Impaired hypothalamic-pituitary-adrenocortical (HPA) system is related to severity of benzodiazepine withdrawal in patients with depression.
A concatenation of data indicates that the pathogenesis of depression is related to an increased production and secretion of corticotropin-releasing hormone (CRH). Benzodiazepines profoundly suppress the basal and stress-related activation of the hypothalamic-pituitary-adrenocortical (HPA) system and discontinuation of these drugs results in rebound activation. We therefore investigated whether the extent of HPA system dysregulation is related to the severity of benzodiazepine withdrawal in patients with depression. We performed the combined dexamethasone/CRH test before benzodiazepine discontinuation (taper-off max. 5 mg diazepam-equivalents/week) in 14 depressed patients (13 f, 1 m, mean age 54.6 +/- 14.6) who responded to the antidepressant treatment. The severity of withdrawal symptoms was measured using the Clinical Institute Withdrawal Assessment-Benzodiazepines (CIWA-B) questionnaire. The depressive psychopathology was monitored using the Hamilton Depression Rating Scale, Montgomery Asberg Depression Rating Scale and Beck Depression Inventory. Patients with more severe benzodiazepine withdrawal (CIWA-B-increase > 14 pts; n = 7) showed a significant higher cortisol and ACTH response in the dexamethasone/CRH test preceding the discontinuation of benzodiazepines than patients displaying less severe withdrawal symptoms (CIWA-B-increase <14 pts.; n = 7) (ANCOVA, p < 0.05). Both groups did not differ in the pre-taper psychopathology ratings and their basal neuroendocrine activity. In view of the GABAergic inhibition of HPA system activity and the anxiogenic effect of CRH, benzodiazepine withdrawal symptoms may be partly due to a disinhibition of the HPA system during discontinuation of benzodiazepines.
Wichniak
Adam
A
Max Planck Institute of Psychiatry, Kraepelinstr. 10, 80804 Munich, Germany. awichniak@poczta.onet.pl
Brunner
Hans
H
Ising
Marcus
M
Pedrosa Gil
Francisco
F
Holsboer
Florian
F
Friess
Elisabeth
E
D000324:Adrenocorticotropic Hormone / Q000097:blood; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000928:Antidepressive Agents / Q000009:adverse effects* / Q000627:therapeutic use; D001569:Benzodiazepines / Q000009:adverse effects* / Q000627:therapeutic use; D001960:Bromazepam / Q000009:adverse effects / Q000627:therapeutic use; D003346:Corticotropin-Releasing Hormone; D003866:Depressive Disorder / Q000097:blood* / Q000150:complications / Q000188:drug therapy; D003907:Dexamethasone; D003975:Diazepam / Q000009:adverse effects / Q000627:therapeutic use; D005260:Female; D005938:Glucocorticoids; D006801:Humans; D006854:Hydrocortisone / Q000097:blood; D007030:Hypothalamo-Hypophyseal System / Q000187:drug effects* / Q000503:physiopathology; D008140:Lorazepam / Q000009:adverse effects / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D010912:Pituitary-Adrenal Function Tests; D010913:Pituitary-Adrenal System / Q000187:drug effects* / Q000503:physiopathology; D012720:Severity of Illness Index; D013375:Substance Withdrawal Syndrome / Q000097:blood* / Q000150:complications
D000928:Antidepressive Agents; D005938:Glucocorticoids; D001569:Benzodiazepines; D003907:Dexamethasone; D000324:Adrenocorticotropic Hormone; D003346:Corticotropin-Releasing Hormone; D008140:Lorazepam; D003975:Diazepam; D006854:Hydrocortisone; D001960:Bromazepam