ACCORDING TO Mick Jagger in his 1965 song Mother’s Little Helper, “Mother needs something to calm her down, and though she’s not really ill there’s a little yellow pill …and it helps her on her way, gets her through her busy day”.
Thus opened the RCSI MiniMed Lecture on 25 February at the Royal College of Surgeons in Ireland, delivered by Dolores Keating, Honorary Senior Clinical Lecturer at RCSI and Head of Pharmacy at Saint John of God Hospital.
The term “mother’s little helper” refers to the benzodiazepine diazepam, more commonly known as Valium. Benzodiazepine use has long been controversial, with the psychiatrist Dr David Healy referring to them as “one of the 20th century’s greatest inventions”, and Phil Woods MP citing them as “responsible for more pain, unhappiness and damage than anything else in our society”.
The history of anxiety treatment
With a strikingly visual slide show, Keating gave an entertaining history of anti-anxiety medications, from alcohol in Biblical times to a range of nineteenth-century over-the-counter nostrums, often secretly laced with cannabis, opiates, chloral hydrate or alcohol.
With early-twentieth-century Freudian psychoanalysis both expensive and time consuming, the public was receptive to medications as “a more accessible way to relieve suffering”. According to Keating, barbiturates were marketed from 1903 and sales mushroomed during World War II when they were used to treat trauma in soldiers and civilians alike. Unfortunately they were sedative, highly addictive and lethal in overdose. Marilyn Monroe was just one of many subsequent casualties.
Keating talked us through the development of meprobamate, launched in 1955 as Milltown (named after a “tranquil” little town in New Jersey). Although a survey of 200 doctors had found they wouldn’t be willing to prescribe a medication for everyday anxiety, sales of Milltown nonetheless rocketed. Tranquillisers were the new means of personal fulfilment; Schwab’s Pharmacy on Hollywood Boulevard sold it to the stars; Lucile Ball kept a stock of it on the set of I Love Lucy; Aldous Huxley gave it a glowing review; Tennessee Williams became addicted; and Salvador Dali based an entire exhibition on it.
Commodifying happiness
“Industry was suddenly interested in pills to banish anxiety,” observed Keating. “In 1960, Roche pharmaceuticals launched chlordiazepoxide as Librium (derived from ‘equilibrium’). Valium followed three years later and since then over a thousand similar compounds have been developed.”
In the television series Mad Men, Don Draper famously observes that advertising is based on happiness, which is essentially freedom from fear. In the 1960s, happiness was suddenly a commodity marketable like the latest refrigerator or television. Gender-specific advertisements shamelessly portrayed women as stereotypes: the trapped and unfulfilled housewife; the neurotic 35-year-old single who cannot find a man to marry; the menopausal teacher with mood fluctuations. Benzodiazepines would not set you free, but might allow you tolerate your situation without complaining.
Roche sold 2.3 billion Valium tablets in 1978 but by now the drug was toppling from its pedestal. Betty Ford booked herself into a rehabilitation clinic, concerned that she had begun to overmedicate herself. A wave of panic spread through America, withdrawal effects and addiction increasingly evident. Senator Edward Kennedy chaired a congressional hearing. The Boston Women’s Health Collective held protests over the portrayal of women as “a problem that needed to be medicated”. Esther Rantzen exposed benzodiazepines on the BBC’s That’s Life. The modern solution had become a postmodern problem.
How can people be helped?
Common anxiety disorders include agoraphobia, social phobia, generalised anxiety disorder, panic disorder, obsessive compulsive disorder and post-traumatic stress disorder. One in five people will acquire a diagnosable anxiety disorder during their lifetime, so how can they be helped?
With this theme in mind, Keating’s talk was followed by a panel discussion chaired by Professor Paul Gallagher of the School of Pharmacy, RCSI. The panel included: Dr Grainne Cousins of the School of Pharmacy, RCSI; Dr Mike Scully, consultant psychiatrist and chair of the Faculty of Addiction at the College of Psychiatrists of Ireland; Dr Ide Delargy, general practitioner; Ms Noeleen Harvey, community pharmacist; and Dr Keith Gaynor, senior clinical psychologist at Saint John of God Hospital, Dublin.
The panel agreed that, when used appropriately for short periods of time, benzodiazepines remain valuable medicines, especially for the treatment of acute anxiety and insomnia. They can, however, cause difficulties if inappropriately prescribed. For example, patients can become dependent on benzodiazepines if they are used regularly over a prolonged period of time. The panel stressed that benzodiazepines are generally inappropriate for older patients because of their association with falls, fractures and road traffic accidents.
Benzodiazepine use is on the rise in Ireland
The panel noted that benzodiazepine use in Ireland is increasing, especially among women. Harvey remarked on the ease with which benzodiazepines can be purchased illegally over the internet. Reasons for the rise in benzodiazepine use are unclear, but the panel cited an increase in anxiety disorders, inappropriate prescribing, poor access to psychological treatments, and lack of knowledge among patients regarding the risk of addiction. Significant health hazards were highlighted, with benzodiazepines implicated in one third of all deaths by drug poisoning between 1998 and 2007.
The panel agreed that improvements in benzodiazepine use will only be made by addressing key issues, including better access to more appropriate treatments such as cognitive behavioural therapy (CBT). Dr Gaynor observed that the NHS has channelled several hundred million pounds into the development of frontline CBT. Antidepressants – which are not addictive – may also be useful.
Time to change the record
The panel called for better education of health professionals about benzodiazepines, enhanced communication between healthcare service providers, improved data collection and research regarding benzodiazepine use, and appropriate legislative changes to protect patients from addiction. These are in line with recommendations made in 2002 by the Department of Health’s Benzodiazepine Committee.
But perhaps the last word should go to Dolores Keating, whose talk highlighted both the history and the complexity of tranquiliser usage over the last century. “A fresh approach is needed in the management of anxiety disorders. Certainly the perception of the benzodiazepine as ‘mother’s little helper’ is an antiquated one. Isn’t it time to change the record?”
Dr Stephen McWilliams is a consultant psychiatrist and author. He is clinical lead of the Psychosis Programme at Saint John of God Hospital, Stillorgan, Co Dublin. Dr McWilliams and Ms Keating are married. This event is part of the RCSI MiniMed Lecture Series. For more information on these lectures, open free of charge to the public, visit www.rcsi.ie/minimed.
To embed this post, copy the code below on your site
have your say