Older people in benzos

[lockian]

You inherit an elderly patient who has been on benzos for years if not decades. You inform them of the risks and they opt for the “if it’s not broken don’t fix it approach.” Let’s say that long term SSRIs and therapy are on board but seem to not be enough to allow the patient to exist without benzos. You say fine, let’s see how things develop. Some time later they start falling and having memory problems. You are concerned that the benzos are finally catching up to them. You tell them. They invoke every rationalization in the book, and I don’t blame them. Getting off benzos after decades is objectively awful. Any tips and tricks or thoughts on what has worked in such scenarios?

---

Members don't see this ad.

 

[splik]

If an elderly person has been on benzos for many years (which is often the case, unusual for it to have been recently started), the risks of trying to taper them off far outweigh any hypothetical risks. There usually isn't much risk of falls if theyve been on it for years.

It makes no sense that the benzos would be the cause of their falls and memory problems. Of course benzos can exacerbate cognitive problems, but most demented pts on benzos say they are willing to take the cognitive hit than to do without.

Some yrs ago I had a very geriatric pt (over 90) come to me because their PCP was trying to take them off their Ambien, taken for many years without dose escalation. Pt was having recurrent falls. Said would rather be dead than off them. Had capacity to make decision about this and I wrote to PCP supporting their request for it.

As I always taught my residents in certain scenarios the answer is "just give them the damn benzos". This is one of them. document clearly conversation of potential risks and benefits and patient's capacity to make such decisions. As long as such a discussion has been had and documented with rationale for continuation explained you cannot be faulted if the pt falls and breaks their neck.

 

[WisNeuro]

Some people will never want to come off, some will if given the rationale and a plan of action. I helped my spouse put together a fact sheet for her elderly patients that she uses and she gets several a year that agree to a taper. And, at least in those patients they are largely thankful after they're off, reporting that it feels like night and day in terms of feeling groggy/out of it/snowed/etc. For those that refuse to voluntarily go off, I'd just document very clearly that the fall/mortality risk was discussed. The fall risk has been a pretty consistent and fairly robust finding, so I wouldn't discount that just because they've been on them for a while.

 

[lockian]

Some people will never want to come off, some will if given the rationale and a plan of action. I helped my spouse put together a fact sheet for her elderly patients that she uses and she gets several a year that agree to a taper. And, at least in those patients they are largely thankful after they're off, reporting that it feels like night and day in terms of feeling groggy/out of it/snowed/etc. For those that refuse to voluntarily go off, I'd just document very clearly that the fall/mortality risk was discussed. The fall risk has been a pretty consistent and fairly robust finding, so I wouldn't discount that just because they've been on them for a while.

See, I always wonder. You can discuss and they can say they understand but still want the thing. They can even be documented to have capacity. But ultimately you are the one with the DEA license and you don’t have to go along with the patient’s decision. It’s up to you to decide to give them the benzos or not. So it’s your decision that on the one hand may cause them to fall and have severe injuries, but on the other hand lead to a lot of emotional and physical distress that all parties involved will have to tolerate. You can cop out by giving them a few bridge prescriptions and terminating care but given the sad state of access to care that is just as hard a decision. Do you mind sharing the info sheet?

 

[forchinet121]

If an elderly person has been on benzos for many years (which is often the case, unusual for it to have been recently started), the risks of trying to taper them off far outweigh any hypothetical risks. There usually isn't much risk of falls if theyve been on it for years.

It makes no sense that the benzos would be the cause of their falls and memory problems. Of course benzos can exacerbate cognitive problems, but most demented pts on benzos say they are willing to take the cognitive hit than to do without.

Some yrs ago I had a very geriatric pt (over 90) come to me because their PCP was trying to take them off their Ambien, taken for many years without dose escalation. Pt was having recurrent falls. Said would rather be dead than off them. Had capacity to make decision about this and I wrote to PCP supporting their request for it.

As I always taught my residents in certain scenarios the answer is "just give them the damn benzos". This is one of them. document clearly conversation of potential risks and benefits and patient's capacity to make such decisions. As long as such a discussion has been had and documented with rationale for continuation explained you cannot be faulted if the pt falls and breaks their neck.

I hope you are correct because this is the approach that I take but I’ve had several attendings who disagree and they tell the patient “we’re going to taper or you need to find another provider” which I think is harsh..ultimately you are writing the prescription they say so you are essentially encouraging their use so if they fall the liability is on you because this is an addictive substance and obviously the patient wants to continue it (that’s their reasoning I’m not sure if it’s correct)

 

[WisNeuro]

See, I always wonder. You can discuss and they can say they understand but still want the thing. They can even be documented to have capacity. But ultimately you are the one with the DEA license and you don’t have to go along with the patient’s decision. It’s up to you to decide to give them the benzos or not. So it’s your decision that on the one hand may cause them to fall and have severe injuries, but on the other hand lead to a lot of emotional and physical distress that all parties involved will have to tolerate. You can cop out by giving them a few bridge prescriptions and terminating care but given the sad state of access to care that is just as hard a decision. Do you mind sharing the info sheet?

I'm liability risk averse, and I know the literature on long-term benzos. So, personally, I'd tell them to find a new prescriber if it were me. She's out of town at the moment, when she's back I'll see if she will send me the document to share.

 

[hallowmann]

I hope you are correct because this is the approach that I take but I’ve had several attendings who disagree and they tell the patient “we’re going to taper or you need to find another provider” which I think is harsh..ultimately you are writing the prescription they say so you are essentially encouraging their use so if they fall the liability is on you because this is an addictive substance and obviously the patient wants to continue it (that’s their reasoning I’m not sure if it’s correct)

To be honest, there is a middle ground between "we're cutting you off" and "you will be an 80 yo on TID Xanax, you know assuming you don't fall, fracture a hip and die in a year anyways".

There are lots of things that can contribute to memory concerns in a geri patient and there is no way you can say that the benzos aren't in some way contributing. Sure it might not be the primary issue, but its probably a catalyst.

Personally I take the approach of "this is something that we know can cause you more and more problems as you get older, so let's work together to get you on a better regimen. Afterall the best dose is the lowest effective dose and the best number of meds is the smallest number to achieve the intended goal." Then I will map out with them how every month I will reduce their script by 2 tabs and they can choose which days or time of day to split their tabs a bit. I never increase, but I'll sometimes pause (i.e. skip a month of reduction).

I've done this many times and at the very least people end up on a much lower dose, or they develop a momentum, get excited and taper faster. I too have only had people tell me how much better they feel off of them. You will lose some people, but that's fine and ultimately up to them if they want to get it elsewhere. They also won't feel good, but there is a benzo fog that they get to when they reach 30-50% reduction, and most really start feeling better.

 

[Crayola227]

Yeah, wow, it's your legal liability (which can be mitigated) and your DEA license (not likely to be in danger even if you had atrocious practices and outcomes) yet I find deferring to that and essentially putting that first as the thing you're going to serve, as though it is most important, like not terribly compelling when stacked against the patient and their experience and their QOL. I'm with splik here. If the most negative consequence you are actually likely to endure is wondering if the patient suffered a theoretical harm (that might have happened anyway) as a result of informed consent prescribing, but it is highly likely you mitigated their suffering, than I truly don't understand the appeal to authority here.

 

[J ROD]

Inpatient - I tend to taper off
Outpatient - I tend to try and taper off it possible. I will at least taper dose to what I think is "more" appropriate. Will continue to give if been decades and not super abusive with them.

 

[lockian]

To be honest, there is a middle ground between "we're cutting you off" and "you will be an 80 yo on TID Xanax, you know assuming you don't fall, fracture a hip and die in a year anyways".

There are lots of things that can contribute to memory concerns in a geri patient and there is no way you can say that the benzos aren't in some way contributing. Sure it might not be the primary issue, but its probably a catalyst.

Personally I take the approach of "this is something that we know can cause you more and more problems as you get older, so let's work together to get you on a better regimen. Afterall the best dose is the lowest effective dose and the best number of meds is the smallest number to achieve the intended goal." Then I will map out with them how every month I will reduce their script by 2 tabs and they can choose which days or time of day to split their tabs a bit. I never increase, but I'll sometimes pause (i.e. skip a month of reduction).

I've done this many times and at the very least people end up on a much lower dose, or they develop a momentum, get excited and taper faster. I too have only had people tell me how much better they feel off of them. You will lose some people, but that's fine and ultimately up to them if they want to get it elsewhere. They also won't feel good, but there is a benzo fog that they get to when they reach 30-50% reduction, and most really start feeling better.

Reduce by 2 pills a month? Did I read that right? So if they are on 30 per mos you go to 28? I think you may be onto something. That’s a slowness of pace most people will hardly notice, but it’s still progress.

I’ve had people who in good faith try to taper after decades and they get horrible withdrawal even with the smallest dose change you can achieve, but maybe the issue is I’ve been doing a dose per day reduction as opposed to a pills per month plan.

 

[lockian]

Yeah, wow, it's your legal liability (which can be mitigated) and your DEA license (not likely to be in danger even if you had atrocious practices and outcomes) yet I find deferring to that and essentially putting that first as the thing you're going to serve, as though it is most important, like not terribly compelling when stacked against the patient and their experience and their QOL. I'm with splik here. If the most negative consequence you are actually likely to endure is wondering if the patient suffered a theoretical harm (that might have happened anyway) as a result of informed consent prescribing, but it is highly likely you mitigated their suffering, than I truly don't understand the appeal to authority here.

Yeah, I was mostly channeling an attending from residency about the liability. He was really risk averse and always made us imagine how we would defend a hypothetical unlikely but catastrophic outcome in court. Not the best way to teach, in retrospect. I have trauma from things that never actually happened as a result of that teaching method.

In reality I see people prescribe atrociously all the time, what with the patients I inherit. And I also stalk my state board disciplinary action records, and it’s all people who prescribe opioids (which psychiatrists don’t typically… and I never see suboxone in those cases)
and have inappropriate relationships with patients. So IDK.

 

[TheRightMedication]

I strongly disagree with giving a patient something that will harm them. I don't think informed consent is ethically relevant in such cases.

 

[birchswing]

You inherit an elderly patient who has been on benzos for years if not decades. You inform them of the risks and they opt for the “if it’s not broken don’t fix it approach.” Let’s say that long term SSRIs and therapy are on board but seem to not be enough to allow the patient to exist without benzos. You say fine, let’s see how things develop. Some time later they start falling and having memory problems. You are concerned that the benzos are finally catching up to them. You tell them. They invoke every rationalization in the book, and I don’t blame them. Getting off benzos after decades is objectively awful. Any tips and tricks or thoughts on what has worked in such scenarios?

<Not a doctor or medical student>

What stood out to me is that you said the patient rationalized maintaining the medication.

But to use your own words you said scenario 1 (without the benzos) is one in that does " not ... allow the patient to exist"

If that's the benefit, existence, but the harm is falls and cognitive issues (assuming those are really from the benzos), isn't the benefit/risk ratio clear? There was a better option decades ago, but at this point I'm not sure you'll see cognitive improvement from withdrawal. I don't know how many years they have left, but it takes time in a taper during which you might see worse "brain fog" before there is improvement. And some people don't improve. I'm not entirely sure also what you mean by catching up to them. There are theories of how benzodiazepines have long-term cognitive effects, but there are with SSRIs, as well, and all anticholinergics.

Edit: Also, I don't have any experience to know about this, but I was wondering if anyone else was going to comment on the liver enzyme metabolized benzodiazepines versus those with direct liver metabolization (I think it's glucuronidation—I'm really only familiar with lorazepam vs diazepam and the drugs it spawned). I kind of recall the ads for Ativan even called them "liver sparing." Is the type of benzodiazepine in older age a factor? As in, if they are on diazepam, is more of it accumulating? Maybe that is the "catching up" you are seeing.

 

[clausewitz2]

In reality I see people prescribe atrociously all the time, what with the patients I inherit. And I also stalk my state board disciplinary action records, and it’s all people who prescribe opioids (which psychiatrists don’t typically… and I never see suboxone in those cases)
and have inappropriate relationships with patients. So IDK.

Realistically to get in trouble for prescribing benzos to people you would need to be prescribing them, frequently, to people you either are related to or to patients that you can't document any kind of visits for. You might get sued by a family in some case for a bad outcome but you point to the guidelines that say they are indicated for anxiety disorders of various kinds and it becomes really hard for them to demonstrate malpractice.

I tend to agree with splik for the most part, but also my own experience is that if you have the conversation about the bad things that benzos could be responsible for and potential downsides with older folks, make it clear you're prepared to help them taper very slowly (Ashton-style taper over months, not weeks) with as many pauses along the way as they feel like they need, that they got into this situation through absolutely no fault of their own, and then drop it for a while, most of the time they get around to pushing for it themselves. Once you talk about falls in the over 70 set almost everyone knows somebody who broke a hip and had a catastrophic outcome. I end up doing a lot more validating anger expressed at previous prescribers who they feel did not warn them adequately about risks than needing to push people to taper.

Young people are a completely different matter.

 

[hallowmann]

Reduce by 2 pills a month? Did I read that right? So if they are on 30 per mos you go to 28? I think you may be onto something. That’s a slowness of pace most people will hardly notice, but it’s still progress.

I’ve had people who in good faith try to taper after decades and they get horrible withdrawal even with the smallest dose change you can achieve, but maybe the issue is I’ve been doing a dose per day reduction as opposed to a pills per month plan.

Yes. That is probably the slowest I would taper, but for the patients that are very apprehensive/resistant, it is usually reasonably well received. Realistically you could likely taper much faster, but this adds more buy-in and improve the therapeutic alliance in my experience, especially with people who have been on benzos for going on decades.

 

[randomdoc1]

See, I always wonder. You can discuss and they can say they understand but still want the thing. They can even be documented to have capacity. But ultimately you are the one with the DEA license and you don’t have to go along with the patient’s decision. It’s up to you to decide to give them the benzos or not. So it’s your decision that on the one hand may cause them to fall and have severe injuries, but on the other hand lead to a lot of emotional and physical distress that all parties involved will have to tolerate. You can cop out by giving them a few bridge prescriptions and terminating care but given the sad state of access to care that is just as hard a decision. Do you mind sharing the info sheet?

Yes, I do a similar approach too. I show them the medical literature. I'm not as sophisticated as making a fact sheet, but that is an excellent idea. Once people see the peer reviewed literature, most get very very turned off. I also explain the mechanism of action, how tolerance and dependence builds up and how it just pharmacologically makes no sense for it to actually be doing anything therapeutic. Most of the patients I spoke to, responded to science and facts. And sometimes, you just have to draw that line and there's many ways you can do that. Despite all the overwhelming information, some people just want to be on benzos. I'm dealing with that with a geriatric patient right now. I've seen her for years and told her, if it was truly as easy and marvelous as doling them out, don't you think I'd do that for everyone? Have you ever thought there is a reason why I don't? Because there's robust evidence showing its consistent link with adverse outcomes. Comfortable does not always equate to safe or therapeutic. Comfortable can sometimes be what I call a quick fix but it's just a matter of time before it catches up. And again, I say, I am their physician. The easy route is to keep doling out more and more benzos. Patient keeps coming back (and so religiously), patient does not complain. But what service am I doing as a healthcare provider? In that method we are serving ourselves, not the patient. And I tell them that. Even though patients know it is not a good idea, in some cases, it is like a smoker who decides to keep smoking. As long as there is a supplier, they will do it and they vary in the degrees of how hard they will seek it. It helps if you have great marketing too as a respected provider in the community lol. I do tell them, they need to be on board with an evidence based plan of some sort or randomdoc1 will not continue to work with them because we only practice high quality evidence based care here. If you're around something with a strong reputation, it enhances your clout. I also tell them, wouldn't it be nice to have one less prescription on their med list?! Especially one that has so many adverse long term possibilities? I draw the line very much like below.

Reduce by 2 pills a month? Did I read that right? So if they are on 30 per mos you go to 28? I think you may be onto something. That’s a slowness of pace most people will hardly notice, but it’s still progress.

I’ve had people who in good faith try to taper after decades and they get horrible withdrawal even with the smallest dose change you can achieve, but maybe the issue is I’ve been doing a dose per day reduction as opposed to a pills per month plan.

Yes, I call it, the micro taper. I tell patients, I'm pretty confident they can miss 0.5mg clonazepam once out of that month. And they will progressively start to see improvements. That I have yet to see a patient, once fully tapered, yet to complain and say they were soooooo much better on those benzos. They do build momentum, confidence and get that positive reinforcement. I have yet to see the pills per month plan fail. And I say hey, progress is progress, you are exposing yourself to less risk. Then I start to introduce the evidence based therapies and other modalities.

 

[Stagg737]

I will always try and taper older patients off or at the very least to the lowest dose we can. Sometimes total discontinuation is not possible, but minimizing the dose is always a good thing. Other things to consider:

1. If they've been on a dose for decades, they may actually have higher serum levels d/t metabolic changes as they age. My patients typically either haven't understood or appreciated this, but all the more reason to decrease doses if possible.

2. Old people are on lots of meds which are often times adjusted frequently. Were other med changes made that change the metabolism or serum level of the benzo? There may be an inadvertent increase in the amount that's in their system without any actual change in dosing. ETA: My point here is that having the benzo on board can be responsible for a fall/fall risk if the amount in their system is unintentionally increased.

3. Most patients don't like taking a bunch of pills. Probably the most effective reasoning I use when trying to taper anything is just pointing out how many pills they're taking and asking, "You're taking XXX pills every day, wouldn't it be nice to not have to take so many?" It's amazing how quickly some resistant people will buy in when you put it in that context, especially patients who have to take them 2-3x per day.

I strongly disagree with giving a patient something that will harm them. I don't think informed consent is ethically relevant in such cases.

By this logic you shouldn't be prescribing patients any psych meds at all. All our meds carry a fairly significant risk of side effects, I think the only field where risk vs benefit is as prevalent of a factor in prescribing practices is palliative care, for obvious reasons.

Once you talk about falls in the over 70 set almost everyone knows somebody who broke a hip and had a catastrophic outcome. I end up doing a lot more validating anger expressed at previous prescribers who they feel did not warn them adequately about risks than needing to push people to taper.

Same. It's sometimes shocking to me to hear patients tell me what they weren't informed of before a med was started, and more often than not they're appreciative that I'm having a more global discussion regarding their meds. I also discuss the possible increased risk of permanent neurocognitive impairments with chronic benzo use (yes, I'm aware of the mixed data and inform patients of that), but for some patients that is enough for them to want to get off of them.

 

[the5thelement]

Agree with Splik. Always discuss risks vs benefits and use sound clinical judgement . Like the surgeons scalpel, benzodiazepines are also a tool which can relieve suffering if used correctly.

 

[TheRightMedication]

I believe that treating anxiety with benzodiazepine when an elderly patient is falling does more harm than good. I do not, then, leave the choice to them by informed consent.

I appreciate many will differ in the risk / benefit assessment, I only mean to clarify my above statement.

 

[Stagg737]

I believe that treating anxiety with benzodiazepine when an elderly patient is falling does more harm than good. I do not, then, leave the choice to them by informed consent.

I appreciate many will differ in the risk / benefit assessment, I only mean to clarify my above statement.

I don't think that's a totally unreasonable position, but what if the patient's anxiety without the benzo is severe enough that they don't wish to live like that and they become agoraphobic or suicidal? Imo, there are some situations regarding QoL with truly severe chronic anxiety that create a worse risk than an elderly person falling.

 

[Candidate2017]

I don't expect patients on long term benzos to readily agree to tapering off. Benzos feel good and it's human nature to want to continue something that feels good, even if it is harmful.

I have to accept I am part of the problem because I am a source of benzos. How can I, someone who possesses a controlled substance license, be expected to convince people who love controlled substances, that they shouldn't be taking them?

I don't expect a barkeep to effectively convince customers, who came for alcohol, to willingly give up alcohol when the barkeep has alcohol on the formulary. The only way the barkeep can prevent bargoers from demanding and expecting alcohol is to close down the bar. So, I close the bar. With a fixed, scheduled taper of course.

 

[Candidate2017]

Agree with Splik. Always discuss risks vs benefits and use sound clinical judgement . Like the surgeons scalpel, benzodiazepines are also a tool which can relieve suffering if used correctly.

Well, surgeons think a lot harder before deciding whether to cut a patient, reject more candidates for the scalpel than they accept, and there is a finite number of times they will use the scalpel on a patient before they say, "I'm sorry, I've done all I can and have nothing more to offer." But many psychiatrists and PCPs are ok with reflexively doling out benzos like candy for "my anxiety", indefinitely.

The difference between a surgeon and a bad psychiatrist is the surgeon is able to tolerate their own distress and handle the responsibility of inflicting physical and psychic pain upon a patient in the hope of improving the patient's life, as well as being able to tolerate the nontrivial chance of significant adverse effects, up to and including death.

These anxiety patients on long term benzos are not end stage cancer patients for which alleviating suffering is the primary goal. The primary goal is to restore to function and evoke meaningful change and growth, which is always painful. Some medical interventions are painful, but all psychotherapeutic interventions are necessarily painful. We cannot expect nor accompany our patients on the path to change if we cannot endure our distress over their distress.

 

[randomdoc1]

I don't think that's a totally unreasonable position, but what if the patient's anxiety without the benzo is severe enough that they don't wish to live like that and they become agoraphobic or suicidal? Imo, there are some situations regarding QoL with truly severe chronic anxiety that create a worse risk than an elderly person falling.

Are you referencing that patient from Catalonia?

 

[TheRightMedication]

I don't think that's a totally unreasonable position, but what if the patient's anxiety without the benzo is severe enough that they don't wish to live like that and they become agoraphobic or suicidal? Imo, there are some situations regarding QoL with truly severe chronic anxiety that create a worse risk than an elderly person falling.

You're right to point out there can't be absolutes, and there is probably some scenario where the risk of decomposition outweighs the risk of falls.

Even so its hard to imagine a scenario where I don't tell the patient I will begin tapering off benzos while we treat anxiety with a variety of other means, and if you think you'll die go to the ED.

As I say this I imagine the sort of frail patient that the OP described. There's a lot of grey area there with people who aren't as vulnerable to falls and other risks.

Candidate2017 speaks very well to the question of whether we are healing people with benzos in the first place, a discussion I'd love to have and may warrant it's own thread.

 

[Merovinge]

Well, surgeons think a lot harder before deciding whether to cut a patient, reject more candidates for the scalpel than they accept, and there is a finite number of times they will use the scalpel on a patient before they say, "I'm sorry, I've done all I can and have nothing more to offer." But many psychiatrists and PCPs are ok with reflexively doling out benzos like candy for "my anxiety", indefinitely.

The difference between a surgeon and a bad psychiatrist is the surgeon is able to tolerate their own distress and handle the responsibility of inflicting physical and psychic pain upon a patient in the hope of improving the patient's life, as well as being able to tolerate the nontrivial chance of significant adverse effects, up to and including death.

These anxiety patients on long term benzos are not end stage cancer patients for which alleviating suffering is the primary goal. The primary goal is to restore to function and evoke meaningful change and growth, which is always painful. Some medical interventions are painful, but all psychotherapeutic interventions are necessarily painful. We cannot expect nor accompany our patients on the path to change if we cannot endure our distress over their distress.

That's really well written, my SO is a surgeon and I don't think I could have said the difference better myself. I see her struggle with ensuring that distress and accepting the responsibility, but she does so with conscious thought, as opposed to the click refill on Xanax TID next approach I have seen from many PCPs over the years.

 

[ObsequiousAplomb]

That's really well written, my SO is a surgeon and I don't think I could have said the difference better myself. I see her struggle with ensuring that distress and accepting the responsibility, but she does so with conscious thought, as opposed to the click refill on Xanax TID next approach I have seen from many PCPs over the years.

I think they were making a fine point. There are, however, many psychiatrists who consider benzodiazepines the way the surgeon was described. Everyone who has been "anti-anti-benzodiazepine" in this thread describes a long and thorough assessment. There are also many hack surgeons who operate on everyone who sees them for a consultation and they continue to offer operations until the patient seeks care elsewhere or dies.

 

[G Sheb]

Well, surgeons think a lot harder before deciding whether to cut a patient, reject more candidates for the scalpel than they accept, and there is a finite number of times they will use the scalpel on a patient before they say, "I'm sorry, I've done all I can and have nothing more to offer." But many psychiatrists and PCPs are ok with reflexively doling out benzos like candy for "my anxiety", indefinitely.

The difference between a surgeon and a bad psychiatrist is the surgeon is able to tolerate their own distress and handle the responsibility of inflicting physical and psychic pain upon a patient in the hope of improving the patient's life, as well as being able to tolerate the nontrivial chance of significant adverse effects, up to and including death.

These anxiety patients on long term benzos are not end stage cancer patients for which alleviating suffering is the primary goal. The primary goal is to restore to function and evoke meaningful change and growth, which is always painful. Some medical interventions are painful, but all psychotherapeutic interventions are necessarily painful. We cannot expect nor accompany our patients on the path to change if we cannot endure our distress over their distress.

Not really. Who makes us the arbiter of 'restoring function, meaningful change and growth'?
It's the patient who decides what is function, what is meaningful change and growth.
You don't have to go along if you disagree with what the patient wants, but I really take issue with this sort of normative approach to something inherently subjective. Our obligation is to provide ethical care, keeping the patient's interests front and center, not to decide what is good for them.

On this topic, I fully agree that if an elderly person has been on long term benzos you weigh the pros and the cons of a taper and whether they are on board or not. I am not sure closing shop and telling them to find someone else is the right thing to do.

 

[Merovinge]

Not really. Who makes us the arbiter of 'restoring function, meaningful change and growth'?
It's the patient who decides what is function, what is meaningful change and growth.
You don't have to go along if you disagree with what the patient wants, but I really take issue with this sort of normative approach to something inherently subjective. Our obligation is to provide ethical care, keeping the patient's interests front and center, not to decide what is good for them.

Us as the highly trained professional? We deal with so many illnesses that cloud insight (psychosis, mania, severe depression, severe OCD, severe social anxiety d/o, eating disorders, addiction, etc), that it is of utmost importance for psychiatrists to understand how to promote functional status and tailor that to the individual culture and personal goals but not entirely warp that to the personal goals. I have patient's who's goals are to be at a BMI of 16 or to remain manic, I absolutely am only working towards what will restore them to optimal functioning as best I can. That is ethical care.

 

[samac]

I really appreciate this thread. It helps my perspective. I know there’s patients I’ll never get off benzos, and I accept that as long as they continue to listen to me discuss the risks. My biggest problems are I inherited so many geriatric patients that get benzos from us and chronic opioids from a pain doctor. I’m talking Klonopin 2-3mg QID to Hydrocodone 10mg TID. Anyone have a good way on how to be firm about coming down on the dose? Of course I want to do it slowly, but continuing that is not something I’m willing to do.

And what do you all do when you inherit someone who’s 30 begging to go up on the benzos they’ve been taking for a year? This has also been a common problem I’m running into and I in good conscious will not go up on them, they’ve got to try other avenues (therapy, SSRIs, Buspar).

 

[G Sheb]

Us as the highly trained professional? We deal with so many illnesses that cloud insight (psychosis, mania, severe depression, severe OCD, severe social anxiety d/o, eating disorders, addiction, etc), that it is of utmost importance for psychiatrists to understand how to promote functional status and tailor that to the individual culture and personal goals but not entirely warp that to the personal goals. I have patient's who's goals are to be at a BMI of 16 or to remain manic, I absolutely am only working towards what will restore them to optimal functioning as best I can. That is ethical care.

Trained professionals in the technical aspects of medicine to improve suffering (that's pretty much the whole point of medicine), not to be moral and spiritual arbiters of 'growth, change and function'.
I've seen this sort of paternalistic and normative attitude especially among psychodynamic therapists and I entirely disagree. its history in psychiatry is particularly toxic and nefarious. Most of the time it just means imposing normative cultural values on those who digress, and it's been especially harmful towards minorities of all kinds.
Obviously when someone is either a risk to self or others, it's when we intervene against the will of the patient for treatment. But I don't treat hypomania or psychosis because I think it's impeding their 'growth and change'.

 

[Crayola227]

Us as the highly trained professional? We deal with so many illnesses that cloud insight (psychosis, mania, severe depression, severe OCD, severe social anxiety d/o, eating disorders, addiction, etc), that it is of utmost importance for psychiatrists to understand how to promote functional status and tailor that to the individual culture and personal goals but not entirely warp that to the personal goals. I have patient's who's goals are to be at a BMI of 16 or to remain manic, I absolutely am only working towards what will restore them to optimal functioning as best I can. That is ethical care.

This is fair, but you are citing instances where the ability to have informed consent is impaired by impaired insight. While this *may* occur in older patients on benzos with anxiety, it also is not actually a given like it likely is in say, severe psychosis, where the definition of the condition itself makes it highly likely this insight is impaired and the patient may not be able to make these decisions (lacks capacity). Meaning, the simple fact of being an older person with anxiety on benzos at risk of falls/falling yet after considering risk/benefit wants to continue is not itself proof that the patient is unable to make a risk/benefit analysis for themselves anymore. It doesn't go without saying.

The point is, that you are not wrong, but neither was the other poster. It really depends on the patient, their condition, insight, and ability to make informed decisions (capacity).

 

[birchswing]

Us as the highly trained professional? We deal with so many illnesses that cloud insight (psychosis, mania, severe depression, severe OCD, severe social anxiety d/o, eating disorders, addiction, etc), that it is of utmost importance for psychiatrists to understand how to promote functional status and tailor that to the individual culture and personal goals but not entirely warp that to the personal goals. I have patient's who's goals are to be at a BMI of 16 or to remain manic, I absolutely am only working towards what will restore them to optimal functioning as best I can. That is ethical care.

<Not a doctor or medical student>

Functional status to what end?

It reminds me of the lifesaving medical care given to a prisoner with a suicide attempt right before being executed.

That's why I was curious how old the OP's patient is.

If you sit down with them and say, for example, you probably have about five years left. What do you want to do between now and dead? This is the best estimate I can give you as to whether these benzos are causing your memory lapses and falls. This is what withdrawal will likely be like, but we can't know until we try. What do you want to do?

The context of being functional is that we have very short lives--all of us. I could understand on the younger side being more assertive. But I think being ethical has to take a a very holistic view. I mean do you want a 90 year old to be more functional, for what? So they're in top military fighting shape? Functional for them might mean having nice moments with their families. I suppose that what it means for everyone. But at that age if you have few years left and don't want to be going through withdrawal with unclear benefit regarding falls and memory, maybe you go for as good as it gets. If you're younger and have a lot of years on the other side, the equation changes.

 

[Crayola227]

Trained professionals in the technical aspects of medicine to improve suffering (that's pretty much the whole point of medicine), not to be moral and spiritual arbiters of 'growth, change and function'.
I've seen this sort of paternalistic and normative attitude especially among psychodynamic therapists and I entirely disagree. its history in psychiatry is particularly toxic and nefarious. Most of the time it just means imposing normative cultural values on those who digress, and it's been especially harmful towards minorities of all kinds.
Obviously when someone is either a risk to self or others, it's when we intervene against the will of the patient for treatment. But I don't treat hypomania or psychosis because I think it's impeding their 'growth and change'.

Exactly, and this kind of thinking, where a physician substitutes *their* judgement of an appropriate QOL risk/benefit, I've seen it lead to what I consider some pretty disgusting unethical decisions.

Frequently I saw people I worked with in the hospital essentially declare that because someone is bed-bound and then with all the problems that goes along with that, that their life isn't worth living anymore and we should try to de-escalate care somehow just to save money and because there is no good reason to try to delay the inevitable. But this is in spite of a patient with capacity who can articulate that yes, they want the dialysis or the next course of antibiotics, that they still enjoy eating ice cream or playing video games or simply sitting with their family. And they understand the risks and the potential for discomfort, but they are willing to endure for the chance to extend their life.

And I remember telling these people, that if I was in a Christopher Reeves type situation (quad) or like ALS, that I would tolerate an enormous amount of suffering to extend my life every minute if I could still watch Star Trek or communicate in any way with my loved ones. I was actually shocked by how many physicians declared that even just being relegated to a wheelchair (unable to walk) they would no longer want to live anymore. (Which, spoken like a young able bodied person who has never had to contend with disability, but I digress. And given who they were saying this to, the height of insensitivity).

My main issue with their opinion being, that they would wish to substitute THAT judgement, they would want to impose medical decisions and override the will of say someone such as myself, who has a different idea of acceptable QOL. We don't get to decide how much suffering patients wish to endure in order to live. We don't judge the value of their life and its continuance (speaking for adults with capacity who have expressed wanting to live at high/any cost). Putting stewardship of resources/etc aside for the moment.

This is an extreme example (but not in the least uncommon I've found) of physician judgement being substituted for that of the patient.

But it happens easily enough when I think it is clear it should not. So I think even more caution is needed in cases where it is not so clear-cut.

It may seem silly to say, well, palliative is different than not-palliative care. But we used to make the same arguments for trying to make people die "sober" of horrific cancers. But why must someone be dying before we say to hell with extending their life, let's make them comfortable?

For the patient that isn't going to die, I think we would be wise to be sure that we are not putting extension of life so above and beyond QOL that we miss that point as well.

Some people will never live/function well "sober" or not on drugs, however that comes to be. Certainly in our distant past as hunter gatherers they may have found a way. But that is no longer the reality we find ourselves in. So yes, I am talking a bit about harm reduction as a model.

We imagine these people can live without drugs, and live better. But at what point is it just that, something we imagine that will never actually be?

These are the things we grapple with, because intrinsically the practice of psychiatry is NOT the practice of surgery.

In any case, paternalism and sweeping judgements about QOL and function doesn't serve the patient. Yes, nor should the physician be made to serve as a drug dealer or forced to shorten people's lives in every case a patient wants that, there are ethics regarding what is fair to make a physician do. But on the balance I don't believe it is about what we think best, our licenses, etc.

 

[G Sheb]

Exactly, and this kind of thinking, where a physician substitutes *their* judgement of an appropriate QOL risk/benefit, I've seen it lead to what I consider some pretty disgusting unethical decisions.

Frequently I saw people I worked with in the hospital essentially declare that because someone is bed-bound and then with all the problems that goes along with that, that their life isn't worth living anymore and we should try to de-escalate care somehow just to save money and because there is no good reason to try to delay the inevitable. But this is in spite of a patient with capacity who can articulate that yes, they want the dialysis or the next course of antibiotics, that they still enjoy eating ice cream or playing video games or simply sitting with their family. And they understand the risks and the potential for discomfort, but they are willing to endure for the chance to extend their life.

And I remember telling these people, that if I was in a Christopher Reeves type situation (quad) or like ALS, that I would tolerate an enormous amount of suffering to extend my life every minute if I could still watch Star Trek or communicate in any way with my loved ones. I was actually shocked by how many physicians declared that even just being relegated to a wheelchair (unable to walk) they would no longer want to live anymore. (Which, spoken like a young able bodied person who has never had to contend with disability, but I digress. And given who they were saying this to, the height of insensitivity).

My main issue with their opinion being, that they would wish to substitute THAT judgement, they would want to impose medical decisions and override the will of say someone such as myself, who has a different idea of acceptable QOL. We don't get to decide how much suffering patients wish to endure in order to live. We don't judge the value of their life and its continuance (speaking for adults with capacity who have expressed wanting to live at high/any cost). Putting stewardship of resources/etc aside for the moment.

This is an extreme example (but not in the least uncommon I've found) of physician judgement being substituted for that of the patient.

But it happens easily enough when I think it is clear it should not. So I think even more caution is needed in cases where it is not so clear-cut.

It may seem silly to say, well, palliative is different than not-palliative care. But we used to make the same arguments for trying to make people die "sober" of horrific cancers. But why must someone be dying before we say to hell with extending their life, let's make them comfortable?

For the patient that isn't going to die, I think we would be wise to be sure that we are not putting extension of life so above and beyond QOL that we miss that point as well.

Some people will never live/function well "sober" or not on drugs, however that comes to be. Certainly in our distant past as hunter gatherers they may have found a way. But that is no longer the reality we find ourselves in. So yes, I am talking a bit about harm reduction as a model.

We imagine these people can live without drugs, and live better. But at what point is it just that, something we imagine that will never actually be?

These are the things we grapple with, because intrinsically the practice of psychiatry is NOT the practice of surgery.

In any case, paternalism and sweeping judgements about QOL and function doesn't serve the patient. Yes, nor should the physician be made to serve as a drug dealer or forced to shorten people's lives in every case a patient wants that, there are ethics regarding what is fair to make a physician do. But on the balance I don't believe it is about what we think best, our licenses, etc.

Your example is extreme but I’ve also seen these things plays out in more subtle but very harmful ways. Sometimes it’s an older psychiatrist or therapist whose cultural/normative values aren’t in tune with todays social standards. For example, assuming that everyone wants to be in a 9-5 job, otherwise something is wrong with you.
Or that casual sexual relationships are harmful.
Or that everyone needs to be in a relationship to be fulfilled. Or that they need to get married and have kids.
This also applies to SMI. I don’t think I’m in a position to tell someone that their psychosis or hypomania needs changing. Many patients are at their most productive and creative when they are hypomanic. Of course there usually is a flip side (like depression) that they want to change, and this we can work on.

Historically these sort of paternalistic attitudes about normality are reasons why psychiatry has a terrible history with women and lgbt. Few people know that up until the early 90s lgbt individual were refused access to psychoanalytic training programs. Traditional psychoanalysts are very guilty of this but I think this seeps into medicine as a whole.

We would all be better if psychiatrists come in with open minds to these encounters and admit the inherent subjectivity of what we’re dealing with. I don’t think we go a good enough job in medicine to delineate simple concepts like the difference between disease and illness or the centrality of patient suffering to medicine, and I think this is especially true in psychiatry.

 

[ObsequiousAplomb]

Antipsychotic use in elderly patients is more robustly associated with hastening of death than benzodiazepines. Do the people who see benzodiazepine use in the elderly as so abhorrent that they will never prescribe it to people who have been stable with it for 30 years also taper all elderly people off of their antipsychotics due to the putative risks?

 

[TheRightMedication]

Antipsychotic use in elderly patients is more robustly associated with hastening of death than benzodiazepines. Do the people who see benzodiazepine use in the elderly as so abhorrent that they will never prescribe it to people who have been stable with it for 30 years also taper all elderly people off of their antipsychotics due to the putative risks?

I think your point is worth considering, but I have one critique. The natural history of GAD is not comparable to the natural history of bipolar disorder or schizophrenia, so the benzo / antipsychotic comparison is as apples / oranges.

Unless of course you mean the use of antipsychotics for treating anxiety in which case I answer, yes.

 

[TheRightMedication]

Also, regarding the criticism of paternalism - I do reserve the right to insist my patients get thier psyches in good order rather than confront problems in living with sedatives. Not claiming the moral high ground here, but that's the service I offer.

 

[ObsequiousAplomb]

I think your point is worth considering, but I have one critique. The natural history of GAD is not comparable to the natural history of bipolar disorder or schizophrenia, so the benzo / antipsychotic comparison is as apples / oranges.

Unless of course you mean the use of antipsychotics for treating anxiety in which case I answer, yes.

I specifically bolded all to apply to antipsychotics, they way all benzodiazepines are being considered upthread, regardless of indications. It's worth remembering that a large portion of patients who benefited from antipsychotics from age 20-55 don't need an antipsychotic after age 55, since you're talking about natural histories.

 

[TheRightMedication]

I specifically bolded all to apply to antipsychotics, they way all benzodiazepines are being considered upthread, regardless of indications. It's worth remembering that a large portion of patients who benefited from antipsychotics from age 20-55 don't need an antipsychotic after age 55, since you're talking about natural histories.

It's a bold argument you make.

The indication does matter, of course. If you'll grant that I don't demand catatonic patients come off their benzos immediately, I'm not sure there's a good indication left after GAD. We're left, then, with the important distinctions to be found in antipsychotic indication, which I stand by as above.

Edit - I've bolded the word "good," I'm not unteachable.

 

[smalltownpsych]

I think the problem with an over-reliance on all medications happens way before the patient gets to be elderly. This is both a societal problem and a problem in our field. I have found that level of stress coupled with resilience or vulnerability correlates with symptoms more closely than medications. It can be difficult to see that in either outpatient or brief inpatient stays because we can’t control the variables that lead to stress, but in a long term residential program that can titrate exposure to the world, the effects of environmental stressors becomes crystal clear. Not saying that medications aren’t an essential tool, but too often they are the only tool and even when we add in a weekly visit with someone like myself, it’s not sufficient to prevent a worsening course for the more vulnerable, fragile, or severe. I also think that the paternalistic model plays a role in this as well. Hence some of my tendency to disagree with the harsh stance although that is often appropriate and works better when there is a viable alternative.

 

[tr]

Antipsychotic use in elderly patients is more robustly associated with hastening of death than benzodiazepines. Do the people who see benzodiazepine use in the elderly as so abhorrent that they will never prescribe it to people who have been stable with it for 30 years also taper all elderly people off of their antipsychotics due to the putative risks?

Yes, elderly people without psychotic disorders should not be prescribed antipsychotics. Schlogging elderly people with Seroquel to keep them from making annoying demands of care staff is a travesty.

If you're talking about someone who needs the antipsychotic to control a chronic psychotic disorder, this is not comparable to benzodiazepines because antipsychotics are effective (to greater or lesser degrees) for psychosis, while chronic use of benzodiazepines is generally not effective for anything other than prevention of benzodiazepine withdrawal, so it's a totally different risk/benefit ratio.

 

[clausewitz2]

Unfortunately if you propose to eliminate all moral and value judgements from psychiatry, we discard all of the personality disorders straight out of the gate and very quickly run into problems with a plurality of other conditions as defined in the DSM.

Mental healthcare cannot define what it treats by aberrant values in lab tests or imaging. It can only treat what it defines as aberrant based on some comparison with an idea of what is or should be normative for people in a specific society at a specific time. You don't get to escape value judgements if you are diagnosing people with psychiatric disorders, for better or for worse.

 

[G Sheb]

Unfortunately if you propose to eliminate all moral and value judgements from psychiatry, we discard all of the personality disorders straight out of the gate and very quickly run into problems with a plurality of other conditions as defined in the DSM.

Mental healthcare cannot define what it treats by aberrant values in lab tests or imaging. It can only treat what it defines as aberrant based on some comparison with an idea of what is or should be normative for people in a specific society at a specific time. You don't get to escape value judgements if you are diagnosing people with psychiatric disorders, for better or for worse.

I don't think there is any field in medicine that is defined by treating aberrant values in lab tests or imaging. There is always a value judgement; a value judgement of the suffering patient.
The only exception is when there's a risk to self or others.

 

[clausewitz2]

I don't think there is any field in medicine that is defined by treating aberrant values in lab tests or imaging. There is always a value judgement; a value judgement of the suffering patient.
The only exception is when there's a risk to self or others.

Oh the rest of medicine definitely doesn't escape this issue entirely. However, we cannot define our disorders without using shoulds about human behaviors and experiences based on some idea of the normative, flourishing person, rather than some qualitatively abnormal finding not primarily dependent on someone's verbal report.

 

[randomdoc1]

I think the problem with an over-reliance on all medications happens way before the patient gets to be elderly. This is both a societal problem and a problem in our field. I have found that level of stress coupled with resilience or vulnerability correlates with symptoms more closely than medications. It can be difficult to see that in either outpatient or brief inpatient stays because we can’t control the variables that lead to stress, but in a long term residential program that can titrate exposure to the world, the effects of environmental stressors becomes crystal clear.

yup, very much this. I have found that when I have a longer "med management" visit, the psychotherapy although brief is a tremendous help in history gathering and improving patient insight and involvement in their treatment planning. I tell people, often they are pleasantly surprised to see how simple their regimen can be. And what can be more empowering than that?! Versus not taking ownership or a more active role, you are allowing yourself to be a prisoner and putting yourself at the mercy of what little medications can do in many circumstances. Although, I think some people get a need met maladaptively by staying in the patient role (and sometimes the caregiver from the attention and/or want to quiet down the patient) and we start to broach that delicate topic of, why they want to stay in that position and how to have healthier, more fulfilling life experiences. Because the truth is, they can say what they want and try to believe what they want, but their actions show they still feel miserable. They are free to try to force medications on a non-medication issue, much like trying to force a square peg into a round hole, but the outcome will not be any more favorable just because they force it harder. That's where the therapeutic alliance is such a must. Patients do seem to get a better grasp when you explain the pharmacology in ways they can digest and that the medications are designed to treat disease processes, not wipe away symptoms. When there is a symptom, like any good healthcare provider, one must try to identify the underlying cause and treat said cause.

 

[Evidence Based]

I really appreciate this thread. It helps my perspective. I know there’s patients I’ll never get off benzos, and I accept that as long as they continue to listen to me discuss the risks. My biggest problems are I inherited so many geriatric patients that get benzos from us and chronic opioids from a pain doctor. I’m talking Klonopin 2-3mg QID to Hydrocodone 10mg TID. Anyone have a good way on how to be firm about coming down on the dose? Of course I want to do it slowly, but continuing that is not something I’m willing to do.

And what do you all do when you inherit someone who’s 30 begging to go up on the benzos they’ve been taking for a year? This has also been a common problem I’m running into and I in good conscious will not go up on them, they’ve got to try other avenues (therapy, SSRIs, Buspar).

This is a great question that I think got lost a bit in the discussion. Wondering what your context is (PCP office, psych, etc)?

For the Benzos + opioids question, especially for full agonists like hydrocodone or if people are using street fentanyl, I try to be kind but firm that this regimen is associated with a higher risk of mortality, especially through accidental overdose. Not because I think they're misusing either medication, but as an elderly person with crappy drug clearance it wouldn't take a lot to get a little sick, add another unrelated med, or do something else that changes drug clearance to increase OD risk even if their dose of opioids/benzos is unchanged. The doses you describe are pretty eye popping (12mg TDD of clonazepam is a lot!!), especially in someone who's elderly.

For a younger person requesting to go up on their benzo, I guess it would depend a little bit on their dose (ex. is this someone on 0.25mg BID or 1 TID already), but in general I would ask what would make this dose change different, and what would stop us from having the same conversation again in 6 months? This gives space to talk about habituation/tolerance, other interventions to improve anxiety, etc. This would also be a good time to assess trauma if you haven't already, because although it happens all the time benzos are well known to interfere with effective PTSD treatment. Sometimes you can get buy in from someone about not sabotaging their trauma recovery if this is important to them.

At the end of the day though, I feel like the answer is just that sometimes you have to say no. It's not particularly fun, but I find that if it's truly done with the patient's best interests in mind and explained as such (rather than hiding behind the DEA or medical board), it often doesn't go as bad as you would expect.

 

[ObsequiousAplomb]

Yes, elderly people without psychotic disorders should not be prescribed antipsychotics. Schlogging elderly people with Seroquel to keep them from making annoying demands of care staff is a travesty.

If you're talking about someone who needs the antipsychotic to control a chronic psychotic disorder, this is not comparable to benzodiazepines because antipsychotics are effective (to greater or lesser degrees) for psychosis, while chronic use of benzodiazepines is generally not effective for anything other than prevention of benzodiazepine withdrawal, so it's a totally different risk/benefit ratio.

I agree and do not prescribe antipsychotics to non-psychotic elderly patients. Even those who are psychotic due to a delirium I try to avoid antipsychotics as much as possible. I usually see people switching Valium 5 mg to Seroquel 50 mg for elderly patients with GAD, and I think that's ridiculous. I see a great deal of antipsychotics used for delirium and behavioral disturbances of dementia without prior trials of SSRIs or behavioral management. I think that both of those actions are worse than continuing the Valium 5 mg someone has been taking for 30+ years.

Many people with schizophrenia who may have been actively, floridly psychotic during periods of time without antipsychotics from age 20 to 60 do not require antipsychotics in their elderly years. You're skipping over that part of what I said. I don't at all believe that people with schizophrenia deserve to have their antipsychotics stopped at age 60. I do think there's a parallel with tapering off the benzodiazepines for 70+ year old people with GAD and attempting to lower/taper/discontinue the antipsychotics in persons with schizophrenia when they reach that same age. In general, I would be more inclined to taper off the benzodiazepine. There are, however, people in both groups who will severely decompensate and suffer from an heuristic of always tapering off a medication class in certain demographics. The people who seem to be ignoring this aspect of these arguments in this thread seem to be conflating mild, everyday anxieties with the severely crippling anxieties mentioned by those making similar arguments to mine. Clearly I'm aware of chronic severe schizophrenia and the benefits/risks of antipsychotics. Antipsychotics are, in my experience, much more readily given to elderly patients for poor indications than benzodiazepines.

 

[Merovinge]

Your example is extreme but I’ve also seen these things plays out in more subtle but very harmful ways. Sometimes it’s an older psychiatrist or therapist whose cultural/normative values aren’t in tune with todays social standards. For example, assuming that everyone wants to be in a 9-5 job, otherwise something is wrong with you.
Or that casual sexual relationships are harmful.
Or that everyone needs to be in a relationship to be fulfilled. Or that they need to get married and have kids.
This also applies to SMI. I don’t think I’m in a position to tell someone that their psychosis or hypomania needs changing. Many patients are at their most productive and creative when they are hypomanic. Of course there usually is a flip side (like depression) that they want to change, and this we can work on.

Historically these sort of paternalistic attitudes about normality are reasons why psychiatry has a terrible history with women and lgbt. Few people know that up until the early 90s lgbt individual were refused access to psychoanalytic training programs. Traditional psychoanalysts are very guilty of this but I think this seeps into medicine as a whole.

We would all be better if psychiatrists come in with open minds to these encounters and admit the inherent subjectivity of what we’re dealing with. I don’t think we go a good enough job in medicine to delineate simple concepts like the difference between disease and illness or the centrality of patient suffering to medicine, and I think this is especially true in psychiatry.

Jobs, sex, relationship, marriage, kids, absolutely 100% yes, I agree it is garbage care to use your values and impose them on patients.

Not wanting to treat hypomania though I strongly disagree with. I don't care if they are at their most productive when hypomanic, there are such significant risks of conversion to full mania and depressive/mixed episodes along with suicide/OD risks that it significantly bothers me that there are psychiatrists who would not even discuss treatment if a patient wants to remain this way. Sure, you can't certify someone in this state, but you absolutely can have the discussion before, during, and after the episode about rationale for treatment and have boundaries around staying under your care.

The above example is exactly the risk of swinging the pendulum way too far in the other direction to not wanting to be paternalistic. All of medicine requires some paternalism to have the tough conversations and tell people things they don't want to hear. The newer generation of doctors (of which I am one) that shy away from this to maximize their google rating and not be paternalistic is doing a real disservice to patients and the profession of the physician.

 

[G Sheb]

Oh the rest of medicine definitely doesn't escape this issue entirely. However, we cannot define our disorders without using shoulds about human behaviors and experiences based on some idea of the normative, flourishing person, rather than some qualitatively abnormal finding not primarily dependent on someone's verbal report.

Not sure if 'defining' is the issue here.
We define hypertension based on whatever measurement we get (or other criteria..etc), but we aren't treating people for hypertension because they deviate from that measurement. We're treating them because we do not want them to have strokes and suffer. Ultimately, the experience of suffering (i.e illness) is the arbiter of medicine, and it's the patient's subjective experience, not ours. It's the critical difference between disease and illness. Disease is a practical, scientific way of looking at biological function but its ultimate goal is to treat illness (which is inherently subjective). It's the same concept in psychiatry. I do not treat psychiatric illness because I think something needs fixing and it deviates from normal. I treat it because the patient is coming with an experience of suffering and they need and request help with this.

Now it's true, you bring a good point with personality disorders, but just because we do things one way (whoever sat on those DSM meetings really), it doesn't mean it's the right way. I mentioned classical psychoanalysis and it was the mainstream of psychiatry for a few decades, and its history is terrible, basically because they tried to pathologize everything that deviates from social norms.
We run the risk of doing the same thing whenever "a flourishing person" is the standard. This means so many different things in many different settings.

Since then, we moved into concepts of distress which are most certainly more patient-centered, and personality disorders themselves don't have a shortage of critics.

 

[G Sheb]

Jobs, sex, relationship, marriage, kids, absolutely 100% yes, I agree it is garbage care to use your values and impose them on patients.

Not wanting to treat hypomania though I strongly disagree with. I don't care if they are at their most productive when hypomanic, there are such significant risks of conversion to full mania and depressive/mixed episodes along with suicide/OD risks that it significantly bothers me that there are psychiatrists who would not even discuss treatment if a patient wants to remain this way. Sure, you can't certify someone in this state, but you absolutely can have the discussion before, during, and after the episode about rationale for treatment and have boundaries around staying under your care.

The above example is exactly the risk of swinging the pendulum way too far in the other direction to not wanting to be paternalistic. All of medicine requires some paternalism to have the tough conversations and tell people things they don't want to hear. The newer generation of doctors (of which I am one) that shy away from this to maximize their google rating and not be paternalistic is doing a real disservice to patients and the profession of the physician.

I think we're talking about different things here. We're not disagreeing.