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Tranquillisers and health care in crisis
Soc. Sci. Med. Vol. 32, No. 4, pp. 449-454, 1991
0277-9536/91 $3.00 + 0.00 Copyright ~' 1991 Pergamon Press plc
Printed in Great Britain. All rights reserved
TRANQUILLISERS AND HEALTH CARE IN CRISIS JONATHAN GABE 1'2 a n d MICHAEL BURY 2
~Department of Community Medicine, University College and Middlesex Hospital School of Medicine, 66 72 Gower Street, London WCIE 6EA, U.K. and 2Royal Holloway and Bedford New College, University of London, Egham Hill, Egham, Surrey, TW20 0EX, U.K. Abstract--This paper addresses the issue of the crisis of therapeutic efficacy in Britain through a case study of benzodiazepine tranquilliser dependence. The paper traces the rise of tranquillisers and the crisis of legitimacy in prescribing behaviour in the 1980s. It documents growing concern with dependence and the claims made about it by experts and consumer groups. The paper goes on to analyse the importance of the television in these claims-making activity and its influence in shaping perceptions. Finally, we consider the implications of these events for the future of benzodiazepine tranquillisers as a form of treatment.
Key words--efficacy, benzodiazepine tranquillisers, claims-making, television
INTRODUCTION
Since the 19608 concern about the efficacy of medical treatments has grown rapidly. Following the immediate post-war period of therapeutic optimism, criticism of the role of medicine has come from within the medical profession and from without. Clinicians such as Cochrane [1] and McKeown [2] have raised doubts about the effectiveness of many routine procedures and their impact on the improvement of health. Social scientists amongst others have challenged the medicalization of key areas of social experience [3]. Childbirth and mental health, for example, have become the focus of heated debate within health care, and the subject of vigorous public discussion [4, 5]. This paper focusses on one aspect of the debate in Britain about therapeutic efficacy in mental health, namely the use of benzodiazepine tranquillisers for anxiety and sleeplessness. Our argument is presented in three stages. First, we discuss the rise in popularity of these minor tranquillisers in the 1960s and early 1970s, and the creation of a therapeutic consensus about their use. Second, we identify the emergence of a crisis in the legitimacy of prescribing behaviour by doctors in the early 1980s. This resulted from the growing scientific evidence of dependence, the reactions of a divided medical profession and the impact of a vocal consumer rights movements in mental health. Third, we analyse the way in which the crisis was fuelled by the media. The media not only provided an arena for the claims for various individuals and interest groups, but also amplified a range of meanings around the issue. Finally, we consider the implications of these events for the future therapeutic use of tranquillisers.
ceeded them. As Lader [7] put it, they were perceived as more effective in alleviating anxiety and stress responses, safer in overdose and less liable to induce dependence than barbiturates. The latter impression was reinforced a few years later by favorable reports of clinical practice [8, 9] and endorsed by lavish advertising campaigns in the medical press [7]. As elsewhere on the health care scene at that time, scientific breakthroughs and treatment regimens seemed to herald a new era for both doctors and patients. Given this reception it is not surprising that benzodiazepine prescribing increased rapidly in Britain. Between 1965 and 1970, prescriptions for benzodiazepine tranquillisers rose by 110% compared with a 9% increase for all psychotropic drugs [10]. In 1965 under 5 million prescriptions for the three main benzodiazepines (Librium, Valium and Mogadon) were dispensed in retail pharmacies in England and Wales; by 1970 the figure had increased to nearly 12½ million [10]. During the next decade concern was expressed in some quarters that these drugs were being overused [10, l l] or misused [12, 13]. However, their efficacy at therapeutic dose apparently continued to be accepted by most physicians and valued by the great majority of users [14]. It was therefore unsurprising that prescriptions for minor tranquillisers continued to rise [14]. Indeed, it was only in 1979 that benzodiazepines peaked at almost 31 million prescriptions [15]. THE GROWING CRISIS OF THERAPEUTIC EFFICACY
In 1980 it was still possible for the British government's watchdog, the Committee on the Review of Medicines, to state in its guidelines to physicians that "On present available evidence, the true addictive potential evidence of benzodiazepines [is] low" [16]. Since then, however, the phase of 'euphoric ignorance' has been replaced by a period of 'paranoid uncertainty' [17]. Why has this happened? Concern about tranquilliser prescribing at therapeutic dose has always a 'developmental possibility', given the
THE GROWTH IN POPULARITY OF BENZODIAZEPINES
The benzodiazepine era began in the early 1960s with the production of Librium and Valium [6]. The latter were quickly accepted by the medical profession in Britain as highly effective, safe drugs which did not create physical or psychological dependence or other unwanted effects attributed to the drugs which pro449
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persistent concern about the side effects of prescribed drugs in general [18]. However, it is only since clinical and epidemiological evidence of dependence at therapeutic dose (defined by the W H O [19] in 1974 in physical terms as 'intense physical disturbances when the administration of the drug is suspended') has started to appear that the crisis of therapeutic efficacy has really got under way. Since the early 1980s, studies of relatively small numbers of people (usually about 40) agreeing to or requesting withdrawal from long term benzodiazepine use at therapeutic dose have reported that a significant number experience symptoms of dependence on withdrawal [20-22], and that these symptoms can last a year or more [22]. Furthermore, studies using representative samples and control groups [20, 21] have found that between 27% and 45% of long term users are dependent on their drugs. If this is the case this would represent a substantial number of people, as it has recently been estimated that as many as 1.2 million people in Britain have been using anti-anxiety/sedative drugs (mainly benzodiazepines) for a year or more [15, 23]. This clinical and epidemiological evidence in turn has provided a terrain for the development of claimsmaking activities by hospital based medical experts, especially psychiatrists. It has been announced that a "withdrawal syndrome" has been discovered amongst long-term users of benzodiazepines at therapeutic dose, and that, given the prevalence of longterm use, such evidence of dependence represents an "epidemic in the making" of alarming proportions [24]. Not content with making such claims these experts have also sought to identify the source of the problem, particularly by blaming genearl practitioners, for failing to establish the limits of therapeutic use. Thus GPs have been castigated for writing repeat prescriptions without seeing the patient [25, 26] and for subscribing to the belief that people troubled by family, social and occupational problems can legitimately seek help from the medical profession [27]. One expert has even gone as far as to claim that behaviour like this is "souring the doctor-patient relationship" [28] and has created a crisis of confidence amongst the "anxious members of our community" [26]. We suggest that such claims-making has both revealed and exacerbated a set of relationships at the heart of health care. On the one hand it illustrates the persistent historical division between hospital specialists, in this case psychiatrists, and general practitioners [29], and the former's jockeying for position as they attempt to fashion a new role for themselves in a period of changing attitudes towards psychiatric disorder. On the other hand it may be helping to fuel a crisis of public confidence in the doctor-patient relationship, as allegations against specific doctors are raised to a new level. It is also interesting to note in this context that potential patients have not been singled out for moral opprobrium. Unlike studies of general practice in the 1960s and 1970s, which revealed a tendency amongst doctors to blame patients for presenting with trivial complaints [30, 31] most of the concern expressed by medical experts has been about doctors' prescribing behaviour. This may be because patients are seen
primarily as victims and as "passive dependent personalities" [21-22, 32]. However, recent pressure on medical experts concerning their own behaviour has led at least one to put the ball back in the court of the patient by stressing the role of personality factors in tranquilliser dependence in creating a demand for such treatment [33]. As we have seen, arguments about tranquilliser dependence have largely focussed on the prescribing behaviour of general practitioners. Two positions have emerged about this behaviour. Som~ experts have argued that "no one doubts that most patients usually taking benzodiazepines should stop them", and have suggested ways of doing so [26]. For these proponents benzodiazepines should not be prescribed for normal people at times of acute stress such as bereavement or divorce and, if prescribed at all, should be given for a short period at the lowest possible dose [26, 34]. Others have struck a less strident note and argued not only that they have an important place in the short term treatment of distress and insomnia, but that one should not assume that the long-term prescribing of benzodiazepines and the consequent high risk of dependence are to be avoided at all cost [32]. Alongside the claims of medical experts about dependence has been the growing voice of the consumer fights movements in mental health. Release, an organisation offering advice and referral on drug problems, has argued on the basis of "recent research" concerning "the physical withdrawal syndrome", that "tranx (benzodiazepines) are highly addictive to some users" and that, in its experience, the degree of distress felt on withdrawal is often far more extreme than that which first led a user to seek help from their general practitioner [35]. Similarly DAWN, the feminist pressure group concerned with women drug users, considers tranquillisers to be "very addictive to some (women) users" and states that "there is no doubt that withdrawal effects are not just the original anxiety coming back". Whilst as we have noted some medical opinion has described the passive nature of patients' behaviour, these groups see such dependence as perpetuating women's passivity and domesticity, and suggest that women wanting to come off tranquillisers should seek help from a specialist agency and from other women, particularly those who have had a similar experience [36]. MIND, the British mental health pressure group, has stated that it is "a fact" that people taking benzodiazepines can "get hooked physically or psychologically or both", and that "people often experience some withdrawal symptoms" when coming off these drugs, particularly if they have been taking them for more than a few weeks. On the basis of "research" and the views of the American Food and Drug Administration regarding the dependence potential of Valium, it suggested that "the danger of drugs in the benzodiazepine group are clear" and that "even very limited use may be ill advised" [37]. Elsewhere it has also argued that patients have a fight to be informed about these "dangers" and should be given a detailed data sheet about them with each prescription for a benzodiazepine [38]. It has also been suggested that money should be made available by the state to fund self-help groups for
Tranquillisers and health care in crisis those who have used the drug and have then had difficulty stopping [39]. Pressure groups like M I N D have also been instrumental in involving lawyers in possible litigation against drug companies. A U.K. 'benzodiazepine solicitors group' of around 320 law firms has been set up to co-ordinate research for potential legal action and is currently putting pressure on manufacturers to set up a compensation scheme for claimants without going to court [40]. The legal challenge to therapeutic activities is perhaps one of the most notable developments in the social relations of health care during the last decade, and tranquillisers have become a major example of such a challenge. It is also noteworthy that these pressure groups have generally been less careful in their use of terminology than most of the medical experts whose work they have drawn on, and have used "addiction", "being hooked" and "dependence" interchangeably. At the same time they have shared with these experts a willingness to attribute much of the blame for the problem of dependence to the general practitioner. As previously, the GPs have been castigated for giving a repeat prescription rather than asking patients about their lives and how they are feeling. They have also been criticised for failing to recognise or acknowledge that their patients might be dependent on these drugs, and for being unwilling to employ a psychotherapist or counsellor to give their patients the amount of time and attention that they need to resolve their difficulties. In this way, then, consumer rights groups have also played a part in heightening public concern about the trust that can be placed in general practitioners' clinical judgements and medical treatments. In the claimsmaking activity surrounding tranquilliser dependence we can see the importance of the interaction between professionally derived concerns and lay ideas about illness and its treatment [41]. Initial concern on the part of experts gathering clinical and epidemiological evidence has interacted with strongly held views held by patients and consumer groups. The broadening of clinical concerns with dependence and withdrawal to encompass a view of tranquillisers as "addictive" has crystallized a wider set of meanings concerned with drugs and their use. To this picture we must now add the activities of the media which, during the 1980s, has increasingly taken an interest in tranquilliser dependence. Indeed, the media has covered a wide range of health related issues during this period and in turn has increased public concern about the role of professional expertise. This is in contrast to the earlier presentation of health in the media in which the preoccupations of the medical profession were dominant [42]. MEDIA REPRESENTATION
The importance of the media in heightening public concern lies not only in its ability to provide opportunities for the expression of public opinion, or the "empowering" of individuals in their attempts to air grievances, but also in organizing meanings into recognizable images and narratives [43]. An analysis of television coverage, in particular, reveals its central role in the expression and organisation of expert and
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lay views surrounding tranquiUiser dependence. Not only, therefore, have expert and lay opinion interacted with each other, but both have also interacted with the media. Since 1983 there has been a series of programmes on British television dedicated to the subject, and information slots on day time television. Press coverage has also been extensive, and we have dealt with this in a separate paper [44]. We have examined all of the key programmes broadcast on British television in recent years, The main examples which we draw on here are as follows: the BBC magazine programme That's Life with a Sunday night audience of around 10 million which dealt with the issue on at least 4 occassions between 1983 and 1985; the BBC current affairs programme Brass Tacks which dealt with the issue on two occasions in 1988 and attracted an audience of 2.5 million viewers each time; and the Central Television investigatory programme The Cook Report which covered the issue once, again in 1988, in front of 6 million viewers. Through a content analysis of transcripts and video tapes, we have identified the opportunities for medical experts and consumer groups to publically express their views, and the specific ways in which the media has itself portrayed the problem of tranquilliser dependence. We now deal with each of these in turn. EXPRESSING OPINION T H R O U G H T H E MEDIA
In setting out to cover tranquilliser dependence each of the programmes has provided opportunities for medical experts and consumer groups to air their views. Starting with the medical experts, they have expressed at least three kinds of claim. First, they have argued that the size of the tranquilliser problem is a major cause for concern. For instance, Professor Malcolm Lader, who has appeared on each of the programmes, has claimed that "something like J million people in the country are taking one form of tranquilliser or another. And I would say a quarter of a million people are not able to get off the ones they've taken" (That's Life 12.6.83). This calculation, extrapolating from small scale studies, helps Lader to legitimate the seriousness of the problem and the need for action to tackle it. Second, television coverage has provided a vehicle for hospital based medical experts to establish their claims about GPs' behaviour. Again, on That's Life, a consultant psychiatrist attacked general practitioners who had allegedly prescribed tranquillisers to children. Similarly, on Brass Tacks and The Cook Report general practitioners were criticised in part as a result of claims being made by medical experts. In the former case GPs were provided with an opportunity to state their own position in response. Third, the programmes have been used to call for action to alter current patterns of tranquilliser prescribing. Experts on both Brass Tacks and The Cook Report discussed one particular benzodiazepine, Ativan, and the apparently high level of dependence associated with it. On Brass Tacks a debate ensued about whether special action should be taken to withdraw Ativan from the market. The Chairman of the Committee on the Safety of Medicines declined to isolate this benzodiazepine and issue special
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instructions about prescribing it. On The Cook Report, on the other hand, Professor Lader argued that the drug should be withdrawn from the market and that other benzodiazepines could be used instead. At the same time consumer groups have been using television to advance their own causes and campaigns. Thus they have suggested that patients have a right to be informed about the risks of dependence and have criticised GPs and the pharmaceutical companies for failing to do so. The mental health campaigning group MIND, for example, co-operated with That's Life following their initial coverage of the subject, in mounting a survey of tranquilliser use and dependence. This information was used in subsequent programmes to provide information about the risks of dependence and as the basis for a joint publication calling for the development of self-helf groups on the issue. Profits from this book went to M I N D [45]. In the second Brass Tacks programme the Assistant Director of M I N D was able, through careful preparation, to make a forceful intervention in the studio discussion. Unlike other participants he had brought along special 'flash cards' to hold up to the camera. These alledgedly illustrated the way in which benzodiazepine manufacturers promoted their products amongst GPs in an unethical way by "taking the thinking out of prescribing". In so doing he was able to advance M I N D ' s claims that manufacturers were in part to blame for tranquilliser dependence. From these brief examples of medical expert and consumer group activity it seems clear that the media have provided an important terrain on which claims can be advanced. In so doing, however, these groups have done more than advance their own interests. They have also contributed to the growing sense of doubt concerning medical treatments and the role of doctors in dealing with mental health issues. However, it needs to be stressed that the media have their own agenda and operate within definite structures. This is reflected in part by the routines and procedures that different programme formats employ [46]. For example, That's Life, working within a consumer format, not surprisingly gives more credence to consumer based claims than those of medical experts. In contrast, Brass Tacks, working within a current affairs format which stresses the need for balance and debate, gives greater opportunity for different medical experts to express their views, Not only has television organised opinion about tranquillisers through its use of different formats but by employing a range of images and narratives, it has further heightened concern about the efficacy of these drugs and prescribed drugs in general. It is to these images and narratives we now turn. IMAGES AND NARRATIVES
By themselves, tranquillisers are innocuous in appearance. Wrapped in silver foil or stored in medicine bottles, they are like many preparations that are part of our every day lives. But when presented as dangerous drugs they can appear frightening and fearful, just as white powder appears harmless until we are told that it is heroin or cocaine. In television, two ways have been employed to create powerful imagery in order to underpin the crisis with tranquillisers.
First, tranquillisers have been portrayed as drugs of 'addiction'. Each programme we have considered opened with a sequence that either described, or showed, an individual patient 'hooked' on these drugs. On the Brass Tacks programme the opening sequence, in which a man drew up his fix, was followed by pictures of packets of tablets which were then repeated through the programme. Second, the television pictures of the drugs themselves have enhanced the image of them as dangerous and frightening, especially in The Cook Report. Whilst other programmes were prepared to rely largely on descriptions of the drugs provided by the patients, The Cook Report created graphic representations in order to press home its message. The drugs were shown being manufactured in large quantities, emerging from the factory production line in their thousands, or showering down from the top of the screen in a colourful cascade. As the programme unfolded this latter image was repeated no less than 7 times, reinforcing the image of a massive quantity of the drugs that are made and consumed, and conveying the idea that we are almost drowning in them. In turn, these images form part of a narrative structure which is central to television [47]. Constructing the story of tranquilliser dependence involves making use of emotional and symbolic meanings concerning responsibility and good and evil. In 'That's Life' for example, tranquilliser dependence is not only a problem in itself, but also an illustration of the dangers that might befall an uninformed or unwary consumer. The narrative, here, concerns an innocent (in retrospect, possibly gullible) request for a service and irresponsible drug promotion and prescribing. Tranquilliser dependence becomes a case study of personal troubles and their exploitation which can be read in different ways by different audiences. In The Cook Report the metaphorical aspect of television narrative is developed further. The forces of good (in this case, the innocent patient) and evil (the drugs, the doctors and the drug companies) are invoked which lay the foundations for, and legitimise, the programme's 'denouement'. This comprises a confrontation scene between the chairman of Wyeth, the manufacturers of Ativan, and Cook, on the chairman's golf course. This dramatic scene in which Cook attempts to 'door step' and interview the chairman, and in which the chairman verbally and physically attacks Cook in return, offers the viewer a sense of dramatic action being taken. It is action which ordinary individuals have neither the resources or courage to undertake themselves. What is at work here, however, is not simply the examination of the morality of drug manufacture. The case of tranquilliser dependence also reveals television's preoccupation with mediating and shaping social conflicts. As we have seen, the claims making activity surrounding tranquillisers involves the clash of a number of interest groups, within medicine and outside. The narratives of television programmes organise and frame these conflicts in a variety of ways. The story of tranquilliser dependence feeds into wider concerns about the use of prescribed drugs in the treatment of a variety of ailments.
Tranquillisers and health care in crisis In summary, the media, and especially television provides the means for publicising and legitimising claims about tranquilliser dependence, but also creates and recreates meanings around it. The images and narratives constituted by, and contained in television programmes present a picture that "imposes coherence and resolution upon a world that has neither" [43, p. 130]. Those hoping to use the media, therefore, in order to advance their claims about tranquilliser dependence, are confronted with the fact that they, in turn, become used as part of a more complex media agenda. CONCLUSION The controversy surrounding tranquilliser dependence may be seen as an example of a range of debates concerning the efficacy of modern medical treatments. The enthusiasm surrounding the introduction of tranquillisers in the 1960s reflected not only a reaction to the earlier use of barbiturates, but the general atmosphere of progress in health care overall. Tranquillisers epitomised the belief that new safe treatments would become increasingly available across the board. The disillusionment with many forms of medicine which has grown in recent years allows us to place the problem of tranquilliser dependence in context. The emphasis on costs compared with the benefits of treatments, especially social costs, has come to affect a wide range of activities, especially those associated with women's health. Contraceptive, anti-emetic and anti-rheumatic drugs preceded tranquillisers as causes for concern. Legal campaigning over the Dalcon Shield, for example, continues in Britain today. From this viewpoint, the case of tranquilliser dependence should be seen as part of the widespread questioning of the role of medical treatments. Part of this picture, which we have touched on here, has been the challenge to traditional medical authority. Although the arguments over tranquilliser dependence, particularly between hospital doctors and general practitioners, is a reflection of the longstanding divide in British medicine [29], the willingness of doctors to publically express their views about each other is new. So, too, is the willingness of consumer groups to take a more active stance. The legal battle over tranquilliser dependence, whatever its final outcome, marks a break with traditional attitudes concerning trust towards, and among doctors. Although it is always possible to exaggerate the degree of change, the examination of tranquilliser dependence suggests that we are witnessing a major shift, if not a crisis, in the social relations of health care. We have argued that the claims about tranquillisers have become inevitably caught up in media coverage. The modern mass media, and especially television now occupies a strategic site on which social conflicts, including those in health are managed. We have attempted to show that not only is television crucial to the claims making activities of different interest groups, but that through powerful imagery and narrative it creates a range of meanings itself. Television both enables and constrains experts and patients, offering them opportunities to express their views,
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but presenting them as part of a selective portrayal of the issues. Television's treatment is almost inevitably prone to amplification and exaggeration. In particular, television creates a strong emotional field around social problems in its desire to dramatise their character. Again, tranquilliser dependence illustrates the processes at work. What is less clear is the future use of benzodiazepine tranquillisers as thrapeutic agents. We can only speculate about the impact of television coverage on the actions of the various groups identified here; consumers, practitioners and manufacturers alike. Certainly there are signs that practitioners may be more reluctant to sanction long term use of these drugs, and some form of reappraisal is clearly under way [48]. The legal campaign currently in train in Britain could turn out to be the key to the future use of benzodiazepines. On the other hand, it seems clear from our analysis that the imagery and language of 'addiction', together with the emotional portrayal of withdrawal on television, has made detachment in undertaking an appraisal of the value of these drugs more difficult. Here too, however, we may be describing an example of a general trend in health care. REFERENCES
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0277-9536/91 $3.00 + 0.00 Copyright ~' 1991 Pergamon Press plc
Printed in Great Britain. All rights reserved
TRANQUILLISERS AND HEALTH CARE IN CRISIS JONATHAN GABE 1'2 a n d MICHAEL BURY 2
~Department of Community Medicine, University College and Middlesex Hospital School of Medicine, 66 72 Gower Street, London WCIE 6EA, U.K. and 2Royal Holloway and Bedford New College, University of London, Egham Hill, Egham, Surrey, TW20 0EX, U.K. Abstract--This paper addresses the issue of the crisis of therapeutic efficacy in Britain through a case study of benzodiazepine tranquilliser dependence. The paper traces the rise of tranquillisers and the crisis of legitimacy in prescribing behaviour in the 1980s. It documents growing concern with dependence and the claims made about it by experts and consumer groups. The paper goes on to analyse the importance of the television in these claims-making activity and its influence in shaping perceptions. Finally, we consider the implications of these events for the future of benzodiazepine tranquillisers as a form of treatment.
Key words--efficacy, benzodiazepine tranquillisers, claims-making, television
INTRODUCTION
Since the 19608 concern about the efficacy of medical treatments has grown rapidly. Following the immediate post-war period of therapeutic optimism, criticism of the role of medicine has come from within the medical profession and from without. Clinicians such as Cochrane [1] and McKeown [2] have raised doubts about the effectiveness of many routine procedures and their impact on the improvement of health. Social scientists amongst others have challenged the medicalization of key areas of social experience [3]. Childbirth and mental health, for example, have become the focus of heated debate within health care, and the subject of vigorous public discussion [4, 5]. This paper focusses on one aspect of the debate in Britain about therapeutic efficacy in mental health, namely the use of benzodiazepine tranquillisers for anxiety and sleeplessness. Our argument is presented in three stages. First, we discuss the rise in popularity of these minor tranquillisers in the 1960s and early 1970s, and the creation of a therapeutic consensus about their use. Second, we identify the emergence of a crisis in the legitimacy of prescribing behaviour by doctors in the early 1980s. This resulted from the growing scientific evidence of dependence, the reactions of a divided medical profession and the impact of a vocal consumer rights movements in mental health. Third, we analyse the way in which the crisis was fuelled by the media. The media not only provided an arena for the claims for various individuals and interest groups, but also amplified a range of meanings around the issue. Finally, we consider the implications of these events for the future therapeutic use of tranquillisers.
ceeded them. As Lader [7] put it, they were perceived as more effective in alleviating anxiety and stress responses, safer in overdose and less liable to induce dependence than barbiturates. The latter impression was reinforced a few years later by favorable reports of clinical practice [8, 9] and endorsed by lavish advertising campaigns in the medical press [7]. As elsewhere on the health care scene at that time, scientific breakthroughs and treatment regimens seemed to herald a new era for both doctors and patients. Given this reception it is not surprising that benzodiazepine prescribing increased rapidly in Britain. Between 1965 and 1970, prescriptions for benzodiazepine tranquillisers rose by 110% compared with a 9% increase for all psychotropic drugs [10]. In 1965 under 5 million prescriptions for the three main benzodiazepines (Librium, Valium and Mogadon) were dispensed in retail pharmacies in England and Wales; by 1970 the figure had increased to nearly 12½ million [10]. During the next decade concern was expressed in some quarters that these drugs were being overused [10, l l] or misused [12, 13]. However, their efficacy at therapeutic dose apparently continued to be accepted by most physicians and valued by the great majority of users [14]. It was therefore unsurprising that prescriptions for minor tranquillisers continued to rise [14]. Indeed, it was only in 1979 that benzodiazepines peaked at almost 31 million prescriptions [15]. THE GROWING CRISIS OF THERAPEUTIC EFFICACY
In 1980 it was still possible for the British government's watchdog, the Committee on the Review of Medicines, to state in its guidelines to physicians that "On present available evidence, the true addictive potential evidence of benzodiazepines [is] low" [16]. Since then, however, the phase of 'euphoric ignorance' has been replaced by a period of 'paranoid uncertainty' [17]. Why has this happened? Concern about tranquilliser prescribing at therapeutic dose has always a 'developmental possibility', given the
THE GROWTH IN POPULARITY OF BENZODIAZEPINES
The benzodiazepine era began in the early 1960s with the production of Librium and Valium [6]. The latter were quickly accepted by the medical profession in Britain as highly effective, safe drugs which did not create physical or psychological dependence or other unwanted effects attributed to the drugs which pro449
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persistent concern about the side effects of prescribed drugs in general [18]. However, it is only since clinical and epidemiological evidence of dependence at therapeutic dose (defined by the W H O [19] in 1974 in physical terms as 'intense physical disturbances when the administration of the drug is suspended') has started to appear that the crisis of therapeutic efficacy has really got under way. Since the early 1980s, studies of relatively small numbers of people (usually about 40) agreeing to or requesting withdrawal from long term benzodiazepine use at therapeutic dose have reported that a significant number experience symptoms of dependence on withdrawal [20-22], and that these symptoms can last a year or more [22]. Furthermore, studies using representative samples and control groups [20, 21] have found that between 27% and 45% of long term users are dependent on their drugs. If this is the case this would represent a substantial number of people, as it has recently been estimated that as many as 1.2 million people in Britain have been using anti-anxiety/sedative drugs (mainly benzodiazepines) for a year or more [15, 23]. This clinical and epidemiological evidence in turn has provided a terrain for the development of claimsmaking activities by hospital based medical experts, especially psychiatrists. It has been announced that a "withdrawal syndrome" has been discovered amongst long-term users of benzodiazepines at therapeutic dose, and that, given the prevalence of longterm use, such evidence of dependence represents an "epidemic in the making" of alarming proportions [24]. Not content with making such claims these experts have also sought to identify the source of the problem, particularly by blaming genearl practitioners, for failing to establish the limits of therapeutic use. Thus GPs have been castigated for writing repeat prescriptions without seeing the patient [25, 26] and for subscribing to the belief that people troubled by family, social and occupational problems can legitimately seek help from the medical profession [27]. One expert has even gone as far as to claim that behaviour like this is "souring the doctor-patient relationship" [28] and has created a crisis of confidence amongst the "anxious members of our community" [26]. We suggest that such claims-making has both revealed and exacerbated a set of relationships at the heart of health care. On the one hand it illustrates the persistent historical division between hospital specialists, in this case psychiatrists, and general practitioners [29], and the former's jockeying for position as they attempt to fashion a new role for themselves in a period of changing attitudes towards psychiatric disorder. On the other hand it may be helping to fuel a crisis of public confidence in the doctor-patient relationship, as allegations against specific doctors are raised to a new level. It is also interesting to note in this context that potential patients have not been singled out for moral opprobrium. Unlike studies of general practice in the 1960s and 1970s, which revealed a tendency amongst doctors to blame patients for presenting with trivial complaints [30, 31] most of the concern expressed by medical experts has been about doctors' prescribing behaviour. This may be because patients are seen
primarily as victims and as "passive dependent personalities" [21-22, 32]. However, recent pressure on medical experts concerning their own behaviour has led at least one to put the ball back in the court of the patient by stressing the role of personality factors in tranquilliser dependence in creating a demand for such treatment [33]. As we have seen, arguments about tranquilliser dependence have largely focussed on the prescribing behaviour of general practitioners. Two positions have emerged about this behaviour. Som~ experts have argued that "no one doubts that most patients usually taking benzodiazepines should stop them", and have suggested ways of doing so [26]. For these proponents benzodiazepines should not be prescribed for normal people at times of acute stress such as bereavement or divorce and, if prescribed at all, should be given for a short period at the lowest possible dose [26, 34]. Others have struck a less strident note and argued not only that they have an important place in the short term treatment of distress and insomnia, but that one should not assume that the long-term prescribing of benzodiazepines and the consequent high risk of dependence are to be avoided at all cost [32]. Alongside the claims of medical experts about dependence has been the growing voice of the consumer fights movements in mental health. Release, an organisation offering advice and referral on drug problems, has argued on the basis of "recent research" concerning "the physical withdrawal syndrome", that "tranx (benzodiazepines) are highly addictive to some users" and that, in its experience, the degree of distress felt on withdrawal is often far more extreme than that which first led a user to seek help from their general practitioner [35]. Similarly DAWN, the feminist pressure group concerned with women drug users, considers tranquillisers to be "very addictive to some (women) users" and states that "there is no doubt that withdrawal effects are not just the original anxiety coming back". Whilst as we have noted some medical opinion has described the passive nature of patients' behaviour, these groups see such dependence as perpetuating women's passivity and domesticity, and suggest that women wanting to come off tranquillisers should seek help from a specialist agency and from other women, particularly those who have had a similar experience [36]. MIND, the British mental health pressure group, has stated that it is "a fact" that people taking benzodiazepines can "get hooked physically or psychologically or both", and that "people often experience some withdrawal symptoms" when coming off these drugs, particularly if they have been taking them for more than a few weeks. On the basis of "research" and the views of the American Food and Drug Administration regarding the dependence potential of Valium, it suggested that "the danger of drugs in the benzodiazepine group are clear" and that "even very limited use may be ill advised" [37]. Elsewhere it has also argued that patients have a fight to be informed about these "dangers" and should be given a detailed data sheet about them with each prescription for a benzodiazepine [38]. It has also been suggested that money should be made available by the state to fund self-help groups for
Tranquillisers and health care in crisis those who have used the drug and have then had difficulty stopping [39]. Pressure groups like M I N D have also been instrumental in involving lawyers in possible litigation against drug companies. A U.K. 'benzodiazepine solicitors group' of around 320 law firms has been set up to co-ordinate research for potential legal action and is currently putting pressure on manufacturers to set up a compensation scheme for claimants without going to court [40]. The legal challenge to therapeutic activities is perhaps one of the most notable developments in the social relations of health care during the last decade, and tranquillisers have become a major example of such a challenge. It is also noteworthy that these pressure groups have generally been less careful in their use of terminology than most of the medical experts whose work they have drawn on, and have used "addiction", "being hooked" and "dependence" interchangeably. At the same time they have shared with these experts a willingness to attribute much of the blame for the problem of dependence to the general practitioner. As previously, the GPs have been castigated for giving a repeat prescription rather than asking patients about their lives and how they are feeling. They have also been criticised for failing to recognise or acknowledge that their patients might be dependent on these drugs, and for being unwilling to employ a psychotherapist or counsellor to give their patients the amount of time and attention that they need to resolve their difficulties. In this way, then, consumer rights groups have also played a part in heightening public concern about the trust that can be placed in general practitioners' clinical judgements and medical treatments. In the claimsmaking activity surrounding tranquilliser dependence we can see the importance of the interaction between professionally derived concerns and lay ideas about illness and its treatment [41]. Initial concern on the part of experts gathering clinical and epidemiological evidence has interacted with strongly held views held by patients and consumer groups. The broadening of clinical concerns with dependence and withdrawal to encompass a view of tranquillisers as "addictive" has crystallized a wider set of meanings concerned with drugs and their use. To this picture we must now add the activities of the media which, during the 1980s, has increasingly taken an interest in tranquilliser dependence. Indeed, the media has covered a wide range of health related issues during this period and in turn has increased public concern about the role of professional expertise. This is in contrast to the earlier presentation of health in the media in which the preoccupations of the medical profession were dominant [42]. MEDIA REPRESENTATION
The importance of the media in heightening public concern lies not only in its ability to provide opportunities for the expression of public opinion, or the "empowering" of individuals in their attempts to air grievances, but also in organizing meanings into recognizable images and narratives [43]. An analysis of television coverage, in particular, reveals its central role in the expression and organisation of expert and
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lay views surrounding tranquiUiser dependence. Not only, therefore, have expert and lay opinion interacted with each other, but both have also interacted with the media. Since 1983 there has been a series of programmes on British television dedicated to the subject, and information slots on day time television. Press coverage has also been extensive, and we have dealt with this in a separate paper [44]. We have examined all of the key programmes broadcast on British television in recent years, The main examples which we draw on here are as follows: the BBC magazine programme That's Life with a Sunday night audience of around 10 million which dealt with the issue on at least 4 occassions between 1983 and 1985; the BBC current affairs programme Brass Tacks which dealt with the issue on two occasions in 1988 and attracted an audience of 2.5 million viewers each time; and the Central Television investigatory programme The Cook Report which covered the issue once, again in 1988, in front of 6 million viewers. Through a content analysis of transcripts and video tapes, we have identified the opportunities for medical experts and consumer groups to publically express their views, and the specific ways in which the media has itself portrayed the problem of tranquilliser dependence. We now deal with each of these in turn. EXPRESSING OPINION T H R O U G H T H E MEDIA
In setting out to cover tranquilliser dependence each of the programmes has provided opportunities for medical experts and consumer groups to air their views. Starting with the medical experts, they have expressed at least three kinds of claim. First, they have argued that the size of the tranquilliser problem is a major cause for concern. For instance, Professor Malcolm Lader, who has appeared on each of the programmes, has claimed that "something like J million people in the country are taking one form of tranquilliser or another. And I would say a quarter of a million people are not able to get off the ones they've taken" (That's Life 12.6.83). This calculation, extrapolating from small scale studies, helps Lader to legitimate the seriousness of the problem and the need for action to tackle it. Second, television coverage has provided a vehicle for hospital based medical experts to establish their claims about GPs' behaviour. Again, on That's Life, a consultant psychiatrist attacked general practitioners who had allegedly prescribed tranquillisers to children. Similarly, on Brass Tacks and The Cook Report general practitioners were criticised in part as a result of claims being made by medical experts. In the former case GPs were provided with an opportunity to state their own position in response. Third, the programmes have been used to call for action to alter current patterns of tranquilliser prescribing. Experts on both Brass Tacks and The Cook Report discussed one particular benzodiazepine, Ativan, and the apparently high level of dependence associated with it. On Brass Tacks a debate ensued about whether special action should be taken to withdraw Ativan from the market. The Chairman of the Committee on the Safety of Medicines declined to isolate this benzodiazepine and issue special
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instructions about prescribing it. On The Cook Report, on the other hand, Professor Lader argued that the drug should be withdrawn from the market and that other benzodiazepines could be used instead. At the same time consumer groups have been using television to advance their own causes and campaigns. Thus they have suggested that patients have a right to be informed about the risks of dependence and have criticised GPs and the pharmaceutical companies for failing to do so. The mental health campaigning group MIND, for example, co-operated with That's Life following their initial coverage of the subject, in mounting a survey of tranquilliser use and dependence. This information was used in subsequent programmes to provide information about the risks of dependence and as the basis for a joint publication calling for the development of self-helf groups on the issue. Profits from this book went to M I N D [45]. In the second Brass Tacks programme the Assistant Director of M I N D was able, through careful preparation, to make a forceful intervention in the studio discussion. Unlike other participants he had brought along special 'flash cards' to hold up to the camera. These alledgedly illustrated the way in which benzodiazepine manufacturers promoted their products amongst GPs in an unethical way by "taking the thinking out of prescribing". In so doing he was able to advance M I N D ' s claims that manufacturers were in part to blame for tranquilliser dependence. From these brief examples of medical expert and consumer group activity it seems clear that the media have provided an important terrain on which claims can be advanced. In so doing, however, these groups have done more than advance their own interests. They have also contributed to the growing sense of doubt concerning medical treatments and the role of doctors in dealing with mental health issues. However, it needs to be stressed that the media have their own agenda and operate within definite structures. This is reflected in part by the routines and procedures that different programme formats employ [46]. For example, That's Life, working within a consumer format, not surprisingly gives more credence to consumer based claims than those of medical experts. In contrast, Brass Tacks, working within a current affairs format which stresses the need for balance and debate, gives greater opportunity for different medical experts to express their views, Not only has television organised opinion about tranquillisers through its use of different formats but by employing a range of images and narratives, it has further heightened concern about the efficacy of these drugs and prescribed drugs in general. It is to these images and narratives we now turn. IMAGES AND NARRATIVES
By themselves, tranquillisers are innocuous in appearance. Wrapped in silver foil or stored in medicine bottles, they are like many preparations that are part of our every day lives. But when presented as dangerous drugs they can appear frightening and fearful, just as white powder appears harmless until we are told that it is heroin or cocaine. In television, two ways have been employed to create powerful imagery in order to underpin the crisis with tranquillisers.
First, tranquillisers have been portrayed as drugs of 'addiction'. Each programme we have considered opened with a sequence that either described, or showed, an individual patient 'hooked' on these drugs. On the Brass Tacks programme the opening sequence, in which a man drew up his fix, was followed by pictures of packets of tablets which were then repeated through the programme. Second, the television pictures of the drugs themselves have enhanced the image of them as dangerous and frightening, especially in The Cook Report. Whilst other programmes were prepared to rely largely on descriptions of the drugs provided by the patients, The Cook Report created graphic representations in order to press home its message. The drugs were shown being manufactured in large quantities, emerging from the factory production line in their thousands, or showering down from the top of the screen in a colourful cascade. As the programme unfolded this latter image was repeated no less than 7 times, reinforcing the image of a massive quantity of the drugs that are made and consumed, and conveying the idea that we are almost drowning in them. In turn, these images form part of a narrative structure which is central to television [47]. Constructing the story of tranquilliser dependence involves making use of emotional and symbolic meanings concerning responsibility and good and evil. In 'That's Life' for example, tranquilliser dependence is not only a problem in itself, but also an illustration of the dangers that might befall an uninformed or unwary consumer. The narrative, here, concerns an innocent (in retrospect, possibly gullible) request for a service and irresponsible drug promotion and prescribing. Tranquilliser dependence becomes a case study of personal troubles and their exploitation which can be read in different ways by different audiences. In The Cook Report the metaphorical aspect of television narrative is developed further. The forces of good (in this case, the innocent patient) and evil (the drugs, the doctors and the drug companies) are invoked which lay the foundations for, and legitimise, the programme's 'denouement'. This comprises a confrontation scene between the chairman of Wyeth, the manufacturers of Ativan, and Cook, on the chairman's golf course. This dramatic scene in which Cook attempts to 'door step' and interview the chairman, and in which the chairman verbally and physically attacks Cook in return, offers the viewer a sense of dramatic action being taken. It is action which ordinary individuals have neither the resources or courage to undertake themselves. What is at work here, however, is not simply the examination of the morality of drug manufacture. The case of tranquilliser dependence also reveals television's preoccupation with mediating and shaping social conflicts. As we have seen, the claims making activity surrounding tranquillisers involves the clash of a number of interest groups, within medicine and outside. The narratives of television programmes organise and frame these conflicts in a variety of ways. The story of tranquilliser dependence feeds into wider concerns about the use of prescribed drugs in the treatment of a variety of ailments.
Tranquillisers and health care in crisis In summary, the media, and especially television provides the means for publicising and legitimising claims about tranquilliser dependence, but also creates and recreates meanings around it. The images and narratives constituted by, and contained in television programmes present a picture that "imposes coherence and resolution upon a world that has neither" [43, p. 130]. Those hoping to use the media, therefore, in order to advance their claims about tranquilliser dependence, are confronted with the fact that they, in turn, become used as part of a more complex media agenda. CONCLUSION The controversy surrounding tranquilliser dependence may be seen as an example of a range of debates concerning the efficacy of modern medical treatments. The enthusiasm surrounding the introduction of tranquillisers in the 1960s reflected not only a reaction to the earlier use of barbiturates, but the general atmosphere of progress in health care overall. Tranquillisers epitomised the belief that new safe treatments would become increasingly available across the board. The disillusionment with many forms of medicine which has grown in recent years allows us to place the problem of tranquilliser dependence in context. The emphasis on costs compared with the benefits of treatments, especially social costs, has come to affect a wide range of activities, especially those associated with women's health. Contraceptive, anti-emetic and anti-rheumatic drugs preceded tranquillisers as causes for concern. Legal campaigning over the Dalcon Shield, for example, continues in Britain today. From this viewpoint, the case of tranquilliser dependence should be seen as part of the widespread questioning of the role of medical treatments. Part of this picture, which we have touched on here, has been the challenge to traditional medical authority. Although the arguments over tranquilliser dependence, particularly between hospital doctors and general practitioners, is a reflection of the longstanding divide in British medicine [29], the willingness of doctors to publically express their views about each other is new. So, too, is the willingness of consumer groups to take a more active stance. The legal battle over tranquilliser dependence, whatever its final outcome, marks a break with traditional attitudes concerning trust towards, and among doctors. Although it is always possible to exaggerate the degree of change, the examination of tranquilliser dependence suggests that we are witnessing a major shift, if not a crisis, in the social relations of health care. We have argued that the claims about tranquillisers have become inevitably caught up in media coverage. The modern mass media, and especially television now occupies a strategic site on which social conflicts, including those in health are managed. We have attempted to show that not only is television crucial to the claims making activities of different interest groups, but that through powerful imagery and narrative it creates a range of meanings itself. Television both enables and constrains experts and patients, offering them opportunities to express their views,
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but presenting them as part of a selective portrayal of the issues. Television's treatment is almost inevitably prone to amplification and exaggeration. In particular, television creates a strong emotional field around social problems in its desire to dramatise their character. Again, tranquilliser dependence illustrates the processes at work. What is less clear is the future use of benzodiazepine tranquillisers as thrapeutic agents. We can only speculate about the impact of television coverage on the actions of the various groups identified here; consumers, practitioners and manufacturers alike. Certainly there are signs that practitioners may be more reluctant to sanction long term use of these drugs, and some form of reappraisal is clearly under way [48]. The legal campaign currently in train in Britain could turn out to be the key to the future use of benzodiazepines. On the other hand, it seems clear from our analysis that the imagery and language of 'addiction', together with the emotional portrayal of withdrawal on television, has made detachment in undertaking an appraisal of the value of these drugs more difficult. Here too, however, we may be describing an example of a general trend in health care. REFERENCES
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