Benzo vs other options for anxiety

[tr]

It’s a good question—the limited data we have (a few 1-3 year follow up studies in PD) indicate that anxiolytic tolerance does not form and that side effect burden is much less than with SSRIs. This is not the strongest evidence base but it does tell us something.

????
Surely you jest. SSRIs are not associated with falls, dementia, or all-cause mortality.

Association Between Benzodiazepine Use With or Without Opioid Use and All-Cause Mortality in the US

This cohort study uses data from the National Health and Nutrition Examination Surveys to evaluate whether benzodiazepine use, with or without opioid use, is associated with increased all-cause mortality relative to the use of low-risk antidepressants.

jamanetwork.com

The impact of SSRIs on mortality and cardiovascular events in patients with coronary artery disease and depression: systematic review and meta-analysis - Clinical Research in Cardiology

Background Depression is common in patients after acute coronary syndromes (ACS) and with stable coronary artery disease (CAD) and has been associated with increased mortality and morbidity. However, it is unclear whether selective serotonin receptor inhibitors (SSRIs) reduce mortality or...

link.springer.com

Even if tolerance does occur, an important question is: is this complete tolerance? (Pt is back at baseline prior to starting the benzo) or partial tolerance? And how much? 30-40% tolerance means 60-70% sustained relief in a treatment-resistant anxiety patient who has done the therapy, SRIs, buspar, Remeron, atypical antipsychotics heaven forbid, what have you.

I don't think I have ever encountered a long-term benzo patient who had previously done therapy, SRIs, BuSpar, and Remeron. Usually they were started on the benzo first or second line, with or without SSRI, and simply continued to take it for decades. Most of them have never had effective exposure therapy for anxiety.

Finally, if anxiolytic tolerance does occur with benzos, I don’t see why this cannot also apply to SSRIs. Unless we collectively feel like the benzo-induced “euphoria” to which tolerance develops is the anxiolysis itself.

Some people do seem to develop tolerance to SSRIs, though it doesn't seem to be as common/universal as with benzos. Have you not seen this? It can take anywhere from a year or two to decades, where the patient starts to feel like their medication isn't working anymore. I'm not sure about mechanism but it doesn't seem to be class-based because switching to a different SSRI usually fixes the problem.

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[smalltownpsych]

I don't think I have ever encountered a long-term benzo patient who had previously done therapy, SRIs, BuSpar, and Remeron. Usually they were started on the benzo first or second line, with or without SSRI, and simply continued to take it for decades. Most of them have never had effective exposure therapy for anxiety.

I would imagine that even a supportive psychotherapy like client-centered would reduce need for benzos. Talking to people who care about you makes you feel better. Add in a little gradual exposure to the anxiety provoking stimulus and maybe learn to challenge some of the irrational thoughts and the person will feel even better and this improvement will help to override the need for benzos. Also, if they truly are anxious, then the potential negative effects of long term use will increase their anxiety and motivation to eventually discontinue.

Another point is that if they are really an addict trying to get high, there are much better drugs for that including alcohol and they’re probably just mixing it with that anyway. Psychiatry or psychotherapy won’t help these folk much. I have one like that right now who just went back for another stint at rehab. Sometimes it amazes me how hard it is for most clinicians to tell the difference between the anxious person who benefits from a benzo and can become dependent on it for that reason and the addict who is lying to themselves and us while they are spinning out of control and grasping at straws.

 

[TexasPhysician]

Low-dose, long-acting benzodiazepines like clonazepam probably don’t yield a signal comparable to amphetamines and opiates, or Xanax or Valium.

I’m confused by your argument. Valium is a less potent, longer acting benzo when compared to clonazepam.

 

[calvnandhobbs68]

I’m confused by your argument. Valium is a less potent, longer acting benzo when compared to clonazepam.

Yeah I think they're getting confused there, probably trying to refer to the fact that valium is way more lipid soluble, so that's why it tends to be more "reinforcing" (faster blood brain barrier cross, faster onset of action).

 

[ObsequiousAplomb]

????
Surely you jest. SSRIs are not associated with falls, dementia, or all-cause mortality.

Association Between Benzodiazepine Use With or Without Opioid Use and All-Cause Mortality in the US

This cohort study uses data from the National Health and Nutrition Examination Surveys to evaluate whether benzodiazepine use, with or without opioid use, is associated with increased all-cause mortality relative to the use of low-risk antidepressants.

jamanetwork.com

The impact of SSRIs on mortality and cardiovascular events in patients with coronary artery disease and depression: systematic review and meta-analysis - Clinical Research in Cardiology

Background Depression is common in patients after acute coronary syndromes (ACS) and with stable coronary artery disease (CAD) and has been associated with increased mortality and morbidity. However, it is unclear whether selective serotonin receptor inhibitors (SSRIs) reduce mortality or...

link.springer.com

I don't think I have ever encountered a long-term benzo patient who had previously done therapy, SRIs, BuSpar, and Remeron. Usually they were started on the benzo first or second line, with or without SSRI, and simply continued to take it for decades. Most of them have never had effective exposure therapy for anxiety.


Some people do seem to develop tolerance to SSRIs, though it doesn't seem to be as common/universal as with benzos. Have you not seen this? It can take anywhere from a year or two to decades, where the patient starts to feel like their medication isn't working anymore. I'm not sure about mechanism but it doesn't seem to be class-based because switching to a different SSRI usually fixes the problem.

Both benzodiazepines and SSRIs are associated with dementia and falls in the elderly. I would nearly always prefer an SSRI over a benzodiazepine (I don't think I've ever given a benzodiazepine without an SSRI, SNRI, TCA, Remeron, or other longer-term solution for any patient outside of MAW), though what you're saying is just not supported by the evidence. SSRIs are on the Beers list for falls. I agree that the risk is probably lesser for SSRIs than benzodiazepines.

Patterns of selective serotonin reuptake inhibitor use and risk of falls and fractures in community-dwelling elderly people: the Three-City cohort - PubMed

In this large community-dwelling elderly sample, SSRI users were at higher risk of falls and fractures. This association was not due to reverse causality or residual depressive symptoms. Different SSRI drugs may have specific adverse effects on falls and fractures.

pubmed.ncbi.nlm.nih.gov

Increased Risk of Dementia in Patients with Antidepressants: A Meta-Analysis of Observational Studies

Antidepressants are the most commonly and widely used medication for its effectiveness in the treatment of anxiety and depression. A few epidemiological studies have documented that antidepressant is associated with increased risk of dementia so far. ...

www.ncbi.nlm.nih.gov

 

[VA Hopeful Dr]

Both benzodiazepines and SSRIs are associated with dementia and falls in the elderly. I would nearly always prefer an SSRI over a benzodiazepine (I don't think I've ever given a benzodiazepine without an SSRI, SNRI, TCA, Remeron, or other longer-term solution for any patient outside of MAW), though what you're saying is just not supported by the evidence. SSRIs are on the Beers list for falls. I agree that the risk is probably lesser for SSRIs than benzodiazepines.

Patterns of selective serotonin reuptake inhibitor use and risk of falls and fractures in community-dwelling elderly people: the Three-City cohort - PubMed

In this large community-dwelling elderly sample, SSRI users were at higher risk of falls and fractures. This association was not due to reverse causality or residual depressive symptoms. Different SSRI drugs may have specific adverse effects on falls and fractures.

pubmed.ncbi.nlm.nih.gov

Increased Risk of Dementia in Patients with Antidepressants: A Meta-Analysis of Observational Studies

Antidepressants are the most commonly and widely used medication for its effectiveness in the treatment of anxiety and depression. A few epidemiological studies have documented that antidepressant is associated with increased risk of dementia so far. ...

www.ncbi.nlm.nih.gov

Decent bit of hyponatremia in my experience as well.

 

[mistafab]

I think most common offenders of falls with SRI medications in geriatrics tends to be with polypharmacy. A common scenario is Wellbutrin added to someone on fluoxetine or paroxetine. This is an easy recipe for dangerous falls. Also, any of the more anticholinergic SRIs are riskier in geriatric patients for falls, delirium, and cognitive impairment in general. I have also never seen SIADH from SRI in an adult patient, i've only exclusively encountered this in the elderly on SRIs - not sure other's experience here.

On discussing risk of mortality on benzos, I agree this is very well established in the elderly. The risk of death is just much higher when someone is prescribed a benzo in advanced age vs not. Lots of good data to support this.

 

[VA Hopeful Dr]

So let me preface this by saying that I'm just a family doctor and I don't start chronic benzos.

With that out of the way, some of you must be living in a psychiatric paradise. Our local therapists are booked out 6 months if they are taking new patients at all. None take Medicaid, over half don't take insurance at all. I have no idea if any of them are actually any good because none of my patients can get to see them/afford them. Most also can't take time off of work every single week to do decent therapy.

SSRI side effects are super common. Weight gain and sexual side effects for some weird reason really bother people.

Now I'm not at all saying you should be handing klonopin out like candy. But this wonderful world where everyone can tolerate their SSRIs and get into a good therapist isn't the reality for everyone.

 

[painballer27]

What about higher dose gabapentin or buspar for GAD?

 

[TexasPhysician]

So let me preface this by saying that I'm just a family doctor and I don't start chronic benzos.

With that out of the way, some of you must be living in a psychiatric paradise. Our local therapists are booked out 6 months if they are taking new patients at all. None take Medicaid, over half don't take insurance at all. I have no idea if any of them are actually any good because none of my patients can get to see them/afford them. Most also can't take time off of work every single week to do decent therapy.

SSRI side effects are super common. Weight gain and sexual side effects for some weird reason really bother people.

Now I'm not at all saying you should be handing klonopin out like candy. But this wonderful world where everyone can tolerate their SSRIs and get into a good therapist isn't the reality for everyone.

What geography are we talking? I’m in a popular metro area of Texas. It’s possible to see a counselor and psychiatrist within 48 hours. With telepsychiatry (knowing where to look), this means that someone anywhere in Texas could see someone in that time frame.

Side effects aren’t rare, but few patients of mine go through many antidepressants without finding a good option without minimal side effects.

 

[WisNeuro]

What geography are we talking? I’m in a popular metro area of Texas. It’s possible to see a counselor and psychiatrist within 48 hours. With telepsychiatry (knowing where to look), this means that someone anywhere in Texas could see someone in that time frame.

Side effects aren’t rare, but few patients of mine go through many antidepressants without finding a good option without minimal side effects.

We've got pretty good availability in our metro. For most cases, when a referral comes up on our listserv, we've got a handful of psychologists who can see that person within the next week. Medicaid may be a longer wait to see a psychologist, but they could get into a midlevel pretty quickly at several agencies that have decent coverage. Neuropsych availability on the other hand, that'll take a while.

 

[tr]

So let me preface this by saying that I'm just a family doctor and I don't start chronic benzos.

With that out of the way, some of you must be living in a psychiatric paradise. Our local therapists are booked out 6 months if they are taking new patients at all. None take Medicaid, over half don't take insurance at all. I have no idea if any of them are actually any good because none of my patients can get to see them/afford them. Most also can't take time off of work every single week to do decent therapy.

SSRI side effects are super common. Weight gain and sexual side effects for some weird reason really bother people.

Now I'm not at all saying you should be handing klonopin out like candy. But this wonderful world where everyone can tolerate their SSRIs and get into a good therapist isn't the reality for everyone.

No need to be restricted to your local area any longer. In the past couple of years there has been a proliferation of companies that provide reasonable-quality psychotherapy by telepsych, covered by insurance.

helloalma.com
betterhelp.com
treatmyocd.com
try.talkspace.com

As for SSRI side effects, agree they are common and often unpleasant. I wouldn't want to tolerate weight gain or sexual impairment either personally (I don't consider that 'weird'). I usually switch people to a different drug if they get weight gain or sexual side effects. Lexapro seems to be the big offender for weight gain, I don't see it much with other SSRIs. Bupropion and mirtazapine do not impair sexual response and may actually improve it. Alternatively, if the SSRI is working well otherwise, sometimes sexual side effects can be combatted with adjunctive treatments like bupropion, buspirone, amantadine, etc.

 

[VA Hopeful Dr]

We've got pretty good availability in our metro. For most cases, when a referral comes up on our listserv, we've got a handful of psychologists who can see that person within the next week. Medicaid may be a longer wait to see a psychologist, but they could get into a midlevel pretty quickly at several agencies that have decent coverage. Neuropsych availability on the other hand, that'll take a while.

What geography are we talking? I’m in a popular metro area of Texas. It’s possible to see a counselor and psychiatrist within 48 hours. With telepsychiatry (knowing where to look), this means that someone anywhere in Texas could see someone in that time frame.

Side effects aren’t rare, but few patients of mine go through many antidepressants without finding a good option without minimal side effects.

I'd like to point out that you both live in metro areas while I do not (town of around 40k in SC). I could as easily be complaining about not having a Trader Joe's and y'all being confused because you both have one 4 miles away.

 

[VA Hopeful Dr]

No need to be restricted to your local area any longer. In the past couple of years there has been a proliferation of companies that provide reasonable-quality psychotherapy by telepsych, covered by insurance.

helloalma.com
betterhelp.com
treatmyocd.com
try.talkspace.com

As for SSRI side effects, agree they are common and often unpleasant. I wouldn't want to tolerate weight gain or sexual impairment either personally (I don't consider that 'weird'). I usually switch people to a different drug if they get weight gain or sexual side effects. Lexapro seems to be the big offender for weight gain, I don't see it much with other SSRIs. Bupropion and mirtazapine do not impair sexual response and may actually improve it. Alternatively, if the SSRI is working well otherwise, sometimes sexual side effects can be combatted with adjunctive treatments like bupropion, buspirone, amantadine, etc.

Funny you say that, my internist wife and I were just talking about looking into telepysch options for our patients.

There's one patient in particular that I've been thinking about. Depression with panic attacks. Lexapro works great but significant weight gain and sexual side effects. Same with celexa. Paxil killed their energy level. Prozac made them jittery. So did effexor. Tried adding wellbutrin to Lexapro, made panic attacks worse. Trintellix works quite well for the depression, minimal side effects but doesn't do much for the anxiety. Next plan is to try buspar.

Interestingly, panic attacks have gotten way worse since starting ozempic for weight loss and apparently this is something that can sometimes happen so we've stopped that for now. If that doesn't help then buspar is next up.

 

[TexasPhysician]

I'd like to point out that you both live in metro areas while I do not (town of around 40k in SC). I could as easily be complaining about not having a Trader Joe's and y'all being confused because you both have one 4 miles away.

SC has a ton of mental health clinicians. I’d be surprised if there aren’t tele options easily available.

I’m not sure what Trader Joe’s is or if they offer tele services.

 

[VA Hopeful Dr]

SC has a ton of mental health clinicians. I’d be surprised if there aren’t tele options easily available.

I’m not sure what Trader Joe’s is or if they offer tele services.

You're joking right? I've practiced in half the state at various points and at no time was it easy to get people in to see psychiatry/psychology. Therapists have had the same problems I mentioned previously. Now I will say that privately insured or cash patients aren't usually as difficult.

I've just started looking into tele options. Could be a great option assuming we don't run into the same cost/missed work issue I mentioned previously.

 

[clausewitz2]

No need to be restricted to your local area any longer. In the past couple of years there has been a proliferation of companies that provide reasonable-quality psychotherapy by telepsych, covered by insurance.

helloalma.com
betterhelp.com
treatmyocd.com
try.talkspace.com

As for SSRI side effects, agree they are common and often unpleasant. I wouldn't want to tolerate weight gain or sexual impairment either personally (I don't consider that 'weird'). I usually switch people to a different drug if they get weight gain or sexual side effects. Lexapro seems to be the big offender for weight gain, I don't see it much with other SSRIs. Bupropion and mirtazapine do not impair sexual response and may actually improve it. Alternatively, if the SSRI is working well otherwise, sometimes sexual side effects can be combatted with adjunctive treatments like bupropion, buspirone, amantadine, etc.

Re: sexual side effects, daily tadalafil seems to have a pretty good success rate in my practice for men and women.

 

[WisNeuro]

I'd like to point out that you both live in metro areas while I do not (town of around 40k in SC). I could as easily be complaining about not having a Trader Joe's and y'all being confused because you both have one 4 miles away.

It's definitely easier in metro areas. But I also believe most providers don't have a handle on what's available. You can contact your state associations for psychology and social work and ask about referral listservs. May get a lot easier for you soon to find tele consults as PSYPACT has been enacted and is just waiting for final approval from the commission.

 

[VA Hopeful Dr]

It's definitely easier in metro areas. But I also believe most providers don't have a handle on what's available. You can contact your state associations for psychology and social work and ask about referral listservs. May get a lot easier for you soon to find tele consults as PSYPACT has been enacted and is just waiting for final approval from the commission.

A few months ago I asked a local psychiatrist and he also lamented the difficulty in finding local therapists.

 

[WisNeuro]

A few months ago I asked a local psychiatrist and he also lamented the difficulty in finding local therapists.

You may have better luck asking the sources. The psych and SW associations about contacts for new referrals. I have gotten the same thing in the past from referral sources saying that they can't find a therapist even in the metro. I send out one message on our practice division listserv and I have a list of names within a few hours of people with openings. Expand that to SW and masters level therapists and the pool of pretty deep.

 

[Mad Jack]

Question for the psychiatrists here from a pain physician.

All the national guidelines I’ve read about anxiety management, state that virtually no one should be prescribed chronic daily benzodiazepines for anxiety, (particularly short acting agents such as Xanax), and definitely not tid or qid dosing. Some papers do mention a small supply for rescue benzo doses to be used 3-5 times a month max.

Everything else should be used instead of benzos, so psychotherapy, multiple SSRI, buspirone, and other meds, etc is what I read in all these national guidelines.

However from my dozen years of experience working in the community of 3 very different states, I see countless patients on chronic TID Xanax.

A decent percentage of these #90 monthly Xanax scripts are written by PCPs, but far more come from psychiatrists than I would expect.

Please help me understand this discrepancy and what is discussed in psychiatry national meetings/residencies as I’d like to better understand if there is any true quality literature support for chronic daily bzd, particularly TID, qid dosing?

I've never once started a patient in Xanax, it's unique propensity for addiction really makes me wish it was off the market. Many of these scripts, in my personal experience, come from providers that bought into the idea that benzos were safe and minimally addictive that pharmaceutical companies were pushing back in the day. That or they just don't have much time with patients and feel like benzos are a fast and easy way to create a satisfied patient. I am very clear up front with patients that if they want chronic benzos I'm not the doctor for them, because chronic use only strengthens anxiety pathways over time and inevitably leads to severe tolerance, rebound symptoms, and risk of serious withdrawal should their medication be interrupted. I'm a doctor, not a dealer.

 

[Mad Jack]

I don't see a reason why people from Catalonia should get a special exception

Living under the disorganized and fiscally reckless shackles of Spain is enough to merit the exception

 

[VA Hopeful Dr]

You may have better luck asking the sources. The psych and SW associations about contacts for new referrals. I have gotten the same thing in the past from referral sources saying that they can't find a therapist even in the metro. I send out one message on our practice division listserv and I have a list of names within a few hours of people with openings. Expand that to SW and masters level therapists and the pool of pretty deep.

I'll give that a shot, thanks!

 

[WisNeuro]

I'll give that a shot, thanks!

Yeah, in some of our very rural areas, like places where there are no cities with a population greater than 1k for a couple hour, coverage is going to be spotty at best. But, generally, in areas of 20k+ or not that far from a metro area, you can get decent coverage. Caveat of Medicaid availability. This is very state dependent, and in some states, slots for Medicaid patients will be limited no matter where you are.

 

[TexasPhysician]

You're joking right? I've practiced in half the state at various points and at no time was it easy to get people in to see psychiatry/psychology. Therapists have had the same problems I mentioned previously. Now I will say that privately insured or cash patients aren't usually as difficult.

I've just started looking into tele options. Could be a great option assuming we don't run into the same cost/missed work issue I mentioned previously.

I am not. With MUSC and general popularity of the state, SC has more mental health coverage than most for commercial insurance and cash patients. I called a psych clinic that does tele just now and was offered an appointment next week with a BC psychiatrist that took my insurance.

If you are talking about Medicare/Medicaid, that will be difficult anywhere. Mental health is not a priority for our government. I knew a CAP psychiatrist that took Medicaid. Medicaid patients overwhelmed the clinic with appointments and constant needs. He ended up seeing 3x the patients I see on a daily basis and couldn’t keep the doors open. He closed and now makes more money at a government contract job that pays him well to see maybe 3 patients per day. Government is so mismanaged

When I consult with private clinics, I always advise not taking Medicare/Medicaid. I get that it’s terrible to need to do that, but if you look at my above example, this psychiatrist was so destroyed that he is now significantly under-utilized in helping the general population. In retrospect, he shouldn’t have taken government plans, and he would likely be making a significant difference in the local population.

Government plans require grants or university centers. Your city is likely too small to have those.

 

[VA Hopeful Dr]

I am not. With MUSC and general popularity of the state, SC has more mental health coverage than most for commercial insurance and cash patients. I called a psych clinic that does tele just now and was offered an appointment next week with a BC psychiatrist that took my insurance.

If you are talking about Medicare/Medicaid, that will be difficult anywhere. Mental health is not a priority for our government. I knew a CAP psychiatrist that took Medicaid. Medicaid patients overwhelmed the clinic with appointments and constant needs. He ended up seeing 3x the patients I see on a daily basis and couldn’t keep the doors open. He closed and now makes more money at a government contract job that pays him well to see maybe 3 patients per day. Government is so mismanaged

When I consult with private clinics, I always advise not taking Medicare/Medicaid. I get that it’s terrible to need to do that, but if you look at my above example, this psychiatrist was so destroyed that he is now significantly under-utilized in helping the general population. In retrospect, he shouldn’t have taken government plans, and he would likely be making a significant difference in the local population.

Government plans require grants or university centers. Your city is likely too small to have those.

That's what I was waiting on. MUSC. Medicine in SC does exist outside of Charleston you know. Outside of them its not great. Even my PP patients can either wait 4-5 months here or drive the 45 minutes to Greenville (3 months there generally).

I'll admit that I haven't looked much into telepsych and after this thread I'm working on that. Hopefully that does the trick.

The problem with our university centers (at least Greenville and Columbia) is they only take patients from their respective counties. I don't live in Greenville County so the USC clinics won't see my patients. Had the same issue when I lived in a Columbia suburb that was in the next county over.

 

[ObsequiousAplomb]

No need to be restricted to your local area any longer. In the past couple of years there has been a proliferation of companies that provide reasonable-quality psychotherapy by telepsych, covered by insurance.

helloalma.com
betterhelp.com
treatmyocd.com
try.talkspace.com

As for SSRI side effects, agree they are common and often unpleasant. I wouldn't want to tolerate weight gain or sexual impairment either personally (I don't consider that 'weird'). I usually switch people to a different drug if they get weight gain or sexual side effects. Lexapro seems to be the big offender for weight gain, I don't see it much with other SSRIs. Bupropion and mirtazapine do not impair sexual response and may actually improve it. Alternatively, if the SSRI is working well otherwise, sometimes sexual side effects can be combatted with adjunctive treatments like bupropion, buspirone, amantadine, etc.

I often hear people say that about bupropion and mirtazapine. I often have given bupropion and mirtazapine to mitigate sexual side effects with some benefit. I have had a fair number of patients who end up referred to me after they have had significant sexual dysfunction with either or both of them, though. I've pitched Buspar and amantadine to people for this before, but haven't had many take me up on the offer. Usually nefazodone is helpful when I switch to that. I love nefazodone for these patients, especially if they've failed trazodone (usually benefited but couldn't tolerate escalated doses). They almost never have heard of it or tried it in the past. When I discuss the risk of liver injury I think it enhances some placebo effect, and the risk of liver injury is so rare I don't expect to ever see it.

I've also found nefazodone to be my best medication to give to wean someone off of benzodiazepines. Usually if the benzodiazepine predated the SSRI I don't find terribly great success with an SSRI or SNRI, especially if someone won't tolerate the SSRI due to sexual side effects, weight gain, or sweating. So far it's been every single patient who tolerated nefazodone that I've been able to get off the benzodiazepine. My experience is only my experience, though.

Where I am insurance-taking providers tend to have 3+ month waitlists. People can get in to see someone for cash, but not everyone is willing / interested to pay cash rates or have psychotherapy via telemedicine. Again, my experience is only my experience, but that group of people tend to be happy with the meds and therapy I give and come off benzodiazepines. Obviously there's a bias since some of them come referred to me specifically to come off the benzodiazepines.

More interesting to me are the people who come to me specifically to taper off of their SSRIs because they have significant SRI discontinuation symptoms when they have tried to come off of them. The PCP referred them to me out of desperation after what they thought were nice, gradual tapers that ended up with acutely upset patients, frequently with multiple ER visits. I switch them over to Prozac oral solution (or discuss water titration) and set them up for an incredibly gradual taper (1-5 mg per month) and after about 3 months they decide they don't want to come off of SSRIs anymore. While there are risks to needlessly continuing an SSRI, I usually don't push hard at all. They have the oral solution and the instructions for a taper. If I don't see them in a few months I usually find out they came off on their own or they went back to their PCP and are taking 20 or 40 mg caps now.

 

[docksan]

I freaking love nefazodone.

 

[Batman's Underwear]

Probably SNRI (maybe venlafaxine) or SSRI +/- PRN Vistaril. I hate benzo but few subsets of people do well with low dose long-acting benzo. No to gabapentin soley for anxiolytic purposes. Sometime i consider low dose seroquel TID, other SRI like buspirone

 

[forchinet121]

Probably SNRI (maybe venlafaxine) or SSRI +/- PRN Vistaril. I hate benzo but few subsets of people do well with low dose long-acting benzo. No to gabapentin soley for anxiolytic purposes. Sometime i consider low dose seroquel TID, other SRI like buspirone

I’ve found gabapentin when tapering off benzo has been helpful for anxiety

 

[Batman's Underwear]

It’s a good question—the limited data we have (a few 1-3 year follow up studies in PD) indicate that anxiolytic tolerance does not form and that side effect burden is much less than with SSRIs. This is not the strongest evidence base but it does tell us something.

Even if tolerance does occur, an important question is: is this complete tolerance? (Pt is back at baseline prior to starting the benzo) or partial tolerance? And how much? 30-40% tolerance means 60-70% sustained relief in a treatment-resistant anxiety patient who has done the therapy, SRIs, buspar, Remeron, atypical antipsychotics heaven forbid, what have you.

Finally, if anxiolytic tolerance does occur with benzos, I don’t see why this cannot also apply to SSRIs. Unless we collectively feel like the benzo-induced “euphoria” to which tolerance develops is the anxiolysis itself.

I think you are cherry picking few facts

You are correct that about ~30% do develop "tolerance" towards to SSRI they have been taking for the decades. However, the simple answer is to switch SSRI and they responds fine and they are not true "tolerance" because of the effects of chronic SSRI can cause 5HT2A downregulation, it can sort of stop developing tolerance.

Benzo is an excellent drug, and it is indeed better than SSRI (SNRI>Benzo>SSRI) when it comes to anxiety. But you wouldn't white phosphorus to kill an ant since it is more effective ant spray

 

[Batman's Underwear]

I’ve found gabapentin when tapering off benzo has been helpful for anxiety

Gabapentin does have efficacy for treating EtOH use disorder and EtOH withdrawal so I am not surprised. But I am not sure whether patients or even physicians can accurately tell the difference between craving/withdrawal vs primary anxiety..

 

[FlowRate]

Gabapentin is generally considered safe and usually well-tolerated. However, there are some side effects:

• Dizziness
• Weight gain
• Dry mouth
• Unsteadiness when walking
• Double or blurred vision or eyes moving from side to side
• Drowsiness
• Shaking

ChatGPT, is that you?

 

[annoyedpsychiatrist]

I think we’re neglecting the potential harms of SSRIs. Both SSRIs and long-acting benzos form dependence. Neither are addictive. Benzodiazepines likely work at least as well, are better tolerated (no emotional and sexual numbing, no risk of chronification of depression—Nardi, 2012). If anxiolytic tolerance does develop with benzos (which I’m not sure is true) why wouldn’t this also occur with SSRIs? Is there something special about the GABA receptor that leads to tolerance? Or were benzos inappropriately maligned when Prozac came out only to find over the last 30 years that SSRIs have their problems, too.

i know this topic is old but i love this post, lol. Benzos are better tolerated than ssris, haha. Benzos don't cause emotional numbing? whattttt. neither are addictive? Then why does everyone in my clinic want xanax? 1/3 of my intakes are people asking for benzos. By comparison, you know how many people present asking for SSRIs? Also why do benzos have significantly more street value and are controlled substances?

not that i expect a reply, if this was a troll post it was pretty good. No way a psychiatrist could believe any of these statements, lol

 

[littlefred]

i know this topic is old but i love this post, lol. Benzos are better tolerated than ssris, haha. Benzos don't cause emotional numbing? whattttt. neither are addictive? Then why does everyone in my clinic want xanax? 1/3 of my intakes are people asking for benzos. By comparison, you know how many people present asking for SSRIs? Also why do benzos have significantly more street value and are controlled substances?

not that i expect a reply, if this was a troll post it was pretty good. No way a psychiatrist could believe any of these statements, lol

Have you not worked with psychiatrists trained before the 80's? Very common statements from that generation.

Interesting to see how prescribing tendencies change depending on what decade you were trained.

 

[annoyedpsychiatrist]

Have you not worked with psychiatrists trained before the 80's? Very common statements from that generation.

Interesting to see how prescribing tendencies change depending on what decade you were trained.

tbh even the older ones in residency i worked with still didnt practice that way.

 

[tennisall]

i know this topic is old but i love this post, lol. Benzos are better tolerated than ssris, haha. Benzos don't cause emotional numbing? whattttt. neither are addictive? Then why does everyone in my clinic want xanax? 1/3 of my intakes are people asking for benzos. By comparison, you know how many people present asking for SSRIs? Also why do benzos have significantly more street value and are controlled substances?

not that i expect a reply, if this was a troll post it was pretty good. No way a psychiatrist could believe any of these statements, lol

i know this topic is old but i love this post, lol. Benzos are better tolerated than ssris, haha. Benzos don't cause emotional numbing? whattttt. neither are addictive? Then why does everyone in my clinic want xanax? 1/3 of my intakes are people asking for benzos. By comparison, you know how many people present asking for SSRIs? Also why do benzos have significantly more street value and are controlled substances?

not that i expect a reply, if this was a troll post it was pretty good. No way a psychiatrist could believe any of these statements, lol

It’s a controversial subject.
See the long term study below A randomized, naturalistic, parallel-group study for the long-term treatment of panic disorder with clonazepam or paroxetine - PubMed
“Patients treated with clonazepam had significantly fewer adverse events than those treated with paroxetine (28.9% vs 70.6%, P < 0.001).”

Benzos definitely don’t cause the degree of sexual and emotional numbing that SSRIs do, although have the potential to do so.

I’m talking specifically about pts without a substance abuse hx. They do not tend to abuse benzos and in my clinical experience, dont self-escalate their doses over time unless they have major personality issues/substance abuse issues.

In the right patient, they have these advantages. Diazepam and alprazolam are much more reinforcing and have higher street value than clonazepam due to faster on-effect (relatively higher fat solubility)

 

[awfulhover]

Question for the psychiatrists here from a pain physician.

All the national guidelines I’ve read about anxiety management, state that virtually no one should be prescribed chronic daily benzodiazepines for anxiety, (particularly short acting agents such as Xanax), and definitely not tid or qid dosing. Some papers do mention a small supply for rescue benzo doses to be used 3-5 times a month max.

Everything else should be used instead of benzos, so psychotherapy, multiple SSRI, buspirone, and other meds, etc is what I read in all these national guidelines.

However from my dozen years of experience working in the community of 3 very different states, I see countless patients on chronic TID Xanax.

A decent percentage of these #90 monthly Xanax scripts are written by PCPs, but far more come from psychiatrists than I would expect.

Please help me understand this discrepancy and what is discussed in psychiatry national meetings/residencies as I’d like to better understand if there is any true quality literature support for chronic daily bzd, particularly TID, qid dosing?

Well, first off, not all doctors keep up with the latest guidelines. Some might be stuck in their old ways or just not know any better. Plus, different places might have their own traditions and habits, so that could be a reason too.

And let's not forget about patients. Some folks might straight-up demand Xanax because it's fast-acting and helps them chill out right away. So, some doctors might just give in to keep their patients happy.

Another thing is that docs sometimes have limited time and resources, especially primary care ones. They might go for the easy fix, which, unfortunately, can be prescribing Xanax.

And there's the issue of alternatives. Not all places have easy access to things like therapy or other meds, so Xanax might be the only option for some folks. Education and communication can help everyone.

 

[annoyedpsychiatrist]

It’s a controversial subject.
See the long term study below A randomized, naturalistic, parallel-group study for the long-term treatment of panic disorder with clonazepam or paroxetine - PubMed
“Patients treated with clonazepam had significantly fewer adverse events than those treated with paroxetine (28.9% vs 70.6%, P < 0.001).”

Benzos definitely don’t cause the degree of sexual and emotional numbing that SSRIs do, although have the potential to do so.

I’m talking specifically about pts without a substance abuse hx. They do not tend to abuse benzos and in my clinical experience, dont self-escalate their doses over time unless they have major personality issues/substance abuse issues.

In the right patient, they have these advantages. Diazepam and alprazolam are much more reinforcing and have higher street value than clonazepam due to faster on-effect (relatively higher fat solubility)

comparing benzos to the worst tolerated SSRI is not a fair comparison though, and I would argue long term adverse effects of klonopin likely outweigh paxil, depending on the dose of each.

I have had plenty of patients without a a SUD or personality disorder misuse benzos. Yes I agree klonopin is less misused than xanax/valium but it definitely still happens. Benzos create a psychological dependence in patient's that is quite frankly hard to undo.

Do benzos have a place in psychiatry? Yes I don't think they're 100% evil and I do use them. However, it is extremely rare i even go higher than .5mg doses when i do use them. Most of the people ive tapered down from moderate-high dose benzos their anxiety is better or the same as when they are on the benzo.

 

[Ceke2002]

i know this topic is old but i love this post, lol. Benzos are better tolerated than ssris, haha. Benzos don't cause emotional numbing? whattttt. neither are addictive? Then why does everyone in my clinic want xanax? 1/3 of my intakes are people asking for benzos. By comparison, you know how many people present asking for SSRIs? Also why do benzos have significantly more street value and are controlled substances?

not that i expect a reply, if this was a troll post it was pretty good. No way a psychiatrist could believe any of these statements, lol

Is OP perhaps differentiating between psychological addiction and physical dependency? I can't speak for anyone else, but benzos can definitely result in both from personal experience. I had 3 phases of Xanax addiction - the "Let's go Dr shopping and party" phase, which definitely lead to psychological addiction; the "Oops I went on a meth bender, now I've flipped out and need a chill pill stat" phase, which lead to increased psychological addiction and physical dependency; and the "Halp! I'm now experiencing a paradoxical reaction, someone get me off of these things," phase, at which point the psychological addiction was almost nil but I was obviously still physically dependent.

There was at least one Doctor where I lived at the time, who was basically supplying unlimited scripts to street dealers in exchange for sexual favours and a cut of the profits (I really wish I was joking). Funnily enough he never ran the same racket with SSRI's.

 

[aim-agm]

There was at least one Doctor where I lived at the time, who was basically supplying unlimited scripts to street dealers in exchange for sexual favours and a cut of the profits (I really wish I was joking). Funnily enough he never ran the same racket with SSRI's.

To be fair, with SSRIs he might have run into practical issues with the sexual favors bit...

 

[Mad Jack]

There are levels of abuseability. Low-dose, long-acting benzodiazepines like clonazepam probably don’t yield a signal comparable to amphetamines and opiates, or Xanax or Valium. This runaway positive signal you speak of would predict benzo users escalating their doses over time and losing benefit, which they do not according to the limited long-term data available (Nardi, 2012 among others). Anxious patients without a substance use history don’t ruin their lives with escalating drug-seeking behavior (a signal of addiction) from taking benzodiazepines like klonopin. They ruin it when tapering too quickly, just as with SSRIs.

Sure, there may be tolerance to the mild euphoria over time, but I this is not incompatible with sustained anxiolysis in the right patient.

Having treated many patients for clonazepam addiction over the years, I've gotta disagree. Lower addiction potential does not equal no addiction potential. A major issue with addiction, in general, is that you don't know who is going to be predisposed to it until it becomes a problem. They may have a genetic predisposition that was never realized until introduction of the substance or an associated stressor or trauma that turned their medication into a problem. An example of the latter would be a patient who had been using clonazepam as prescribed for years until a sexual assault, after which she began to abuse it. The former, it's just a genetic crapshoot.

It’s a good question—the limited data we have (a few 1-3 year follow up studies in PD) indicate that anxiolytic tolerance does not form and that side effect burden is much less than with SSRIs. This is not the strongest evidence base but it does tell us something.

Even if tolerance does occur, an important question is: is this complete tolerance? (Pt is back at baseline prior to starting the benzo) or partial tolerance? And how much? 30-40% tolerance means 60-70% sustained relief in a treatment-resistant anxiety patient who has done the therapy, SRIs, buspar, Remeron, atypical antipsychotics heaven forbid, what have you.

Finally, if anxiolytic tolerance does occur with benzos, I don’t see why this cannot also apply to SSRIs. Unless we collectively feel like the benzo-induced “euphoria” to which tolerance develops is the anxiolysis itself.

It doesn't happen with SSRIs because the mechanism is entirely different. SSRIs cause significant changes in neural plasticity that make for better long-term outcomes through the development of more robust neural connections. This does not happen mechanistically with benzos, which cause changes in neural modulation over the long term that make individuals more sensitive to anxiogenic stimuli

 

[Mad Jack]

Have you not worked with psychiatrists trained before the 80's? Very common statements from that generation.

Interesting to see how prescribing tendencies change depending on what decade you were trained.

I have seen a fairly well-regarded doctor (whom also tends to collect a lot of pharmaceutical $$$) argue that you are doing a disservice to patients by not prescribing benzos, because anxiety is a significant comorbidity in suicidal patients and alleviating it may reduce risk for suicide. My counter-argument to this would be that benzodiazepines are disinhibiting and may take the edge off of the fear that would be otherwise associated with a suicide attempt, but I digress. Having seen many from his panel, he seems to practice what he preaches... Which becomes a real problem when patients are discharged after 3 missed appointments and come to your office with concerns for benzo withdrawal. Not saying he's prescribing incorrectly, but he prescribes in a very old school way.

That actually makes me wonder- what do other people here do in such cases? If you've got someone that clearly needs prescribing who has been discharged by another prescriber for whatever reason? I would always insist on a taper if I found the situation to not be consistent with my prescribing practices, but if the patient wasn't amenable to that and I turned them away, would that fall on the prescriber that had cut them off if they went into withdrawal or would it fall on my shoulders?

 

[FlowRate]

I have seen a fairly well-regarded doctor (whom also tends to collect a lot of pharmaceutical $$$) argue that you are doing a disservice to patients by not prescribing benzos, because anxiety is a significant comorbidity in suicidal patients and alleviating it may reduce risk for suicide. My counter-argument to this would be that benzodiazepines are disinhibiting and may take the edge off of the fear that would be otherwise associated with a suicide attempt, but I digress. Having seen many from his panel, he seems to practice what he preaches... Which becomes a real problem when patients are discharged after 3 missed appointments and come to your office with concerns for benzo withdrawal. Not saying he's prescribing incorrectly, but he prescribes in a very old school way.

I think there's a kernel of truth to this but it's a rare situation--I have a handful of patients who have a real clear anxious distress presentation and I think benzos are helpful if you're not otherwise able to get that extremely severe anxiety under control. The anxiety seems to be the thing that's making them the most miserable and likely to kill themselves...