright © 2005 by Srisurapanont et al; licensee BioMed Central Ltd.
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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1471-2296
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15975145
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Abstract

Background: Over-prescribing of benzodiazepines appears common in many countries, a better understanding of prescribing practices and attitudes may help develop strategies to reduce prescribing. This study aimed to evaluate benzodiazepine prescribing behaviour and attitudes in general practitioners practising in Chiang Mai and Lampoon, Thailand. Methods: Questionnaire survey of general practitioners in community hospitals, to estimate: i) use of benzodiazepines for anxiety/insomnia, panic disorder, depression, essential hypertension, and uncomplicated low back pain and ii) views on the optimal duration of benzodiazepine use. Results: Fifty-five of 100 general practitioners returned the completed questionnaires. They reported use of benzodiazepines for anxiety/insomnia (n = 51, 93%), panic disorder (n = 43, 78%), depression (n = 26, 43%), essential hypertension (n = 15, 27 %) and uncomplicated low back pain (n = 10, 18%). Twenty-eight general practitioners would prescribe benzodiazepines for non- psychiatric conditions, 17 for use as muscle relaxants. Seventy-five per cent, 62% and 29% of the general practitioners agreed or totally agreed with the use of benzodiazepines for insomnia, anxiety and depression, respectively. Practitioners agreed that prescribing should be less than one week (80%); or from 1 week to 1 month (47%); or 1 to 4 months (16%); or 4 to 6 months (5%) or more than 6 months (2%). Twenty-five general practitioners (45%) accepted that they used benzodiazepines excessively in the past year. Conclusion: A considerable proportion of general practitioners in Chiang Mai and Lampoon, Thailand inappropriately use benzodiazepines for physical illnesses, especially essential hypertension and uncomplicated low back pain. However, almost half of them thought that they overused benzodiazepines. General practitioner's lack of time, knowledge and skills should be taken into account in improving prescribing behaviour and attitudes. cally significant anxiety and insomnia. They have a better Background Benzodiazepines (BZDs) are approved for treating clini- safety profile in comparison to barbiturates – their Page 1 of 5 (page number not for citation purposes) BMC Family Practice 2005, 6:27 http://www.biomedcentral.com/1471-2296/6/27 predecessors, and many physicians have overestimated scribing. We therefore proposed to evaluate the prescrib- their safety. It is now widely accepted that BZD prescribing ing behaviour and attitudes of GPs practicing in Northern has many risks, including tolerance, dependence and mis- Thailand. Two major foci of the survey were the indica- use, as well as BZD-induced depression, cognitive impair- tions for and appropriate duration of BZD treatment. ment, disinhibition and psychomotor impairment [1]. Because most GPs in developing countries are overloaded BZD has become more restricted recently. The UK data by a large number of patients in their everyday practice, sheets for diazepam and temazepam recommend that patient medical records, e.g. diagnosis, are usually not BZD should be used for short-term (2 – 4 weeks) manage- completed or inaccurate. We therefore decided to conduct ment. They are unlikely to be efficacious in the treatment a survey using mailed questionnaires. of anxiety after 4 months [2]. BZD addiction can occur when doses within the clinical range are taken regularly This survey concerned only the GPs' practice at public set- over about 6 months [3]. In addition, a recent review sug- tings, where pharmacists take a role in dispensing the pre- gests that, even in general anxiety disorder – a major indi- scribed drugs, and GPs practice as non-dispensing cation for BZDs – this treatment may do more harm than physicians. This decision was made because most Thai good [4]. physicians have their own private practice and are allowed to dispense almost all prescribed drugs, including BZDs, BZD use has been studied in high income countries, and in their private settings. The results of a previous study it appears that prescribing levels have come down as the have shown that dispensing and non-dispensing physi- risks of addiction and adverse effects have become more cians have different patterns of prescribing [13]. widely publicised [5]. However, little research has been carried out in developing countries. Limited evidence sug- Methods Study population gests that BZD use is common in these countries. A recent community survey in Lebanon found that 9.6% (N = Questionnaire survey to all 100 general practitioners 1000) of the population had taken BZD in the previous working in community hospitals located in Chiang Mai month [6]. This study also found that approximately 30% and Lampoon, Northern Thailand. of BZD users took these medications for more than 12 months. Although many developing countries allow Questionnaire BZDs to be sold over-the-counter in pharmacies, a litera- The questionnaire for this study included four parts: ture review of BZD use in Brazil found that the vast major- ity of BZD consumption was due to medical prescription i) GP's were asked to say whether they would prescribe [7]. BZDs and/or brief (3–5 minutes) supportive psychother- apy/advice for five case vignettes of anxiety/insomnia fol- While psychiatrists are specialised in caring for people lowing a stressful life event, panic disorder, depression, with mental health and substance use problems, their essential hypertension and uncomplicated low back pain numbers are very limited, especially in developing coun- (see Annex). Brief supportive psychotherapy/advice could tries. Therefore, GPs play an important role in prescribing be given by the GPs or other medical professionals in the BZDs. For example, a survey in Chile found that 69% of community hospitals. those taking BZDs received the medications from commu- nity clinics [8]. A cross-sectional study of prescriptions in ii) GPs were asked whether they agreed with the use of 3,368 patients visiting a primary health unit in Brazil also BZDs for clinically significant insomnia, anxiety and showed that 20.6% of prescriptions included BZDs [9]. A depression, as well as non-psychiatric illnesses, by using a survey of community hospitals in a rural area of Thailand 10 cm line of visual analogue scale (VAS) ranging from demonstrated that 15% of all adult outpatients received totally disagree to totally agree. A VAS score of 0.00–1.9, benzodiazepines [10]. These results seem to agree with a 2.0–3.9, 4.0–6.0, 6.1–8.0, and 8.1–10.0 were classified as previous questionnaire survey among Thai GPs, which totally disagree, disagree, neutral, agree and totally agree, found that approximately 50% of them prescribed BZDs respectively. for more than 25% of their patients [11]. As there is a trend to increase the provision of mental health care at the iii) the same VAS and its scoring system were used to ask primary care level [12], GPs may prescribe more BZDs in the GPs whether they agreed with the regular use of BZDs the future. for less than 1 week, 1 week to 1 month, more than 1 month to 4 months, more than 4 months to 6 months A survey of BZD prescribing practice and attitudes would and more than 6 months. increase understanding of BZD prescribing problems, important in developing a strategy to reduce BZD pre- Page 2 of 5 (page number not for citation purposes) BMC Family Practice 2005, 6:27 http://www.biomedcentral.com/1471-2296/6/27 Table 1: Number of GPs giving BZDs and brief supportive psychotherapy or medical advices for the 5 case vignettes (N = 55) Clinical conditions No. of GPs (%) giving BZDs No. of GPs (%) giving brief supportive psychotherapy or advice 1. Stressful life event and anxiety and insomnia 51 (92.7) 39 (70.9) 2. Panic disorder 43 (78.2) 35 (63.6) 3. Depression 26 (47.2) 29 (52.7) 4. Essential hypertension 15 (27.3) 46 (83.6) 5. Uncomplicated low back pain 10 (18.2) 38 (69.1) iv) finally, GPs were asked if they thought they over-pre- numbers of GPs giving brief supportive psychotherapy/ scribed BZDs and if so why (more than one reason could advice for anxiety/insomnia and panic disorder were be chosen). lower (22% and 15%, respectively). While 47% of the GPs would give BZDs for depression, 27% and 18% would Procedures give BZDs for essential hypertension and uncomplicated The GPs were informed that the survey did not intend to lower back pain, respectively. Of 26 GPs (47% of the GPs) assess their knowledge but wished to understand their who gave BZDs for depression, 16 of them would admin- practice. The answers should be based on their everyday ister antidepressants concurrently. practice in public settings only (mainly community hospi- tals). The GPs were also asked to return the questionnaires Agreement on the indications and durations of BZD use with no answer if: i) they did not wish to respond or ii) are shown in Table 2. In respect to indications, 75%, 62% they saw less than five adult out-patients per week. and 29% of the GPs agreed or totally agreed with the use of BZD for insomnia, anxiety, and depression, respec- To maximize responses, 6 weeks after the first mailing, we tively. Twenty-eight GPs specified the use of BZDs for sent the questionnaire to all GPs who had not replied. Six nonpsychiatric illnesses, especially the use of BZDs as weeks after the second mailing, we sent the questionnaire muscle relaxants in 17 GPs. Eighty percent, 47%, 16%, 5% for the third (and last) time to GPs who had still not and 2% of the GPs agreed or totally agreed with the regu- responded. The survey was carried out between July and lar treatment of BZD for less than 1 week, 1 week – 1 November 2003. month, more than 1 month – 4 month, more than 4 months – 6 months and more than 6 months, Statistical analysis respectively. Descriptive statistics (percentages, means and standard deviations) were calculated. Twenty-five GPs (45.5%) accepted that they excessively used BZDs in the past year. The reasons for the over-pre- scribing were lack of time (17 responses), lack of knowl- Results Fifty-eight of 100 GPs (58%) returned the questionnaires edge and skills (14 responses), intention to keep doctor- to us. Three were excluded; two GPs refused to answer the patient relationship (i.e., patient demand -13 responses), questionnaire, and another one saw less than five adult lack of alternative treatment to BZDs (12 responses) and patients per week. Questionnaires from 55 GPs (32 males saving costs (10 responses). and 23 females) were subsequently analyzed. The GPs mean (SD) age in years was 31.6 (7.1), with a mean of 6.7 Discussion (5.8) years in practice and working for an average of 38.7 This survey was conducted in young Thai GPs practicing (18.2) hours per week. The mean number of patients seen in community hospitals. One of the surprising findings per week (SD) was 392.8 (243.9). Of 13 GPs who had spe- was these doctors reported that they would use BZDs for cial training, four were paediatricians, three were essential hypertension and uncomplicated low back pain, internists, two each were surgeons and orthopaedists, and as well as the use as muscle relaxants. Almost half of the there was one family practitioner and one obstetrician/ GPs agree that they over-prescribe BZDs. gynaecologist. BZD prescribing for essential hypertension and low back Table 1 shows the number of GPs giving BZDs and brief pain is relatively common in developing countries [10]. supportive psychotherapy/advice for the 5 case vignettes. Although there is some evidence supporting the benefits The majority of GPs would give BZDs for anxiety/insom- of BZDs for these conditions [14-16], the administration nia following a stressful life event and panic disorder. The of these drugs may be detrimental [17]. This practice Page 3 of 5 (page number not for citation purposes) BMC Family Practice 2005, 6:27 http://www.biomedcentral.com/1471-2296/6/27 Table 2: Agreement on the use of BZD assessed by using a 10 cm line of visual analogue scale from totally disagree to totally agree* Issues Totally disagree, n (%) Disagree, n (%) Neutral, n (%) Agree, n (%) Totally agree, n (%) 1. For clinically significant insomnia 2 (3.6) 1 (1.8) 11 (20.0) 14 (25.5) 27 (49.1) 2. For clinically significant anxiety 7 (12.7) 4 (7.3) 10 (18.2) 15 (27.3) 19 (34.5) 3. For clinically significant depression 16 (29.1) 11 (20.0) 12 (21.8) 5 (9.1) 11 (20.0) 4. For regular use of less than 1 week 2 (3.6) 1 (1.8) 8 (14.5) 13 (23.6) 31 (56.4) 5. For regular use of 1 week – 1 month 15 (27.3) 2 (3.6) 12 (21.8) 15 (27.3) 11 (20.0) 6. For regular use of more than 1 month – 4 28 (50.9) 10 (18.2) 8 (14.5) 5 (9.1) 4 (7.3) months 7. For regular use of more than 4 months – 6 39 (70.9) 9 (16.4) 4 (7.3) 1 (1.8) 2 (3.6) months 8. For regular use of more than 6 months 47 (85.5) 4 (7.3) 3 (5.5) 0 (0.0) 1 (1.8) *A VAS score of 0.00–1.9, 2.0–3.9, 4.0–6.0, 6.1–8.0, and 8.1–10.0 were classified as totally disagree, disagree, neutral, agree, and totally agree should be obsolete as a number of inexpensive drugs with reflect the 'real world' practice. As most physicians have preferred risk/benefit profiles are widely available, e.g., realized the detrimental effects of BZDs, the answers of propanolol, orphenadrine citrate. many respondents may be based on their knowledge, or what they perceive to be 'best practice', but not their actual The results of this and previous studies [18] demonstrate practice. Due to this limitation, we focus our interpreta- that BZD prescribing is a dilemma for GPs. Many of them tion and discussion only on outstanding findings, e.g., the realize the harmful effects of BZDs, but cannot control use of BZDs for physical illnesses, the acceptance of BZD their prescribing. Improvement of knowledge and skills over-prescribing. Second, the moderate response rate alone may not solve the problem. GPs in this survey have (58%) of this survey may have some impact on the valid- to see approximately 10 patients per hour, and this time ity of this study. Third, the results of present study may pressure should be taken into account in developing any not be widely applicable because the GPs in Thailand may strategy to solve the problem. have different backgrounds from those in other parts of the world, e.g., culture, education, health care systems. The findings of this survey are helpful in developing a However, the findings may provide insight for further strategy to reduce BZD use, especially among GPs practic- studies elsewhere particularly developing countries. Last, ing in developing countries. Because almost half of the most (16 of 26) GPs who gave BZDs for treating depres- GPs have already identified BZD prescribing as a problem, sion would also administer antidepressants concurrently. a simple and practical strategy to reduce prescribing BZDs and anti-depressants should not be co-prescribed would be welcomed. As lack of knowledge and skills con- for longer than four weeks [20]. As the survey did not tributes to the problem, an educational programme assess duration of BZD co-prescribing in depressed should be a part of the strategy. Firm evidence showing patients, we cannot determine the appropriateness of that fluoxetine can be used to treat patients with anxiety these co-prescriptions. and/or depression safely and cost-effectively in primary care settings of low-income countries [19] should be pre- Conclusion sented to the GPs. GPs perceived causes of BZD over-pre- This survey found that a considerable proportion of GPs scribing, e.g., lack of knowledge and skills, lack of in Chiang Mai and Lampoon, Thailand inappropriately alternative treatment to BZDs and saving cost of treat- use BZDs for physical illnesses, especially essential hyper- ment, could be solved. Improving GPs' communication tension and uncomplicated low back pain. However, and training other health professionals, e.g., nurses, to many GPs are aware that they over-prescribe BZDs. The provide brief supportive psychotherapy/advice may be problems of lack of time, knowledge and skills should be also helpful, especially, in maintaining health profes- taken into account in improving the prescribing behav- sional-patient relationship. In addition, this can be used iour and attitude. as an alternative or an adjunct to BZD treatment. Because sufficient consultation time is a key for quality patient List of abbreviations care, it should be kept in mind that the impact of any strat- BZD = benzodiazepine egy may be reduced if this problem cannot be mitigated. GP = general practitioner Some limitations should be considered in interpreting the study findings. First, a questionnaire survey may not VAS = visual analog scale Page 4 of 5 (page number not for citation purposes) BMC Family Practice 2005, 6:27 http://www.biomedcentral.com/1471-2296/6/27 13. Trap B, Hansen EH, Hogerzeil HV: Prescription habits of dispens- Competing interests ing and non-dispensing doctors in Zimbabwe. Health Policy Plan The author(s) declare that they have no competing 2002, 17:288-295. interests. 14. Pozenel H, Buckert A, Amrein R: The antihypertensive effect of lexotan (bromazepam) – a new benzodiazepine derivative. Int J Clin Pharmacol Biopharm 1977, 15:31-39. Authors' contributions 15. Lasagna L: The role of benzodiazepines in nonpsychiatric med- ical practice. Am J Psychiatry 1977, 134:656-658. MS conceived and initiated the study, conducted the sur- 16. Van Tulder MW, Touray T, Furlan AD, Solway S, Bouter LM: Muscle vey and analyzed the data. PG and JC conceived and initi- relaxants for nonspecific low back pain: a systematic review ated the study. NW conducted the survey. All authors within the framework of the Cochrane Collaboration. Spine 2003, 28:1978-1992. participated in the writing of successive drafts of the man- 17. Krogh C, McLean WM, LaPierre YD: Minor transquillizers in uscript and all have read and approved the final somatic disorders. Can Med Assoc J 1978, 118:1097-1108. manuscript. 18. Bendtsen P, Hensing G, McKenzie L, Stridsman AK: Prescribing benzodiazepines – a critical incident study of a physician dilemma. Soc Sci Med 1999, 49:459-467. Additional material 19. Patel V, Chisholm D, Rabe-Hesketh S, Dias-Saxena F, Andrew G, Mann A: Efficacy and cost-effectiveness of drug and psycho- logical treatments for common mental disorders in general health care in Goa, India: a randomised, controlled trial. Lan- Additional File 1 cet 2003, 361:33-39. Five case vignettes used in the survey. 20. Furukawa TA, Streiner DL, Young LT: Is antidepressant-benzodi- Click here for file azepine combination therapy clinically more useful? A meta- [http://www.biomedcentral.com/content/supplementary/1471- analytic study. J Affect Disord 2001, 65:173-177. 2296-6-27-S1.pdf] Pre-publication history The pre-publication history for this paper can be accessed here: Acknowledgements This study was supported by a grant from Effective Health Care Programme http://www.biomedcentral.com/1471-2296/6/27/prepub Alliance, International Health Research Group, Liverpool School of Tropi- cal Medicine, Liverpool, U.K. The authors would like to thank the 58 general practitioners who responded to our mailed questionnaires. References 1. Royal College of Psychiatrists: Benzodiazepines: risks, benefits or dependence – a re-evaluation (Council Report CR 59) London: Royal Col- lege of Psychiatrists; 1997. 2. Committee on the review of medicines: Systematic review of the benzodiazepines. BMJ 1980, 280:910-912. 3. Uhlenhuth BH, DeWit H, Balter MB, Johanson CE, Mellinger GD: Risks and benefits of long-term benzodiazepine use. J Clin Psychopharmacol 1988, 8:161-167. 4. 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Horta BL, de Lima MS, Faleiros JJ, Weiderpass E, Horta RL: Benzo- diazepines: prescription study in a primary health care unit. Sir Paul Nurse, Cancer Research UK Revista da Associacao Medica Brasileira 1994, 40:262-264. Your research papers will be: 10. Chuyana N, Garner P: Primary care nurses using guidelines in Thailand: a randomised controlled trial. . in submission available free of charge to the entire biomedical community 11. Saipanish R, Zartrungpak S, Silpakit C: A survey of psychotropic peer reviewed and published immediately upon acceptance drug prescription of general practitioners in primary care settings. Journal of the Psychiatric Association of Thailand 1998, cited in PubMed and archived on PubMed Central 43:316-324. in Thai yours — you keep the copyright 12. World Health Organization: World Health Report 2001 Geneva: World Health Organization; 2001. 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