symptoms ranging from restlessness,
Sedative-Hypnotic
Medications
What are sedative-hypnotics?
Sedative-hypnotics are drugs which
depress or slow down the body's functions.
Often these drugs are referred to as
tranquilizers and sleeping pills or
sometimes just as sedatives. Their effects
range from calming down anxious people to
promoting sleep. Both tranquilizers and
sleeping pills can have either effect,
depending on how much is taken. At high
doses or when they are abused, many of
these drugs can even cause unconsciousness
and death.
What are some of the sedative-hypnotics?
Barbiturates and benzodiazepines are
the two major categories of sedative-
hypnotics. The drugs in each of these groups
are similar in chemical structure. Some
well-known barbiturates are secobarbital
(Seconal) and pentobarbital (Nembutal).
Diazepam (Valium), chlordiazepoxide (Librium),
and chlorazepate (Tranxene) are examples
of benzodiazepines. A few sedative-
hypnotics do not fit in either category. They
include methaqualone (Quaalude),
ethchlorvynol (Placidyl), chloral hydrate
(Noctec), and mebrobamate (Miltown). All of
these drugs can be dangerous when they
are not taken according to a physician's
instructions.
Can sedative-hypnotics cause dependence?
Yes. They can cause both physical and
psychological dependence. Regular use over
a long period of time may result in
tolerance, which means people have to
take larger and larger doses to get the
same effects. When regular users stop
using large doses of these drugs suddenly,
they may develop physical withdrawal
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insomnia and anxiety, to convulsions and
death. When users become psychologically
dependent, they feel as if they need the
drug to function. Finding and using the drug
becomes the main focus in life.
Is it true that combining sedative-hypnotics
with alcohol is especially dangerous?
Yes. Taken together, alcohol and
sedative-hypnotics can kill. The use of
barbiturates and other sedative-hypnotics
with other drugs that slow down the body,
such as alcohol, multiplies their effects
and greatly increases the risk of death.
Overdose deaths can occur when
barbiturates and alcohol are used
together, either deliberately or
accidentally.
Can sedative-hypnotics affect an unborn
fetus?
Yes. Babies born to mothers who abuse
sedatives during their pregnancy may be
physically dependent on the drugs and
show withdrawal symptoms shortly after
they are born. Their symptoms may include
breathing problems, feeding difficulties,
disturbed sleep, sweating, irritability, and
fever. Many sedative-hypnotics pass
through the placenta easily and have
caused birth defects and behavioral
problems in babies born to women who have
abused these drugs during their pregnancy.
What are barbiturates?
Barbiturates are often called "barbs"
and "downers." Barbiturates that are
commonly abused include amobarbital
(Amytal), pentobarbital (Nembutal), and
secobarbital (Seconal). These drugs are sold
in capsules and tablets or sometimes in a
liquid form or suppositories.
What are the effects of barbiturates when
they are abused?
Dinoy Edward Arlu V. BSN II-D
 The effects of barbiturates are, in many
ways, similar to the effects of alcohol.
Small amounts produce calmness and relax
muscles. Somewhat larger doses can cause
slurred speech, staggering gait, poor
judgment, and slow, uncertain reflexes.
These effects make it dangerous to drive a
car or operate machinery. Large doses can
cause unconsciousness and death.
How dangerous are barbiturates?
Barbiturate overdose is a factor in
nearly one-third of all reported drug-
related deaths. These include suicides and
accidental drug poisonings. Accidental
deaths sometimes occur when a user takes
one dose, becomes confused and
unintentionally takes additional or larger
doses. With barbiturates there is less
difference between the amount that
produces sleep and the amount that kills.
Furthermore, barbiturate withdrawal can
be more serious than heroin withdrawal.
methaqualone include injury or death from
car accidents caused by faulty judgment
and drowsiness, and convulsions, coma, and
death from overdose.
What are sedative-hypnotic "look-alikes"?
These are pills manufactured to look
like real sedative-hypnotics and mimic their
effects. Sometimes look-alikes contain over-
the-counter drugs such as antihistamines
and decongestants, which tend to cause
drowsiness. The negative effects can
include nausea, stomach cramps, lack of
coordination, temporary memory loss,
becoming out of touch with the
surroundings, and anxious behavior.
Source: National Institute on Drug
Abuse, 1984

What other sedative-hypnotics are abused?

All the other sedative-hypnotics can

be abused, including the benzodiazepines.
Diazepam (Valium), chlordiazepoxide (Librium),
and chlorazepate (Tranxene) are examples
of benzodiazepines. These drugs are also
sold on the street as downers. As with the
barbiturates, tolerance and dependence
can develop if benzodiazepines are taken
regularly in high doses over prolonged
periods of time. Other sedative-hypnotics
which are abused include glutethimide
(Doriden), ethchlorvynol (Placidyl), and
methaqualone (Sopor, Quaalude).

What is methaqualone?

Methaqualone ("Sopors," "ludes") was

originally prescribed to reduce anxiety
during the day and as a sleeping aid. It is
one of the most commonly abused drugs and
can cause both physical and psychological
dependence. The dangers from abusing

2|Page: Assignment in Pharmacology Dinoy Edward Arlu V. BSN II-D


Alternative & Complementary
Therapies for Anxiety
Adrian R White, Max H Pittler
Anxiety is an unpleasant emotional
state involving both fear and physical
symptoms. It is a normal reaction to
stressful events (state anxiety), but can be
regarded as pathological when it is unduly
severe or prolonged (trait anxiety). Anxiety
may present as one symptom of a cluster of
related, overlapping conditions, the most
common of which are generalised anxiety
disorder, phobic disorder and panic disorder.
Generalised anxiety disorder is common,
affecting about 2–5% of a typical western
population, and may present with a range
of psychological and/or physical symptoms.
Conventional treatment for anxiety may
include tranquillisers such as
benzodiazepines for short-term use and a
range of psychological therapies from
superficial psychotherapy to cognitive and
behaviour therapies. These conventional
psychological therapies will not be
considered in this review. We shall
consider the effect of complementary
therapies only on the psychological
symptoms of anxiety. Physical disorders
that may be secondary to anxiety (such as
hypertension) or may be aggravated by it
(such as asthma) are not the major focus of
this article.
Therapies for anxiety are not
universally successful and, as the
symptoms of anxiety are chronic and (in
general) non-life-threatening, patients are
likely to seek help from complementary
medicine. Recent survey data suggest that
anxiety is one of the most frequent
conditions treated with complementary
therapies.1 An important distinction must be
drawn between treatments that have
effects on state anxiety and those that are
capable of producing lasting effects on
3|Page: Assignment in Pharmacology
trait anxiety. Short-term relief of anxiety
may lead to dependency on the practitioner.
Relaxation techniques
There is a range of therapies or self-
learned practices that uses physical and
mental/spiritual procedures to different
extents, with the aim of inducing a
peaceful mental and physical state. Benson
and Clipper2 emphasised the bidirectional
nature of the relationship between mind
and body and provided evidence of an
effect of progressive muscular relaxation.
Rigorous investigation of these methods
faces the problem of selecting a suitable
control procedure: often, trials that
compare two similar techniques show little
difference, so no conclusion can be made
about the specific effects of either. If a
therapy is found to be superior to an
untreated control, this could be the result
of many ‘context’ effects, such as the
therapeutic relationship, instead of or in
addition to any therapeutic effect.
In an extensive meta-analysis of 76
controlled trials of all forms of
relaxation and meditation techniques in
the management of anxiety, Eppley et al.3
found overall evidence of a small but
significant effect of the interventions,
grouped by the type of relaxation or
meditation. Psychiatric patients were
specifically excluded, so the role of these
therapies in generalised anxiety disorder is
not known. Separate analyses of the
studies that used situation- or attention-
control arms were not performed, so this
review does not demonstrate specific
effects unequivocally.
There is clear evidence from more
than 10 randomised controlled trials (RCTs)
in healthy volunteers that muscle
relaxation may lead to a significant
reduction in state anxiety. Among employees,
those practising regular relaxation felt
more in control of their health4 and more
Dinoy Edward Arlu V. BSN II-D
able to cope with stress at work.5 In
elderly patients with high anxiety, Rankin
et al.6 found a significant reduction in the
anxiety state compared with the effect of
attention control. Medical investigations
are a common cause of anxiety: Quirk and
colleagues7 showed that the anxiety
engendered by magnetic resonance imaging
could be improved significantly more by
relaxation and information than by
counselling and information or by
information alone. In patients with newly
diagnosed cancer, relaxation with or
without imagery improved anxiety as well
as other aspects of mood.8 In a similar
population, Bridge and colleagues9 found a
significant reduction in state anxiety after
relaxation compared with untreated
controls, but there was no significant
effect on trait anxiety.
Biofeedback
Biofeedback involves measuring some
physical parameter (muscle tension, skin
temperature, bowel activity) and using the
data to alter the pitch or intensity of a
visual or auditory signal, which is then fed
back to the subject. With repeated practice,
subjects can learn to influence the
measured parameter; this is presumed to
induce generalised relaxation, although
Ince et al.10 have pointed out the lack of
direct evidence supporting this concept.
Biofeedback may have the advantage of
being easier to learn than relaxation, with
the disadvantage that some subjects find it
difficult to continue practising relaxation
in the long term without the aid of the
apparatus.
Fehring found biofeedback to be more
effective in reducing anxiety among a group
of normal students than muscle relaxation
alone. These results are supported by those
of several RCTs that have investigated
biofeedback training for state anxiety. One
clinical study measured trait anxiety in
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children who were identified by their
teachers as anxious and then randomised to
biofeedback or no treatment groups.12 The
biofeedback group achieved significant
reductions in both state and trait anxiety
compared with the untreated control
group. However, the actual results were
poorly presented in the published report,
and long-term benefit was not tested as
the children were not followed up after
the end of treatment.
Meditation
The overall effect of meditation is
supported by several RCTs. The clearest of
these was a trial in which the control
group sat quietly for the same length of
time, twice daily: meditation led to a
significantly greater fall in anxiety, as
measured by the State Trait Anxiety
Inventory.13 In a meta-analysis of trials of
all forms of relaxation and meditation
techniques mentioned above,
transcendental meditation proved to be
clearly superior to progressive muscle
relaxation and all other forms of
relaxation.3 The evidence seems to point to
this not being simply an effect of
expectation (for example, the difference
becomes greater over time), but possibly
associated with the ‘effortlessness’ of the
procedure. The results also suggested that
methods of relaxation that involve fierce
concentration seem to be less effective in
reducing anxiety.
Autogenic training
A systematic review located eight
controlled trials, all of which showed
significant reduction in anxiety of the
treatment groups (Kanji, White & Ernst,
unpublished data). Autogenic training
reduced experimentally induced anxiety in
volunteer students, and it reduced anxiety-
related sickness absence in nurses when
compared with untreated control groups.
There were only two studies using patient
Dinoy Edward Arlu V. BSN II-D
groups: autogenic training was shown to be
as effective as hypnotherapy and as a
particular form of transcutaneous
electrical nerve stimulation in reducing
anxiety in patients diagnosed with chronic
hysteria. Autogenic training and hypnosis
both reduced anxiety significantly in a
group of young anxious patients, with no
significant difference between the groups.
Overall, therefore, the evidence is not
conclusive. Control groups chosen were not
appropriate, and autogenic training was
used in combination with a variety of other
therapies, which may themselves have
contributed to the result.
Self-hypnosis
Patients undergoing coronary artery
bypass surgery were randomised to receive
either a self-hypnotic relaxation technique
or no intervention. There were no benefits
shown during surgery, but significantly
greater relaxation and reduced analgesic
use were noted in the treated group after
surgery up to the time of discharge.14
In summarising the evidence from
trials of all relaxation/meditation
techniques, it seems clear that these
techniques can have a positive effect,
albeit small, in reducing state anxiety in
normal healthy subjects. There is some
evidence that they can improve patients’
overall ability to cope with conditions
such as cancer. There is, however,
insufficient evidence to conclude that they
are of benefit in the treatment of chronic
generalised anxiety. In experienced and
responsible hands, these therapies are
mostly safe for normal individuals:
however, meditation should not be
performed for longer than the stipulated
time and has been associated with
depersonalisation syndrome; hypnosis has
been associated with false memory
syndrome. These treatments should be used
5|Page: Assignment in Pharmacology
with care, if at all, in patients with
personality and psychotic disorders.
Exercise
It has been shown that exercise can
reduce anxiety acutely. Measures of stress
fall about 15 minutes after starting
aerobic exercise and the effect lasts for 3–
4 hours after the exercise has finished.
Suggested mechanisms include distraction,
experience of mastery, release of
endogenous opioids and reduction in muscle
tension and other physical markers of
stress response. There is much more doubt
about its effect on trait anxiety.15 On
balance, it seems that the evidence is
insufficient to justify recommendation.
For some time, there was concern
that exercise might provoke panic attacks
in susceptible individuals as a response to
the symptoms of sympathetic activation.
This is now known to be unfounded and, in
fact, a recent well-designed and carefully
performed RCT has shown that exercise may
have a useful role in treating panic
disorder, although the response is smaller
in size and slower in onset than that seen
with clomipramine.16 T’ai chi has also been
shown to have a positive effect in reducing
mental and emotional stress, but this was
partially accounted for by the subjects’
high expectations of benefit.17
Herbal remedies
Herbal remedies are among the
complementary treatments most often used
for anxiety.1 Extract of kava (Piper
methysticum Forst.) is one of the best
researched herbal remedies for this
condition. However, most of the research
has been published in German, and little is
available in the English language. Kava
extract significantly reduces anxiety when
given in a dosage of 300–450 mg
(standardised to 60–240 mg of kava-lactones)
daily (Pittler & Ernst, unpublished data).
Dinoy Edward Arlu V. BSN II-D
Adverse effects are mild and infrequent.
Stomach complaints, restlessness,
drowsiness, tremor, headache and tiredness,
and scaling of the skin after long-term
administration, have been reported.
German chamomile (Matricaria
recutita L.) is also used as a treatment for
anxiety. One of its active constituents, the
flavonoid apigenin, may have affinity for
benzodiazepine receptors, which may
explain its beneficial effects. There is
insufficient evidence from well-performed
trials to support its clinical effectiveness.
Chamomile is usually prepared as a tea and
administered at a dosage of 2–4 g of dried
flower heads three times daily. It is
considered safe by the US Food and Drug
Administration but allergic reactions to
chamomile have been reported in patients
with allergies to ragweed.
Despite the long-standing use of
lemon balm (Melissa officinalis L.) as an
anxiolytic,18 there is little trial evidence
supporting its clinical effectiveness for
anxiety. The doses administered range from
1 to 4 g daily. No adverse effects have been
reported from ingestion of lemon balm.
Passion flower (Passiflora incarnata
L.), skullcap (Scutellaria laterifolia L.) and
valerian (Valeriana officinalis L.) are
mainly used as sedatives/hypnotics but may
also have beneficial effects in the
treatment of anxiety.19 The last one has
been a calming agent for centuries and its
use as mild sedative is approved in Germany.
Although it is considered safe, paradoxical
reactions, including restlessness and
palpitations, have been reported in a small
number of patients.
Other therapies
Massage given twice a week for 5
weeks was shown to be superior to
relaxation therapy for depressed
adolescent mothers. Both groups scored
6|Page: Assignment in Pharmacology
lower anxiety, but the effect in the
massage group was confirmed by objective
measurement of the reduction in anxious
behaviour and urinary steroid
concentrations.20 In a further RCT, massage
was shown to reduce anxiety in elderly
institutionalised patients to a greater
extent than conversation or no
intervention.21 If these benefits are
confirmed, it would be important to
determine their duration.
Aromatherapy is widely promoted for
the treatment of ‘stress’, but its efficacy in
this condition is not supported by good-
quality clinical research. The majority of
the trials of aromatherapy have
investigated its effects on anxiety (as well
as other outcomes) in a variety of
settings/indications.22,23 Several of these
studies report that anxiety scores improved
in both treatment and control groups, but
that there were no statistically
significant differences between groups. The
majority of these trials conducted are of
poor methodological quality and are also
poorly reported, often lacking important
details.
Music’s power to calm anxious minds
has been used in many healthcare settings,
such as operating theatres, but this does
not mean that music therapy has a direct
beneficial effect on patients in similar
situations. Uncontrolled studies of music in
coronary care units have had inconsistent
results. A rigorous randomised study
involving 56 patients admitted to a
coronary care unit in Australia compared
two or three sessions of either listening to
light classical music or following
relaxation instructions (breathing and
feelings of heaviness, not progressive
muscle relaxation, which involves
isometric muscle contraction) for 30
minutes. Neither therapy had any effect on
anxiety, and subjects had no benefit
compared with untreated controls.24 A
Dinoy Edward Arlu V. BSN II-D
number of RCTs have failed to show any
beneficial effect of music on the anxiety
that patients experience during various
surgical procedures. However, a controlled
study found that patients who listened to
self-selected music tapes during
sigmoidoscopy suffered less anxiety than
control subjects who had no music.25

There is very little evidence from

controlled clinical trials on which to form
an opinion of the effectiveness of the
other major complementary therapies in
treating anxiety. A single study suggested
that homoeopathy may have an effect in
reducing agitation in children after
surgery.26 Chiropractic was no better than
sham chiropractic in reducing anxiety in
adult hypertensive patients, although it
was associated with a significant fall in
blood pressure.27 There are no controlled
trials of acupuncture for anxiety.

In conclusion, anxiety is a problem

that attracts many individuals to
complementary practitioners. Encouraging
results exist for short-term responses to
relaxation, meditation, autogenic training,
kava extract and massage. Regrettably, firm
conclusions on efficacy are impossible, as
many of the clinical trials have
methodological flaws.

7|Page: Assignment in Pharmacology Dinoy Edward Arlu V. BSN II-D