Benzos as first line?

[whopper]

Trazodone-highly associated with hangover. Same with TCAs.
Ambien-it's not a benzo but it's very much like a benzo. Again studies show after several months of use it actually makes sleep worse. A thing about medicine as we all know is that there's several exceptions.

All of the above meds have data supporting increased risk of dementia with long-term use of these meds.

I've had several patients have success in improving sleep using methods outside of medication.
Coffee-how can it help you sleep? I've noticed several people on stimulants with ADHD actually sleep better while on them and it makes sense cause stimulants calm ADHD sx including physical-hyperactivity. (If you have someone on Wellbutrin and they calm down while on it they most likely have ADHD). I've also noticed that even in people where it doesn't make them sleepy withdrawal from it does.

I've increased my coffee intake cause I have slight ADHD but also cause of the newer data showing possible health benefits. I've noticed after drinking about 2-4 cups a day, I slept much better and I won't take any after about 3 PM. By night it's all out of my system and I undergo a slight caffeine withdrawal. On weekends if I don't drink coffee at all I sleep over 9 hrs (I typically sleep 8 or less). Coffee also has mild-antidepressant effects. Since I've drank daily coffee I don't need to use my SAD lamp anymore for winter blues.

Lavender oil/incense-helps a lot of patients.

Sleep tracker. These are on Fitbits. I've found them very useful to in tracking patient's sleep. You can also now buy beds that can help track sleep.

Alpha-Stim: Studies show it helps sleep. I used the device only a few times and noticed I slept much better for a few days after using the device.
Excercise-we all know this helps with sleep but as treating physicians we should tell any patient to make sure they're exercising. Most don't.

Heavy blankets. What? Yep it helps some people and a better alternative to using most meds.

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[erg923]

Unless acutely psychotic/manic or have robust documentation of true insomnia: Sleep hygiene, CBTish stuff/psychoeducation, and dig a ditch? Sleep happens when you are exhausted, doesn't really matter what mental disorder you have.

I have concerns about the overall wellness effects of any medication or supplement that is artificial inducing sleep, or the natural process of sleep, if you are doing it is ongoing for more than a few weeks.

 

[Crayola227]

I hope no one was suggesting melatonin for depression. We got sidetracked talking about using benzos for sleepers (no bueno) and what we use instead.

While it comes up that melatonin is just good for chronotherapy, I find when I take it, a couple hrs later I do get hit with a burst of sleepiness. If I ride that train at the time, it helps me sleep. Although if I want to I can resist the urge and stay up, and that bit of sleepiness fades.

Correct that the Lewy research and some other resources suggest ways to figure out the best time to take it for bedtimes. It's something to experiment with.

I find that melatonin is fairly safe, non-addicting, cheap, few side effects, and that patients have quite variable reactions to it. Given what I've said, that's why I think it's at least worth a try, certainly before one would ever reach for a benzo for sleep.

Especially if coupled with other things. I've had people be able to cut back on other things they were using for sleep.

Some of these things you can use in a combination for sleep that won't snow you or hang you over.

I just iterate over and over not to think "more is better" with it.

I have read that some depressed folks find it makes them feel more down, and I have read that as a rare side effect. Also the nightmares, I've experienced first hand. They often die down after a few weeks of regular use.

I was quite pleased using it inpt when I got pages for sleep meds. I was pretty surprised how many pts that are pretty attached to opiods or benzos or Ambien, would appreciate it. Maybe at that point it's placebo, but I'd rather make the floor happy as the melatonin candy woman than using anything else. It caught on where I work and it's been a nightfloat fairy tale ending for everyone involved for the most part.

The trazodone hang over is pretty variable. I can't do benadryl, I'll sleep but when I wake up it feels like I never slept the whole night despite being in a coma. That's how I feel on gen anesthesia. When I was younger I had the trazodone hangover and decided it was a an evil drug. I think that was because it was like 100-250 mg. Now if I use it, personally, I use like 25-50 mg, and it works without a hangover. I start really really small on trazodone and titrate up for patients, hoping to get benefit before hangover. If not, just d/c. In fact, I've been able to get benefit this way in patients that complained of trazodone hangover. I think some people might just be more sensitive to it. I've course I've had patients get no benefit whatsoever at doses below hangover, or hangover at low doses.

Maybe it's crazy to have a cocktail of a touch of trazodone + melatonin, +/- other things, but I personally think it's better than getting habituated to Ambien or benzos for sleep, and I'd rather not use that for sleep at any point. Whatever you give someone for sleep, if it works, they can become crazy attached to. I'd rather not have patients fall in love with Ambien or benzos so I try not to expose them to them, especially not first line. That's how I feel about benadryl, too. I've seen too many people overdo it with big bad consequences, and it won't be as safe for them as they age.

Sleep is multifactorial, and I think for some insomniacs there can be a cumulative benefit to interventions, like blackout curtains + cool room + heavy blankets + warm milk + melatonin + touch trazodone + etc. All this I think superior to giving a patient a pill so powerful (like Ambien or benzos) that it lets them skip a sleep hygiene routine and what I consider less harmful meds.

 

[Crayola227]

Trazodone-highly associated with hangover. Same with TCAs.
Ambien-it's not a benzo but it's very much like a benzo. Again studies show after several months of use it actually makes sleep worse. A thing about medicine as we all know is that there's several exceptions.

All of the above meds have data supporting increased risk of dementia with long-term use of these meds.

I've had several patients have success in improving sleep using methods outside of medication.
Coffee-how can it help you sleep? I've noticed several people on stimulants with ADHD actually sleep better while on them and it makes sense cause stimulants calm ADHD sx including physical-hyperactivity. (If you have someone on Wellbutrin and they calm down while on it they most likely have ADHD). I've also noticed that even in people where it doesn't make them sleepy withdrawal from it does.

I've increased my coffee intake cause I have slight ADHD but also cause of the newer data showing possible health benefits. I've noticed after drinking about 2-4 cups a day, I slept much better and I won't take any after about 3 PM. By night it's all out of my system and I undergo a slight caffeine withdrawal. On weekends if I don't drink coffee at all I sleep over 9 hrs (I typically sleep 8 or less). Coffee also has mild-antidepressant effects. Since I've drank daily coffee I don't need to use my SAD lamp anymore for winter blues.

Lavender oil/incense-helps a lot of patients.

Sleep tracker. These are on Fitbits. I've found them very useful to in tracking patient's sleep. You can also now buy beds that can help track sleep.

Alpha-Stim: Studies show it helps sleep. I used the device only a few times and noticed I slept much better for a few days after using the device.
Excercise-we all know this helps with sleep but as treating physicians we should tell any patient to make sure they're exercising. Most don't.

Heavy blankets. What? Yep it helps some people and a better alternative to using most meds.

Trazodone associated with dementia? Wow.

Ditto about coffee and ADHD. I've had several ADHD patients that had this benefit from caffeine. My dad had really really bad adult ADD, and he would drink a pot of coffee in the evening before bed and start to nod off.

I never use caffeine past 4 pm because it has a long half life that can mess with sleep quality. If I have it in the AM I find that come 4 pm I need a freaking nap. I don't have ADHD and I'm not a typically a napster type.

I HAVE to eat something before bed. There's studies that show that eating before bed is bad for weight loss, and certainly not good with GERD. Have to iterate dental hygeine. But there's also studies that show lack of sleep contributes to being overweight, too. Trade off.

 

[birchswing]

I had done some research about benzos and trauma, and it wasn't good for PTSD and so they were trying to see if you could administer it even sooner after the traumatic event. From what I recall, even that was not helpful and even harmful in the process of normal memory consolidation.

The counter-example is surgery where you administer the amnesic before and during the trauma, which seems quite effective.

So that seems to be the rub—administering an amnesic before a traumatic event. That would take some sort of sci-fi contraption. Like a car or airplane that can tell you're about to be in a crash and before the crash happens it auto-injects some fast-acting anesthetic so that you can't form memories of the event.

We used to think that early infancy surgeries were inconsequential because the nervous system wasn't fully articulated and there would be no memory of the event, so infants were not anesthetized or not anesthetized for pain for even very invasive procedures.

But research later showed that infants who were anesthetized for procedures showed reduced psychological sequelae and pain response later in life:

https://hms.harvard.edu/sites/default/files/HMS_OTB_Winter11_Vol17_No1.pdf

 

[whopper]

Trazodone associated with dementia? Wow.

All anticholinergics it appears could associated with dementia. So that could include meds like Paroxetine, Quetiapine....Remember a lot of psych meds have anticholinergic properties.

A question is so yes there's a link between anticholinergics but is it all of them? No one med-specifically tested each one, but it appears in general anticholinergics promote dementia.

Cumulative Use of Strong Anticholinergic Medications and Incident Dementia

Common anticholinergic drugs like Benadryl linked to increased dementia risk - Harvard Health Blog

If you think about it makes sense. In fact this makes me speculate that perhaps nicotine patches might help dementia. No I'm not recommending them to patients but this crosses my mind as a something that could be studied.

I remember while in medschool a professor said he knows of some data showing nicotine can benefit memory with dementia but that you tell this to patients and all of a sudden they get this wrong idea that you're promoting nicotine use in everyone, addicts will use this data inappropriately and out of context to justify their addiction, and the people that might actually benefit from this will immediately love/hate you in an out-of-proportion manner. Further we all know that long-term use of nicotine would promote atherosclerosis in the entire body including the brain.

 

[WisNeuro]

All anticholinergics it appears could associated with dementia. So that could include meds like Paroxetine, Quetiapine....Remember a lot of psych meds have anticholinergic properties.

A question is so yes there's a link between anticholinergics but is it all of them? No one med-specifically tested each one, but it appears in general anticholinergics promote dementia.

Yeah, this is my modal patient. The ACB is a useful-ish scale that has looked at cognitive decline depending on anticholinergic burden, with a dose response seen in at least cognitive screening measures. IMO, a very under-appreciated issue given the amount of polypharmacy in many patients.

 

[Crayola227]

All anticholinergics it appears could associated with dementia. So that could include meds like Paroxetine, Quetiapine....Remember a lot of psych meds have anticholinergic properties.

A question is so yes there's a link between anticholinergics but is it all of them? No one med-specifically tested each one, but it appears in general anticholinergics promote dementia.

Cumulative Use of Strong Anticholinergic Medications and Incident Dementia

Common anticholinergic drugs like Benadryl linked to increased dementia risk - Harvard Health Blog

If you think about it makes sense. In fact this makes me speculate that perhaps nicotine patches might help dementia. No I'm not recommending them to patients but this crosses my mind as a something that could be studied.

I remember while in medschool a professor said he knows of some data showing nicotine can benefit memory with dementia but that you tell this to patients and all of a sudden they get this wrong idea that you're promoting nicotine use in everyone, addicts will use this data inappropriately and out of context to justify their addiction, and the people that might actually benefit from this will immediately love/hate you in an out-of-proportion manner. Further we all know that long-term use of nicotine would promote atherosclerosis in the entire body including the brain.

interesting
right, and nicotine use appears to reduce risk of Parkinson's

 

[Crayola227]

there is a link between sleep deprivation and atherosclerosis

there's really no winning, in some ways it's just dealing with the problem at hand

 

[Stagg737]

@wolfvgang22 , what I hear from them is that you get significant metabolic downsides for unimpressive results when used for sleep alone. And certainly the literature evidence base is not robust. I find it sometimes hard in the absence of clear empirically results to square the clinical experience of experts with the clinical experience of so many other people. Not sure where I land tbh.

So they're basically opposed because of the metabolic side effects right? If so, I was taught something similar from my mentor during med school. He loved to use Remeron 7.5-15 while pts were on the unit for depression with sleeping difficulties but said he never prescribes it for longer than 2 weeks because of the metabolic issues. I'm still trying to figure out what to use and when for pts with sleeping difficulties, but benzos are certainly far from first line for sleep for me (at least with what I've been taught so far).

For sleep I recommend these first: Melatonin up to 20 mg (more so if 20 mg gets them to fall asleep but not keep them asleep), Tryptophan, Glycine. If these don't work then Trazodone or Gabapentin.

Gabapentin for sleep? I don't think I've ever seen that before other than as a secondary effect for pts with neuropathic issues. Given that the proposed MOA for Gabapentin is still a form of GABA modulation (like benzos), why would this be a part of your second line?

 

[Crayola227]

there's a ton in the literature for mirtazapine and GI motility and other GI stuff, the GI Jesus at my institution, when I asked what was the one GI thing as a non-GI that he wanted me to know, said not to use mirtazapine for GI stuff EVER, unless I'm doing palliative care on someone on their way out of this life.

It's easy to see why that's something that's been explored in GI, as since we've learned more about the neurochemical basis for GI ailments like IBS and such.

That's an aside to using it in psych, but personally, especially given the comorbidity of GI and psych issues, I would avoid it.

Course, when it comes to GI or psych issues, lack of sleep hardly helps any of it.

 

[Crayola227]

On the sleep issue, I've found getting people onto appropriate use of CPAP to do so much for mental health as to sometimes obviate the need for meds for depression, anxiety, ADHD, etc etc.

Much as we feel we can hardly diagnose or effectively treat the mentally ill where substance abuse is a major confounder in the picture, I feel sleep has just as powerful a role. They gotta stop doing drugs and start sleeping, or they likely will never feel really good.

TLDR:
Almost no one can feel really "good" with chronic sleep deprivation. CPAP can be a game changer when indicated.

 

[birchswing]

All anticholinergics it appears could associated with dementia. So that could include meds like Paroxetine, Quetiapine....Remember a lot of psych meds have anticholinergic properties.

A question is so yes there's a link between anticholinergics but is it all of them? No one med-specifically tested each one, but it appears in general anticholinergics promote dementia.

Cumulative Use of Strong Anticholinergic Medications and Incident Dementia

Common anticholinergic drugs like Benadryl linked to increased dementia risk - Harvard Health Blog

If you think about it makes sense. In fact this makes me speculate that perhaps nicotine patches might help dementia. No I'm not recommending them to patients but this crosses my mind as a something that could be studied.

I remember while in medschool a professor said he knows of some data showing nicotine can benefit memory with dementia but that you tell this to patients and all of a sudden they get this wrong idea that you're promoting nicotine use in everyone, addicts will use this data inappropriately and out of context to justify their addiction, and the people that might actually benefit from this will immediately love/hate you in an out-of-proportion manner. Further we all know that long-term use of nicotine would promote atherosclerosis in the entire body including the brain.

I first found out about this from my YouScript interaction checker. It has the highest level of warning (red stop sign) for my Paxil, Seroquel, and Zantac due to the synergistic anti-cholinergic effect. Other interaction checkers don't mention this at all. It's a great checker because it's always being updated with new research. Unfortunately, I will lose patient access as of next summer when it will be doctor-only. It's helped me so many times—I've been in the hospital and they've wanted to give me things that I check on my laptop that have had big interactions. Right now I'm doing an h pylori eradication and it was extremely helpful in finding which combo wouldn't potentiate my Valium and Seroquel.

Re: nicotine use, there was an episode of Always Sunny in Philadelphia that referenced a character smoking to try to prevent Parkinson's (Season 12, Episode 6).

 

[cara susanna]

I took the board exam this fall and it is first line sometimes per the APA.
I am in the minority here, a lot don't prescribe. I feel if someone has panic disorder and isn't functioning and can't work, care for their children etc, it is appropriate to start so they can function while also having the patient in therapy and started on an SSRI. I also use them with severely anxious patients who can't handle the initial anxiety of an SSRI for 2 weeks until that side effect wears off.
And now lots of others will say the exact opposite. …………………………………….

Speaking as a therapist, the concern I have with that is that the most effective therapies that we have for anxiety aren't going to work if the patient is on a benzo.

 

[Ironspy]

Speaking as a therapist, the concern I have with that is that the most effective therapies that we have for anxiety aren't going to work if the patient is on a benzo.

Short term benzos are ok if there is a clearly identifiable end point. Long term benzos are basically palliative care (i.e. Patient dying or so low functioning that you're giving up on meaningful recovery). Chronic benzos do more harm than good for ~95% of psych patients imo

 

[birchswing]

Short term benzos are ok if there is a clearly identifiable end point. Long term benzos are basically palliative care (i.e. Patient dying or so low functioning that you're giving up on meaningful recovery). Chronic benzos do more harm than good for ~95% of psych patients imo

In addition, the long-term use makes the short-term for identifiable end point (like flying) useless. Flying solo, flying with one time use benzo, or flying while tapering from long-term benzos and having developed tolerance—one is not like the others.

 

[futuredo32]

Speaking as a therapist, the concern I have with that is that the most effective therapies that we have for anxiety aren't going to work if the patient is on a benzo.

Speaking as a psychiatrist who does a lot of psychotherapy, I have found that for severely anxious patients, it actually helps in therapy. They aren't so anxious and can participate in therapy.

 

[LadyHalcyon]

Speaking as a psychiatrist who does a lot of psychotherapy, I have found that for severely anxious patients, it actually helps in therapy. They aren't so anxious and can participate in therapy.

She is likely referring to exposure based therapies

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[WisNeuro]

Short term benzos are ok if there is a clearly identifiable end point. Long term benzos are basically palliative care (i.e. Patient dying or so low functioning that you're giving up on meaningful recovery). Chronic benzos do more harm than good for ~95% of psych patients imo

Trouble is, this isn't how they are used in actual practice. 90+% of the time, someone is just given maintenance benzos, or PRN benzos that turn into maintenance. Whether it's cluelessness, acquiescing to patient demands, or ignorantly believing that you are helping the patient, the end result is usually in making their lives worse in the long run. Iatrogenesis is a hell of a drug.

 

[cara susanna]

She is likely referring to exposure based therapies

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Yes, I'm referring to exposure work. I get that it's important to have the patient be able to attend session consistently, but a benzo is going to seriously impede any progress that they can make within that type of therapy.

 

[LadyHalcyon]

Speaking as a psychiatrist who does a lot of psychotherapy, I have found that for severely anxious patients, it actually helps in therapy. They aren't so anxious and can participate in therapy.

I find an ssri can often be useful for that specific issue. I guess my problem with benzos is they work too well. Pop a Xanax and within 10 or so minutes your anxiety vanishes. It is hard to compete with that. Why endure psychological distress during therapy sessions when all you have to do is take a pill? But this "quick fix" cultural epidemic doesn't only apply to benzos......

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[WisNeuro]

I find an ssri can often be useful for that specific issue. I guess my problem with benzos is they work too well. Pop a Xanax and within 10 or so minutes your anxiety vanishes. It is hard to compete with that. Why endure psychological distress during therapy sessions when all you have to do is take a pill? But this "quick fix" cultural epidemic doesn't only apply to benzos......

Sent from my SM-G950U using SDN mobile

Actually it just "vanishes" temporarily, and you've just introduced a safety cue that reinforces your anxiety and makes it more entrenched.

 

[LadyHalcyon]

Actually it just "vanishes" temporarily, and you've just introduced a safety cue that reinforces your anxiety and makes it more entrenched.

You mean like the people who have a panic attack when they realize they accidentally left their benzo at home?

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[futuredo32]

I find an ssri can often be useful for that specific issue. I guess my problem with benzos is they work too well. Pop a Xanax and within 10 or so minutes your anxiety vanishes. It is hard to compete with that. Why endure psychological distress during therapy sessions when all you have to do is take a pill? But this "quick fix" cultural epidemic doesn't only apply to benzos......

Sent from my SM-G950U using SDN mobile

I often prescribe two weeks of a low dose benzo for patients with panic disorder if they can't tolerate the initial increased SSRI induced anxiety and explain clearly it is for TWO WEEKS.

 

[Crayola227]

Speaking as a psychiatrist who does a lot of psychotherapy, I have found that for severely anxious patients, it actually helps in therapy. They aren't so anxious and can participate in therapy.

but I thought you were super anti-benzo

 

[WisNeuro]

but I thought you were super anti-benzo

From previous discussions, I thought it was the polar opposite.

 

[futuredo32]

but I thought you were super anti-benzo

NO I got kinda bashed in a post awhile back for prescribing them. I don't want to be the pill mill Dr but I do think they have their place.

 

[futuredo32]

From previous discussions, I thought it was the polar opposite.

I prescribe them judiciously.

 

[WisNeuro]

I prescribe them judiciously.

I remain skeptical as there are very few reasons to prescribe them at all.

 

[LadyHalcyon]

I often prescribe two weeks of a low dose benzo for patients with panic disorder if they can't tolerate the initial increased SSRI induced anxiety and explain clearly it is for TWO WEEKS.

That makes sense to me. I never like to vilify an entire class of drugs. They all have pros and cons.

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[WisNeuro]

That makes sense to me. I never like to vilify an entire class of drugs. They all have pros and cons.

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Some cons overwhelmingly shadow the pros.

 

[LadyHalcyon]

Some cons overwhelmingly shadow the pros.

True, but even benzos are useful imo. Maybe not for the treatment of generalized anxiety, ptsd, or panic attacks, but I'm hesitant to label them as "all bad." There are certain circumstances where they may be applicable; ultimately I believe it should be up to the physician to carefully weigh the pros and cons. If you go to the ER with a seizure history because you think you are having a seizure they will likely give you Ativan. Obviously seizures and anxiety aren't the same thing but you get my point. Maybe I'll change my mind about them though. Stranger things have happened!

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[WisNeuro]

True, but even benzos are useful imo. Maybe not for the treatment of generalized anxiety, ptsd, or panic attacks, but I'm hesitant to label them as "all bad." There are certain circumstances where they may be applicable; ultimately I believe it should be up to the physician to carefully weigh the pros and cons. If you go to the ER with a seizure history because you think you are having a seizure they will likely give you Ativan. Obviously seizures and anxiety aren't the same thing but you get my point. Maybe I'll change my mind about them though. Stranger things have happened!

Sent from my SM-G950U using SDN mobile

Well its, but the clinician in 90%+ of cases does not know the data about the pros and cons, and prescribes them in a way that is dangerous. We're not talking about legitimate inpatient uses here, we're talking about outpatient abuses.

 

[Crayola227]

In movement disorders clinic, but I've also seen psychiatrists do this as well, there is a place for using them for some of the EPS sx from using atypicals.

 

[Attending1985]

What about the person who comes to you on maintenance benzos with no complaints and they’re not elderly. You counsel them on all the problems with benzos and they’re like please don’t taper or reduce. This is where I become ambivalent about a unilateral taper. I would like to have patient assent but also hate leaving them on benzos.

 

[Ironspy]

What about the person who comes to you on maintenance benzos with no complaints and they’re not elderly. You counsel them on all the problems with benzos and they’re like please don’t taper or reduce. This is where I become ambivalent about a unilateral taper. I would like to have patient assent but also hate leaving them on benzos.

I tell them that I think long term benzos are palliative care and that I think they have a chance of meaningful recovery. Then I ask them if they want to get better or stay on benzos.

I won't continue maintenance benzos long term but can refer if they want. I'm in an urban area and there are plenty of psychiatrists that are more liberal with benzos and I tell that to patients

 

[Attending1985]

I tell them that I think long term benzos are palliative care and that I think they have a chance of meaningful recovery. Then I ask them if they want to get better or stay on benzos.

I won't continue maintenance benzos long term but can refer if they want. I'm in an urban area and there are plenty of psychiatrists that are more liberal with benzos and I tell that to patients

I like that but I am in a very underserved area and have no one to refer to

 

[Trismegistus4]

I remain skeptical as there are very few reasons to prescribe them at all.

The main reason to prescribe benzos is to get the incessantly benzo-requesting patient who keeps scheduling follow-ups with you every time you have an opening to come back and plead for benzos and claim that nothing else works and that SSRIs, SNRIs, TCAs, MAOIs, BuSpar, and mirtazapine give them intolerable side effects, oh, and therapy doesn't work either, to finally shut the hell up, go away, and leave you alone.

Sadly, I find myself giving into this more and more, because I am employed in a situation where I can't just fire these people, which is what I really want to do. I can't wait to leave this job and go back to inpatient, where once they're not going to kill themselves or anyone else or walk down the middle of a road naked ranting and raving, you can just discharge them and they're not your problem anymore.

 

[Evidence Based]

I thought some of the stories on this thread were a joke, but I recently saw a patient (at an extremely prestigious psychiatric hospital) who is on standing clonazepam 2mg daily, prn Ativan 1mg BID (which she usually takes), and pro clonazepam 1mg TID prn (usually gets at least two of those). Also thorazine and tegretol (????). All for what seems to be anxiety and axis II pathology.
Of course she's been inpatient for months and doesn't seem to be getting better, which is Very Shocking.

 

[birchswing]

I thought some of the stories on this thread were a joke, but I recently saw a patient (at an extremely prestigious psychiatric hospital) who is on standing clonazepam 2mg daily, prn Ativan 1mg BID (which she usually takes), and pro clonazepam 1mg TID prn (usually gets at least two of those). Also thorazine and tegretol (????). All for what seems to be anxiety and axis II pathology.
Of course she's been inpatient for months and doesn't seem to be getting better, which is Very Shocking.

I could name names of psychiatrists who in their minds have legitimate reasons for starting a young patient on multiple benzos simultaneously (one of those reasons was that Klonopin isn't really a benzodiazepine—not sure what that means, but there you go). And I have the medical records to prove it (well not prove the reasoning but proving what was prescribed simultaneously as first-line treatment and what was not attempted before that prescribing). I won't because this an anonymous forum and asymmetrical attacks are unethical and it wouldn't serve a purpose. I suppose one doctor's clinical pearl of wisdom is another doctor's turd of ignorance.

 

[WisNeuro]

The main reason to prescribe benzos is to get the incessantly benzo-requesting patient who keeps scheduling follow-ups with you every time you have an opening to come back and plead for benzos and claim that nothing else works and that SSRIs, SNRIs, TCAs, MAOIs, BuSpar, and mirtazapine give them intolerable side effects, oh, and therapy doesn't work either, to finally shut the hell up, go away, and leave you alone.

Sadly, I find myself giving into this more and more, because I am employed in a situation where I can't just fire these people, which is what I really want to do. I can't wait to leave this job and go back to inpatient, where once they're not going to kill themselves or anyone else or walk down the middle of a road naked ranting and raving, you can just discharge them and they're not your problem anymore.

This part sucks. Another reason I left the VA.

 

[raisinbrain]

Yes, I'm referring to exposure work. I get that it's important to have the patient be able to attend session consistently, but a benzo is going to seriously impede any progress that they can make within that type of therapy.

Curious about this as I've heard arguments on both sides. My question is also for those whose anxiety seems to impede therapy work in sessions. I've seen one successful example of someone treated with an SSRI and a very low dose clonazepam - but not prn, and not right before sessions, to try to get a better baseline distress tolerance in order to actually participate in therapy.

Anyone else seen this be successful? Clearly prn uses will impair the ability to modify emotional responses to triggers, but thoughts on lower dose baseline meds, also temporary until therapy has progressed?