If psychiatrists believe that long-term benzodiazepine use is so beneficial, why are there not more benzo success stories?

Unfortunately, in the field of psychiatry, there is too much prescribing of psychotropic medication and not enough talk therapy. This is especially true of anxiety medication prescribed for an anxiety disorder.

What happens when someone shows up to psychiatry services with a complaint of severe anxiety and panic attacks? They are diagnosed with a panic disorder and given a prescription for one of several selective serotonin reuptake inhibitors, or possibly a tricyclic antidepressant.

Additionally, they are prescribed a benzo. Benzodiazepine prescribing is so common, because benzos work well short term for stopping panic attacks. Unfortunately, after many months or years of taking a benzodiazepine prescription, the patient risks serious benzodiazepine withdrawal.

People who take a benzodiazepine prescription describe the feeling as being as if the sharp edges of life have been smoothed over. When it is time to renew their psychiatric medication, patients request that they get a refill of their benzo.

Many psychiatrists prefer clonazepam, also known by the brand name, Klonopin. Others prefer Ativan (lorazepam), Valium (diazepam), or Xanax (alprazolam). These are some of the most common benzodiazepine drugs.

Can polypharmacy present as poly-benzodiazepine prescribing?

Do you know what polypharmacy means? It is a medical word that means a patient is prescribed multiple medications. Usually, it also means that the patient is over medicated and at risk for drug interactions.

How many medications are too many? If you do not take prescribed medications, you may not believe how many regular, monthly prescriptions some people take.

For example, I have seen patients with as many as 20-30 prescription drugs that they take each and every day. A person might take 3-4 blood pressure medications, 2-3 cholesterol drugs, 3-4 diabetes drugs, and several psych drugs, and multiple supplements, and other prescription drugs that may be used to counter the side effects of the other drugs.

So, what about benzodiazepines? Are there psychiatrists who prescribe more than one benzo to a single patient at the same time?

I have seen patients where their psychiatrist had prescribed as many as two to three benzodiazepines at once. Once, I called the psychiatrist to see if there was a mistake, and his secretary assured me that it was not a mistake. The patient was supposed to take two different benzos at the same time.

Is long-term benzodiazepine prescribing a good idea?

Many psychiatrists prescribe a benzo and an antidepressant together with the intention of removing the benzo somewhere down the road. After a month or two, the patient continues to report getting symptom relief from the benzo, so the psychiatrist keeps refilling it indefinitely.

Unfortunately, we have learned in recent years that long-term benzodiazepine use can be a major problem for some patients. Benzo withdrawal is difficult, due to benzo dependence, and some patients are left with protracted withdrawal symptoms. While benzodiazepine addiction is rare, benzo dependence is common.

Additionally, there are some serious consequences for some patients, including akathisia, a terrifying movement disorder. Other long-term problems may persist, including depersonalization-derealization, insomnia, anxiety, and some unusual adverse effects, including histamine intolerance.

Do most psychiatrists realize that benzodiazepines should not be prescribed long-term? The FDA-approved literature for benzodiazepines has changed recently, in 2020, including new black box warnings.

Some psychiatrists do not revisit literature about the drugs they prescribe. They may assume that benzos are safe, because they were considered to be safe many years ago, when the psychiatrist may have started practicing.

Is there a safe mental health medication?

This is a good question. In recent years, we have learned that many drugs used for mental health treatment are not as safe, or even as effective, as once believed.

For example, the SSRIs, which include Prozac, Paxil, and Zoloft, are not thought to be far less effective than we once believed. Additionally, these drugs can cause serious withdrawal symptoms if stopped suddenly.

One issue with these medications is that they are designed to be taken every single day. When a drug is taken every day, the risk of side effects and adverse reactions over time is increased.

An alternative for treating a mental health condition is to get ketamine infusion therapy. One major benefit of ketamine is that the patient only needs a limited series of infusions, and benefits continue long-term.

While there are risks to ketamine therapy, the risks of ongoing drug use are avoided, because the drug is not taken every day, and the series is usually completed within a few weeks. In the near future, we will likely see similar mental health treatments developed.

Can ketamine treatments replace benzodiazepines or SSRIs?

Ketamine is used for a variety of psychiatric disorders, including obsessive compulsive disorder (OCD), depressive disorder, bipolar disorder, and even opioid use disorder and other forms of substance abuse. In recent years, we have seen an explosion of ketamine clinics in communities across the country.

An important element of ketamine therapy is that many clinics integrate talk therapy into their program. Where traditional psychiatry has dropped the ball, prescribing mood stabilizers without adequate psychotherapy, ketamine clinics ensure that their clients get both ketamine IV infusion and talk therapy for their mental health disorder.

For now, ketamine therapy will not replace traditional drugs for mental disorders, because of the inertia of the healthcare system and the power of big pharma. Even if we learned tomorrow that SSRIs were completely ineffective, doctors would probably still prescribe them, and patients would still take them.

We must also keep in mind that ketamine is not a cure-all that we should expect to solve all mental health care issues. Lifestyle changes and ongoing psychotherapy are critical for the best outcomes.

One good thing about talk therapy is that it works well as a form of online therapy. If you want to see a therapist or psychologist, you can see them in the comfort of your own bedroom, on a video telehealth call.

Should benzodiazepines be outlawed?

While the negative effects of benzodiazepines can be severe, there are still benefits to prescribing benzos short term. For example, benzodiazepines work very well for detoxing people off of alcohol.

Benzodiazepines are also used in surgical procedures and other procedures, such as colonoscopies. However, benzo use in procedures has been declining.

Another problem with outlawing benzos is that there are people doing very slow, gradual tapers, with a plan of coming off of benzodiazepines. A safe taper, such as one that follows the Ashton Manual, can take several years.

If benzos were to be outlawed, it would be difficult, or impossible, for people doing slow tapers to obtain their medication. They would then be at increased risk for protracted withdrawal if they are forced to taper more quickly, or to quit cold turkey.

The best course of action is to better educate psychiatrists who prescribe benzodiazepines and other psych drugs. For decades, we have accepted the expert medical decision-making of these mental health professionals, but it is time to start questioning polypharmacy prescribing, and long-term prescribing of benzodiazepines.