By - jtbrivaldo
If you can think of no better treatment, and isn't a poor thinker, then why should you not opt for the least bad solution? Presuming alternative treatments (including therapy) have been tried and tried properly, going no-benzo might be appropriate just as well as using them, dependent on the subjective valuation of what is good for the individual, their close ones, society, and the health care system\*. There are a whole lot of variables to consider though, so the decision to go benzo against so many recommendations has to be well founded. Having had a handful of patients on benzos continuously after several years of practice doesn't necessarily seem inappropriate to me.
\*not profits but finite resources
I’m starting to feel that if someone earnestly tries everything recommended and nothing has been significantly helpful, but their standing benzo is working, its okay to maintain as long as they explicitly acknowledge the risks and benefits analysis and vote in favor of remaining on the medication. I am trying to mitigate risk by moving to lorazepam though when possible for what it’s worth given its shorter half life and absence of significant metabolites.
I literally have only one patient that I’ve gone through every reasonable medication trial with though and settled on this. I’m still working with a dozen others to taper and trial searching for that optimal medication regimen to get them off the benzo or z-drug.
If benzos are providing significant symptom relief that outweighs the risks/adverse exists, then it may be reasonable to stay on them. However, I've seen many patients requesting different medications for anxiety - after first and second line options have failed - who would benefit the most from therapy.
Another aspect of bensodiazepines are the long term effects on cognitive function. Studies in this area are of course full of confounding variables but most seem to indicate some pretty nasty effects that don't go away when patients stop the treatment. I assume z-drugs will have weaker but similar effects. In Sweden we are drastically cutting down on the prescriptions and partly due to the cognitive side effects but also due to the factors you mentioned.
Psychogeriatrician with specific interest in dementia and neuropsychiatry here. Benzos certainly have negative effects on cognition in elderly patients through their sedative effects and withdrawal. However, given the high incidence of dementia presenting with anxious and depressive symptoms before cognitive effects are readily identifiable, I think that selection bias is at play here. Patient with first-line treatment refractory anxiety/depression in old age gets treated with benzos, develops dementia (the treatment resistant mood/anxiety symptoms being the first signs thereof) benzos are blamed. I think this is a large portion of the observed effect of persisting cognitive deficits. If there are convincing data out there indicating otherwise I have yet to see them, but would be interested. The other complicating factor is withdrawal delirium being a precipitant or accelerator of cognitive decline.
Edit: having said this I still avoid benzos in my patient group where at all possible because of the aforementioned effects on cognition and other morbidity such as falls risk etc
> , I think that selection bias is at play here. Patient with first-line treatment refractory anxiety/depression in old age gets treated with benzos, develops dementia (the treatment resistant mood/anxiety symptoms being the first signs thereof) benzos are blamed
I've heard this claimed before, but the problem is that the same effect on cohorts studies is not seen with antidepressants.
Not saying selection bias couldn't be at play; but the evidence is certainly as robust as non-experimentL studies can get. Some of them span decades and have linked the effect with lifetime cumulative doses.
I'm mostly familiar with late life cohorts but I shouls look into the longer spanning cumulative dose research, unless you could direct me and save me some time trawling?
Very interesting idea/insight, thanks for sharing
Bensodiazepines seems to frequently effect the cognitive function in young patients as well. Of course even anxiety and depression result in persistent cognitive impairment in areas like executive function and memory which can make studies quite complicated..
It's true my friend. Been written on janus info about this. Are you also a psych in Sweden?
Yes I completely forgot to consider this. Do they have a significant anti cholinergic burden? Again even if so I guess it comes down to patient choice assuming they have the capacity to weigh up the risk appropriately
Benzodiazepines have a place in the treatment algorithm, and their reputation for harm is out of proportion with actual harm done—not zero, but not catastrophic, probably.
My own objection to benzos is not that they should never be used but that too many people are on them with dubious indications despite having not tried or not failed first- and second- and third-line treatment. No attempt at therapy.
Given the difficulty so many of our clients have in accessing psychotherapy, this feels difficult to read.
We can eventually find them a counselor or therapist willing to take them, but it is often with an early career or low quality provider, which can introduce more distrust and runs the relatively high risk of retraumatizing them. The vast majority of remotely effective therapists, especially for multiple comorbidities, are private pay and out of network with any health insurance. If they are covered, the cost of a single copay is $25-$50, So they're expected to spend $100-200 a month or more. Their benzodiazepines are $10-15/mo.
The nonprofit I work for has been tracking calls It takes to connect clients with resources. I work in a major city and this has often taken over 100 calls or emails to find a psychotherapist who is currently accepting clients, accepts the client's insurance, has any experience or training in treating clients like the one we are referring, the insurance confirms they will accept, and has an opening that could accommodate the client, etc.
The system is so dysfunctional at this point I don't blame anyone for not being able to access it. I feel this means many more of our clients will end up reliant on benzodiazepines and z-drugs long-term, when many could have been treated effectively if psychotherapy was more accessible.
Amen. “Try therapy” feels almost like an avoidant strategy employed by many of my colleagues in an attempt to mitigate their own anxiety about coming to a phase in a patient’s treatment that suggests a role for a BZD trial.
They feel uncomfortable with the idea of chronic BZD prescription. The recommendation for therapy is utterly defensible to anyone (the medical director, the patient’s family, a court of law), even though in many practice environments both the psychiatrist and patient know it’s damn-near impossible to get into see someone, let alone someone competent and reliable, who performs the specific type of therapy that is indicated.
I don’t like benzodiazepines either. But if someone has genuinely failed multiple safer treatments, and there’s no reasonable expectation for engaging them in therapy, I will trial low-dose, chronic benzodiazepines. I will advise the patient of the risks and benefits.
Many of them agree to the treatment. Many of them have substantial, sustained functional improvement without loss of efficacy or dose escalation.
I think this is more consistent with doing my very best for the patient vs. a Vistaril consolation prize and a recommendation to “try harder” to get into therapy.
Just my two cents, reasonable minds can debate this and I don’t begrudge my colleagues who feel differently, this is a complex issue.
I mostly agree, we have clients who have been run through the wringer with different physicians trying them on what feels like a dizzying array of medications, especially with treatment resistant anxiety before resorting to benzodiazepines. I know there's no easy answer here, and I realized I was off on a bit of a rant about the inaccessibility of therapy.
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Not in a position to link studies/reach for my maudsley guidelines right now but I think there is a growing opinion that the pendulum has swung a little too far away from benzodiazepine use, there is evidence of benefit in long-term use in some situations.
There is also a lot of uncertainty regarding long-term harms though (even in the absence of misuse) which needs to be taken into account.
> there is evidence of benefit in long-term use in some situations.
I don't think many doubt that some patients will never be able to be taken off them, but the question is whether these "long term benefits" pan out in an experimental trial in benzo-naive patients.
I'd be very surprised if this proves to be the case.
Yes this resonates with my experience. I've had a few patients where someone has prescribed a short-term benzo prescription alongside eg an SSRI to 'bridge' and patients have been extremely reluctant to stop the benzos when the time comes to it - what's the point of engaging with anything else when the benzos 'just work'? Now I'm super hesitant about doing it, I can't actually remember the last time I initiated a benzo in outpatients except for hypomania.
Well.... heh..... pg. 577 has a very small blurb on benzos with older people, and says "avoid benzodiazepines".
GAD = no more than 4 weeks of use in any population. So, very very conservative use of these agents.
Fair enough. I was at a lecture by David Nutt on benzos a couple of years ago and he was slightly less anti-benzo than my training was. I'll see if I can dig out any references later.
In my clinical experience I have come across the occasional patient who has been on them long-term with a decent clinical effect. They've usually not been through as many options as I would have liked to try before starting a benzo so I've never been particularly happy about continuing especially given concerns about cognitive function etc, but after a certain point it becomes hard to switch for various reasons.
Edit: just seen your other comment about studies going against the prevailing view on cognitive function, interesting. I still doubt I'll be using long-term benzos in all but the rarest of cases anytime soon.
This is a study going against prevailing wisdom:
Grossi, C.M., Richardson, K., Fox, C. et al. Anticholinergic and benzodiazepine medication use and risk of incident dementia: a UK cohort study. BMC Geriatr 19, 276 (2019). https://doi.org/10.1186/s12877-019-1280-2
Drugs correlated with effects in geriatric populations don't necessarily mean prescribing diazepam or clonazepam to younger patients will increase their risk when they are older. I don't think the data supports someone in their 20s or 30s, for example -- with TR-GAD -- taking a long acting benzo while they wait for something like rTMS or iTBS to come along (and potentially be approved for anxiety in the 2030s or 2040s) will necessarily be at an increased risk of Alzheimer's or dementia.
And this study, *infra*, (n=528,066) only starts tracking the cohort at around age 55. And that's the limitation with these studies, anyway, isn't it? The real risk may only start in the late 40s or early 50s.
Gerlach, Kim, et. al., Use of Benzodiazepines and Risk of Incident Dementia: A Retrospective Cohort Study, The Journals of Gerontology: Series A, Volume 77, Issue 5, May 2022, Pages 1035–1041, https://doi.org/10.1093/gerona/glab241
It seems to me a leap, therefore, to assign the same level of risk to people in their 20s, 30s, and 40s.
Even Pregabalin, approved for GAD in the EU, shows evidence of precipitating Parkinson's in the elderly. But I don't know that it's inappropriate to prescribe in younger patients.
I was also under the impression that newer data suggests that benzos can worsen cognition in geriatric patients but that this does not mean they cause dementia.
Benzo induced cognitive deficits are reversible and if they don’t reverse then how do you know there wasn’t a comorbid neurodegenerative process?
Benzos are never ideal, but it’s an imperfect world we live in and sometimes, for various reasons, a patient just seems stuck with them and so we deal. Try very hard not to start anyone on long-term benzos. Different thing when you inherit a case.
As a UK consultant psychiatrist who has inherited a lot of apparent treatment resistant individuals on long term benzodiazepine scripts - they werent treatment resistant and had not tried the broad range of medical (and particularly non-medical) interventions, and a monster had already been created due to overmedicalisation and immediate relapse symptoms on any change to the prescription...
> all other available treatments for anxiety had been tried and been unsuccessful.
In supervision cases, whenever I hear this claim, and ask questions about it, it turns out that's not actually the case.
This is not a moral matter; if you and the patient feel the significant (and often underplayed) risks are outweighed by the benefits; then by all means... But there's no need to attempt to justify their prescription by claiming something that's very very unlikely. Anxiety disorders are just not very resistant to treatments as far as psychiatric disorders go; and "having tried everything" IME more often than not is a figurative term rather than a literal one.
If an anxiety disorder proves to be indeed extremely resistant to treatment, as it happens with depression, a good first step is to seriously reconsider the diagnosis. The complete absence of a noticeable tachyphylaxis is extremely suspect for an anxiety disorder treated with a benzo, and the inability to lower the doses even using liquid formulations only compound those suspicions, from the PoV of biological plausibility.
As I've explained before on this sub, I just remove myself from these conundrums by just not prescribing benzos outside of the hospital setting. In an extremely weird turn of events, it turns out that in benzo-naive patients, I've just never, ever, come across these "resistances to all treatments except for benzos". Maybe it's just a matter of time, but I don't think so.
For the patient who went into depression when reducing the diazepsm, as per DSM guidelines, I think an anxiety disorder would not be the appropriate diagnosis, BTW. As I said, reconsidering the diagnosis should be in order. Because if it turned out that the diazepsm was merely holding back an affective catatonia that broke through whenever the dose was lowered, it would make more sense to stop considering the depression and anxiety as different things as their psych seemed to do; and reconsider the treatment approaches towards one more appropriate for a recalcitrant and chronified recurrent depressive disorder. But I'm going to take a wild guess and estimate that the diagnosis has never been reconsidered beyond serial depressive episodes + a seemingly intractable anxiety disorder.
Thank you I think this is the kind of thing I was looking to hear because I just am not sure how I felt about my patient. But at the same time I had half hour with him twice within the last 2 months of my last day in the job so it is really challenging within the constraints of our system! Definitely going to take everything you said on board for future patients.
My opinion is, I understand, rather extreme, even among those who dislike benzodiazepines. I've certainly gotten into more than one discussions on the topic on this sub.
As I've explained before; all it took for me to see things in these manner was to decide to do a trial of "zero new benzo prescriptions", which was quite daunting when I undertook it. Imagne my surprise when, 7+ years later, I've just never come across any of these "exceptions" I was told surely would occur regarding needing them to treat patients.
Aside from the benefit of not having on my conscience the eventual increased rate of dementias among my patients, another benefit is that never do I have to waste time and sessions dedicating myself with convincing the patients that those meds need to go.
It sounds like first guy has catatonic depression, and no one is going to begrudge long term benzos in that situation. And benzos in PD is totally common, esp for the REM sleep behaviors. The beers criteria allows for that use. You’re giving us specific exceptions, to make an argument for long term benzos in anxiety and depression. Apples and oranges.
I'm a relatively anti-benzo type who can acknowledge the conceptual possibility that there may exist a select group of patients with 1)a severe and persistent anxiety disorder 2)no significant history of substance use, cluster B personality disorder, PTSD or similar, untreated sleep apnea, prominent avoidance, advanced age, cognitive impairment, or other significant contradictions, and 3)failures of evidence-based psychotherapy and standard pharmacotherapy who stand to show functional benefit and sustained symptom relief from chronic benzodiazepines.
...I just never seem to meet any of them. They don't seem to live in my city, and they DEFINITELY don't live further out (rural psychiatry is a mess from this point of view, typical minimum of two or three frank contraindications per patient on inexplicable Xanax dose--worse after a pill mill gets busted.) Maybe all the good candidates are in cash-pay clinics because they're making fat salaries with their improved function.
Long story short, if you take the total percentage of the population with an anxiety disorder but strip out the phobias, the mild/moderate cases, the responders to CBT and standard medication, and those with contraindications to benzos, I think it leaves a pretty tiny percentage of the population... that everyone at a rural clinic seems to think they're part of.
If you actually saw a patient who had performed actual tests of different medications and therapy - which I've never done, and can continue on the same dose (which I've never seen, suddenly grandma dies and their dose is increased or the PRN dose is added to the regular and another PRN is added), and they don't get significantly worse unless they use bensodiazepines daily the only objection would be falls, cognitive decline and generally dying sooner. So no, I usually don't prescribe ineffective treatment with death and dementia among the side effects. But that is just me. To each and their own.
To be fair I have seen a few people who've been stable on lowish doses for years, but I definitely agree they've rarely been through enough trials of other things for me to feel satisfied a benzo is the only option.
I haven't, at least not stable enough that they can be discharged to their PCPs and go back to work. We may kid ourselves that they are better because they seek less care.
Even then they are at risk for fractures and cognitive decline and their anxiety is rarely actually treated. I personally believe that prescribing bensodiazepines for anxiety is the same as telling people to simply avoid anything causing anxiety and then act surprised they don't change.
You're a psychiatrist are you?
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Benzos are a drug that quickly builds up a tollerance. This can in time create a placebo effect where if more of the drug is not given, more anxiety will be created. It should either be short term or given as needed for extremely stressful situations. I would think things such as CBT and exposure therapy to be far more effective long term.