Speaking of benzos I have tapered over 50 long term benzo users at my SMI clinic. My caseload is 100% benzo free
When I did private practice, less than 5% of my patients were on benzos. There were only three types patients I had on benzos over a month that I could think of off the top of my head.
1-Panic disorder-
I've never had 1 panic disorder patient that got completely controlled with SSRIs at maximum dosage. What almost always happened was by the 2nd or 3rd SSRI their panic attacks went from a few times a day to a few times a week, then added Buspirone at max dosage which then decreased it to a few times a month, then maybe add a B-blocker which further curbed it down but they still happened a few times a month.
Those patients got Ativan 1-2 mg pills, as many times as they had panic attacks a month plus 1-2 to keep in their pocket and pop in their mouth if they felt a panic attack coming on.
So, these patients only got a few pills a month. If they were found not to be abusing them after a few months I just gave them 30 and told them this was to last them a few months.
Yes I did tell these patients to do CBT. Most of them told me they didn't have the time, but they were not abusing the benzos.
2-Really bad anxiety and nothing's working or they're already on a heck of a lot of stuff and still have bad anxiety. These were only a few patients out of literally hundreds I had. I've had a few outilers where no SSRI, SNRI, or TCA I tried on them worked. Then I went to Gabapentin, B-blockers, etc and sometimes those worked, but if then nothing else did then I told them I was open to a benzo but I still didn't like it.
Seriously, I think maybe cannabis would be better for these patients but it's not legal (at least in most states as of now).
I did learn something being a young attending in private practice that I didn't learn in residency. I actually did have quite a few people whose anxiety was well controlled with gabapentin. It was tried out of desperation after the conventional meds didn't work, and then wow, some of these patients it worked very very well.
3-Some idiot doctor put them on a high amount of benzos and they've been on them for months to even decades so now I had to be the guy to get them off of them. Such people I couldn't taper off quickly so we did about a 5-10% reduction per month. I remember one patient I tapered her off of Xanax over the course of about a year. Getting her off of that med was like getting a monkey off the back.
A very bad pattern I noticed among some attendings is they put a patient on a benzo, then expectedly it stops working after a few weeks to months so they up the dose, then later again it stops working, then they up the dosage again.
Now the patient is on the maximum dosage and the doc instead of dealing with the problem for real tells them to go see a different doctor cause they're done with case.
What happened to me when I was doing private practice was the only few psychiatrists in town were all terrible (this was not in Cincinnati but a small suburb town about 30 minutes outside of Cincinnati. Cincinnati itself has plenty of very good psychiatrists, most in the university). Whenever one of those docs screwed over one of their patients in the above manner they'd dump their case to me. It got to the point where I didn't want to take their cases anymore cause the initial meeting was pretty much me always telling them in a diplomatic manner that their previous doctor screwed them up and did practice that's not acceptable by professional standards.
We weren't in the same office. They'd pretty much tell their patients they were done with them and there was only one other psychiatrist in town.....me. Trust me, I was not part of some arrangement with these bozos. If anything I felt like telling them I had little respect for their practice.
One of those patients I took after the psychiatrist put her on lithium with no labs before or after the lithium was started. She became lithium-toxic. She ended up going to the hospital with renal damage and ended up losing about 1 month of work. She was one of the few patients where I told her to consider getting a lawyer to review her case. The lawyer sent the psychiatrist letters demanding her medical records and the doctor refused to comply.
It was one of the reasons why I left private practice to work for the university despite what was > a $50K paycut. I felt like I was coming home to work in a place where so many people were hard-working, cutting-edge and very smart, and it showed in their work.