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Adverse Psychological Reactions. (An Assessment of 16,000 Cases) N

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Adverse Psychological Reactions. (An Assessment of 16,000 Cases) N Complications of Intravenous Diazepam Adverse Psychological Reactions. (An assessment of 16,000 cases) N. Bruce Litchfield, M.D.S., F.R.A.C.D.S. INTRODUCTION of schizophrenic disorders such as autism, paranoid The author is presently engaged in an assessment delusions and hallucinations. Another' found that of 16,000 cases overall, including seven detailed diazepam was more effective with patients in the psy- studies of 6,000 cases over a thirteen year period choneurotic category but found that the eight pa- where intravenous diazepam has been used in general tients examined with phobic reactions had the least dental practice in order to determine the incidence successful response. of complications. It is well established that diazepam causes depres- The benzodiazepines have been proved to be sion and 'suicidal tendencies in quite a high propor- relatively free of side effects compared with the tion of patients who are on long term oral diazepam phenothiazines, barbiturates and most other therapy5'8 It was even stated8 that diazepam no longer similar drugs. However, they do produce some can be recommended as a useful drug in psychiatric complications, which are related to their emotional illness, but is recommended for the alleviation of and prolonged central depressant effects. The limbic anxiety in those suffering from psyehoneuroses, and system of the brain contains many reverberatory must be used with special caution in psychotic or circuits and the benzodiazepines, by interfering with severely depressed patients. The effects of 30 mg. of transmission, can affect mood and memory. diazepam or 45 mg. of phenelyzine were compared' Of the benzodiazepines, diazepam, flunitrazepam in patients who were divided into depression sub- and lorazepami have been used intravenously. Mid- types instead of their responses and found that there azolam, a new product which shows promise, is still was a significant number of anxious patients who undergoing clinical trials. Diazepam is the onlv bein- responded to diazepam but it was a poor treatment zodiazepine available for intravenous use in Australia for hostile depressives. These patients were restless, and has been proved to be very useful in dentistrv anxious, negativistic, suspicious and irritable. Oxa- since 1967. zepam did not appear to provoke these reactions The complications of diazepamn, previously noted, and the potential of diazepam for provoking them largely relate to long term oral administration ancl might be related to its unusually slow metabolic con- most research has been devoted to this. Much less version to oxazepam in certain individuals. These research has been done relating to its parenteral untoward effects have also been observed in normal administration, particularly in the comparatively subjects. 1 12 large single doses commonlv used in dentistrv on Soon after diazepam was used intravenously in amlulant and reasonably healthy patients. It has i)een dentistry in 1967, it was found that adverse psycho- well stated recently bv Donaldson and Gibson' that logical reactions occurred at a relatively high fre- reports in the literature of complicationis of intra- quency in children, adolescents and those psycho- venous diazepam have been sparse, indicating its logically disturbed. These reactions made operating high therapeutic index. conditions difficult even though patients may have Diazepam is administered because of its sedating, been amnesic at the time. Carmichael and McDonald tranquilizing, amnesic aind relaxing properties. If an " found several cases in which intravenous diazepam opposite (paradoxical) reaction occurs, it is classified was ineffective in tranquilizing adult patients and that as an adverse psychological reaction anid it is these they were unable to claim a success rate of greater that the author reports on. than 60-70% of the age group 7-16 years and that there is a hard core of adults and children on whom REVIEW OF satisfactory operating conditions cannot be achieved LITERATURE with any of the currently available sedation tech- Adverse psychological reactions to oral diazepam niques. Foreman'4 commented that no single method were found SOOI1 after the drug was first produced. of sedation is a panacea and although the majority One report2 stated that (liazepamn (lid not help of difficult patients respond well to intravenous di- chronic schizophrenic patients when given in the azepam, there are some highly resistant, often psy- dosage of 30 mg. daily. Another3 found that while chological disturbed patients who can be treated diazepam was effective in 77% of all psvchiatric con- only with general anaesthesia and even this will not ditions it did not, however, affect the second order always be without problems. Brown et al15 examnined NOVEMBER-DECEMBER 1980 175 one hundred and eight patients for minor oral sur- ually aroused in the recovery room or at home. gery and found that 4.6% of cases gave poor results There was no admission of sexual arousal during the in the operator's opinion. Their experience using operative period. diazepam with children has been disappointing; even It is clear from this review of the literature that among adults there are those whom it is impossible reports of adverse psychological reactions to intra- to sedate satisfactorily with the drugs presently avail- venous diazepam in dentistry are scanty and scattered able. They were not able to change a person's basic and because of this it was decided to examine the attitude, especially those who were aggressively un- matter in greater detail. cooperative. Shane'16 mentions that diazepam alone or with methohexitone is unsatisfactory for long Material and Methods operations or for the surgical removal of impacted The occurrence of adverse psychological third molars because it creates restlessness and irrit- reactions during the thirteen year period when ability in teenagers and young children soon after intravenous diazepam was used in general dental its administration. Hodge'7 refers to "sedation- practice may be divided into three groups: resistant patients" and states that these may react 1. Immediately after injection during the operative quite violently and vocally to prevent the operator period, manifesting itself in talkativeness, obtaining reasonable operative conditions. He states emotional release, loss of inhibitions, excite- that there may be no obvious indication of the pa- ment, rage, abreaction and other paradoxical tient's sedation resistance until the treatment has reactions. commenced. 2. Immediately post-operatively and during the Sara'8 comments that the success rate of intrave- day of the operation. These manifest themselves nous diazepam would appear to be around 85%; as a continuation of the complications occur- children and adolescents do not react well. Success ring during the operative period, euphoria and with diazepam as a hypno-sedative depends firstly on a false sense of well being, depression, insomnia the faith and enthusiasm of the administrator in the and distortion of time, events and actions. medication and this attitude is then communicated 3. Extending beyond the day of the operation to the patient. Understanding the patient's problem which is seen in prolonged recovery of the com- and supplementing diazepam with the dentist's atti- plications already referred to, especially depres- tude is necessary for success. sion, excitability and hallucinations. Other com- In a survey of two hundred dentists, taught intra- plications of course can occur and are those venous sedation by Trieger'" and who had been given normally expected for diazepam. a questionnaire to complete which included various Another important factor which affects the oc- complications, it was found that of the 157 dentists currence of adverse phychological reactions is the who responded, 9% reported hyperexcitement as addition of other drugs. In most of the 16,000 cases one of the complications. Donaldson and Gibson' when intravenous diazepam was used by the author, assessed two hundred and twentv cases over a seven small amounts of metho hexitone were added. This year period of complications from intravenous di- resulted in much fewer adverse reactions during the azepam, which were reported to the United States operative period but as it wore off, being short Department of Health, Education and Welfare, of acting, adverse reactions appear and even extend patients from all different categories. Included among beyond the day of the operation. them was "hysteria" with an incidence of 9.5% of all The author has made a special study of diazepam the complications. They state that the delayed onset used alone in the first two of the seven studies un- of hysterical reactions and hallucinations make it dertaken. A part of the first study2' related to the use mandatory for out-patients receiving intravenous of diazepam alone in four hundred and forty-five diazepam to be escorted for the remainder of the cases in general dentistry, on patients ranging from day. 2-83 years. The average dose of diazepam was 20 mg. Campbell et al2" in examining 110 oral surgery pa- and it was used with atropine sulphate (0.5 mg.) fol- tients who had fentanvl, diazepam and methohexi- lowed by local anesthetic. tone sedation, found that in addition to having The second study22 involved one thousand oIne other complications, had adverse psychological re- hundred and forty-two oral surgery patients, the actions which did not involve violent physical and majority of whom were over fifteen years of age.
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