In outpatient, I try to avoid the use of benzos completely. I have given them from time to time.
Whenever someone has an anxiety disorder, if it does not appear to be severe, I usually don't even offer them. What do I consider severe? Some examples: the person has debilitating panic attacks, the person is on the verge of losing their job due to their anxiety, the person's anxiety is so visible that during the meeting I'm actually greatly troubled by it.
What do I not consider severe? The person is still able to manage themselves in school or at work.
I usually only give out benzos for a month tops if at all. From personal experience, I've allowed only about 15% of new patients with an anxiety disorder on it during that first month.
I also give a benzo speech about how it's addictive and in some studies, dependence can start as early as a few weeks. Given my current outpatient private practice setting, the overwhelming majority, upon hearing that speech actually don't even want a benzo. Unfortunately in other settings, and I hate saying it because it sounds judgmental, the lower the SES, often times I get a heck of a lot more people just looking for the quicker fix and wanted a benzo. In such settings, for this reason, I'm even more hesitant to give out benzos.
I've also at time substituted Gabapentin to treat anxiety and while it's not indicated there is data supporting that it as a treatment for anxiety. I've also used Vistaril.
A problem with giving out benzos in the first place is some patients will demand to stay on them even after they've been placed on an SSRI claiming the SSRI doesn't work or they need the benzo even if the SSRI is working. In my private practice setting this is rare, and again, I hate saying this, in lower SES settings, the patients demanding a benzo have been much higher. I still stop it even if they are still experiencing anxiety, telling the patient that it'll be even worse if I they become addicted and dependent to the benzo. If the SSRI isn't working then it's either not the right one or not at the right dosage.
This is a reason why I am very gung-ho about getting SSRIs to maximum dosages as fast as I can within the guidelines (all things being equal, if the patient has bipolar disorder, that's another story). There's no point IMHO for a patient to remain depressed or anxious at Zoloft 50 mg for 4 months when it's going to be the 200 mg dosage that may be the one that get's them better. I tell the patients to increase the dosage per the manufacturer's guidelines as quickly as possible and to call me if there's a problem. If they get better, then we can discuss pulling their dosage back. It could be several months before a patient feels better if you only increase the dosage once every few weeks to months as I've seen several other doctors do it. I don't understand the logic of someone still being depressed and anxious on Zoloft 50 mg after 6 months, when all the data shows that you give it about one month on the current dosage to see what it's going to do at that dosage. Why didn't their doctor increase it sooner? I don't understand the logic of someone being on 50 mg Qdaily for even a month (unless it's what the patient wants, they happened to get better on that dosage, or they have side effects at higher dosages) when the data suggests that at lower dosages, SSRIs usually don't do much at all. I usually increase the dosage automatically after one week. When it hits a moderate dosage, that's when I'm willing to bide more time, though I will still increase it if that's what the patient wants. Remember, STAR*D showed that even at maximum dosages, SSRIs work, but even then they don't work well. Going up slowly on SSRIs when you don't have to go slowly is like asking a patient to watch the water and wait for it to boil. If the SSRI doesn't work, that'll just delay the time even more before the doctor can figure it out and try the next one. I also will not increase faster than the guidelines permit.
If you warn the patient you will get them off the medication ahead of time and why, you will get a lot less backlash by the time you stop it against a patient's will. Again, I hate saying this, but in lower SES patients, I often get the excuse, "Doctor, when I took the Klonopin, I felt so much better I decided I didn't want the antidepressant." That's a reason why I drill it into the patient's head from the beginning that the benzo will be stopped whether they like it or not and that the real long-term treatment is the SSRI (or SNRI).
And I've mentioned this in other threads. I've noticed a subset of patients who come to me with a chief complaint of anxiety but when I tried multiple SSRIs and SNRIs, their anxiety doesnt' get better. After doing TOVA testing, these people actually ended up having ADHD, and the ADHD treatment ended up relieving their anxiety. If a few trials of an SSRI or SNRI don't work, consider ADHD.
The only times I can remember where I continued benzo use after 3 months was mentioned above: patients with panic disorder that take benzos on the order of only a few times a month, and patients on the order of only a handful out of a few thousand I've treated. Right now I can only remember 4 off the top of my head.
To give you an example of some of the few cases where I continued an benzo ....
In one of those cases, the guy was on Clonazepam 1 mg Qdaily for years. I took him off of it and he had a panic attack. I told him about my concerns of dependence, but he was stable on that dosage and it didn't have to be increased. I wasn't the doctor that started him on that regimen. The guy has real real bad bipolar disorder when he's manic, and I dare not give him an SSRI. His bipolar is to the degree where he's received ECT several times. One of his inpatient psychiatric hospitalizations was over 1 year. He's stable now and I don't want to rock that boat.
Another case, and I mentioned it before (is it in this thread)?, I have an MR patient in a group home that was on Ativan 8 mg Qdaily from some idiot doctor who didn't know what he was doing. I weaned her down to 0.5 mg Qdaily. If she is taken off the Ativan, she freaks out (threatens to drink bleach, and she's actually had to be held down to prevent that). If she freaks out, she's sent to the local hospital where the ER doc gives her lots of Ativan. It's either 0.5 mg a day or a lot of it from some idiot ER doctor, and then I got to wean her off again. If this were inpatient, I'd seriously just stop it and if she freaked out, we'd deal with it then, but she's in a group home where they don't have the manpower to deal with this, and I'm only there once a month for about one hour.
The patient doesn't understand that she's taking Ativan 0.5 or 8. She just feels that she has to take it as if it's some type of magical Dumbo feather. I've tried to explain to her that she most definitely doesn't need Ativan but we're talking a very concrete person here. While I'd love to give her a placebo and tell her it's Ativan, we all know I'm not allowed to do that. I've tried to tell her, "I got something better than Ativan," but she won't accept it.
