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Clinician's Corner

May 27, 2015

 
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Various clinical practice guidelines for the management of posttraumatic stress disorder (PTSD) caution clinicians against the chronic use of benzodiazepines (e.g., Xanax, Paxor, Valium, Serax, Retoril) due to a lack of data confirming their efficacy and a growing body of evidence highlighting their potential risks (Benedek, Friedman, Zatzick, & Ursano, 2009; Department of Veterans Affairs, 2010; Forbes, Creamer et al., 2010; Friedman, Davidson et al. 2009). However, their use in PTSD remains contentious.

Currently no data support the efficacy of benzodiazepines for the treatment of “core” PTSD symptoms, such as re-experiencing, avoidance, negative alterations in cognition and mood and hyperarousal. Nonetheless, benzodiazepines have been commonly prescribed to patients with PTSD, presumably to manage secondary symptoms of insomnia and apprehensiveness due to the rapid short-term relief they provide.

However, the boundaries between the disorders represented by these symptoms are blurry, with posttraumatic hyperarousal often mistaken for general anxiety or insomnia. Thus, a focus on decreasing benzodiazepine use in patients with PTSD presents a significant opportunity for improvement in the quality of clinical care.

Moreover, a growing body of work has noted the potential for harm from chronic benzodiazepine use overall, not just in patients with psychiatric diagnoses such as PTSD. Beyond the long-recognized risks of tolerance, dependence, accidents, fractures and falls, there are new documented concerns.

Recent evidence suggests significantly high rates of mortality associated with long-term use of benzodiazepines prescribed for sleep (Weich, Pearce et al. 2014). An increasing area of concern is related to the cognitive effects of benzodiazepines, not just a cognitive “slowness” that has been previously recognized, but new findings suggesting an increased risk of the development of dementia and Alzheimer’s Disease among those using these medications (de Gage, Bégaud et al. 2012, de Gage, Moride et al. 2014).

This is a particular concern for older patients with PTSD because PTSD itself is now recognized as a risk factor for the development of dementia, with studies finding dementia to be almost twice as prevalent among older veterans with PTSD versus those without PTSD (Qureshi, Kimbrell et al. 2010). Another concern regards the increasing numbers of patients with PTSD who also have a history of traumatic brain injury, for whom particular caution should be observed about the use of sedative medications.

There also are a number of other reasons why the debate about the continued use of benzodiazepines has reopened recently. There are now newer and safer medications for the symptoms targeted by benzodiazepines for patients with PTSD, such as the serotonin-selective reuptake inhibitors (SSRIs) and the serotonin-norepinephrine reuptake inhibitors (SNRIs). Additionally, the diagnosis of PTSD has been moved from the Anxiety Disorders category to one of Trauma and Stressor-Related Disorders in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition or DSM-5, suggesting that a single focus on the treatment of anxiety-related symptoms is not the ideal target for PTSD interventions. Finally, there has been a change in the treatment recommendations for anxiety, which promote the use of SSRIs over benzodiazepines (Baldwin, Anderson et al. 2005) in conjunction with cognitive-behavioral therapy (CBT).

Recent efforts have been undertaken by individual researchers as well as U.S. Department of Veterans Health Administration (VHA) quality improvement programs to decrease the use of benzodiazepines in patients with PTSD and to offer supportive educational materials to clinicians and veterans and to provide alternative approaches to the symptoms they are working to address.

Building on early work that highlighted concerns about the chronic use of benzodiazepines in older adults (Cook, Biyanova et al. 2007, Cook, Marshall et al. 2007), researchers at the National Center for PTSD have conducted a body of research using VHA administrative data to identify specific factors to address in a targeted intervention for reducing the use of benzodiazepines in the management of PTSD.

Women, older veterans, those living in more rural areas, those with a history of substance use disorder or a traumatic brain injury, and those who are taking other sedative medications such as opioids to treat chronic pain, have all been identified as patient groups who are especially at risk and should receive education about the long-term risks of benzodiazepine use and information about safer, more effective treatment options ((Bernardy, Lund et al. 2012; Bernardy, Lund et al. 2013; Bernardy, Lund et al. 2014; Lund, Bernardy et al. 2012). This research also suggests that sleep concerns continue to be a major factor in prescribing practices in PTSD and the use of benzodiazepines may reflect an attempt to address insomnia that is not responsive to first-line PTSD recommended treatments.

Current research and quality improvement efforts in the VHA as well as community providers are now focused on the use of an intervention using an academic detailing model of individualized care delivery. This model provides educational outreach visits to prescribing clinicians that focus on interactive discussions of evidence-based presentations of the literature in a one-on-one setting with a mental health clinical pharmacist suggesting treatment options on a patient panel (Perkins, Jensen et al. 2007).

When working with specific health care providers, key messages regarding the potential harms of long-term benzodiazepine use are delivered, as well as safer, alternative suggestions for symptoms of insomnia and anxiety, such as CBT or the use of antidepressants or prazosin for nightmares. The program then monitors the decrease in “inappropriate” medications, the increase in what would be considered safer appropriate medications, and referrals to evidence-based treatments for PTSD, such as CBT. For sample brochures, see the VHA’s National Center for PTSD website (www.ptsd.va.gov).  

Finally, work conducted outside the United States has shown that patients, when informed about the risks of chronic benzodiazepine use, can and do choose to safely taper from these medications (Tannenbaum, Martin et al. 2014; Vicens, Fiol et al. 2006). Researchers at the National Center for PTSD are currently developing educational materials that will offer information to community providers on safe and effective pharmacotherapy treatments for PTSD. The materials are intended to be used in a shared-decision making model of care in which the patient and family member meet with the provider to discuss various treatment options and then, using the information, make the best decisions for their PTSD care.

This model suggests that prescribing practices might best be improved by simultaneously targeting both prescribing clinicians and their patients. Although psychotherapies are and should be the first-line treatment to address PTSD (Friedman 2015), pharmacotherapy still plays an important role. We owe it to our patients to figure out how to provide them with the best approaches.

About the Author

Nancy Bernardy, PhD, is a clinical research psychologist at the Executive Division of the National Center for PTSD in Vermont and an Assistant Professor, Department of Psychiatry, The Geisel School of Medicine at Dartmouth. She directs the national PTSD Mentoring Program; a program that shares best administrative practices in PTSD specialty clinics to improve the delivery of quality PTSD care for Veterans. She is a funded VA MH QUERI and the Office of Rural Health researcher and her work has focused on improvement of the quality of treatment of Veterans with PTSD in VA through appropriate prescribing of medications and access to evidence-based psychotherapies.

References

Benedek, D., Friedman, M. J., Zatzick, D., & Ursano, R. J. (2009). Practice Guidelines for the treatment of patients with Acute Stress Disorder and Posttraumatic Stress Disorder.http://www.psychiatrityonline.com/pracGuide/pracGuideTopic_11.aspx, Guideline Watch.

Bernardy, N. C., Lund, B. C., Alexander, B., & Friedman, M. F. (2014). Increased polysedative use in veterans with posttraumatic stress disorder. Pain Medicine, 15, 1083-1090.

Bernardy, N. C., Lund, B. C., Alexander, B., Jenkyn, A. B., Schnurr, P. P., & Friedman, M. J. (2013). Gender differences in prescribing among veterans diagnosed with posttraumatic stress disorder. Journal of General Internal Medicine, 28, Suppl 2, 542-548.

Bernardy, N. C., Lund, B. C., Alexander, B., A.,& Friedman, M. J. (2012). Prescribing trends in veterans with Posttraumatic Stress Disorder. Journal of Clinical Psychiatry, 73, 297-303.

Cook, J. M., Biyanova, T., Thompson, R., & Coyne, J. C. (2007). Older primary care patients' willingness to consider discontinuation of chronic benzodiazepines. General Hospital Psychiatry 29, 396-401.

Cook, J. M., Marshall, R., Masci, C.,& Coyne, J. C. (2007). Physicians' perspectives on prescribing benzodiazepines for older adults: A qualitative study. Journal of General Internal Medicine, 22, 303-307.

de Gage, S. B., Bégaud, B., Bazin, F., Verdoux, H., Dartigues, J. F., Pérès, K., Kurth, T., & Pariente, A. (2012). Benzodiazepine use and risk of dementia: Prospective population based study. British Medical Journal, 345, 6231.

de Gage, S. B., Y. Moride, T. Ducruet, T. Kurth, H. Verdoux, M. Tournier, A. Pariente and B.Bégaud (2014). Benzodiazepine use and risk of Alzheimer’s disease: Case-control study. British Medical Journal, 349, 5205.

Department of Veterans Affairs. (2010, October 2010). Post Traumatic Stress Disorder: VA/DoD Clinical Practice Guideline. Retrieved 4/17/2014, 2014, from http://www.healthquality.va.gov/Post_Traumatic_Stress_Disorder_PTSD.asp.

Forbes, D., M. C. Creamer, J. I. Bisson, J. A. Cohen, B. E. Crow, E. B. Foa, M. J. Friedman, T. M. Keane, H. S. Kudler and R. J. Ursano (2010). A guide to guidelines for the treatment of PTSD and related conditions. Journal of Traumatic Stress, 23, 537-552.

Friedman, M.J. (2015). Psychological treatments for PTSD. Posttraumatic and acute stress disorders (6th edition). M.J. Friedman, Springer International Publishing: 53-92.

Friedman, M. J., Davidson, J. R. T., & Stein, D. J. (2009). Psychopharmacotherapy for adults. Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies (2nd Ed.). E. B. Foa, T. M. Keane, M. J. Friedman & J. A. Cohen. New York, Guilford Press: 245-268.

Lund, B. C., Bernardy, N. C., Alexander, B. A, & Friedman, M. J. (2012). Declining benzodiazepine use in veterans with Posttraumatic Stress Disorder. Journal of Clinical Psychiatry, 73, 292-296.

Perkins, M. B., P. S. Jensen, J. Jaccard, P. Gollwitzer, G. Oettingen, E. Pappadopulos and K. E.Hoagwood (2007). Applying theory-driven approaches to understanding and modifying clinicians' behavior: What do we know? Psychiatric Services 58, 342-348.

Qureshi, S. U., T. Kimbrell, J. M. Pyne, K. M. Magruder, T. J. Hudson, N. J. Petersen, H. J. Yu, P. E. Schulz and M. E. Kunik (2010). Greater prevalence and incidence of dementia in older veterans with posttraumatic stress disorder. Journal of American Geriatrics Society, 58, 1627-1633.

Tannenbaum, C., Martin, P., Tamblyn, R., Benedetti, A., & Ahmed, S. (2014). Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial. JAMA Internal Medicine, 174, 890-898.

Vicens, C., Fiol, F., Llobera, J., Campoamor, F., Mateu, C., Alegret, S., & Socías I. (2006). Withdrawal from long-term benzodiazepine use: Randomised trial in family practice. British Journal of General Practice, 56, 958-963.

Weich, S., Pearce, H. L., Croft, P., Singh, S., Crome, I., Bashford, J., & Frisher, M. (2014). Effect of anxiolytic and hypnotic drug prescriptions on mortality hazards: Retrospective cohort study. British Medical Journal 348, 1996.