ABSTRACT
- Rationale, Aims and Objectives: Despite guideline
recommendations against their use, clinicians prescribe
benzodiazepines for various symptoms to patients with posttraumatic
stress disorder (PTSD). Clinicians’ reasons in making these decisions
are not fully understood. This qualitative study sought to
characterize factors identified by prescribing clinicians in clinical
decision making in PTSD regarding the use of benzodiazepines.
- Methods: The descriptive study involved semi-structured
interviews with 26 prescribing clinicians across thirteen VA medical
centers. Our overall aim in the study was to explore clinicians’
benzodiazepine practices in veterans with a PTSD diagnosis. We
audio-recorded, transcribed, and analyzed the interviews using
grounded theory methodology.
- Results: Facilitators and barriers that contribute to
benzodiazepine prescribing to veterans with PTSD included
organizational, provider, and patient aspects. Most providers
interviewed indicated that they inherited patients already on these
medications initiated by other clinicians. These providers, as well as
others interviewed, voiced concerns that tapering benzodiazepines may
cause more harm than the risks of maintenance, particularly in older
patients. Clinicians who noted consistent treatment practices among
their hospital colleagues found it easier to decrease both new and
maintenance benzodiazepine prescribing.
- Conclusions: Patients with PTSD at increased risk of harms,
such as older patients, are still receiving benzodiazepines suggesting
that innovative solutions are now needed to decrease use. Specific
protocols for inherited patient caseloads, increased dissemination of
effective psychotherapies for symptoms such as insomnia and anxiety
and the use of direct to consumer educational materials should help to
foster needed culture change and increased evidence-based PTSD
practice.
INTRODUCTION
Over the last decade, the US Department of Veterans Affairs (VA) has
implemented initiatives to promote effective pharmacotherapy treatment
of posttraumatic stress disorder (PTSD). Prominent among these has been
the national dissemination of academic detailing (AD), an educational
outreach intervention led by clinical pharmacists that offers best
practice in a clinical area such as PTSD by trained educators in the
practitioner’s office.1,2 AD enables pharmacists to
use a developed pharmacotherapy dashboard to review a prescribing
clinician’s caseload and medications prescribed for specific patients.
Another resource is the Psychotropic Drug Safety Initiative, the PDSI, a
national psychopharmacology quality improvement program that offers
clinicians support by providing hospital data on prescribing measures
and didactic lectures on specific medications.3 Rather
than the focus on individual patients seen in AD, the PDSI focuses on
specific pharmacotherapy hospital metrics. Both initiatives have
concentrated on veterans with PTSD who are most at risk from
benzodiazepine use including the older veteran population aged 65 and
over. The two programs have been largely successful with only about
10% of veterans with PTSD still
receiving benzodiazepine prescriptions,4 a decrease
from 30% we observed a decade earlier.5 The decrease
is encouraging, yet the 10% of veterans with PTSD who are still
prescribed drugs from this class of medications, half of whom are over
the age of 65, suggests a knowledge gap between clinician decision
making and recognition of the evidence of harms from chronic
benzodiazepine use. It further supports the need to examine the reasons
providers prescribe benzodiazepines to high risk patients to help
educators develop new strategies to decrease use.
The 2017 joint VA/DoD (Department of Defense) Clinical Practice
Guideline (CPG) for PTSD6 offers treatment
recommendations to guide clinicians in clinical decision making. New in
2017 to the guideline is a recommendation of trauma-focused cognitive
behavioral psychotherapies as first-line PTSD treatment. Four specific
antidepressants are recommended as pharmacologic monotherapy and the
revised CPG again recommends against the use of benzodiazepines due to a
lack of efficacy and safety concerns.
Although there are concerns about both short-term and long-term
benzodiazepine use, the documented harms of chronic benzodiazepine use
(typically > 3 months) are well-established and include
accidents, falls, hip fractures and cognitive
dysfunction.7 These risks are highest in older adults
who comprise the majority of patients with PTSD treated in the
VA.8 There is some evidence that chronic
benzodiazepine use, especially in patients with PTSD because of its own
unique risk, can lead to the development of dementia; an obvious concern
among older patients.9,10 Recent research also notes
immune system harmful effects, a risk that is particularly relevant now
due to Covid-19.11
Concerns around decision making regarding benzodiazepine use in patients
with PTSD, however, are not unique to the VA. The prescribing of
benzodiazepines nationally in ambulatory care has increased
substantially with primary care visits in the U.S. accounting for about
half of all benzodiazepine visits.12 Previous work
examined reasons for prescribing benzodiazepines by primary care
providers working in the community and found these clinicians doubted
the risks of chronic benzodiazepine use and were pessimistic that
patients would agree to tapers.13 Recent research also
noted increased rates of benzodiazepine prescribing in community mental
health settings to patients with co-occurring mental health and
substance use disorders, a practice that should be avoided.14 Although our work is concerned with better
understanding decision making regarding benzodiazepine prescribing among
US VA clinicians, we believe that it provides general lessons for
clinical decision making for non-veteran patients with PTSD in the US
and also in other countries, particularly those with national healthcare
and insurance systems. Similar to
such national systems, VA which is comprised of a nation-wide system of
hospitals and outpatient facilities with a shared mission, caring for
the nations’ veterans; and as such, is able to implement system-wide
clinical policies and mandates for improving care and rendering it more
compliant with evidence.
METHODS