- Email: [email protected]
Health and social characteristics of long-term psychotropic drug takers
Sm. SC;. Med. Vol.’16. pp. Printedin Great Brttain
0277-95361821
1595lo 1598.1982
I8 159s04$03.00:0
Pergamon Press Ltd
RESEARCH NOTE HEALTH AND SOCIAL CHARACTERISTICS OF LONG-TERM PSYCHOTROPIC DRUG TAKERS JOANNA MURRAY, PAUL WILLIAMS
and ANTHONY CLARE
General Practice Research Unit, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5, England Abstract-Prolonged use of drugs for the treatment of specific chronic disorders such as hypertension. diabetes and asthma can be explained largely in clinical terms. The use of psychotropic drugs, on the other hand. appears lo be in response to such a broad range of indications that prolonged use requires investigation from a sociomedical perspective. In this paper we consider the contributions of illness behaviour and social network theories to an understanding of long-term use of psychotropic drugs. The present sample emerged from a cohort of general practice patients beginning a new episode of psychotropic drug treatment. Twenty-six patients from a cohort of 124 continued to receive prescriptions for at least 6 months and 19 were interviewed for this pilot study.
INTRODUCTION
Studies of psychotropic drug consumption have been more concerned with the characteristics of users than with patterns of use [l-5]. Findings from these studies show that twice as many women as men are users and that consumption increases with age. These data represent a cross-section of people taking the drugs in a given period; they do not shed any light on the reasons for variation in length of use among the different demographic groups. Prescription analyses [6.7] reveal that for most recipients medication is not repeated after 1 month, although 155, in one study continued to receive prescriptions continuously for at least a year [6]. In an earlier study of general practice patients [8], 2.8% of the practice populations registered with 20 general practitioners had been prescribed psychotropic drugs in sufficient quantities and frequently enough to supply at least one dose every day for at least 1 year. Over SOP, of these ‘long-repeat’ patients were aged over 40 years. and women were twice as likely as men to be among this group. As part of the same project, Woodcock’s colleagues [9] attempted to unravel the dynamics of continuous repeat prescribing (irrespective of drug type) by detailed case studies. A recurrent theme in the cases they examined was the modest level of medication taken by many long-repeat patients and the regular, although somewhat distant, contact they seemed to need with their doctors. Most resisted any attempt to change the medication in any way and made it clear to the doctor that too close an exploration of their problems would be unwelcome. Repeat prescribing was seen as the result of a longstanding collusion between doctor and patient aimed at maintaining ‘peace’ for both parties. The information which the doctors were able to glean about these patients suggested ‘an unfavourable balance between frustration and satisfaction in their lives’. most notably in the lack of close. confiding relationships. The medication seemed to be a way of compensating for disappointment. loneliness and alienation.
. Although they do not use the term themselves, Balint and his colleagues, like many researchers in the field of illness behaviour, indicate the importance of the individual’s social network. Studies of patients with both physical and psychiatric disorders have demonstrated the influence of the social network in perceiving and interpreting symptoms, seeking help and in the process of recovery or adjustment to changed circumstances [l&17]. The work of Pattison et al. [18] and Tolsdorf Cl93 has shown the restricted nature of the social contacts of psychiatric patients, while other studies have indicated the degree of protection against the impact of stressful life events conveyed by social support [20,21] and the particular value of close confidantes [22,23-J. In addition to aspects of the social network, the present authors felt that an exploration of reliance on doctors and medicines should be included in a study of the characteristics of long-term psychotropic drugtakers. Dunnell and Cartwright [24] found that some individuals had a greater tendency to rely on their general practitioners, irrespective of the number and type of symptoms they reported. Reliance on the GP for emotional support was associated with a greater use of prescribed drugs. The small scale study reported here, represents an attempt to explore some aspects of illness behaviour (GP consultation, drug consumption), social support and psychiatric and physical illness among long-term psychotropic drug consumers.
1595
METHOD
The opportunity to stud) this group arose from a longitudinal study of patients receiving a new prescription for psychotropic drugs. Six general practitioners collaborated in the study. recording for a period of up to 3 months all patients aged over 15 years for whom they wrote a new prescription for a psychotropic drug. Included in this category were minor tranquillisers, antidepressants and hypnotics. ‘New prescription’ was defined as the first prescription for that drug for at least 3 months. The resulting
Research Note
I596
cohort comprised 153 patients. who completed questionnaires on entry into the study and again at 1 month. The GPs also completed questionnaires on the patients on the same two occasions. The findings for the whole cohort are reported elsewhere [25]. At the end of 6 months, the general practice record of each cohort member was searched to determine the duration of therapy. and those who had continued to receive prescriptions regularly and frequently throughout the period were assigned to the present sample. These long-term recipients were then contacted and invited to take part in an interview with a social worker (JM). The interview covered past and present complaints and illnesses, drug usage patterns, family composition and social support. Reliance on doctors and medicines and compliance with medical advice were measured by means of modified versions of the scales used by Dunnell and Cartwright [24]. Eight respondents agreed to an interview with a doctor (AC or PW) and a Clinical Interview Schedule [26] was administered to them. This semi-structured instrument was designed for use in community surveys to measure neurotic symptoms, and provides for a symptom score, psychiatric diagnosis and overall severity rating. FINDINGS
Prescribing information for 6 months was available for 124 of the original 153 cohort members. Of these, 26 (210;) had continued to receive prescriptions for psychotropic drugs throughout the 6 month period and formed the present sample. Nineteen were interviewed; the unsuccessful contacts were due to hospitalisation for severe illness (2 subjects), incapacity for interview (one subject was totally deaf and one mentally subnormal) and 3 refusals. The demographic characteristics of the 9 male and 10 female respondents are presented in Table I. Drug taking
All 19 had been continuous users for at least 6 months, although 5 respondents had stopped taking the drugs by the time they were interviewed. Eleven had taken one psychotropic drug during the survey period (3 hypnotics; 3 antidepressants and 5 minor tranquillisers) and the remaining 8 had used 2 of these drugs simultaneously. For the majority this was not the first course of psychotropic drugs. All but 4 regarded the drugs as helpful, although side-effects (drowsiness, nightmares, weight gain, excessive sweating, headache, dizziness, nausea and impotence) were reported by some. Symptoms und complaints In most cases, respondents felt that the condition for which they had been prescribed psychotropic drugs was related to depression, anxiety or ‘nerves’ although the presenting complaint was often somatic or functional (e.g. gastritis, dizziness, headache, sleep disturbance. tiredness). Psychiatric problems tended to be of long duration and recurrent. All except 3 (who considered their complaints to be entirely physical) attributed the onset of the present episode to a specific event or culmination of pressures in their lives; bereavement, physical illness, conflict at work
or within the family. In few cases had those problems been resolved and everday activities were still affected by such impairments as lassitude. loss of interest. inability to work and fear of eoing out or travelling. On the basis of the Clinical Interview Schedule, only 5 people were classified as psychiatric cases. although 8 others were suffering from a suficient degree of impairment to be assigned to a second category, ‘non-cases but functionally impaired’. Chronic physical conditions were common in the sample (diverticulitis. arth, Otis. hypertension. migraine) and 13 people were long-term users of nonpsychotropic prescribed drugs. on doctors
Reliance
and medicines
Most respondents appeared to have good relationships with their GPs in that they did not feel they were ever wasting his time and felt able to talk to him about all the things they wished. Indeed, there was a strong belief that “doctors are the right people to consult abou,t emotional or personal problems” and half had called on him for this sort of help. Frequency of consultation covered a wide range and those who had seen their GP at least 12 times in the preceeding year (8 people) were with one exception the patients of one doctor. Faith in doctors rarely extended to the belief that they could cure any of 10 diseases presented in a list. This was particularly true of conditions involving chronic pain (arthritis, rheumaticism) and psychological conditions (depression. sleeplessness, anxiety). They did, however, believe doctors could help to relieve these conditions. Depression, sleep problems and recurrent headaches were the conditions most often thought to require medical consultation. It was considered inappropriate to bother the doctor with colds and sore throats when home remedies or overthe-counter medicines were readily available. Few of the 14 respondents still taking the drugs could conceive of any alternative help for their complaints if for some reason psychotropic drugs were
Table I. Characteristics of the sample
Age 3%44 45-64 65 or over Marital
Male (h’ = 9)
Female ilV = IO)
3 4 2
Z 4 4
status
Z 7
Single Married Widowed Divorced Household
composition
Lives
alone with spouse only with spouse and others with others
5 z 3
2 2
Z 3
5
Z 3
Employment .stutuS
Paid employment Retired Full-time housewife
7 Z _
5 5
Research Note unavailable. Most expressed a desire to give up the drugs, but were deterred by the fear of their symptoms returning. Elderly respondents with chronic problems (sleeplessness, vertigo, restless leg syndrome) felt they would always need to take the drugs. Social support Although there was little evidence of extreme isolation. with most respondents having relatives living nearby, some expressed the feeling of being ‘cut off from the outside world. The elderly women felt almost housebound by their complaints. The majority of married people did not consider they received sympathy and support from their spouses. although in only one case was there open hostility. Others felt unable to burden their closest relatives with their problems since they in turn were suffering
from
psychological
complaints.
1597
Balint and his colleagues [9] found that their longrepeat prescription patients were often characterised by loneliness, unsatisfying marriages, lack of engagement in social activities and a feeling of ‘not belonging’. The interviews we conducted suggest that these are important topics to explore with long-term psychotropic drug users, whose symptoms and degree of impairment cover a wide range. A large-scale longitudinal study is currently being planned by this Unit, with the identification of factors which predispose to long-term use as one of its aims. Acknowledgements-This project was undertaken as part of a research programme funded by the Department of Health and Social Security, under the direction of Professor Michael Shepherd. Thanks are due to Professor Shepherd for his advice and comments. We are particularly indebted to the general practitioners and their patients for taking part in the study.
DISCUSSION
The number of respondents in this study is small and may very well derive from an atypical sample of general practitioners. Nevertheless, the sample provided an opportunity to test out areas judged to be relevant to prolonged psychotropic drug use, namely psychological and physical complaints, illness behaviour (reliance on doctors and medicines) and social support. There was a high prevalence of both physical and psychological ill-health in the sample, which accords with the findings of earlier studies [27-291. Many had a long history of similar disorders and chronic conditions, previously treated with psychotropic drugs. In reporting the findings from the entire cohort of 153 prescription recipients from which the present sample emerged [25], we noted that previous use of psychotropic drugs was positively associated with current long-term consumption. In keeping with other studies [6. 81, increasing age was associated with chronic drug use. but the expected overrepresentation of women was not found. There was little evidence of heavy reliance on either the doctor or medicines in the present sample. Those who had consulted at least monthly in the past year had done so at the instigation of the GP. The majority had consulted less than 6 times. a rate close to the average annual attendances reported by Morrell et al. [30] of 6.6 for women and 5.6 for men. Similarly, the degree of reliance on medicines indicated by responses to the hypothetical conditions did not differ from the findings of Dunnell and Cartwright [24] for the community as a whole. Most of our sample linked the onset of their present symptoms to a life crisis. and it was apparent in many cases that the effects had been prolonged by the absence of appropriate social support. Horwitz [14] found that the affective quality of interaction with the ‘primary attachment group’, and in particular with the spouse. was more crucial to the development and course of psychiatric illness than the amount of time spent together. When an individual’s role changes abruptly. as in widowhood, marital breakdown or retirement. successful readjustment depends on the availability of a variety of intensities of support within the extended social network [13].
REFERENCES
1 Parry H. J., Baiter M. B., Mellinger G. D., Cisin 1. H. and Manheimer D. I. National patterns of psychotherapeutic drug use. Archs gen. Psychiat. 28, 769, 1973. 2. Balter M. B., Levine J. and Manheimer D. Cross-national study of the extent of anti-anxiety/sedative drug use. New Engl. J. Med. 290, 769, 1974. E. H., Balter M. B. and Lipman R. S. 3 Uhlenhuth Minor transquillizers: clinical correlates of use in an urban population. Archs gen. Psychiat. 35, 650. 1978. 4. Pflanz M., Basler H-D. and Schwoon D. Use of tranquillizing drugs by a middle-aged population in a West German city. J. HIth sot. Behac. 18, 194, 1977. A. 5. Murray J., Dunn G., Williams P. and Tarnopolsky Factors affecting the consumption of psychotropic drugs. Psychol. Med. 11. 551. 1981. of psychotropic 6. Parish P. A. (1971). The prescribing drugs in general practice. JI R. CON Gen. Pmct. 21. Suppl. 4, 1, 1971. 7. Skegg D. G., Doll R. and Perry J. (1977). Use of medicines in general practice. Br. Med. J. i, 1561. 1977. 8. Woodcock J. Long-term consumers of psychotropic drugs. In Treatment or Diagnosis (Edited by Balint M. et a[.) Tavistock, London. 1970. 9. Balint M.. Hunt J., Joyce D.. Marinker M. and Woodcock J. Treatment or Diagnosis. Tavistock, London, ‘1970. 10. Finlayson A. Social networks as coping resources: lay help and consultation patterns by women in husband’s post-infarction career. Sot. Sci. Med. 10, 97, 1976. S., Duncan-Jones P., McAuley H. and Rit11. Henderson chic K. The patient’s primary group. Br. J. Psychiat. 132, 74, 1978. 12. Langlie J. K. Social networks, health beliefs and preventive health behaviour. J. Hlth sot. Behac. 18, 244. 1977. K. N., MacBride A. and Vachan M. L. S. 13. Walker Social support networks and the crisis of bereavement. Sot. Sci. Med. 11, 35, 1977. 14. Horwitz A. Family, kin and friend networks in psychiatric help-seeking. Sot. Sci. Med. 12. 297. 1978. 15. Croog S., Lipson A. and Levine S. Help patterns in severe illness: the role of kin network, non-family resources and institutions. J. Marr. Furwily February. 32. 1972. and 16 McKinlay J. B. Social networks, lay consultations help-seeking behaviour. Social Forces 51, 275. 1973. a promising direction 17 Mueller D. P. Social networks: for research on the relationship of the social environ-
1598
18.
19. 20.
21.
22.
23. 24.
Research ment to psychiatric disorder. Sot. Sci. Med. 14A. 147. 1980. Pattison E. M.. Defrancisco D., Wood P.. Frazier H. and Crowder J. A psychosocial kinship model for family therapy. Am. J. Psychiar. 132, 124, 1975. Tolsdorf C. C. Social networks. support and coping: an exploratory study. Family Process. 15. 407. 1976. Nuckolls K. B.. Cassel J. and Kaplan B. Psychosocial assets, life crisis and the prognosis of pregnancy. Am. J. Epid. 95, 431. 1972. Andrews G., Tennant C., Hewson D. M. and Vaillant G. Life event stress, social support, coping style and the risk of psychological impairment. J. nero. ment. Dis. 166, 307, 1978. Brown G. W.. Bhrolchain M. N. and Harris T. Social class and psychiatric disturbance among women in an urban population. Sociology 9, 225, 1975. Miller P. McC. and Ingham J. G. Friends, confidants and symptoms. Sot. Psychint. 11, 51, 1976. Dunneil K. and Cartwright A. Medicine takers, Prg-
Note
25.
26.
27. 28. 29.
30.
scribers and Hoarders. Routledge & Kegan Paul, London, 1972. Williams P.. Murray J. and Glare A. A longitudinal study of psychotropic drug recipients. Ps~chol. .Mrd. 12. 201, 1982. Goldberg D., Cooper B., Eastwood M. R.. Kedward H. B. and Shepherd M. A standardised interview for use in community surveys. Er. J. Prev. Sot,. .Lfrd. 24, 1X. 1970. Solow C. Psychotropic drugs in somatic disorder. Inr. .I. Psychiar. Med. 6, 267. 1975. Williams P. Physical ill-health and psychotroptc drug prescription: A review. Psycho/. Med. 8. 683. 1978. Shapiro S. and Baron S. H. Prescriptions for psychotropic drugs in a non-institutional populatton. Puhl. Hlth Rep. 76, 481. 1961. Morrell D. C., Gage H. C. and Robinson N. A. Patterns of demand in general practice. J/ R. Co//. Grn. Pracr. 19, 331, 197.
0277-95361821
1595lo 1598.1982
I8 159s04$03.00:0
Pergamon Press Ltd
RESEARCH NOTE HEALTH AND SOCIAL CHARACTERISTICS OF LONG-TERM PSYCHOTROPIC DRUG TAKERS JOANNA MURRAY, PAUL WILLIAMS
and ANTHONY CLARE
General Practice Research Unit, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5, England Abstract-Prolonged use of drugs for the treatment of specific chronic disorders such as hypertension. diabetes and asthma can be explained largely in clinical terms. The use of psychotropic drugs, on the other hand. appears lo be in response to such a broad range of indications that prolonged use requires investigation from a sociomedical perspective. In this paper we consider the contributions of illness behaviour and social network theories to an understanding of long-term use of psychotropic drugs. The present sample emerged from a cohort of general practice patients beginning a new episode of psychotropic drug treatment. Twenty-six patients from a cohort of 124 continued to receive prescriptions for at least 6 months and 19 were interviewed for this pilot study.
INTRODUCTION
Studies of psychotropic drug consumption have been more concerned with the characteristics of users than with patterns of use [l-5]. Findings from these studies show that twice as many women as men are users and that consumption increases with age. These data represent a cross-section of people taking the drugs in a given period; they do not shed any light on the reasons for variation in length of use among the different demographic groups. Prescription analyses [6.7] reveal that for most recipients medication is not repeated after 1 month, although 155, in one study continued to receive prescriptions continuously for at least a year [6]. In an earlier study of general practice patients [8], 2.8% of the practice populations registered with 20 general practitioners had been prescribed psychotropic drugs in sufficient quantities and frequently enough to supply at least one dose every day for at least 1 year. Over SOP, of these ‘long-repeat’ patients were aged over 40 years. and women were twice as likely as men to be among this group. As part of the same project, Woodcock’s colleagues [9] attempted to unravel the dynamics of continuous repeat prescribing (irrespective of drug type) by detailed case studies. A recurrent theme in the cases they examined was the modest level of medication taken by many long-repeat patients and the regular, although somewhat distant, contact they seemed to need with their doctors. Most resisted any attempt to change the medication in any way and made it clear to the doctor that too close an exploration of their problems would be unwelcome. Repeat prescribing was seen as the result of a longstanding collusion between doctor and patient aimed at maintaining ‘peace’ for both parties. The information which the doctors were able to glean about these patients suggested ‘an unfavourable balance between frustration and satisfaction in their lives’. most notably in the lack of close. confiding relationships. The medication seemed to be a way of compensating for disappointment. loneliness and alienation.
. Although they do not use the term themselves, Balint and his colleagues, like many researchers in the field of illness behaviour, indicate the importance of the individual’s social network. Studies of patients with both physical and psychiatric disorders have demonstrated the influence of the social network in perceiving and interpreting symptoms, seeking help and in the process of recovery or adjustment to changed circumstances [l&17]. The work of Pattison et al. [18] and Tolsdorf Cl93 has shown the restricted nature of the social contacts of psychiatric patients, while other studies have indicated the degree of protection against the impact of stressful life events conveyed by social support [20,21] and the particular value of close confidantes [22,23-J. In addition to aspects of the social network, the present authors felt that an exploration of reliance on doctors and medicines should be included in a study of the characteristics of long-term psychotropic drugtakers. Dunnell and Cartwright [24] found that some individuals had a greater tendency to rely on their general practitioners, irrespective of the number and type of symptoms they reported. Reliance on the GP for emotional support was associated with a greater use of prescribed drugs. The small scale study reported here, represents an attempt to explore some aspects of illness behaviour (GP consultation, drug consumption), social support and psychiatric and physical illness among long-term psychotropic drug consumers.
1595
METHOD
The opportunity to stud) this group arose from a longitudinal study of patients receiving a new prescription for psychotropic drugs. Six general practitioners collaborated in the study. recording for a period of up to 3 months all patients aged over 15 years for whom they wrote a new prescription for a psychotropic drug. Included in this category were minor tranquillisers, antidepressants and hypnotics. ‘New prescription’ was defined as the first prescription for that drug for at least 3 months. The resulting
Research Note
I596
cohort comprised 153 patients. who completed questionnaires on entry into the study and again at 1 month. The GPs also completed questionnaires on the patients on the same two occasions. The findings for the whole cohort are reported elsewhere [25]. At the end of 6 months, the general practice record of each cohort member was searched to determine the duration of therapy. and those who had continued to receive prescriptions regularly and frequently throughout the period were assigned to the present sample. These long-term recipients were then contacted and invited to take part in an interview with a social worker (JM). The interview covered past and present complaints and illnesses, drug usage patterns, family composition and social support. Reliance on doctors and medicines and compliance with medical advice were measured by means of modified versions of the scales used by Dunnell and Cartwright [24]. Eight respondents agreed to an interview with a doctor (AC or PW) and a Clinical Interview Schedule [26] was administered to them. This semi-structured instrument was designed for use in community surveys to measure neurotic symptoms, and provides for a symptom score, psychiatric diagnosis and overall severity rating. FINDINGS
Prescribing information for 6 months was available for 124 of the original 153 cohort members. Of these, 26 (210;) had continued to receive prescriptions for psychotropic drugs throughout the 6 month period and formed the present sample. Nineteen were interviewed; the unsuccessful contacts were due to hospitalisation for severe illness (2 subjects), incapacity for interview (one subject was totally deaf and one mentally subnormal) and 3 refusals. The demographic characteristics of the 9 male and 10 female respondents are presented in Table I. Drug taking
All 19 had been continuous users for at least 6 months, although 5 respondents had stopped taking the drugs by the time they were interviewed. Eleven had taken one psychotropic drug during the survey period (3 hypnotics; 3 antidepressants and 5 minor tranquillisers) and the remaining 8 had used 2 of these drugs simultaneously. For the majority this was not the first course of psychotropic drugs. All but 4 regarded the drugs as helpful, although side-effects (drowsiness, nightmares, weight gain, excessive sweating, headache, dizziness, nausea and impotence) were reported by some. Symptoms und complaints In most cases, respondents felt that the condition for which they had been prescribed psychotropic drugs was related to depression, anxiety or ‘nerves’ although the presenting complaint was often somatic or functional (e.g. gastritis, dizziness, headache, sleep disturbance. tiredness). Psychiatric problems tended to be of long duration and recurrent. All except 3 (who considered their complaints to be entirely physical) attributed the onset of the present episode to a specific event or culmination of pressures in their lives; bereavement, physical illness, conflict at work
or within the family. In few cases had those problems been resolved and everday activities were still affected by such impairments as lassitude. loss of interest. inability to work and fear of eoing out or travelling. On the basis of the Clinical Interview Schedule, only 5 people were classified as psychiatric cases. although 8 others were suffering from a suficient degree of impairment to be assigned to a second category, ‘non-cases but functionally impaired’. Chronic physical conditions were common in the sample (diverticulitis. arth, Otis. hypertension. migraine) and 13 people were long-term users of nonpsychotropic prescribed drugs. on doctors
Reliance
and medicines
Most respondents appeared to have good relationships with their GPs in that they did not feel they were ever wasting his time and felt able to talk to him about all the things they wished. Indeed, there was a strong belief that “doctors are the right people to consult abou,t emotional or personal problems” and half had called on him for this sort of help. Frequency of consultation covered a wide range and those who had seen their GP at least 12 times in the preceeding year (8 people) were with one exception the patients of one doctor. Faith in doctors rarely extended to the belief that they could cure any of 10 diseases presented in a list. This was particularly true of conditions involving chronic pain (arthritis, rheumaticism) and psychological conditions (depression. sleeplessness, anxiety). They did, however, believe doctors could help to relieve these conditions. Depression, sleep problems and recurrent headaches were the conditions most often thought to require medical consultation. It was considered inappropriate to bother the doctor with colds and sore throats when home remedies or overthe-counter medicines were readily available. Few of the 14 respondents still taking the drugs could conceive of any alternative help for their complaints if for some reason psychotropic drugs were
Table I. Characteristics of the sample
Age 3%44 45-64 65 or over Marital
Male (h’ = 9)
Female ilV = IO)
3 4 2
Z 4 4
status
Z 7
Single Married Widowed Divorced Household
composition
Lives
alone with spouse only with spouse and others with others
5 z 3
2 2
Z 3
5
Z 3
Employment .stutuS
Paid employment Retired Full-time housewife
7 Z _
5 5
Research Note unavailable. Most expressed a desire to give up the drugs, but were deterred by the fear of their symptoms returning. Elderly respondents with chronic problems (sleeplessness, vertigo, restless leg syndrome) felt they would always need to take the drugs. Social support Although there was little evidence of extreme isolation. with most respondents having relatives living nearby, some expressed the feeling of being ‘cut off from the outside world. The elderly women felt almost housebound by their complaints. The majority of married people did not consider they received sympathy and support from their spouses. although in only one case was there open hostility. Others felt unable to burden their closest relatives with their problems since they in turn were suffering
from
psychological
complaints.
1597
Balint and his colleagues [9] found that their longrepeat prescription patients were often characterised by loneliness, unsatisfying marriages, lack of engagement in social activities and a feeling of ‘not belonging’. The interviews we conducted suggest that these are important topics to explore with long-term psychotropic drug users, whose symptoms and degree of impairment cover a wide range. A large-scale longitudinal study is currently being planned by this Unit, with the identification of factors which predispose to long-term use as one of its aims. Acknowledgements-This project was undertaken as part of a research programme funded by the Department of Health and Social Security, under the direction of Professor Michael Shepherd. Thanks are due to Professor Shepherd for his advice and comments. We are particularly indebted to the general practitioners and their patients for taking part in the study.
DISCUSSION
The number of respondents in this study is small and may very well derive from an atypical sample of general practitioners. Nevertheless, the sample provided an opportunity to test out areas judged to be relevant to prolonged psychotropic drug use, namely psychological and physical complaints, illness behaviour (reliance on doctors and medicines) and social support. There was a high prevalence of both physical and psychological ill-health in the sample, which accords with the findings of earlier studies [27-291. Many had a long history of similar disorders and chronic conditions, previously treated with psychotropic drugs. In reporting the findings from the entire cohort of 153 prescription recipients from which the present sample emerged [25], we noted that previous use of psychotropic drugs was positively associated with current long-term consumption. In keeping with other studies [6. 81, increasing age was associated with chronic drug use. but the expected overrepresentation of women was not found. There was little evidence of heavy reliance on either the doctor or medicines in the present sample. Those who had consulted at least monthly in the past year had done so at the instigation of the GP. The majority had consulted less than 6 times. a rate close to the average annual attendances reported by Morrell et al. [30] of 6.6 for women and 5.6 for men. Similarly, the degree of reliance on medicines indicated by responses to the hypothetical conditions did not differ from the findings of Dunnell and Cartwright [24] for the community as a whole. Most of our sample linked the onset of their present symptoms to a life crisis. and it was apparent in many cases that the effects had been prolonged by the absence of appropriate social support. Horwitz [14] found that the affective quality of interaction with the ‘primary attachment group’, and in particular with the spouse. was more crucial to the development and course of psychiatric illness than the amount of time spent together. When an individual’s role changes abruptly. as in widowhood, marital breakdown or retirement. successful readjustment depends on the availability of a variety of intensities of support within the extended social network [13].
REFERENCES
1 Parry H. J., Baiter M. B., Mellinger G. D., Cisin 1. H. and Manheimer D. I. National patterns of psychotherapeutic drug use. Archs gen. Psychiat. 28, 769, 1973. 2. Balter M. B., Levine J. and Manheimer D. Cross-national study of the extent of anti-anxiety/sedative drug use. New Engl. J. Med. 290, 769, 1974. E. H., Balter M. B. and Lipman R. S. 3 Uhlenhuth Minor transquillizers: clinical correlates of use in an urban population. Archs gen. Psychiat. 35, 650. 1978. 4. Pflanz M., Basler H-D. and Schwoon D. Use of tranquillizing drugs by a middle-aged population in a West German city. J. HIth sot. Behac. 18, 194, 1977. A. 5. Murray J., Dunn G., Williams P. and Tarnopolsky Factors affecting the consumption of psychotropic drugs. Psychol. Med. 11. 551. 1981. of psychotropic 6. Parish P. A. (1971). The prescribing drugs in general practice. JI R. CON Gen. Pmct. 21. Suppl. 4, 1, 1971. 7. Skegg D. G., Doll R. and Perry J. (1977). Use of medicines in general practice. Br. Med. J. i, 1561. 1977. 8. Woodcock J. Long-term consumers of psychotropic drugs. In Treatment or Diagnosis (Edited by Balint M. et a[.) Tavistock, London. 1970. 9. Balint M.. Hunt J., Joyce D.. Marinker M. and Woodcock J. Treatment or Diagnosis. Tavistock, London, ‘1970. 10. Finlayson A. Social networks as coping resources: lay help and consultation patterns by women in husband’s post-infarction career. Sot. Sci. Med. 10, 97, 1976. S., Duncan-Jones P., McAuley H. and Rit11. Henderson chic K. The patient’s primary group. Br. J. Psychiat. 132, 74, 1978. 12. Langlie J. K. Social networks, health beliefs and preventive health behaviour. J. Hlth sot. Behac. 18, 244. 1977. K. N., MacBride A. and Vachan M. L. S. 13. Walker Social support networks and the crisis of bereavement. Sot. Sci. Med. 11, 35, 1977. 14. Horwitz A. Family, kin and friend networks in psychiatric help-seeking. Sot. Sci. Med. 12. 297. 1978. 15. Croog S., Lipson A. and Levine S. Help patterns in severe illness: the role of kin network, non-family resources and institutions. J. Marr. Furwily February. 32. 1972. and 16 McKinlay J. B. Social networks, lay consultations help-seeking behaviour. Social Forces 51, 275. 1973. a promising direction 17 Mueller D. P. Social networks: for research on the relationship of the social environ-
1598
18.
19. 20.
21.
22.
23. 24.
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