3.1 Barriers to Guideline-Concordant Benzodiazepine Use in
Veterans with PTSD
3.1.1 .Organizational barriers . The most common
organizational barrier mentioned by both primary care and mental health
prescribing clinicians was “inheriting” large caseloads of patients on
chronic benzodiazepines. Many clinicians placed responsibility of
initial prescriptions onto “older” prescribing clinicians who retired.
Clinicians discussed facing caseloads that included many older-era
veterans with PTSD maintained on benzodiazepines and unwilling to give
them up. For example, a psychiatrist based in Mental Health reported,
“I could almost see a patient and just look at what meds they are on
and make a good guess as to which older physician had been treating
them.”
Although most prescribing clinicians who had been in their jobs for a
decade on average agreed that the inherited caseloads of patients on
benzodiazepines were problematic, they did not agree on how to treat
them. Some clinicians who reported that they never or rarely write
initial benzodiazepine prescriptions, argued they did not necessarily
believe that discontinuation or tapering for the older “inherited”
patients was imperative. They questioned the necessity of trying to
taper the patient if it appeared that the patient was doing well for the
time-being.
We’ve got a few prescribers [who have] been around here a while. It
seems like everybody they see is on something like that or they’re
continuing or starting it. A lot of it is the older prescribers and the
patient already has 100% disability. They get started on these
medications and at this point, it’s not going to hurt them to stay on
them. [Psychiatrist, MH]
Some clinicians reported that they did not feel their facility
leadership supported efforts to decrease the prescribing of
benzodiazepines.
In the past, if you had a patient who was unhappy with you, they would
just run upstairs to the ‘QUAD’ and talk to the leadership secretary.
Next thing you know, I’m getting call saying either give them the benzo
or give them another provider. [Physician’s Assistant, MH]
Most primary care providers said they believe that it is chiefly mental
health’s responsibility to make the decision to maintain or taper
benzodiazepines and questioned the necessity of discontinuation in older
veterans who are doing well. This is in part because primary care
providers believe they do not have the time or resources to devote to
this time-intensive work.
I don’t want to step on Mental Health’s area and yet there is so much of
an overlap between what we do and what they do. But in these areas, like
maybe sleep problems, where it is kind of theirs and kind of mine,
there’s sort of a song and dance there. I send a lot of emails
suggesting maybe you consider prescribing something else. [Physician,
PC]
Organizational factors such as documentation burdens and decreased time
prescribing clinicians now have available with their patients may also
play a role.
We need more time with the patients and the VA seems to be continually
adding new screens and forms and making it harder for us. It’s sort of
like you are running a 400-meter dash and they want you to run faster,
but they then keep adding 5-kilogram weights to the backpack you are
carrying. [Psychiatrist, MH]
3.1.2. Provider barriers . Provider factors that contributed to
both increased incidence and prevalence of benzodiazepine prescriptions
included the belief that there are complex symptoms best managed by
these agents. Sleep and anxiety problems were prominent symptoms
mentioned in the interviews as reasons to prescribe benzodiazepines but
none of the providers intended to keep patients on them for long-term.
There were concerns that depression and anxiety associated with PTSD
increase the risk of suicide and that a benzodiazepine would decrease
that risk.
They come back and say that they still have insomnia and look exhausted.
We use Ambien® [zolpidem] … and that will be for sleep; then
trazodone is our backup medication. For anxiety, then I’ll use lorazepam
and explain to the patient that it is temporary, we don’t plan to keep
them on it for years. [Psychiatrist, MH] I do sometimes prescribe
clonazepam for someone who has suicidal thoughts. There is evidence that
using something like clonazepam or an atypical can take the edge off the
anxiety and help with suicide. So, I don’t use it a lot, but I do when
that is a concern. [Psychiatrist, MH]
Prescribing clinicians mentioned that they occasionally use
benzodiazepines to “kick-start” an SSRI, particularly in Primary Care
where patients cannot be seen again for several months. Providers said
that they use the benzodiazepines until they can get the patient into a
psychotherapy treatment. Providers also report that they have their own
concerns about the guideline-recommended antidepressants. They indicated
concerns about patients not receiving full therapeutic dosage levels and
about how these drugs might affect women, especially in pregnancy.
One of the things that we sometimes struggle to know is whether they
have had an adequate trial before they’ve been moved on to other
medications, or other medications have been added on top of the SSRI.”
[Psychiatrist, MH]
Pharmaceutical and medical fields have not given strong and consistent
recommendations about these agents, in particular SSRIs, in pregnancy,
using them, not using them, which to use, which not to use, etc. So it
is really nervous-making.” [Psychiatrist, MH]
Finally, clinicians mentioned a lack of awareness about other effective
treatment options in their own hospitals. They discussed discomfort
about a severe “type” of PTSD, lack of knowledge regarding complex
comorbidities, and the fact that the CPG does not go far enough to help.
The providers made specific requests for education and guidance in these
areas. This need was especially true for those new to the VA healthcare
system and those within PC rather than MH.
Initially, I was just looking for some guidance. I was rather confused
just first coming to the VA and trying to understand where you start
treating somebody with PTSD pharmacologically. [Psychiatrist, MH]
There’s also the factor that no one on my team I really feel is
competent to do that [follow-up with patient by phone regarding
medication management] as well as far as I could ask a nurse to do
that for diabetes. I don’t even go there with my nurse trying to figure
out what to do with the PTSD. [Physician, PC]
3.1.3 . Patient barriers. Patient factors that the
clinicians identified included patient requests for benzodiazepines and
concerns about antidepressants side effects. First and foremost was the
concern that for many patients, antidepressant medications are
stigmatizing. Younger patients did not want to be on long-term
medication.
I think one of the biggest obstacles as far as – well, not necessarily
initiating SSRIs, other than the patient being hesitant to start a med
if they have never been on one before– I think there’s a lot of stigma
associated with the antidepressant medication to this day. [Behavioral
Health Pharmacist, PC]
Finally, because the US VA system provides benefits for
service-connected disabilities there may be perceived economic
disincentives for deprescribing medications. Many veterans fear that if
they show improvement indicated by a reduction in medications, they will
lose their benefits.
Who knows how true it is, but truth doesn’t matter; it’s the rumor that
exists, that creates this scare of somebody even documenting just in the
notes…of somebody getting better and this person having their
benefits reduced. [Psychiatrist, MH].
Although this may appear to be a VA specific problem, it could
generalize to any system that serves patients whose healthcare coverage
depends on a disability or other type of diagnosis such as American
patients who receive Social Security Disability payments and associated
medical insurance. Of course, in countries where there is universal
healthcare, this barrier would not arise.