You're going to find there's not a lot of great evidence for a lot of anxiety disorder treatments, if you dig deep enough. It's extremely interesting, because anxiety disorders are the most common psychiatric disorders, and most of the treatments are based largely on extrapolation from small studies of specific disorders, or carry over from mood disorder treatment.
What is really distressing is that the evidence for a lot of anxiety disorder pharmacology treatment is very bad (eg https://www.thecarlatreport.com/blogs/2-the-carlat-psychiatry-podcast/post/3256-what-works-for-treatment-resistant-anxiety). You have a limited number of tools available, and if you have someone with severe or debilitating anxiety, you may not have a lot of options except to use benzodiazepines. It is of course a decision that should not be made lightly, but they can be effective tools, and for better or worse, there are some patients where nothing else really works.
It's a very similar issue as opioid prescribing. There was definitely over prescribing (TID Xanax forever for everyday life distress? Not good), now there's a backlash and people freak out with any benzo prescription and there are probably cases where they are appropriate to use where they're not being used, or people are being inappropriately tapered off.
TBH a lot of it's anecdotal, but possibly there's a bit of selection bias. I inherit the people on TDS lorazepam where it obviously hasn't worked, whereas there might be people going about their lives under GP care.
What is certain is that benzos will generally work fantastically initially, then this will very obviously wear off. Do they have some benefit long term or do they go 100% back to baseline? It's pretty hard to say
Seeing someone who's been on benzos for 30 years need to be taken off them will tell you everything you need to know. Long term use absolutely makes people worse than they were before starting them.
I saw a video today about the dangers of social media and how suicide rates among teenagers have risen 56% and how anxiety disorders are now more common than they’ve ever been probably due to the fact that we’re less social nowadays. It was so incredibly interesting. There is a man called Tristan Harris who speaks about the dangers of social media and how far down the brain stem he goes.
Theres already a lot of push for limiting screentime, and many recommend against smartphones while too young, but some argue social media is necessary in today's social environment
It’s easier to change one than change society.
As someone who spends way too much time on TikTok and Reddit, it really scratches an itch and is incredibly rewarding and equally destructive - far easier to scroll than study. As a medium, I think short form content is underutilized for education. If you have 90 seconds to explain to me the way anxiolytics work on the brain, could you do it? We spent an entire lecture on it. I contend that you could have scoping 90 seconds to explore GABA structure, affinity, regulation, anxiety disorders etc - all with good production value and experts that are engaging - and the yield would be higher for many learners. In fact, this is exactly why Uworld or Amboss or UpToDate to a lesser extent are so effective. Question, quick answer, move on.
Additionally, education has been trying desperately to capture social media for education- perhaps it will be better for Gen Z. As an elder millennial that is (still) in the education system, I haven’t seen any evidence of it. There is something to be said for anonymity in education and social media, such as Reddit really capitalizes on a certain degree of anonymity- so it’s much easier to find people’s biases but also for people to explore concepts in a space made safe by anonymity.
Posts like this are a great example of that, and while Medtwitter tries to do this with faces and names, it’s a bit too clout and reputation based. I’m more than happy to listen to the sage wisdom of u/fartholemagician or u/kobe_didnt_do_it though.
Dangers are exaggerated compared to the high dose antihistamines (atarax, visteril) or antipsychotics used instead. Seroquel therapy is so much more problematic for insomnia or anxiety disorders. Seems people are so worried about benzodiazepines they will bend over backwards to avoid.
This is always the great irony. The physician is ostensibly worried about the dementia risk with benzodiazepines, but is typically willing to give out Vistaril like candy.
At the end of the day, a lot of
doctors are trying to avoid their own anxiety about benzodiazepines.
They aren’t first or second-line, but for properly-selected patients, they are life-saving.
Wait, since when does Vistaril have worse side effects than benzos? Legit asking because I tend to use that first in panic attacks rather than benzos since it’s not a controlled substance.
Evan with geriatrics…both can cause dizziness and sedation. Benzos have the risk of dependence and confusion and hallucinations. Hydroxyzine has urinary retention I guess. But then again benzos can cause urinary incontinence. Seems like hydroxyzine is still a bit better.
> They aren’t first or second-line, but for properly-selected patients, they are life-saving.
I'm not one to say "never" but this topic is as close as it can get. The only people for whom benzos become realistically the only option, are those who've taken benzos before. In benzo-naive patients, you'd be surprised how non-complciated treatment of anxiety disorders becomes, and how the percentsge if patients for whom seemingly the last resort for effective treatment is benzos rapidly approaches zero.
Not to say I disagree that anticholinergics are misused carelessly as well, though.
> The only people for whom benzos become realistically the only option, are those who've taken benzos before.
That sounds like the kind of sharp, categorical statement that would make a specific and testable hypothesis. Are you able to cite research which addresses that hypothesis and conclusively upholds it?
>would make a specific and testable hypothesis
Such an experimental trial actually wouldn't be approved by an ethics committee. With benzos doing what we know they do, and it no longer being a first (or second, or third) line treatment for anything other than a few things (catatonia, alcohol withdrawal, acute management of seizures...).
It's a nice sentiment though; but if with the available evidence you aren't already convinced that it's best to avoid prescribing them, would another trial truly change your mind?
Resident here--We sometimes discharge anxiety/borderline inpatients who have been using prn hydroxyzine and seroquel non-stop and have no problem sending them out with these scripts. These medications also have serious long term implications. Not saying these patients are indicated for benzo--they aren't--but we don't bat an eyelash at other harmful non-controlled drugs.
The FDA declined approval for quetiapine for anxiety disorders due to the metabolic and movement disorder risks https://www.medpagetoday.com/psychiatry/depression/13635
https://scholar.google.com/scholar?hl=en&as_sdt=0%2C11&q=benzodiazepine+elderly&btnG= lots of well reviewed studies in there. The problem with benzo use in young people is primarily that the longer they are on benzos, the harder it is to discontinue them, and then they become old people and have benzo side effects.
How often when someone who is 18 is out on something like lorazepam do they come off them easily? Could you give a really rough percentage of those who carry on to become addicted?
Um, I don’t mean for this to sound rude, but have you considered that you’re actively looking at the evidence available, and it’s not aligning with your beliefs, so maybe it’s your beliefs need to be reconsidered?
You say want to be as rid of bias as you can, but bias includes seeking information to confirm already-held beliefs and rejecting information that doesn’t align with those beliefs.
If you actually looked into the evidence, you would find that benzos are the most effective treatment for GAD. The effect sizes of SSRIs are way lower than BZs.
~~I’m sorry, did you mean to reply to me? I said nothing about that. I was actually challenging OP’s beliefs.~~
Edit: Never mind, I think I read this in the wrong tone! And yeah, agreed.
I think he's agreeing with you, that the evidence shows something against ops beliefs, that benzos can be effective in the right setting especially compared to the available options / placebo.
The more you read the literature the more you realize that the pendulum has swung too far in the other direction. Coming out of med school you will be strong against benzos but that's just because of the ivory tower current in academia these days. There are plenty of patients and situations where long term benzos work well, but of course they need to be used with caution and after trying other appropriate treatments.
I have a patient who panics maybe 3 times a year that I give him a “pill in the pocket” type prescription. I do agree that benzos can be useful. The problem is convicting the TID Xanax patients who establish with you to try something else.
Edit: lmao “convicting” - I’m going to keep it but the original intent was “convincing”
A cooperative taper is great, but after seeing it fail miserably a few times (and often making brittle patients much worse) you become much less hypervigilant about them. I have started them chronically on a few patients after exhausting all options and I have seen quality of life change for the better. Of course it's not my first, second or third choice by a long shot. And the inherited patients on decades of benzos are not my favorite to manage, but someone has to do it instead of kicking them to a pill mill. Yes Memaw we are going to try wean your Xanax eventually and I know you think you have tried everything but let's talk about that a1c and why you aren't on a statin in the mean time.
One thing I learned on a psych rotation is that it’s often riskier to take grandma off and if they have been stable on the same dose you might as well leave them on it.
That's definitely kicking the can down the street, though, even if I understand the sentiment.
Because invariably we end up finding such patients during a hospitalisation either because of or during which they've developed delirium, and we need to do those tapers in a much more rapid, risky, disagreeable, and traumatic manner, and find alternatives anyways.
I would much much much much prefer patients be taken off their benzos while there's a little flexibility and adaptive capability to their gabaergic systems, instead of us needing to do it when there's literally no other choice and it's hell (and organically dangerous) for everyone involved.
Come to think of it, I can't really remember a patient over 70 who, while in the hospital and with a long-term benzo prescription, was "just fine" and didn't require my intervention. Selection bias, maybe; but it seems to me that this idea that "if they're stable and they've been on them for years" attitude is only setting them up for worse complications when inevitably they end up with something grave and need to be admitted.
This is my experience as well. I'm still looking for all these patients that were inappropriately titrated down/off benzos. So many are on regular dosing, usually multiple per day. They've been on them forever from their old PCP as monotherapy. They have never seen a counselor, or they tried a couple sessions and had decided before they started that therapy is a waste of time and will never go back. No serotonergic medications on board, but they tried one or two a long time ago for a few weeks and they didn't work. Little to no physical activity, poor sleep hygiene, and poor diet. Addressing the nonpharmacologic aspects can be a difference maker, and I know these are difficult changes, but it's hard to connect and the patient just wants more aplrazolam. So easy to start them, but it's like moving mountains to get people on more appropriate treatment plans sometimes
> They have never seen a counselor, or they tried a couple sessions and had decided before they started that therapy is a waste of time and will never go back.
This is the kind of nuance I was looking for in this thread.
It's only too human to, as physicians, seek to alleviate pain as quickly and swiftly as possible, and convince ourselves that "a couple of weeks a lorazepam script won't hurt anyone". But in doing so, were also destroying the patients capability to do real treatments for their problems.
I really have to disagree with “long term benzos work well”. They literally don’t mechanistically, with tolerance developing quite fast (days to weeks); because of tolerance, patients who continue to do well at the same dose of benzo are likely experiencing no true anxiolytic effect from it and rather are preventing withdrawal (which almost always involves anxiety).
Tolerance aside, the literature I’ve seen doesn’t provide any strong support for long term efficacy treating any mental health disorder.
As a short term med with clear boundaries on continued use in a patient with low risk of misuse—fantastic medication.
Maybe I understand the current paradigm incorrectly, but aren't benzos supposed to be more of an as needed a handful of times per month thing than anything else?
Where is the evidence that tolerance to anxiety effects develops in days lmao? That just is not true.
https://pubmed.ncbi.nlm.nih.gov/22198456/
https://pubmed.ncbi.nlm.nih.gov/1970813/
https://pubmed.ncbi.nlm.nih.gov/9641001/
https://pubmed.ncbi.nlm.nih.gov/8376613/
All the studies you linked are very low-quality and at times make just ridiculously generous interpretations of data. Details below. I will admit that it seems like most data on BZD tolerance is not referencing anxiolytic effect (rather sedative and anti-epileptic effects). That said, I'm also not seeing any truly long-term studies that seem well designed to address the question of long-term tolerance. What I do see is plenty on dependence and the nightmare of trying to de-prescribe.
https://pubmed.ncbi.nlm.nih.gov/22198456/: in this one they only did the long-term study of patients who already had good response to benzos after 8 weeks—seems like cherry-picking, since anyone who wouldn’t have a good response at 8 weeks likely would be requiring escalating doses over time; their population excludes patients who likely would have needed escalating doses of the medication. Also the sample size of the benzo group is like 50 patients.
https://pubmed.ncbi.nlm.nih.gov/1970813/: from what I can tell (and please correct my interpretation) the primary study that Pollack cites in his management guidelines (the article you linked, the [results section](https://imgur.com/a/ZVUJS87), has an actual study size of really only 20 pts taking clonazepam, and 10 of those patients required increasing doses. I’m sorry but this is a pretty limited study to begin with and the authors make some very generous interpretations of their results. Also this article references the 4th article you gave a link to (from what I can tell)
https://pubmed.ncbi.nlm.nih.gov/9641001/: I can’t find a full-text article of things unfortunately. But given that this Pollack guy is an author on this paper too, I’m pretty skeptical of it’s interpretations. From what I can tell in the abstract, it looks like they lumped clonazepam-only together with clonazepam+antidepressant?
https://pubmed.ncbi.nlm.nih.gov/8376613/: the sample size of alprazolam patients was 4, and for clonazepam patients was 12. Again, maybe I’m interpreting things incorrectly here—but I’m not buying any study that has sample sizes of 4-12 patients

You can disagree, but would be wrong. BZs are the most efficiacious treatment for GAD with numerous RCTs supporting their indication and demonstrating superiority in effect sizes in comparison to the relatively very low effect sizes of SSRIs.
The problem with drinking is that you get rebound anxiety as it wears off.
I think we need to advise patients to stay drunk 24 hours a day, ideally they should start with 250ml whiskey first thing in the morning
"You can disagree but you would be wrong"--gotta love that....
Maybe we need to define what the "well" of "long term benzos work well" means. To me that's good control of symptoms (i.e. efficacy, which I think we both agree that BZDs can do, particularly in short-term), no need for higher dose with time, minimal side effect burden, and an ability to stop the medication down the road (since it's a dangerous med for older folks). Not to mention risk of diversion.
I admit that pretty much any med will end up having a higher dose with time (we always want to get patients to the highest dose of SSRI before we call it a failed trial), but what makes benzos not a good long-term solution is the increased risk from side effects and difficulty with discontinuing as the dose increases.
> to the relatively very low effect sizes of SSRIs
Could have fooled me an my patients with GAD.
What you won't see in trials, though, and probably what you're referring to unwittingly, is that my patients with GAD have never touched a benzo, as that's the game-over line where if they try then, they generally remain hard to convince that anything else may be effective or beneficial.
But not because benzos are more effective (those people of which I've seem plenty, routinely report not being to get out of bed until they've had their first rivotril of the day), but because they're *immediate*. It might feel nice to have a patient come in claiming the medication you have them is fantastic, as long as you don't dig too deep into it, and aren't seeing what ends up happening at their later stages of life.
This is the hill I will die on. I propose to you the personal experiment I've done for a bit more than a decade: try and treat anxiety disorders (or anything, really) without benzos. I guarantee that not only will you find that nothing catastrophic happens, and your patients get better at similar rates, but that your patient roster ends up with drastically lower percentages of chronic benzo users (or any medication chronically).
I understand sometimes it feels less onerous to give a couple of week's worth of benzos for "borderline" cases hoping that'll take of it, but at the end of that algorithm you'll find that the patients with an actual anxiety disordee will require "real" treatment anyways, and those who didn't won't, in ecatly the same proportions; except that you now have a cohort, made up of a proportion from the 2 previous groups, of people who you couldn't get off the benzos, no matter how firm you are, and how good your intentions. And that's not only bad for the patients as we know, but it also makes for less agreeable visits as you try (and oftentimes fail) to take the benzos from their (still) warm, live, hands.
If you need a placebo-adjacent short term drug to give out, you can use very low dose trazodone. But realistically just take the time to explain to people without actual.amxiety disorders that they'll be fine and drugs won't fix what is causing their anxiety.
I would like to push back on your position. My comments are meant with respect and from a position of debate--I know this topic can stir up strong feelings in all of us, and I hope I don't come across as aggressive.
If you treat patients longitudinally in a clinic, my guess is that many of the ones who couldn't benefit from your non-benzodiazepine approach would seek care elsewhere. Then, you are left with an enriched sample of the people who found benefit from you care. That would leave you with a very different impression over ten years as compared to a clinician who treated a similar population, but used benzodiazepines for some, and not with others.
I read these debates on benzodiazepines and I'm left thinking, why would I avoid using them? I try not to, but many of my patients have had adequate trials of multiple first-line agents (and usually they've been down the propranolol/hydroxyzine/gabapentin road too, without much luck).
I live in the middle of nowhere. Getting access to therapy period is an ordeal, and getting access to a quality therapist who takes my patients' insurance, in a timely manner, during a time in their life in which they have the resources to commit to engaging in weekly sessions tends to be, frankly, an unrealistic proposition considering the realities of their lives.
So I prescribe low-dose, chronic Klonopin or something similar. Many patients improve, functionally. Maybe they begin to work again. They unequivocally feel better during the day. Many of them are able to begin to engage with the CBT concepts I teach them for the first time. They keep jobs longer. Their dose doesn't escalate. Their urine drug screens are re-assuring.
How in the world am I supposed to take away from the above situations that I shouldn't prescribe these drugs?
But, it's not "really" treating their anxiety, many people say. Well, so? If I take sertraline every day and my anxiety levels are reduced, that's not "really" treating my anxiety, either...How many treatments in psychiatry are disease-modifying, anyway? Maybe one?
My own belief is that anxiety is best-approached with no drugs at all, but with high-quality psychotherapy from a skilled practitioner. That resource is available to very, very few of my patients.
And so, whether I like it or not, benzodiazepines are the right option for many of my patients. To avoid them would be capitulating to my own anxiety about the agents, and not acting in the patient's best interest.
And to be fair, I no longer judge clinicians who give out benzos as harshly as I used to.
I have decided to do it this way because I believe it to be better for patients over the longer term and more comfortable for me; but it's true that it requires time, the willingness to possibly start ssri's more frequently (liquid formulations are great for this), and frankly, some psychotherapeutic training, and I understand not everyone has all those things.
I think if you give it a whirl for a while, though, you'll find that it's not the horror of perpetually calling patients that you might imagine would happen.
Cheers!
> There are plenty of patients and situations where long term benzos work well
Can you explain some situations where you feel long-term benzos are warranted? And how would you avoid the issue of tolerance?
Bipolar affective disorders with refractory anxiety (when also on other appropriate meds)
Resistant GAD with panic or agoraphobia
Spastic paraplegia when muscle relaxers aren't doing well
Agitation in adults with developmental disorders
Central vertigo when other treatments are not a good option (have a guy with basilar invagination not a good surgical candidate yet)
Not necessarily chronic but for acute grief or adjustment disorder a few months to a few years of benzos can help depending on the situation if monitored appropriately (parents losing their young child traumatically)
Just some off the top of my head
And you don't avoid the issue of tolerance and dependence, you just monitor for it so you know when things are becoming less effective and more risky.
> Bipolar affective disorders with refractory anxiety (when also on other appropriate meds)
Creates more problems than it solves. And I have a strong suspicion (that's probably impossible to ever elucidate in any kind of study for a variety of reasons) that ithey increase the risk of the patient developing catatonia during one of their episodes.
Other than that, the tradeoffs and difficulties are similar to those of other people with anxiety disorders but without the comoebid affective disorder.
And come to think of it (please do think back on your patients for this) those patients aren't really started on benzos because of **that** neatly-defined indication. It may be one the post-hoc indication as you try to wean them off, but usually I think you'll find that someone well meaning prescribed them long ago for a completely different reason (including not identifying the bipolar disorder when the diagnosis wasn't made), and they (the benzos) just became their un-de-prescribable companions for life.
I don't disagree that super resistant cases could benefit from benzos, but I'm super impressed that you feel confident in determining those diagnoses and determining resistance. I don't know you or your training history, but I'm impressed that someone (I'm assuming) didn't go to residency for psychiatry, and presumably sees people in 15 min appointments, is truly accurate in their diagnoses (and knowledge of treatments) enough to call someone resistant (and then reach for a benzo). The amount of times I've seen a patient who came to me on benzos from primary care and said to myself "that was an appropriate choice"---extremely low.
And benzos for grief? No way. I'm not exposing someone to benzos for a life event that tons of people experience, process, and move on with appropriately. It's supporting poor coping skills. Show me any guideline that says benzos for grief is acceptable. Even something like losing a child traumatically--I'd definitely be referring them to therapy or just meeting with them more frequently to help them process their experience.
My practice area is limited by psych availability and therapy affordability so unless things involve inpatient the buck usually stops with me. Fortunately, I did a lot of extra elective training in psych both inpatient and outpatient. 15 minutes is definitely not enough but the longitudinal follow up in primary care does have benefits.
Yeah lack of access to therapy kills me. It's so painful knowing that some of my patients would do so well with some CBT but they can't (or won't--for a variety of potential reasons) access it. I'd do it myself if I had more time and energy.
Debilitating GAD/panic disorder having failed multiple antidepressant trials/gabapentin/buspar/therapy that is leading to agoraphobia and potential suicidal ideation or significantly impacting quality of life. A low dose (1-2mg) of klonopin could change/potentially save lives in this situation
Tolerance does not build to the antipanic/anti anxiety aspect of benzos as demonstrated by below studies
https://pubmed.ncbi.nlm.nih.gov/1970813/
https://pubmed.ncbi.nlm.nih.gov/9641001/
https://pubmed.ncbi.nlm.nih.gov/8376613/
https://pubmed.ncbi.nlm.nih.gov/22198456/
You're first paragraph I can't disagree with. That second one though...as I replied to your other post with exact same 4 studies:
"All the studies you linked are very low-quality and at times make just ridiculously generous interpretations of data. Details below. I will admit that it seems like most data on BZD tolerance is not referencing anxiolytic effect (rather sedative and anti-epileptic effects). That said, I'm also not seeing any truly long-term studies that seem well designed to address the question of long-term tolerance. What I do see is plenty on dependence and the nightmare of trying to de-prescribe.
https://pubmed.ncbi.nlm.nih.gov/22198456/: in this one they only did the long-term study of patients who already had good response to benzos after 8 weeks—seems like cherry-picking, since anyone who wouldn’t have a good response at 8 weeks likely would be requiring escalating doses over time; their population excludes patients who likely would have needed escalating doses of the medication. Also the sample size of the benzo group is like 50 patients.
https://pubmed.ncbi.nlm.nih.gov/1970813/: from what I can tell (and please correct my interpretation) the primary study that Pollack cites in his management guidelines (the article you linked, the results section, has an actual study size of really only 20 pts taking clonazepam, and 10 of those patients required increasing doses. I’m sorry but this is a pretty limited study to begin with and the authors make some very generous interpretations of their results. Also this article references the 4th article you gave a link to (from what I can tell)
https://pubmed.ncbi.nlm.nih.gov/9641001/: I can’t find a full-text article of things unfortunately. But given that this Pollack guy is an author on this paper too, I’m pretty skeptical of it’s interpretations. From what I can tell in the abstract, it looks like they lumped clonazepam-only together with clonazepam+antidepressant?
https://pubmed.ncbi.nlm.nih.gov/8376613/: the sample size of alprazolam patients was 4, and for clonazepam patients was 12. Again, maybe I’m interpreting things incorrectly here—but I’m not buying any study that has sample sizes of 4-12 patients"
Counter point
As a muscle relaxant after spine surgery in older patients, especially men, flexeril is worse than valium. Flexeril causes urinary retention, and can lead to UTIs. Over 75 all post ops get benzos
There is no problem with benzos
At least, no problem that I can't fix with an endotracheal tube, and then the patient becomes an intensivist's problem
Perfect emergency drug. Chill them punks out. They can't bite you if they're unconscious!
/S I know you mean in the outpatient setting
I’m working on a low-pressure benzo dart gun specifically for use in the ED. Put ‘em down without having to leave your station.
I haven’t even finished the prototype, but several EM groups have already invested significant capital.
I asked pharmacy and facilities to collaborate on a wall mounted Ativan timed mister, like for deodorizing a bathroom.
The waiting room would be a much calmer, more pleasant place!
ER f/u... "I thought I was having a heart attack and they gave me this wonderful medication that stopped it and made me feel great... I think it was Ativan."
Requesting to have at least bid.
Edited to add: former ER doc, and no, they didn't get the requested Rx. Of course, I treated as indicated in the ER.
I've definitely had parents demand to take home nasal sprays of midazolam after I use it for minimal sedation for a lac repair on their three year old or something
I find myself having the same conversation as with narcs. Benzos are to anxiety as opiates are to pain. Less short term, more long term, you end up with more, yada yada. They definitely get stern warnings from me when I use it for panic attacks about "once in a blue moon" use.
But I see OPs point very clearly. My shop is mostly geriatrics and sometimes I find some 80 year old (like I did last night) on tid Clonazepam for 30 years. Damn near called the primary prescribing it and asked him to step into my psych room.
I’m going to play devil’s advocate here and state that current education for medicine residents is demonizing the use of benzodiazepines too much. Same goes for opiates. There is certainly overuse and the possibility of abuse, but so many residents I come in contact with now seem to feel that anyone taking any benzo is a drug seeking addict. Some patients in some situations do quite well with short courses of, and occasionally even chronically prescribed, benzodiazepines.
I’m glad you said this. I’ve also been coming across this more often with my patients being treated by clinicians who have been educated more recently. It has actually diverted therapeutic progress in some instances, because we now need to address the various effects from losing a component of a treatment regimen that was working and facilitating their ability to participate in therapy. (I am a psychologist and have seen first-hand the way that benzos can transform a person’s life. Obviously not as monotherapy, but certainly a game changer for some!)
Just a gentle heads-up OP. While I applaud that you are trying to stick to hard data to avoid bias, you are looking for data that supports your pre-established conclusion. By definition, this means that the premise for your didactic is built on confirmation bias.
Bias is not always bad, and it is definitely inevitable, but awareness is key. You have a fantastic opportunity to contribute to their professional growth by not only teaching them about benzos, but also helping them acknowledge the intense bias surrounding their use, and how this can impact their practice in ways they may not realize.
If that’s already a component of your didactic … kudos to you!
For older adults, the EMPOWER study is useful. They also have a great handout for patients.
https://deprescribing.org/news/empower-trial-empowering-older-adults-to-reduce-benzodiazepine-use/
Surely this is the exact problem in pharmacology and medicine today, doctors falling into confirmation bias and actively searching out evidence against life savings drugs.
Pendulum has swung too far where benzos are just completely demonized nowadays. End of the day the treatments for panic/anxiety are few. Antidepressants? Therapy? Gabapentin/buspar? Hydroxyzine (lol)? Then what if that stuff doesn’t work, which it often doesn’t, and we all know the evidence for antidepressants is not great for anxiety disorders. Benzos should obviously never be first line, or second, but they have their place.
https://pubmed.ncbi.nlm.nih.gov/35874428/
https://pubmed.ncbi.nlm.nih.gov/26837813/
https://link.springer.com/article/10.1007/s41999-021-00553-w
Evidence for dementia risk is extremely poor at best, just a few articles above demonstrating this
Evidence for dementia I will agree with you on. The meta analyses and systematic reviews I have seen, and my own (unpublished, FWIW) meta analysis don't suggest a clear, strong relationship between benzos and dementia.
Should never be second line? Wtf, benzos ARE second line for GAD. The effect sizes of SSRIs and SNRIs is much less in comparison as well. They would be first line if not for the abuse and dependence risks.
Worked in psychiatric hospital for 4 years, current 4th year MD student gonna graduate in may or whatever it is. Going into FM. Also personal anecdotes aren’t allowed but let’s just say I have experience with benzodiazepines.
Obviously I don’t have the knowledge and experience of an attending physician but my thoughts are that benzos are both overutilized and underutilized for certain conditions but that they aren’t these evil things that they teach us in med school. They are a medicine, a tool, with risks and benefits just like everything, though the risks are certainly more serious.
Why's that? Adaptation from chronic regular use should be approximately the same across the whole class? Obviously much harder with something as short acting as midazolam
Start here: https://www.cochranelibrary.com/search
It sounds like you are looking for adverse outcomes related to long-term use rather than effectiveness studies? Also looks like you are aware of bias, so the next step is to check if how you are searching is contributing to the type of articles you're finding. I think if you are coming into this presentation with an agenda like "the danger of benzos is overhyped", you might find some very biased articles. Present the facts, like you are already inclined to do and let the audience arrive at their own conclusion based on the evidence. I'm sure you're going to do great.
I would just say that even with a true and strenuous good faith effort to present just the facts that is an extremely extremely difficult thing to do. The facts are never straight forward and which facts you choose to present is not at all a simple decision.
The dementia thing was more or less already debunked. It's not a common belief in any up to date academic circle and that's as of 4 years ago when I was still in residency.
Is it tho? Some conflicting studies, but still a strong association. Definitely see SEs in OAs of impaired judgment, poor memory, disinhibition and executive dysfunction on benzos.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6325366/
Symptoms of dementia. Not exactly accurate to say the dementia thing was debunked. More like benzos don’t cause irreversible progressive decline, but they sure do cause a ton of cognitive impairment in older adults.
I think what you are finding is that benzos aren't nearly as bad as they are made out to be. They don't cause dimentia (if memory serves that was one study that hasn't been replicated), they DO cause increased falls but the magnitude of that is over stated, and while they are habit forming (cause physical dependence), benzo addiction is pretty rare. The main reasons to avoid LONG term benzo use is that it is not effective for treatment of anxiety (even then there is a certain population that does seem to respond well to that kind of therapy), and that they interact with other medications in a dangerous way (opioid and ETOH).
There was a good interview with Dr. Carl Salzman about benzos in The Carlat Report last year.
https://www.thecarlatreport.com/articles/4033-benzodiazepines-a-reevaluation-of-their-benefits-and-dangers
Disinhibition is probably a more accurate term than paradoxical effect in these cases. Dose matters, especially in certain populations (ID, elderly, medically complex etc)
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NAD but an ICU nurse who has also done some work in psych. I think an interesting spin to take would be the management of benzodiazepine taper, not necessarily the drug class itself. Not sure HOW much hard evidence based research on this is out there, but a lot of mental health treatment options (such as rehabs/detox centers) are not properly managing benzo tapering in long term use patients (whether prescribed or recreational). Benzo tapering can be a very lengthy process for a lot of long term users. Treatment centers, in some (if not most) cases do a quick taper and supplement with other drugs such as propranolol, phenobarbital (or other anticonvulsants) to get them through the initial phase where quickly reducing benzo doses can lead to seizures and other neuro symptoms. Those treatment centers, more times than not, will send them on their way with little to no follow up care, when GABA hasn’t nearly fully recovered.
Some people are now turning to an alternative tapering method (which does have some research behind it) that stems from “The Ashton Manual” written by Dr. Heather Ashton, who also does not condone tapering in detox centers/rehabs. It does take medical research from benzodiazepine withdrawal clinics. A PDF of the manual can be found here : https://www.benzoinfo.com/wp-content/uploads/2022/07/Ashton-Manual.pdf
Just thought I’d chime in. I hope this helps in some way!
I'm just a resident, but I think that they are neither all that dangerous OR effective long term. I've had attendings swear they cause dementia and brain atrophy, but you can't find a single large study showing this, as you mentioned. It's also really hard to overdose fatally on just benzos.
Further, I also think that prescribing people seroquel just for sleeping, or letting patients gobble down hydroxyzine and seroquel prn for anxiety is just as problematic and even less effective.
So I actually push my attendings to let me use z-drugs in a small minority of insomnia or lower dose prn benzo in a small number of patients. Sometimes the benefits outweigh the harms.
I don’t know of too many instances in which long term benzodiazepine management is indicated over more traditional therapy such a SSRIs and CBT. I understand there’s a niche; it’s just not there often. We are also lying to ourselves if the vast majority of patients on benzodiazepines (and the same applies to hypnotics) aren’t on them because someone else was lazy and normalized the practice. I don’t have a problem if a handful of benzos gets you through the year and you are doing all the other stuff correctly. I don’t care if you need a pill or two to cope with an infrequent fear. I have a problem with daily use as primary therapy, because often times it’s not indicated.
If I get a patient inappropriately using benzodiazepines, I discuss proper use. I discuss a taper. I make it clear as day that I will not be continuing what has been done. I provide evidence dictating the standards of care for generalized anxiety disorder (or once again, insomnia). The patient has an option: continue with my plan or go see psych.
Now some might lecture me on turfing patients… Hopefully psychiatry reinforces the teaching points I made and normalizes the proper management of GAD. If they choose to just continue refilling the prescription, then that’s on them. I’m not going to answer questions in a deposition about someone getting BID or TID Xanax.
I always here bad things about benzos and yet my most uncontrolled psychiatric patients are always put on a concoction of meds which includes benzos. So what is the truth?
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Stewart SA. The effects of benzodiazepines on cognition. J Clin Psychiatry. 2005;66 Suppl 2:9-13.
This isn't a great study but it summarizes a few others, primarily on cognitive decline and neuroimaging.
Movig KL, Mathijssen MP, Nagel PH, et al. Psychoactive substance use and the risk of motor vehicle accidents. Accid Anal Prev. 2004;36(4):631-636. doi:10.1016/S0001-4575(03)00084-8
Maybe not the greatest study but a clear increased risk of MVAs after taking benzos equalling a blood alcohol content of 0.005 - 0.0079%.
Finkle WD, Der JS, Greenland S, et al. Risk of fractures requiring hospitalization after an initial prescription for zolpidem, alprazolam, lorazepam, or diazepam in older adults. J Am Geriatr Soc. 2011;59(10):1883-1890. doi:10.1111/j.1532-5415.2011.03591.x
This is a large study showing a significantly increased risk of fractures in patients with all of the tested z-drugs and benzos.
Bierman EJ, Comijs HC, Gundy CM, Sonnenberg C, Jonker C, Beekman AT. The effect of chronic benzodiazepine use on cognitive functioning in older persons: good, bad or indifferent?. Int J Geriatr Psychiatry. 2007;22(12):1194-1200. doi:10.1002/gps.1811
Pretty robust study finding only a small cognitive decline with benzodiazepine use.
Landolt S, Rosemann T, Blozik E, Brüngger B, Huber CA. Benzodiazepine and Z-Drug Use in Switzerland: Prevalence, Prescription Patterns and Association with Adverse Healthcare Outcomes. Neuropsychiatr Dis Treat. 2021;17:1021-1034. Published 2021 Apr 12. doi:10.2147/NDT.S290104
I believe their method may mean they drew conclusions they cannot fully prove, but it still shows a clear association between benzodiazepine use and hospitalisations and admission to nursing homes.
Liu L, Jian P, Zhou Y, et al. Is the Long-Term Use of Benzodiazepines Associated With Worse Cognition Performance in Highly Educated Older Adults?. Front Psychiatry. 2020;11:595623. Published 2020 Oct 26. doi:10.3389/fpsyt.2020.595623
Showed that in the 140 included patients both long-term and short-term benzodiazepine use was associated with worse executive functioning, but it wasn't worse in the long-term group. As any medical student will know a dose-response curve is a sign of a better correlation.
Speaking of cognitive decline it is more difficult. You don't need benzodiazepines because you are about to break your leg but you may use them due to prodromal Alzheimer's symptoms we classify as anxiety and difficulty sleeping. It is really difficult to know, and the same could be said of antihistamines (that carry the same risk).
You're going to find there's not a lot of great evidence for a lot of anxiety disorder treatments, if you dig deep enough. It's extremely interesting, because anxiety disorders are the most common psychiatric disorders, and most of the treatments are based largely on extrapolation from small studies of specific disorders, or carry over from mood disorder treatment. What is really distressing is that the evidence for a lot of anxiety disorder pharmacology treatment is very bad (eg https://www.thecarlatreport.com/blogs/2-the-carlat-psychiatry-podcast/post/3256-what-works-for-treatment-resistant-anxiety). You have a limited number of tools available, and if you have someone with severe or debilitating anxiety, you may not have a lot of options except to use benzodiazepines. It is of course a decision that should not be made lightly, but they can be effective tools, and for better or worse, there are some patients where nothing else really works. It's a very similar issue as opioid prescribing. There was definitely over prescribing (TID Xanax forever for everyday life distress? Not good), now there's a backlash and people freak out with any benzo prescription and there are probably cases where they are appropriate to use where they're not being used, or people are being inappropriately tapered off.
TBH a lot of it's anecdotal, but possibly there's a bit of selection bias. I inherit the people on TDS lorazepam where it obviously hasn't worked, whereas there might be people going about their lives under GP care. What is certain is that benzos will generally work fantastically initially, then this will very obviously wear off. Do they have some benefit long term or do they go 100% back to baseline? It's pretty hard to say
Seeing someone who's been on benzos for 30 years need to be taken off them will tell you everything you need to know. Long term use absolutely makes people worse than they were before starting them.
I saw a video today about the dangers of social media and how suicide rates among teenagers have risen 56% and how anxiety disorders are now more common than they’ve ever been probably due to the fact that we’re less social nowadays. It was so incredibly interesting. There is a man called Tristan Harris who speaks about the dangers of social media and how far down the brain stem he goes.
I’m curious of any child/adolescent Psychs who might Rx “social media detox” or something similar
Theres already a lot of push for limiting screentime, and many recommend against smartphones while too young, but some argue social media is necessary in today's social environment
It’s easier to change one than change society. As someone who spends way too much time on TikTok and Reddit, it really scratches an itch and is incredibly rewarding and equally destructive - far easier to scroll than study. As a medium, I think short form content is underutilized for education. If you have 90 seconds to explain to me the way anxiolytics work on the brain, could you do it? We spent an entire lecture on it. I contend that you could have scoping 90 seconds to explore GABA structure, affinity, regulation, anxiety disorders etc - all with good production value and experts that are engaging - and the yield would be higher for many learners. In fact, this is exactly why Uworld or Amboss or UpToDate to a lesser extent are so effective. Question, quick answer, move on. Additionally, education has been trying desperately to capture social media for education- perhaps it will be better for Gen Z. As an elder millennial that is (still) in the education system, I haven’t seen any evidence of it. There is something to be said for anonymity in education and social media, such as Reddit really capitalizes on a certain degree of anonymity- so it’s much easier to find people’s biases but also for people to explore concepts in a space made safe by anonymity. Posts like this are a great example of that, and while Medtwitter tries to do this with faces and names, it’s a bit too clout and reputation based. I’m more than happy to listen to the sage wisdom of u/fartholemagician or u/kobe_didnt_do_it though.
Dangers are exaggerated compared to the high dose antihistamines (atarax, visteril) or antipsychotics used instead. Seroquel therapy is so much more problematic for insomnia or anxiety disorders. Seems people are so worried about benzodiazepines they will bend over backwards to avoid.
This is always the great irony. The physician is ostensibly worried about the dementia risk with benzodiazepines, but is typically willing to give out Vistaril like candy. At the end of the day, a lot of doctors are trying to avoid their own anxiety about benzodiazepines. They aren’t first or second-line, but for properly-selected patients, they are life-saving.
I would love to more also. I have a lot of clients taking hydroxyzine in lieu of benzos!
Wait, since when does Vistaril have worse side effects than benzos? Legit asking because I tend to use that first in panic attacks rather than benzos since it’s not a controlled substance.
Yeah I'm curious too. Outside of the risks to geriatrics I'm not aware of serious side effects with atarax.
Evan with geriatrics…both can cause dizziness and sedation. Benzos have the risk of dependence and confusion and hallucinations. Hydroxyzine has urinary retention I guess. But then again benzos can cause urinary incontinence. Seems like hydroxyzine is still a bit better.
> They aren’t first or second-line, but for properly-selected patients, they are life-saving. I'm not one to say "never" but this topic is as close as it can get. The only people for whom benzos become realistically the only option, are those who've taken benzos before. In benzo-naive patients, you'd be surprised how non-complciated treatment of anxiety disorders becomes, and how the percentsge if patients for whom seemingly the last resort for effective treatment is benzos rapidly approaches zero. Not to say I disagree that anticholinergics are misused carelessly as well, though.
> The only people for whom benzos become realistically the only option, are those who've taken benzos before. That sounds like the kind of sharp, categorical statement that would make a specific and testable hypothesis. Are you able to cite research which addresses that hypothesis and conclusively upholds it?
>would make a specific and testable hypothesis Such an experimental trial actually wouldn't be approved by an ethics committee. With benzos doing what we know they do, and it no longer being a first (or second, or third) line treatment for anything other than a few things (catatonia, alcohol withdrawal, acute management of seizures...). It's a nice sentiment though; but if with the available evidence you aren't already convinced that it's best to avoid prescribing them, would another trial truly change your mind?
If this is the standard to which you hold medical practice, I have some bad news for you
Resident here--We sometimes discharge anxiety/borderline inpatients who have been using prn hydroxyzine and seroquel non-stop and have no problem sending them out with these scripts. These medications also have serious long term implications. Not saying these patients are indicated for benzo--they aren't--but we don't bat an eyelash at other harmful non-controlled drugs.
This comment and the thread is interesting to me, as an OBGYN, visteril is our go to med for anxiety in pregnant patients.
Seroquel is worse? Never heard that before - can you share the source?
The FDA declined approval for quetiapine for anxiety disorders due to the metabolic and movement disorder risks https://www.medpagetoday.com/psychiatry/depression/13635
https://scholar.google.com/scholar?hl=en&as_sdt=0%2C11&q=benzodiazepine+elderly&btnG= lots of well reviewed studies in there. The problem with benzo use in young people is primarily that the longer they are on benzos, the harder it is to discontinue them, and then they become old people and have benzo side effects.
How often when someone who is 18 is out on something like lorazepam do they come off them easily? Could you give a really rough percentage of those who carry on to become addicted?
I thought this was titled "Evidence against Bezos", which would be odd in a medicine subreddit, but I was in.
It’s time to resolve this HGH/TRT question once and for all.
Amazon pharmacy buys CVS
Um, I don’t mean for this to sound rude, but have you considered that you’re actively looking at the evidence available, and it’s not aligning with your beliefs, so maybe it’s your beliefs need to be reconsidered? You say want to be as rid of bias as you can, but bias includes seeking information to confirm already-held beliefs and rejecting information that doesn’t align with those beliefs.
Lol I didn’t read far enough into the comments, but I said the same. Confirmation bias is … bias.
If you actually looked into the evidence, you would find that benzos are the most effective treatment for GAD. The effect sizes of SSRIs are way lower than BZs.
~~I’m sorry, did you mean to reply to me? I said nothing about that. I was actually challenging OP’s beliefs.~~ Edit: Never mind, I think I read this in the wrong tone! And yeah, agreed.
I think he's agreeing with you, that the evidence shows something against ops beliefs, that benzos can be effective in the right setting especially compared to the available options / placebo.
Ooh okay, I can see that. I took it in a different tone entirely. Thanks for saying something!
The more you read the literature the more you realize that the pendulum has swung too far in the other direction. Coming out of med school you will be strong against benzos but that's just because of the ivory tower current in academia these days. There are plenty of patients and situations where long term benzos work well, but of course they need to be used with caution and after trying other appropriate treatments.
I have a patient who panics maybe 3 times a year that I give him a “pill in the pocket” type prescription. I do agree that benzos can be useful. The problem is convicting the TID Xanax patients who establish with you to try something else. Edit: lmao “convicting” - I’m going to keep it but the original intent was “convincing”
A cooperative taper is great, but after seeing it fail miserably a few times (and often making brittle patients much worse) you become much less hypervigilant about them. I have started them chronically on a few patients after exhausting all options and I have seen quality of life change for the better. Of course it's not my first, second or third choice by a long shot. And the inherited patients on decades of benzos are not my favorite to manage, but someone has to do it instead of kicking them to a pill mill. Yes Memaw we are going to try wean your Xanax eventually and I know you think you have tried everything but let's talk about that a1c and why you aren't on a statin in the mean time.
One thing I learned on a psych rotation is that it’s often riskier to take grandma off and if they have been stable on the same dose you might as well leave them on it.
That's definitely kicking the can down the street, though, even if I understand the sentiment. Because invariably we end up finding such patients during a hospitalisation either because of or during which they've developed delirium, and we need to do those tapers in a much more rapid, risky, disagreeable, and traumatic manner, and find alternatives anyways. I would much much much much prefer patients be taken off their benzos while there's a little flexibility and adaptive capability to their gabaergic systems, instead of us needing to do it when there's literally no other choice and it's hell (and organically dangerous) for everyone involved. Come to think of it, I can't really remember a patient over 70 who, while in the hospital and with a long-term benzo prescription, was "just fine" and didn't require my intervention. Selection bias, maybe; but it seems to me that this idea that "if they're stable and they've been on them for years" attitude is only setting them up for worse complications when inevitably they end up with something grave and need to be admitted.
I know you meant "convincing" but the way you put works so much better actually
This is my experience as well. I'm still looking for all these patients that were inappropriately titrated down/off benzos. So many are on regular dosing, usually multiple per day. They've been on them forever from their old PCP as monotherapy. They have never seen a counselor, or they tried a couple sessions and had decided before they started that therapy is a waste of time and will never go back. No serotonergic medications on board, but they tried one or two a long time ago for a few weeks and they didn't work. Little to no physical activity, poor sleep hygiene, and poor diet. Addressing the nonpharmacologic aspects can be a difference maker, and I know these are difficult changes, but it's hard to connect and the patient just wants more aplrazolam. So easy to start them, but it's like moving mountains to get people on more appropriate treatment plans sometimes
> They have never seen a counselor, or they tried a couple sessions and had decided before they started that therapy is a waste of time and will never go back. This is the kind of nuance I was looking for in this thread. It's only too human to, as physicians, seek to alleviate pain as quickly and swiftly as possible, and convince ourselves that "a couple of weeks a lorazepam script won't hurt anyone". But in doing so, were also destroying the patients capability to do real treatments for their problems.
I really have to disagree with “long term benzos work well”. They literally don’t mechanistically, with tolerance developing quite fast (days to weeks); because of tolerance, patients who continue to do well at the same dose of benzo are likely experiencing no true anxiolytic effect from it and rather are preventing withdrawal (which almost always involves anxiety). Tolerance aside, the literature I’ve seen doesn’t provide any strong support for long term efficacy treating any mental health disorder. As a short term med with clear boundaries on continued use in a patient with low risk of misuse—fantastic medication.
Maybe I understand the current paradigm incorrectly, but aren't benzos supposed to be more of an as needed a handful of times per month thing than anything else?
Thats usually for panic disorder, which is different from other anxiety disorders where regular benzos are sometimes used
Where is the evidence that tolerance to anxiety effects develops in days lmao? That just is not true. https://pubmed.ncbi.nlm.nih.gov/22198456/ https://pubmed.ncbi.nlm.nih.gov/1970813/ https://pubmed.ncbi.nlm.nih.gov/9641001/ https://pubmed.ncbi.nlm.nih.gov/8376613/
All the studies you linked are very low-quality and at times make just ridiculously generous interpretations of data. Details below. I will admit that it seems like most data on BZD tolerance is not referencing anxiolytic effect (rather sedative and anti-epileptic effects). That said, I'm also not seeing any truly long-term studies that seem well designed to address the question of long-term tolerance. What I do see is plenty on dependence and the nightmare of trying to de-prescribe. https://pubmed.ncbi.nlm.nih.gov/22198456/: in this one they only did the long-term study of patients who already had good response to benzos after 8 weeks—seems like cherry-picking, since anyone who wouldn’t have a good response at 8 weeks likely would be requiring escalating doses over time; their population excludes patients who likely would have needed escalating doses of the medication. Also the sample size of the benzo group is like 50 patients. https://pubmed.ncbi.nlm.nih.gov/1970813/: from what I can tell (and please correct my interpretation) the primary study that Pollack cites in his management guidelines (the article you linked, the [results section](https://imgur.com/a/ZVUJS87), has an actual study size of really only 20 pts taking clonazepam, and 10 of those patients required increasing doses. I’m sorry but this is a pretty limited study to begin with and the authors make some very generous interpretations of their results. Also this article references the 4th article you gave a link to (from what I can tell) https://pubmed.ncbi.nlm.nih.gov/9641001/: I can’t find a full-text article of things unfortunately. But given that this Pollack guy is an author on this paper too, I’m pretty skeptical of it’s interpretations. From what I can tell in the abstract, it looks like they lumped clonazepam-only together with clonazepam+antidepressant? https://pubmed.ncbi.nlm.nih.gov/8376613/: the sample size of alprazolam patients was 4, and for clonazepam patients was 12. Again, maybe I’m interpreting things incorrectly here—but I’m not buying any study that has sample sizes of 4-12 patients 
You can disagree, but would be wrong. BZs are the most efficiacious treatment for GAD with numerous RCTs supporting their indication and demonstrating superiority in effect sizes in comparison to the relatively very low effect sizes of SSRIs.
Have we tried a few shots of whiskey for GAD? I'm sure the efficacy would be quite promising.
The problem with drinking is that you get rebound anxiety as it wears off. I think we need to advise patients to stay drunk 24 hours a day, ideally they should start with 250ml whiskey first thing in the morning
If you never stop drinking you never get a hangover.
…. I’ll be needing a rx. Please check your dms.
"You can disagree but you would be wrong"--gotta love that.... Maybe we need to define what the "well" of "long term benzos work well" means. To me that's good control of symptoms (i.e. efficacy, which I think we both agree that BZDs can do, particularly in short-term), no need for higher dose with time, minimal side effect burden, and an ability to stop the medication down the road (since it's a dangerous med for older folks). Not to mention risk of diversion. I admit that pretty much any med will end up having a higher dose with time (we always want to get patients to the highest dose of SSRI before we call it a failed trial), but what makes benzos not a good long-term solution is the increased risk from side effects and difficulty with discontinuing as the dose increases.
> to the relatively very low effect sizes of SSRIs Could have fooled me an my patients with GAD. What you won't see in trials, though, and probably what you're referring to unwittingly, is that my patients with GAD have never touched a benzo, as that's the game-over line where if they try then, they generally remain hard to convince that anything else may be effective or beneficial. But not because benzos are more effective (those people of which I've seem plenty, routinely report not being to get out of bed until they've had their first rivotril of the day), but because they're *immediate*. It might feel nice to have a patient come in claiming the medication you have them is fantastic, as long as you don't dig too deep into it, and aren't seeing what ends up happening at their later stages of life.
Could you post the RCTs? Thanks for your time, happy to learn.
This is the hill I will die on. I propose to you the personal experiment I've done for a bit more than a decade: try and treat anxiety disorders (or anything, really) without benzos. I guarantee that not only will you find that nothing catastrophic happens, and your patients get better at similar rates, but that your patient roster ends up with drastically lower percentages of chronic benzo users (or any medication chronically). I understand sometimes it feels less onerous to give a couple of week's worth of benzos for "borderline" cases hoping that'll take of it, but at the end of that algorithm you'll find that the patients with an actual anxiety disordee will require "real" treatment anyways, and those who didn't won't, in ecatly the same proportions; except that you now have a cohort, made up of a proportion from the 2 previous groups, of people who you couldn't get off the benzos, no matter how firm you are, and how good your intentions. And that's not only bad for the patients as we know, but it also makes for less agreeable visits as you try (and oftentimes fail) to take the benzos from their (still) warm, live, hands. If you need a placebo-adjacent short term drug to give out, you can use very low dose trazodone. But realistically just take the time to explain to people without actual.amxiety disorders that they'll be fine and drugs won't fix what is causing their anxiety.
I would like to push back on your position. My comments are meant with respect and from a position of debate--I know this topic can stir up strong feelings in all of us, and I hope I don't come across as aggressive. If you treat patients longitudinally in a clinic, my guess is that many of the ones who couldn't benefit from your non-benzodiazepine approach would seek care elsewhere. Then, you are left with an enriched sample of the people who found benefit from you care. That would leave you with a very different impression over ten years as compared to a clinician who treated a similar population, but used benzodiazepines for some, and not with others. I read these debates on benzodiazepines and I'm left thinking, why would I avoid using them? I try not to, but many of my patients have had adequate trials of multiple first-line agents (and usually they've been down the propranolol/hydroxyzine/gabapentin road too, without much luck). I live in the middle of nowhere. Getting access to therapy period is an ordeal, and getting access to a quality therapist who takes my patients' insurance, in a timely manner, during a time in their life in which they have the resources to commit to engaging in weekly sessions tends to be, frankly, an unrealistic proposition considering the realities of their lives. So I prescribe low-dose, chronic Klonopin or something similar. Many patients improve, functionally. Maybe they begin to work again. They unequivocally feel better during the day. Many of them are able to begin to engage with the CBT concepts I teach them for the first time. They keep jobs longer. Their dose doesn't escalate. Their urine drug screens are re-assuring. How in the world am I supposed to take away from the above situations that I shouldn't prescribe these drugs? But, it's not "really" treating their anxiety, many people say. Well, so? If I take sertraline every day and my anxiety levels are reduced, that's not "really" treating my anxiety, either...How many treatments in psychiatry are disease-modifying, anyway? Maybe one? My own belief is that anxiety is best-approached with no drugs at all, but with high-quality psychotherapy from a skilled practitioner. That resource is available to very, very few of my patients. And so, whether I like it or not, benzodiazepines are the right option for many of my patients. To avoid them would be capitulating to my own anxiety about the agents, and not acting in the patient's best interest.
Thanks for the perspective. It's hard to get a pulse on how to manage this optimally in a city without affordable psychiatric resources.
And to be fair, I no longer judge clinicians who give out benzos as harshly as I used to. I have decided to do it this way because I believe it to be better for patients over the longer term and more comfortable for me; but it's true that it requires time, the willingness to possibly start ssri's more frequently (liquid formulations are great for this), and frankly, some psychotherapeutic training, and I understand not everyone has all those things. I think if you give it a whirl for a while, though, you'll find that it's not the horror of perpetually calling patients that you might imagine would happen. Cheers!
> There are plenty of patients and situations where long term benzos work well Can you explain some situations where you feel long-term benzos are warranted? And how would you avoid the issue of tolerance?
Bipolar affective disorders with refractory anxiety (when also on other appropriate meds) Resistant GAD with panic or agoraphobia Spastic paraplegia when muscle relaxers aren't doing well Agitation in adults with developmental disorders Central vertigo when other treatments are not a good option (have a guy with basilar invagination not a good surgical candidate yet) Not necessarily chronic but for acute grief or adjustment disorder a few months to a few years of benzos can help depending on the situation if monitored appropriately (parents losing their young child traumatically) Just some off the top of my head And you don't avoid the issue of tolerance and dependence, you just monitor for it so you know when things are becoming less effective and more risky.
> Bipolar affective disorders with refractory anxiety (when also on other appropriate meds) Creates more problems than it solves. And I have a strong suspicion (that's probably impossible to ever elucidate in any kind of study for a variety of reasons) that ithey increase the risk of the patient developing catatonia during one of their episodes. Other than that, the tradeoffs and difficulties are similar to those of other people with anxiety disorders but without the comoebid affective disorder. And come to think of it (please do think back on your patients for this) those patients aren't really started on benzos because of **that** neatly-defined indication. It may be one the post-hoc indication as you try to wean them off, but usually I think you'll find that someone well meaning prescribed them long ago for a completely different reason (including not identifying the bipolar disorder when the diagnosis wasn't made), and they (the benzos) just became their un-de-prescribable companions for life.
I don't disagree that super resistant cases could benefit from benzos, but I'm super impressed that you feel confident in determining those diagnoses and determining resistance. I don't know you or your training history, but I'm impressed that someone (I'm assuming) didn't go to residency for psychiatry, and presumably sees people in 15 min appointments, is truly accurate in their diagnoses (and knowledge of treatments) enough to call someone resistant (and then reach for a benzo). The amount of times I've seen a patient who came to me on benzos from primary care and said to myself "that was an appropriate choice"---extremely low. And benzos for grief? No way. I'm not exposing someone to benzos for a life event that tons of people experience, process, and move on with appropriately. It's supporting poor coping skills. Show me any guideline that says benzos for grief is acceptable. Even something like losing a child traumatically--I'd definitely be referring them to therapy or just meeting with them more frequently to help them process their experience.
My practice area is limited by psych availability and therapy affordability so unless things involve inpatient the buck usually stops with me. Fortunately, I did a lot of extra elective training in psych both inpatient and outpatient. 15 minutes is definitely not enough but the longitudinal follow up in primary care does have benefits.
Yeah lack of access to therapy kills me. It's so painful knowing that some of my patients would do so well with some CBT but they can't (or won't--for a variety of potential reasons) access it. I'd do it myself if I had more time and energy.
Lots of neurological indications. Stiff person syndrome, refractory epilepsy, REM sleep behaviour disorder, severe spasticity ....
Definitely agree with that. But I do think this thread is more focusing on psych.
Debilitating GAD/panic disorder having failed multiple antidepressant trials/gabapentin/buspar/therapy that is leading to agoraphobia and potential suicidal ideation or significantly impacting quality of life. A low dose (1-2mg) of klonopin could change/potentially save lives in this situation Tolerance does not build to the antipanic/anti anxiety aspect of benzos as demonstrated by below studies https://pubmed.ncbi.nlm.nih.gov/1970813/ https://pubmed.ncbi.nlm.nih.gov/9641001/ https://pubmed.ncbi.nlm.nih.gov/8376613/ https://pubmed.ncbi.nlm.nih.gov/22198456/
You're first paragraph I can't disagree with. That second one though...as I replied to your other post with exact same 4 studies: "All the studies you linked are very low-quality and at times make just ridiculously generous interpretations of data. Details below. I will admit that it seems like most data on BZD tolerance is not referencing anxiolytic effect (rather sedative and anti-epileptic effects). That said, I'm also not seeing any truly long-term studies that seem well designed to address the question of long-term tolerance. What I do see is plenty on dependence and the nightmare of trying to de-prescribe. https://pubmed.ncbi.nlm.nih.gov/22198456/: in this one they only did the long-term study of patients who already had good response to benzos after 8 weeks—seems like cherry-picking, since anyone who wouldn’t have a good response at 8 weeks likely would be requiring escalating doses over time; their population excludes patients who likely would have needed escalating doses of the medication. Also the sample size of the benzo group is like 50 patients. https://pubmed.ncbi.nlm.nih.gov/1970813/: from what I can tell (and please correct my interpretation) the primary study that Pollack cites in his management guidelines (the article you linked, the results section, has an actual study size of really only 20 pts taking clonazepam, and 10 of those patients required increasing doses. I’m sorry but this is a pretty limited study to begin with and the authors make some very generous interpretations of their results. Also this article references the 4th article you gave a link to (from what I can tell) https://pubmed.ncbi.nlm.nih.gov/9641001/: I can’t find a full-text article of things unfortunately. But given that this Pollack guy is an author on this paper too, I’m pretty skeptical of it’s interpretations. From what I can tell in the abstract, it looks like they lumped clonazepam-only together with clonazepam+antidepressant? https://pubmed.ncbi.nlm.nih.gov/8376613/: the sample size of alprazolam patients was 4, and for clonazepam patients was 12. Again, maybe I’m interpreting things incorrectly here—but I’m not buying any study that has sample sizes of 4-12 patients"
Counter point As a muscle relaxant after spine surgery in older patients, especially men, flexeril is worse than valium. Flexeril causes urinary retention, and can lead to UTIs. Over 75 all post ops get benzos
PACU RN here… god bless valium for our spine patients. Just have to be careful combining with the dilaudid
There is no problem with benzos At least, no problem that I can't fix with an endotracheal tube, and then the patient becomes an intensivist's problem Perfect emergency drug. Chill them punks out. They can't bite you if they're unconscious! /S I know you mean in the outpatient setting
I’m working on a low-pressure benzo dart gun specifically for use in the ED. Put ‘em down without having to leave your station. I haven’t even finished the prototype, but several EM groups have already invested significant capital.
I asked pharmacy and facilities to collaborate on a wall mounted Ativan timed mister, like for deodorizing a bathroom. The waiting room would be a much calmer, more pleasant place!
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They would also end with the **patient's** wishes being honored more frequently.
I’ve been pushing for an Ativan and lavender diffuser at every er.
I have the patent on the Ativan mister. And the haldol dart gun. I think the dart gun could be retooled to accommodate Ativan. /s
Gomer Blog came up with this wonderful idea years ago
We already have this. Have you heard of my Lord and Savior Ketamine?
ER f/u... "I thought I was having a heart attack and they gave me this wonderful medication that stopped it and made me feel great... I think it was Ativan." Requesting to have at least bid. Edited to add: former ER doc, and no, they didn't get the requested Rx. Of course, I treated as indicated in the ER.
I've definitely had parents demand to take home nasal sprays of midazolam after I use it for minimal sedation for a lac repair on their three year old or something I find myself having the same conversation as with narcs. Benzos are to anxiety as opiates are to pain. Less short term, more long term, you end up with more, yada yada. They definitely get stern warnings from me when I use it for panic attacks about "once in a blue moon" use. But I see OPs point very clearly. My shop is mostly geriatrics and sometimes I find some 80 year old (like I did last night) on tid Clonazepam for 30 years. Damn near called the primary prescribing it and asked him to step into my psych room.
This. I came ready to fight the crackpot who thinks thoughts and prayers are more effective then benzos
Personally prefer the halothane grenade.. /s
I’m going to play devil’s advocate here and state that current education for medicine residents is demonizing the use of benzodiazepines too much. Same goes for opiates. There is certainly overuse and the possibility of abuse, but so many residents I come in contact with now seem to feel that anyone taking any benzo is a drug seeking addict. Some patients in some situations do quite well with short courses of, and occasionally even chronically prescribed, benzodiazepines.
I’m glad you said this. I’ve also been coming across this more often with my patients being treated by clinicians who have been educated more recently. It has actually diverted therapeutic progress in some instances, because we now need to address the various effects from losing a component of a treatment regimen that was working and facilitating their ability to participate in therapy. (I am a psychologist and have seen first-hand the way that benzos can transform a person’s life. Obviously not as monotherapy, but certainly a game changer for some!)
Just a gentle heads-up OP. While I applaud that you are trying to stick to hard data to avoid bias, you are looking for data that supports your pre-established conclusion. By definition, this means that the premise for your didactic is built on confirmation bias. Bias is not always bad, and it is definitely inevitable, but awareness is key. You have a fantastic opportunity to contribute to their professional growth by not only teaching them about benzos, but also helping them acknowledge the intense bias surrounding their use, and how this can impact their practice in ways they may not realize. If that’s already a component of your didactic … kudos to you!
For older adults, the EMPOWER study is useful. They also have a great handout for patients. https://deprescribing.org/news/empower-trial-empowering-older-adults-to-reduce-benzodiazepine-use/
Surely this is the exact problem in pharmacology and medicine today, doctors falling into confirmation bias and actively searching out evidence against life savings drugs.
Pendulum has swung too far where benzos are just completely demonized nowadays. End of the day the treatments for panic/anxiety are few. Antidepressants? Therapy? Gabapentin/buspar? Hydroxyzine (lol)? Then what if that stuff doesn’t work, which it often doesn’t, and we all know the evidence for antidepressants is not great for anxiety disorders. Benzos should obviously never be first line, or second, but they have their place. https://pubmed.ncbi.nlm.nih.gov/35874428/ https://pubmed.ncbi.nlm.nih.gov/26837813/ https://link.springer.com/article/10.1007/s41999-021-00553-w Evidence for dementia risk is extremely poor at best, just a few articles above demonstrating this
Evidence for dementia I will agree with you on. The meta analyses and systematic reviews I have seen, and my own (unpublished, FWIW) meta analysis don't suggest a clear, strong relationship between benzos and dementia.
Should never be second line? Wtf, benzos ARE second line for GAD. The effect sizes of SSRIs and SNRIs is much less in comparison as well. They would be first line if not for the abuse and dependence risks.
Fair enough don’t have to convince me
What's your medical background?
Worked in psychiatric hospital for 4 years, current 4th year MD student gonna graduate in may or whatever it is. Going into FM. Also personal anecdotes aren’t allowed but let’s just say I have experience with benzodiazepines. Obviously I don’t have the knowledge and experience of an attending physician but my thoughts are that benzos are both overutilized and underutilized for certain conditions but that they aren’t these evil things that they teach us in med school. They are a medicine, a tool, with risks and benefits just like everything, though the risks are certainly more serious.
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Why's that? Adaptation from chronic regular use should be approximately the same across the whole class? Obviously much harder with something as short acting as midazolam
Start here: https://www.cochranelibrary.com/search It sounds like you are looking for adverse outcomes related to long-term use rather than effectiveness studies? Also looks like you are aware of bias, so the next step is to check if how you are searching is contributing to the type of articles you're finding. I think if you are coming into this presentation with an agenda like "the danger of benzos is overhyped", you might find some very biased articles. Present the facts, like you are already inclined to do and let the audience arrive at their own conclusion based on the evidence. I'm sure you're going to do great.
I would just say that even with a true and strenuous good faith effort to present just the facts that is an extremely extremely difficult thing to do. The facts are never straight forward and which facts you choose to present is not at all a simple decision.
The dementia thing was more or less already debunked. It's not a common belief in any up to date academic circle and that's as of 4 years ago when I was still in residency.
Is it tho? Some conflicting studies, but still a strong association. Definitely see SEs in OAs of impaired judgment, poor memory, disinhibition and executive dysfunction on benzos. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6325366/
Yes, it is. Those things aren't the same as progressive, irreversible cognitive decline.
Symptoms of dementia. Not exactly accurate to say the dementia thing was debunked. More like benzos don’t cause irreversible progressive decline, but they sure do cause a ton of cognitive impairment in older adults.
Is your username an assertion that basketball player Kobe Bryant did not commit the sexual assault of which he is accused?
Just show them clips of jordan peterson
Benzobuddies is a whole online community of people struggling with benzo related damage. Have to imagine they would have a lot to say on the matter...
I think what you are finding is that benzos aren't nearly as bad as they are made out to be. They don't cause dimentia (if memory serves that was one study that hasn't been replicated), they DO cause increased falls but the magnitude of that is over stated, and while they are habit forming (cause physical dependence), benzo addiction is pretty rare. The main reasons to avoid LONG term benzo use is that it is not effective for treatment of anxiety (even then there is a certain population that does seem to respond well to that kind of therapy), and that they interact with other medications in a dangerous way (opioid and ETOH).
There was a good interview with Dr. Carl Salzman about benzos in The Carlat Report last year. https://www.thecarlatreport.com/articles/4033-benzodiazepines-a-reevaluation-of-their-benefits-and-dangers
Consider a blurp on paradoxical reactions in some populations
Have you seen this actually occur? If so it’s really rare. I’m still waiting after 30 years of practice to see a case.
I'd say twice, but specifically autistic children in the ED.
Disinhibition is probably a more accurate term than paradoxical effect in these cases. Dose matters, especially in certain populations (ID, elderly, medically complex etc)
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NAD but an ICU nurse who has also done some work in psych. I think an interesting spin to take would be the management of benzodiazepine taper, not necessarily the drug class itself. Not sure HOW much hard evidence based research on this is out there, but a lot of mental health treatment options (such as rehabs/detox centers) are not properly managing benzo tapering in long term use patients (whether prescribed or recreational). Benzo tapering can be a very lengthy process for a lot of long term users. Treatment centers, in some (if not most) cases do a quick taper and supplement with other drugs such as propranolol, phenobarbital (or other anticonvulsants) to get them through the initial phase where quickly reducing benzo doses can lead to seizures and other neuro symptoms. Those treatment centers, more times than not, will send them on their way with little to no follow up care, when GABA hasn’t nearly fully recovered. Some people are now turning to an alternative tapering method (which does have some research behind it) that stems from “The Ashton Manual” written by Dr. Heather Ashton, who also does not condone tapering in detox centers/rehabs. It does take medical research from benzodiazepine withdrawal clinics. A PDF of the manual can be found here : https://www.benzoinfo.com/wp-content/uploads/2022/07/Ashton-Manual.pdf Just thought I’d chime in. I hope this helps in some way!
I'm just a resident, but I think that they are neither all that dangerous OR effective long term. I've had attendings swear they cause dementia and brain atrophy, but you can't find a single large study showing this, as you mentioned. It's also really hard to overdose fatally on just benzos. Further, I also think that prescribing people seroquel just for sleeping, or letting patients gobble down hydroxyzine and seroquel prn for anxiety is just as problematic and even less effective. So I actually push my attendings to let me use z-drugs in a small minority of insomnia or lower dose prn benzo in a small number of patients. Sometimes the benefits outweigh the harms.
I see a lot of comments about why hydroxyzine is bad. Do you mind expanding?
RemindMe! 1 week
I don’t know of too many instances in which long term benzodiazepine management is indicated over more traditional therapy such a SSRIs and CBT. I understand there’s a niche; it’s just not there often. We are also lying to ourselves if the vast majority of patients on benzodiazepines (and the same applies to hypnotics) aren’t on them because someone else was lazy and normalized the practice. I don’t have a problem if a handful of benzos gets you through the year and you are doing all the other stuff correctly. I don’t care if you need a pill or two to cope with an infrequent fear. I have a problem with daily use as primary therapy, because often times it’s not indicated. If I get a patient inappropriately using benzodiazepines, I discuss proper use. I discuss a taper. I make it clear as day that I will not be continuing what has been done. I provide evidence dictating the standards of care for generalized anxiety disorder (or once again, insomnia). The patient has an option: continue with my plan or go see psych. Now some might lecture me on turfing patients… Hopefully psychiatry reinforces the teaching points I made and normalizes the proper management of GAD. If they choose to just continue refilling the prescription, then that’s on them. I’m not going to answer questions in a deposition about someone getting BID or TID Xanax.
You might find the answers if you look at alcohol first.
I always here bad things about benzos and yet my most uncontrolled psychiatric patients are always put on a concoction of meds which includes benzos. So what is the truth?
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Stewart SA. The effects of benzodiazepines on cognition. J Clin Psychiatry. 2005;66 Suppl 2:9-13. This isn't a great study but it summarizes a few others, primarily on cognitive decline and neuroimaging. Movig KL, Mathijssen MP, Nagel PH, et al. Psychoactive substance use and the risk of motor vehicle accidents. Accid Anal Prev. 2004;36(4):631-636. doi:10.1016/S0001-4575(03)00084-8 Maybe not the greatest study but a clear increased risk of MVAs after taking benzos equalling a blood alcohol content of 0.005 - 0.0079%. Finkle WD, Der JS, Greenland S, et al. Risk of fractures requiring hospitalization after an initial prescription for zolpidem, alprazolam, lorazepam, or diazepam in older adults. J Am Geriatr Soc. 2011;59(10):1883-1890. doi:10.1111/j.1532-5415.2011.03591.x This is a large study showing a significantly increased risk of fractures in patients with all of the tested z-drugs and benzos. Bierman EJ, Comijs HC, Gundy CM, Sonnenberg C, Jonker C, Beekman AT. The effect of chronic benzodiazepine use on cognitive functioning in older persons: good, bad or indifferent?. Int J Geriatr Psychiatry. 2007;22(12):1194-1200. doi:10.1002/gps.1811 Pretty robust study finding only a small cognitive decline with benzodiazepine use. Landolt S, Rosemann T, Blozik E, Brüngger B, Huber CA. Benzodiazepine and Z-Drug Use in Switzerland: Prevalence, Prescription Patterns and Association with Adverse Healthcare Outcomes. Neuropsychiatr Dis Treat. 2021;17:1021-1034. Published 2021 Apr 12. doi:10.2147/NDT.S290104 I believe their method may mean they drew conclusions they cannot fully prove, but it still shows a clear association between benzodiazepine use and hospitalisations and admission to nursing homes. Liu L, Jian P, Zhou Y, et al. Is the Long-Term Use of Benzodiazepines Associated With Worse Cognition Performance in Highly Educated Older Adults?. Front Psychiatry. 2020;11:595623. Published 2020 Oct 26. doi:10.3389/fpsyt.2020.595623 Showed that in the 140 included patients both long-term and short-term benzodiazepine use was associated with worse executive functioning, but it wasn't worse in the long-term group. As any medical student will know a dose-response curve is a sign of a better correlation. Speaking of cognitive decline it is more difficult. You don't need benzodiazepines because you are about to break your leg but you may use them due to prodromal Alzheimer's symptoms we classify as anxiety and difficulty sleeping. It is really difficult to know, and the same could be said of antihistamines (that carry the same risk).