Man is tormented by no greater anxiety than to find someone quickly to whom he can hand over that great gift of freedom with which the ill-fated creature is born.
—Fyodor Dostoevsky, The Brothers Karamazov
Several months ago, a new psychiatrist came from a prestigious university in the Northeast to work in the VA hospital out West where I practice. During one of our initial conversations, he expressed the emphatic view that "benzodiazepines are only useful for acute alcohol withdrawal or psychiatric emergencies and other than that they have no place in pharmacology." I juxtaposed this position with that of several of our older clinicians, who are equally strong advocates of the generous use of benzodiazepines for a variety of psychiatric symptoms.
I mentioned this marked difference of opinion among our service to a wise mentor who responded, "benzodiazepines are a religion and this new fellow is an atheist while the others are true believers." While I am sure he meant the statement somewhat ironically, it started me thinking about the subject of science and faith in pharmacology and how this particular class of medications arouses passionate, even sectarian, divisions reminiscent of religious debates. This was not an entirely novel line of thought for me, since I can recall as a resident being struck by the wide and intense spectrum of theory and protocol among the attendings regarding benzodiazepines, especially for patients with a history of substance abuse. I once drew the diagram below to illustrate the polemic and have since employed it with my own residents to illustrate the divergence of faculty perspectives (Figure).
The science of benzodiazepines is not nearly as controversial as the faith.I was fortunate enough to have trained under Dr E. H. Uhlenhuth, one of the world's foremost experts on benzodiazepines. In a series of rigorous reviews and elegant clinical studies,1-3 he has defended these much-maligned medications, as in the following abstract:
"Despite a sharp decline in the prescription of benzodiazepines during the past decade, reservations about their use have continued to escalate. . . . Data from . . . diverse sources . . . 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."4
The last statement of this passage returns to our theme that it is more likely that provider perspectives, rather than cold clinical facts, underlie the immense light and heat surrounding these agents. In an excellent review of the history of attitudes toward benzodiazepines, Rosenbaum5 points out that despite the beneficial aspects of these nearly 4-decade-old drugs, there have been persistent concerns that benzodiazepines were being overprescribed and abused and that the risks of physical dependence and withdrawal were being underplayed. In contrast, proponents of the agents have argued that these objections diminish and dismiss the suffering and severity of anxiety disorders and insomnia.
In an essay in 1972, Klerman6 had characterized these 2 opposing perspectives toward the use of medications that relieve distress with the quasi-theological or moral terms, "pharmacological Calvinism" and "psychotropic hedonism." Kramer,7 in the best-selling Listening to Prozac, revisited this contrast with reference to the mood-brightening properties of fluoxetine. In a footnote in this book, Kramer mentions that, "In the 1980s Klerman told me he wished he had instead used the phrase 'pharmacological puritanism,' as more expressive of the judgmental and prohibitive quality of the objection to medication." For readers for whom it has been a few years since they took a philosophy or religion class, I would like to briefly review the historical schools of puritanism and hedonism to see what, in fact, they have to say about this contemporary issue in modern psychiatry.