Benzodiazepine Question

[aim-agm]

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Agreed that rapport is very important, often though we get seen as the enemy when removing their benzos because "it has worked for them". Do you guys switch to a long acting if theyre on something like xanax tid? I used to do that but ive had more success tapering down their short acting.

It's most expedient to try tapering down on what they are currently on, because converting to a long-acting can take a few sessions and can have unforseen consequences. Then if you are having difficulty with the taper (e.g. they aren't tolerating going down even the smallest increment) you can convert to diazepam, which has an easier taper because of it's ridiculously long half-life and because you can make much smaller incremental changes (there's even a liquid formulation if need be).

 

[smalltownpsych]

I teach students that one of the most important questions to ask about complaints of anxiety is "Can you tell me what you are feeling without using the word 'anxiety'?" Frequently they are not actually experiencing what we call anxiety. They might mean restless/unsettled/etc., and then when you treat their undiagnosed ADHD their "anxiety" disappears. People can have somatic experiences of anxiety, and then confuse those symptoms with anxiety (e.g. a patient that thought he was anxious in the morning because he had abdominal discomfort...the "anxiety" got better when we trialled a morning antacid).

A few local PsychNPs keep giving my patients stimulants for their “untreated ADHD“. Not a big fan of this type of thinking. Stimulants are beneficial to almost everyone in the short term but that doesn’t mean that it really works in the long run.

 

[tr]

So i have a large number of geri patients on long term benzos being referred to me, and getting them off is very unfun. Have you guys noticed that once someone is on a benzo for several years continuously, prescribing stuff like SSRIs is the equivalent of giving them sugar water? I havent found anything really that typically helps that well with anxiety once they were on moderate dose benzos for multiple years.

Right, because SSRIs do not treat the anxiety associated with benzo withdrawal.

Unfortunately the only real solution is an extremely slow taper as others have said.

If you are really needing an adjunctive, gabapentin might work better for easing discontinuation vs an SSRI.

 

[PsyDr]

.... Stimulants are beneficial to almost everyone in the short term ...

Except they don't, they just improve one's perception of performance (Ilieva, 2013; Arria, et al, 2016; Pelham, et al, 2022; Cropsey et al, 2017; etc).

Which is pretty much how alcohol affects my social skills.

 

[tr]

Except they don't, they just improve one's perception of performance (Ilieva, 2013; Arria, et al, 2016; Pelham, et al, 2022; Cropsey et al, 2017; etc).

Wait really? That can't be true. Are you saying the experience of thousands of students and journalists who use contraband stimulants to make their deadlines is illusory?

Can you please post the full citations for the studies above?

 

[romanticscience]

Except they don't, they just improve one's perception of performance (Ilieva, 2013; Arria, et al, 2016; Pelham, et al, 2022; Cropsey et al, 2017; etc).

Which is pretty much how alcohol affects my social skills.

A very odd clinical phenomenon that I find as well. Their rating scales are nearly the same, but they subjectively "feel better."

 

[romanticscience]

Prescription Stimulants' Effects on Healthy Inhibitory Control, Working Memory, and Episodic Memory: A Meta-analysis - PubMed

The use of prescription stimulants to enhance healthy cognition has significant social, ethical, and public health implications. The large number of enhancement users across various ages and occupations emphasizes the importance of examining these drugs' efficacy in a nonclinical sample. The...

pubmed.ncbi.nlm.nih.gov

I think there was a study they reviewed where the effect was mild and approximated that of mindfulness training.

This is why practicing medicine nowadays is so frustrating, contending with the STRONG suggestions from outside the consulting room. People walk in (1) already knowing what's wrong with them and (2) knowing what treatment they need. I get in a Rogerian or motivational sense we should take advantage of that, but it's dicey when the answer is always "adderall." I wonder what the old-time psychiatrists would do. Would Erickson prescribe "what the person thinks would work?" It also sucks that a lot of the psychotherapy wisdom we have that is patient-centered does not discuss this. It was easy for Rogers, he didn't have a prescription pad. The best I've been able to find it in the Motivational Interviewing Book (Miller & Rollnick, 2013), where they say, while finding focus, "I don't offer that."

 

[Stagg737]

Because this is not the basis of the most efficacious treatment. Exposure treatment is geared specifically at sitting with the anxiety until it lessens to train the mind and body to NOT see it as dangerous. Anything that interferes with that habituation, or a safety cue that is associated with "removing the danger" acts against that notion. There is a reason that these sessions are 90 minutes long.

Edit: Psychoeducation is great. When it is part of an active, efficacious, psychotherpautic process. In dismantling studies, it is of little benefit.

Sure, it's not the most effective treatment, but that doesn't change that it is still considered an acceptable and effective treatment by most. Not everyone is capable of achieving habituation, whether it's because of lack of resources or patient insight or abilities. Utilization of safety cues isn't always malignant, and some forms are lower risk and less harmful than habituation or ERT. Especially for patients who have anxiety related to traumas who just aren't ready for it.

I do tell my patients to please practice their breathing exercises daily at a time when they are not particularly anxious, partly for the purpose of making the exercise second nature, but also to avoid having them develop a counterproductive association of the sensation of anxiety with the breathing exercise itself.

Removing oneself from the situation is not a 'skill.' It is a quick fix that is counterproductive in the long run because it reinforces the conviction that the anxiety is dangerous and flight is an appropriate solution. What is ultimately therapeutic is *staying* in the situation (graded for tolerability of course) and learning for oneself that it is not harmful.

That is where the problem arises though. How do you ensure graded situational exposure outside of the office? You can't, which is where the skills (or meds) that are safety cues become useful. We can't just expect people to be able to handle all anxiety-inducing situations, and skills or meds considered safety cues can allow those situations to be manageable, even if they're only meant to be short-term solutions. One of those options is benzodiazepines. Obviously, they have a higher risk than other medications and are not appropriate for all, or even many, patients. However, I do think there are individuals who can benefit from these as a short-term intervention, though this is not something I do in practice outside of specific phobias patients rarely encounter but are necessary events (dental surgeries, those who rarely fly, etc).

 

[smalltownpsych]

Except they don't, they just improve one's perception of performance (Ilieva, 2013; Arria, et al, 2016; Pelham, et al, 2022; Cropsey et al, 2017; etc).

Which is pretty much how alcohol affects my social skills.

I guess I should have qualified that with ”appear” to be beneficial. I don’t drink and when I was a bit younger it was quite fun hanging out at bars with attractive females and watching the drunk men with their weak games strike out so badly. 😁

Wait really? That can't be true. Are you saying the experience of thousands of students and journalists who use contraband stimulants to make their deadlines is illusory?

Can you please post the full citations for the studies above?

Not so sure about actual measure of performance as in the end result or quality of product, but I’m pretty sure that they help these folks stay up all night. Not sure if it’s better than the coffee that I would use for this when I had to sacrifice sleep.

 

[whopper]

Stimulants are beneficial to almost everyone in the short term but that doesn’t mean that it really works in the long run.

I haven't yet seen a clinically published litmus test on when stimulants are fine to use without worry.
ADHD exists, but a problem is it's one of the few disorders where there could be an inappropriate incentive to be diagnosed with it. Simply doing poor in school could create a bias the person has ADHD. Further even if the person has ADHD the stimulant the person is prescribed might not be appropriate for that person.

Methylphenidate could work very well on some people, and poorly on others even if all the people who took it have ADHD.

One of the few clinical changes I've seen where it makes me rest much easier that the patient truly has ADHD and would benefit from a stimulant is if the person, after taking a stimulant, feels emotionally calmer because of it, and is more in the moment. When that happens I've almost always noticed the stimulant could benefit the person at that specific dosage even in the long-term. I've even seen people who sleep better on stimulants. It's unintuitive at first until you think to yourself that if the stimulant truly is treating hyperactivity in ADHD and now that hyperactivity is gone, well maybe that's why the person's calmed down. Then add Nemeroff's own theories that a lot of what we do is change psychopharmacology within the brain to balance it to what is more of what should be a norm. As Nemeroff's stated the old approach of trying a med to try to feel what a patient feels is almost useless because usually we don't have the same disorders the patient has. If we, for example, tried an antipsychotic, if we don't have psychosis, it will shift the chemicals more out-of-balance than in-balance.

The above hasn't been clinically studied as far as I know in an evidenced-based format. A problem with doing such studies to verify what I'm suggesting is it will require long-term follow ups. Clarifying what I'm saying-when I've seen stimulants significantly calm anxiety I've noticed tremendous long-term success with stimulant treatment where it's treating what we want it to treat and the patient is not abusing the medication.

 

[WisNeuro]

Sure, it's not the most effective treatment, but that doesn't change that it is still considered an acceptable and effective treatment by most. Not everyone is capable of achieving habituation, whether it's because of lack of resources or patient insight or abilities. Utilization of safety cues isn't always malignant, and some forms are lower risk and less harmful than habituation or ERT. Especially for patients who have anxiety related to traumas who just aren't ready for it.



That is where the problem arises though. How do you ensure graded situational exposure outside of the office? You can't, which is where the skills (or meds) that are safety cues become useful. We can't just expect people to be able to handle all anxiety-inducing situations, and skills or meds considered safety cues can allow those situations to be manageable, even if they're only meant to be short-term solutions. One of those options is benzodiazepines. Obviously, they have a higher risk than other medications and are not appropriate for all, or even many, patients. However, I do think there are individuals who can benefit from these as a short-term intervention, though this is not something I do in practice outside of specific phobias patients rarely encounter but are necessary events (dental surgeries, those who rarely fly, etc).

The great thing about behavioral habituation is they don't need to have great insight to achieve habituation. I have no idea what you mean about the patient not having "abilities." Do you mean intelligence? Behavioral conditioning is not dependent on average or above intelligence.

 

[romanticscience]

behavioral habituation is they don't need to have great insight to achieve habituation

@WisNeuro Is there any update to this line of thinking:

Failure in treating obsessive-compulsives - PubMed

Failure in treating obsessive-compulsives

pubmed.ncbi.nlm.nih.gov

Foa says "two groups of obsessive-compulsives who failed to respond to treatment, although they complied with its demands, are examined. Patients of the first group held a strong convicrion that their fears were realistic. The second group was composed of patients who manifested severe depression. In the first group, patients habituated within sessions but not between sessions. Neither form of habituation was shown in the second group"

Maybe @clausewitz2 has some insight?

 

[WisNeuro]

@WisNeuro Is there any update to this line of thinking:

Failure in treating obsessive-compulsives - PubMed

Failure in treating obsessive-compulsives

pubmed.ncbi.nlm.nih.gov

Foa says "two groups of obsessive-compulsives who failed to respond to treatment, although they complied with its demands, are examined. Patients of the first group held a strong convicrion that their fears were realistic. The second group was composed of patients who manifested severe depression. In the first group, patients habituated within sessions but not between sessions. Neither form of habituation was shown in the second group"

Maybe @clausewitz2 has some insight?

I will say that in the anxiety world, OCD is a different beast due to the nature of the obsessions in some people. MUCH different than treating things like panic. Treatment efficacy rates support this. Very high efficacy for panic DO, much lower for OCD.

As for the article, I am not sure which treatment is being used here, though it being 1979, likely a very basic form of exposure without the nuances of response prevention and processing.

 

[clausewitz2]

@WisNeuro Is there any update to this line of thinking:

Failure in treating obsessive-compulsives - PubMed

Failure in treating obsessive-compulsives

pubmed.ncbi.nlm.nih.gov

Foa says "two groups of obsessive-compulsives who failed to respond to treatment, although they complied with its demands, are examined. Patients of the first group held a strong convicrion that their fears were realistic. The second group was composed of patients who manifested severe depression. In the first group, patients habituated within sessions but not between sessions. Neither form of habituation was shown in the second group"

Maybe @clausewitz2 has some insight?

Mental rituals are an area that I think is better understood and that more clinicians are aware of than they were in 1979. Rumination in particular is increasingly conceptualized as exactly that, a mental compulsion that is volitional in some sense. Folks who struggle with this fundamentally don't buy on some level that it is okay to not try to "figure out" their fears or resolve the uncertainty that bothers them so much. If you believe that it is actually really important that you resolve the uncertainty to keep someone else safe (or very often, to prevent you yourself harming other people), you're probably going to do a lot of covert ritualizing during the sessions and more importantly the minute someone is not there badgering you into doing it you're going to go right back to it in your regular life. There may also be an element of finding reassurance in the presence of the therapist, along the lines of "oh, well it's okay if I the psychologist/psychiatrist is there, they'll make sure that I can't hurt anyone/it's not too dangerous, but if I'm on my own I'll be totally out of contol". Getting people to do homework/freelances seems to be important.

 

[futureapppsy2]

I teach students that one of the most important questions to ask about complaints of anxiety is "Can you tell me what you are feeling without using the word 'anxiety'?" Frequently they are not actually experiencing what we call anxiety. They might mean restless/unsettled/etc., and then when you treat their undiagnosed ADHD their "anxiety" disappears. People can have somatic experiences of anxiety, and then confuse those symptoms with anxiety (e.g. a patient that thought he was anxious in the morning because he had abdominal discomfort...the "anxiety" got better when we trialled a morning antacid).

This is so critical--every time a patient uses new-to-our-relationship words like "anxiety," "depression," "meltdown," "mood swings," etc., I always ask them to describe what that looks like for them, because it's rarely uniform across patients., and I emphasize to my supervisees the need to do the same

I was talking to an IM hospitalist colleague about this, and she mentioned a patient she had recently who was admitted for an MI and who casually asked if they could give her meds for her "anxiety" as well. My colleague asked what her anxiety looked like, and the patient started describing persistent feelings of never being good enough, etc. Colleague adminstered measures of anxiety and depressive symptoms, and the patient met the criteria for classic severe MDD but actually had very little actual anxiety. Totally a case where a patient could have inappropriately been started on bezos had my colleague not dug deeper.

 

[Stagg737]

The great thing about behavioral habituation is they don't need to have great insight to achieve habituation. I have no idea what you mean about the patient not having "abilities." Do you mean intelligence? Behavioral conditioning is not dependent on average or above intelligence.

Ability as in the capability of even initiating this treatment. Extreme example would be someone with moderate or worse ID whose higher level thought processes are not present and behavior is almost completely reflexive. To clarify, I'm not saying habituation can't happen, as it obviously can. However, the means of achieving this through treatment outside of intensive treatment is not realistic for some as there are some patients who aren't capable of just sitting with their emotions or through a situation. Some patients just aren't willing to do this, and it may be necessary to utilize other methods even if they're not ideal. Would you turn someone away if they weren't willing to participate in habituation or exposure therapy?

 

[WisNeuro]

Ability as in the capability of even initiating this treatment. Extreme example would be someone with moderate or worse ID whose higher level thought processes are not present and behavior is almost completely reflexive. To clarify, I'm not saying habituation can't happen, as it obviously can. However, the means of achieving this through treatment outside of intensive treatment is not realistic for some as there are some patients who aren't capable of just sitting with their emotions or through a situation. Some patients just aren't willing to do this, and it may be necessary to utilize other methods even if they're not ideal. Would you turn someone away if they weren't willing to participate in habituation or exposure therapy?

I mean, yes, we can come up with extreme patient examples that constitute a very statistically small number of the population, and yes, we need to adjust our treatment parameters sometimes in those circumstances. But, these are not the patients that we are talking about who get put on maintenance benzos. And, even in those moderate ID examples, behavioral principles are generally the most efficacious things we can do, and I'd still contend that a modified version of behaviorally based treatment is still probably the best option.

As to the general public being "unable to sit with their emotions," I simply reject that notion outside of acute psychiatric crises requiring inpatient hospitalization. I have yet to treat someone who is not capable of this, including very severe panic disorder with agoraphobia. As far as someone unwilling to do this, you go with a less dangerous method, and refuse to be held hostage for delivering a treatment that makes most people worse off in the end and has quantifiable adverse outcomes in a large proportion of people who take them long-term.

 

[mistafab]

Behavioral habituation does require some underlying buy in from the therapist, particularly believing it all the way. However, some common sense can assist us here in that good can be the enemy of best, but sometimes good is good enough. The experts say you must remove all safety behaviors, however in the real world, progress in life/functioning in general are more important than intervention "effectiveness" in many scenarios.

I feel like we all beat the anti-benzo drum pretty heavy on the forum. And overall, I think most of us agree with that, even the people debating benzos in this thread.

 

[WisNeuro]

Behavioral habituation does require some underlying buy in from the therapist, particularly believing it all the way. However, some common sense can assist us here in that good can be the enemy of best, but sometimes good is good enough. The experts say you must remove all safety behaviors, however in the real world, progress in life/functioning in general are more important than intervention "effectiveness" in many scenarios.

I feel like we all beat the anti-benzo drum pretty heavy on the forum. And overall, I think most of us agree with that, even the people debating benzos in this thread.

As far as the safety behaviors, we reduce/minimize these while doing the intervention, not in perpetuity. The goal is not to ever engage in a safety behavior, it's to reduce the reliance on such as that person has an anxiety pattern that has become severe and maladaptive enough to substantially interfere with their functioning, and that reliance is now reinforcing and magnifying that anxiety.

 

[tr]

That is where the problem arises though. How do you ensure graded situational exposure outside of the office? You can't, which is where the skills (or meds) that are safety cues become useful. We can't just expect people to be able to handle all anxiety-inducing situations, and skills or meds considered safety cues can allow those situations to be manageable, even if they're only meant to be short-term solutions. One of those options is benzodiazepines. Obviously, they have a higher risk than other medications and are not appropriate for all, or even many, patients. However, I do think there are individuals who can benefit from these as a short-term intervention, though this is not something I do in practice outside of specific phobias patients rarely encounter but are necessary events (dental surgeries, those who rarely fly, etc).

I'm totally fine with benzos a couple of times a year for plane flights or dental surgeries. That level of use isn't disruptive enough to be worth eliminating IMO.

But I was just pointing out that the idea of a 'rescue' from anxiety is countertherapeutic whether the 'rescue' is a prn medication, a breathing exercise, or escape from the situation. All of them reinforce the patient's existing belief that anxiety is dangerous and they must be rescued from it, which ultimately worsens the anxiety. This isn't unique to benzodiazepines.

Of course you can ensure graded situational exposure outside the office. This is how homework works. You don't give an acrophobic an assignment to go scale El Capitan. You tell them to go stand on a stepladder for two minutes and write down how anxious they got. Graded exposure.

 

[Stagg737]

I'm totally fine with benzos a couple of times a year for plane flights or dental surgeries. That level of use isn't disruptive enough to be worth eliminating IMO.

But I was just pointing out that the idea of a 'rescue' from anxiety is countertherapeutic whether the 'rescue' is a prn medication, a breathing exercise, or escape from the situation. All of them reinforce the patient's existing belief that anxiety is dangerous and they must be rescued from it, which ultimately worsens the anxiety. This isn't unique to benzodiazepines.

Of course you can ensure graded situational exposure outside the office. This is how homework works. You don't give an acrophobic an assignment to go scale El Capitan. You tell them to go stand on a stepladder for two minutes and write down how anxious they got. Graded exposure.

The bolded is where I disagree. I don't think it's a matter of anxiety being seen as "dangerous" most of the time, it's a matter of it being an abnormal and uncomfortable experience/emotion that can be "fixed", which I think most MH professionals would agree is just not true. This is what I'm talking about in terms of use of safety behaviors and that idea of them always, or even usually, being harmful. It's also why I feel psychoeducation regarding what anxiety actually is becomes so important to treatment, because there are large swaths of the population who don't understand concepts of eustress vs distress or that feeling uncomfortable is often normal.

I mean, yes, we can come up with extreme patient examples that constitute a very statistically small number of the population, and yes, we need to adjust our treatment parameters sometimes in those circumstances. But, these are not the patients that we are talking about who get put on maintenance benzos. And, even in those moderate ID examples, behavioral principles are generally the most efficacious things we can do, and I'd still contend that a modified version of behaviorally based treatment is still probably the best option.

As to the general public being "unable to sit with their emotions," I simply reject that notion outside of acute psychiatric crises requiring inpatient hospitalization. I have yet to treat someone who is not capable of this, including very severe panic disorder with agoraphobia. As far as someone unwilling to do this, you go with a less dangerous method, and refuse to be held hostage for delivering a treatment that makes most people worse off in the end and has quantifiable adverse outcomes in a large proportion of people who take them long-term.

I don't think I've advocated for the bolded at any point, and I agree with it.

I'm surprised you haven't encountered anyone with anxiety at that level of severity. I had quite a few of them in my outpatient year of residency, including a couple who literally could not function without scheduled thorazine reportedly d/t their severe anxiety. I will add, this was during the COVID lockdowns and those people had significant personality pathology as well, but I've absolutely met patients whose baseline anxiety was severe enough that treatment without some kind of autonomic suppression was not possible.

 

[clausewitz2]

The bolded is where I disagree. I don't think it's a matter of anxiety being seen as "dangerous" most of the time, it's a matter of it being an abnormal and uncomfortable experience/emotion that can be "fixed", which I think most MH professionals would agree is just not true. This is what I'm talking about in terms of use of safety behaviors and that idea of them always, or even usually, being harmful. It's also why I feel psychoeducation regarding what anxiety actually is becomes so important to treatment, because there are large swaths of the population who don't understand concepts of eustress vs distress or that feeling uncomfortable is often normal.



I don't think I've advocated for the bolded at any point, and I agree with it.

I'm surprised you haven't encountered anyone with anxiety at that level of severity. I had quite a few of them in my outpatient year of residency, including a couple who literally could not function without scheduled thorazine reportedly d/t their severe anxiety. I will add, this was during the COVID lockdowns and those people had significant personality pathology as well, but I've absolutely met patients whose baseline anxiety was severe enough that treatment without some kind of autonomic suppression was not possible.

The trouble is when the contingencies of that autonomic suppression are perfectly set up to exacerbate the problem. Was treatment without PRNs tried and found wanting, or found difficult and not tried?

Not necessarily your fault, I am hazarding a guess you inherited these people.

 

[Stagg737]

The trouble is when the contingencies of that autonomic suppression are perfectly set up to exacerbate the problem. Was treatment without PRNs tried and found wanting, or found difficult and not tried?

Not necessarily your fault, I am hazarding a guess you inherited these people.

One was a new patient for me, mutually dismissed from the clinic after 2-3 appointments when I wouldn't prescribe benzos, but later came back after I saw her inpatient when she was started on scheduled propranolol and thorazine and showed significant improvement. PRNs were attempted but generally insufficient. She could not go a full day without self-harming in some manner (sometimes to the point of medical hospitalization) without the autonomic suppression. With it she was functional and actually held a part-time job. She was my patient for 3 years and when she left clinic she was actually doing extremely well and was only taking Trazodone and a PRN 2-3x per month. The other I inherited and started on thorazine. Eventually left our clinic, was doing a good deal better than when I started with him but still not functioning well (couldn't hold a job).

 

[smalltownpsych]

One was a new patient for me, mutually dismissed from the clinic after 2-3 appointments when I wouldn't prescribe benzos, but later came back after I saw her inpatient when she was started on scheduled propranolol and thorazine and showed significant improvement. PRNs were attempted but generally insufficient. She could not go a full day without self-harming in some manner (sometimes to the point of medical hospitalization) without the autonomic suppression. With it she was functional and actually held a part-time job. She was my patient for 3 years and when she left clinic she was actually doing extremely well and was only taking Trazodone and a PRN 2-3x per month. The other I inherited and started on thorazine. Eventually left our clinic, was doing a good deal better than when I started with him but still not functioning well (couldn't hold a job).

I worked with lots of patients like this at a long term residential program for young adults. We worked with patients that had already failed multiple treatments and were often a complete mess psychiatrically and psychologically. Often would have patients who spent a month or two being given lots of zyprexa and staring out the window before being able to begin handling even the smallest amounts of distres without decompensating. Some had a primary psychotic disorder or mood disorder with psychotic features and others were anxious to the point of psychosis and others just emotionally distressed and chronically self harming. Many clinicians don’t really work with these patients or just see them in passing in short term settings. They sure as heck aren’t the patients that they use in research studies for efficacy of medications or therapy. What is interesting is our psychiatrist used benzos pretty sparingly given the severity of what we worked with. He also would tend to titrate most of them off them if they were already on them and that seemed to go pretty well in a contained environment where we could regulate exposure fairly well.

 

[clausewitz2]

I worked with lots of patients like this at a long term residential program for young adults. We worked with patients that had already failed multiple treatments and were often a complete mess psychiatrically and psychologically. Often would have patients who spent a month or two being given lots of zyprexa and staring out the window before being able to begin handling even the smallest amounts of distres without decompensating. Some had a primary psychotic disorder or mood disorder with psychotic features and others were anxious to the point of psychosis and others just emotionally distressed and chronically self harming. Many clinicians don’t really work with these patients or just see them in passing in short term settings. They sure as heck aren’t the patients that they use in research studies for efficacy of medications or therapy. What is interesting is our psychiatrist used benzos pretty sparingly given the severity of what we worked with. He also would tend to titrate most of them off them if they were already on them and that seemed to go pretty well in a contained environment where we could regulate exposure fairly well.

I have much less of a problem with scheduled, non-PRN medications designed to tamp down 'anxiety'. Taking it daily regardless of how nervous you might happen to feel at that moment removes a lot of the problematic aspects. I have not had occasion to use thorazine as discussed up thread but have considered it in the past. Have definitely used small doses of other neuroleptics for the same purpose, especially for the sorts of folks you are talking about.

 

[VA Hopeful Dr]

This is so critical--every time a patient uses new-to-our-relationship words like "anxiety," "depression," "meltdown," "mood swings," etc., I always ask them to describe what that looks like for them, because it's rarely uniform across patients., and I emphasize to my supervisees the need to do the same

I was talking to an IM hospitalist colleague about this, and she mentioned a patient she had recently who was admitted for an MI and who casually asked if they could give her meds for her "anxiety" as well. My colleague asked what her anxiety looked like, and the patient started describing persistent feelings of never being good enough, etc. Colleague adminstered measures of anxiety and depressive symptoms, and the patient met the criteria for classic severe MDD but actually had very little actual anxiety. Totally a case where a patient could have inappropriately been started on bezos had my colleague not dug deeper.

See this is why the PCP approach of "SSRIs for everybody" works as well as it does.

 

[PsyDr]

Wait really? That can't be true. Are you saying the experience of thousands of students and journalists who use contraband stimulants to make their deadlines is illusory?

Can you please post the full citations for the studies above?

1) Really. There is a big literature base on this that you might be better equipped to summarize. Conceptually, you can categorize the literature base into Cognition and Performance.

a. Cognition: Do stimulants improve cognition? Broad strokes, no. In non-ADHD samples, stimulants offer limited to no effect on cognitive tasks. There is some evidence of a small effect on rote memorization that does not seem to increase actual performance (i.e., they can sit and memorize better, but when they are later queried, there is no difference). Of course, this gets more complicated based upon type of task and which stimulant on what dosage.

b. Performance-Outcome: Does taking stimulants actually improve outcomes? Non-ADHD stimulant use doesn't increase GPA, nor offer protection against decline in grades. There's a lot of this stuff. I'm interested in it from the ethics standpoint on cognitive enhancement and how it ties into the literature about testosterone's effects on risk in stock trading.


2) Some starting points. It's interesting to see if one's perception of performance has anything to do with one's actual performance. Bonus article about expectation effects.

Ilieva, I., et al. (2013). "Objective and subjective cognitive enhancing effects of mixed amphetamine salts in healthy people." Neuropharmacology 64: 496-505.

Arria, A. M., et al. (2017). "Do college students improve their grades by using prescription stimulants nonmedically?" Addict Behav 65: 245-249.

Pelham, W. E., et al. (2022). "The effect of stimulant medication on the learning of academic curricula in children with ADHD: A randomized crossover study." J Consult Clin Psychol 90(5): 367-380.

Cropsey, K. L., et al. (2017). "Mixed-amphetamine salts expectancies among college students: Is stimulant induced cognitive enhancement a placebo effect?" Drug and alcohol dependence 178: 302-309.

Looby, A., et al. (2022). "Expectation for stimulant type modifies caffeine’s effects on mood and cognition among college students." Experimental and Clinical Psychopharmacology 30: 525-535.

 

[Merovinge]

1) Really. There is a big literature base on this that you might be better equipped to summarize. Conceptually, you can categorize the literature base into Cognition and Performance.

a. Cognition: Do stimulants improve cognition? Broad strokes, no. In non-ADHD samples, stimulants offer limited to no effect on cognitive tasks. There is some evidence of a small effect on rote memorization that does not seem to increase actual performance (i.e., they can sit and memorize better, but when they are later queried, there is no difference). Of course, this gets more complicated based upon type of task and which stimulant on what dosage.

b. Performance-Outcome: Does taking stimulants actually improve outcomes? Non-ADHD stimulant use doesn't increase GPA, nor offer protection against decline in grades. There's a lot of this stuff. I'm interested in it from the ethics standpoint on cognitive enhancement and how it ties into the literature about testosterone's effects on risk in stock trading.


2) Some starting points. It's interesting to see if one's perception of performance has anything to do with one's actual performance. Bonus article about expectation effects.

Ilieva, I., et al. (2013). "Objective and subjective cognitive enhancing effects of mixed amphetamine salts in healthy people." Neuropharmacology 64: 496-505.

Arria, A. M., et al. (2017). "Do college students improve their grades by using prescription stimulants nonmedically?" Addict Behav 65: 245-249.

Pelham, W. E., et al. (2022). "The effect of stimulant medication on the learning of academic curricula in children with ADHD: A randomized crossover study." J Consult Clin Psychol 90(5): 367-380.

Cropsey, K. L., et al. (2017). "Mixed-amphetamine salts expectancies among college students: Is stimulant induced cognitive enhancement a placebo effect?" Drug and alcohol dependence 178: 302-309.

Looby, A., et al. (2022). "Expectation for stimulant type modifies caffeine’s effects on mood and cognition among college students." Experimental and Clinical Psychopharmacology 30: 525-535.

The neuropsychiatrists I trained with mentioned literature showing improved response times on psychostimulants. Notable that most athletic bodies have psychostimulants as banned substances.

 

[WisNeuro]

The neuropsychiatrists I trained with mentioned literature showing improved response times on psychostimulants. Notable that most athletic bodies have psychostimulants as banned substances.

We may have an issue about statistically significant vs. clinically significant change here. If I drill things down to milliseconds, I can find changes in a lot of things. But, what does that mean in terms of performance on neuropsych measures or meaningful daily outcomes?

 

[tr]

1) Really. There is a big literature base on this that you might be better equipped to summarize. Conceptually, you can categorize the literature base into Cognition and Performance.

a. Cognition: Do stimulants improve cognition? Broad strokes, no. In non-ADHD samples, stimulants offer limited to no effect on cognitive tasks. There is some evidence of a small effect on rote memorization that does not seem to increase actual performance (i.e., they can sit and memorize better, but when they are later queried, there is no difference). Of course, this gets more complicated based upon type of task and which stimulant on what dosage.

b. Performance-Outcome: Does taking stimulants actually improve outcomes? Non-ADHD stimulant use doesn't increase GPA, nor offer protection against decline in grades. There's a lot of this stuff. I'm interested in it from the ethics standpoint on cognitive enhancement and how it ties into the literature about testosterone's effects on risk in stock trading.


2) Some starting points. It's interesting to see if one's perception of performance has anything to do with one's actual performance. Bonus article about expectation effects.

Ilieva, I., et al. (2013). "Objective and subjective cognitive enhancing effects of mixed amphetamine salts in healthy people." Neuropharmacology 64: 496-505.

Arria, A. M., et al. (2017). "Do college students improve their grades by using prescription stimulants nonmedically?" Addict Behav 65: 245-249.

Pelham, W. E., et al. (2022). "The effect of stimulant medication on the learning of academic curricula in children with ADHD: A randomized crossover study." J Consult Clin Psychol 90(5): 367-380.

Cropsey, K. L., et al. (2017). "Mixed-amphetamine salts expectancies among college students: Is stimulant induced cognitive enhancement a placebo effect?" Drug and alcohol dependence 178: 302-309.

Looby, A., et al. (2022). "Expectation for stimulant type modifies caffeine’s effects on mood and cognition among college students." Experimental and Clinical Psychopharmacology 30: 525-535.

Holy moly. What about all the people whose driving safety records improve on stimulants? I'm taking patients at their word here but I hear about it a ton and it seems pretty genuine. Any formal investigation on that that you know of?

 

[PsyDr]

Holy moly. What about all the people whose driving safety records improve on stimulants? I'm taking patients at their word here but I hear about it a ton and it seems pretty genuine. Any formal investigation on that that you know of?

1) Do you objectively know that their driving record improves? Or is just their perception of their driving? That's the problem with the literature.

2) I don't know of any evidence that nonmedical use of stimulants improves objective measures of driving. I would imagine IRBs would not be thrilled about a study that documents . "Wanna slap our name on a study that says we know someone is driving under the influence?".

 

[mistafab]

On the topic of stimulants and grades in non-ADHD persons. I will say typically the weakest students were the ones I knew were taking stims. The high performers or myself definitely did not rely on stimulants to succeed.

I would say though, staying awake and focused likely could help with productivity in certain sectors. If you are a coder and they don't care if you learn or not, then I'm sure a stimulant could help keep you awake for 12 hours writing code with or without ADHD. I doubt that a stimulant would INCREASE how well you are doing said task, just that it might help you do said task for longer. I'm sure at some point the staying awake will have diminishing returns as your quality of work will eventually decrease now matter how many stimulants you take.

And I totally understand how a stimulant could make a person think they are more effective. Hell, talk to anyone hooked on meth and they will tell you they think it helps them.

 

[tr]

1) Do you objectively know that their driving record improves? Or is just their perception of their driving? That's the problem with the literature.

I've never requested anyone's driving records. But I have a number of patients who won't drive when off stimulants because they feel it is unsafe. Many have told me they had abysmal driving records prior to starting stimulants. I do a lot of stimulants-in-pregnancy consultations and often have people who self-d/c'ed for pregnancy tell me they have been getting in fender benders since stopping.

2) I don't know of any evidence that nonmedical use of stimulants improves objective measures of driving. I would imagine IRBs would not be thrilled about a study that documents . "Wanna slap our name on a study that says we know someone is driving under the influence?".

I meant prescribed, not recreational.

 

[PsyDr]

I've never requested anyone's driving records. But I have a number of patients who won't drive when off stimulants because they feel it is unsafe. Many have told me they had abysmal driving records prior to starting stimulants. I do a lot of stimulants-in-pregnancy consultations and often have people who self-d/c'ed for pregnancy tell me they have been getting in fender benders since stopping.


I meant prescribed, not recreational.

If it’s prescribed, then there is presumably a diagnosis that indicates objective cognitive impairment or objective sedation (i.e., narcolepsy and similar, which are arguably cognitive on the mental status exam). Absent a specific and objective cognitive impairment, what is the stimulant treating?

The literature describes a difference between objective performance and a subjective evaluation of performance. That's very similar to other substances (e.g., recent literature came out that showed cannabis doesn't increase creativity, it only increases your perception of how creative you are).

 

[tr]

If it’s prescribed, then there is presumably a diagnosis that indicates objective cognitive impairment or objective sedation (i.e., narcolepsy and similar, which are arguably cognitive on the mental status exam). Absent a specific and objective cognitive impairment, what is the stimulant treating?

The literature describes a difference between objective performance and a subjective evaluation of performance. That's very similar to other substances (e.g., recent literature came out that showed cannabis doesn't increase creativity, it only increases your perception of how creative you are).

It's always for AD/HD. I don't treat narcolepsy.

 

[aim-agm]

Tangentially, does anyone have experience with tiagabbine (GABA reuptake inhibitor)?