Psych Meds: Under-prescribing Benzodiazepines and Over-prescribing Anti-Psychotics

 

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I often write about the misuse of psychiatric drugs (and disease mongering by big Pharma). Recently, two journal articles have been published that are in line with what I’ve been saying. (Caveat: I want to make it clear that I am not against the use of psychiatric drugs, which can be very useful and effective when prescribed properly to the right patients).

One of my pet peeves has been the demonization in the psychiatric literature of a class of drugs called benzodiazepines. Probably because they are cheap as well as effective. This includes drugs like Valium, Librium, clonazepam and Xanax. They are used for sleep and anxiety disorders. Whenever they are referred to in the psychiatric press, references to the names are almost always immediately followed by the phrase, “but of course they are addictive.” 

In contrast, references to other drugs, say anti-psychotic meds, are never accompanied by the words, “but of course they can cause diabetes and chronic movement disorders." Nor is any such statement attached to references to a far more often-abused class of drugs: stimulants like Adderall.

Even more strangely, this statement is also usually NOT applied to the references to the so-called “Z-drugs” like Ambien and Lunesta (which are newer and more lucrative for pharma), even though they work in almost exactly the same way as benzos and are just as addictive.

Benzo’s are highly effective for the treatment of short-term insomnia and anxiety, and particularly for the highly disabling panic disorder when it does not respond to an antidepressant alone. While benzo’s certainly can be abused, most of the time they are not. They are listed by the FDA as Schedule 4, which means low abuse potential. Adderall is Schedule 2, meaning a high potential for abuse.

So is benzo addiction really a big problem, especially now that doctors can see if their patients have been getting them from more than one provider? (With the exception of the most addictive benzo – Xanax - there is also no big street market for them). In general, shorter acting drugs are more addictive than longer acting ones, since withdrawal symptoms come much more quickly. 

A new, huge study in Denmark has been published that is consistent with my experience (Rosenquist, T.W. et. al., “Long-Term Use  of Benzodiazepines and Benzodiazepine-Related Drugs: A Register Based Danish Cohort Study.” American Journal of Psychiatry 181.3, March 2024).  It found that only 15% of users stayed on the drugs for over a year, and only 3% for more than 7 years. The median dose stayed rather stable in this population. Long term use of Z drugs was on average higher than with those on a benzo. Patients escalating their intake to higher than prescribed doses was uncommon and was found mostly in people that abused other drugs.

An accompanying editorial in the American Journal of Psychiatry points out that conditions like dementia, drug abuse, and other chronic illnesses often cause bad outcomes, not the treatment itself. As to overdoses, with benzo's they almost are never fatal unless the drugs are combined with opiates (on which one can overdose all by themselves).

When it comes to the overuse of antipsychotics, adding them to an antidepressant in “treatment resistant depression” is widely discussed in the psychiatric press - no doubt because many mental health consultants work for Pharmaceutical companies. 

Now don’t get me wrong, these medications definitely can work in this capacity – I had luck adding Abilify to an antidepressant. (As soon as that drug went generic, the exact same TV ads for depression using a replacement brand-named drug named Rexulti started. The two drugs are nearly identical [what does that tell you?)]. 

The issues are: 1. Using two drugs when one will suffice, and 2. The potential severe side effects of anti-psychotics (especially diabetes and a chronic movement disorder called tardive dyskinesia). There are safer “augmentation” drugs like lithium to try first.

I’ve discussed in a previous post one big reason why depression is labeled "treatment resistant" when it may not be: the conflation of major depression with chronic unhappiness. The latter almost never responds to an antidepressant (not counting the times when it acts like a sedative and is only effective due to that side effect). 

Also, you can be chronically unhappy before a major depressive episode even starts and that is your baseline. If you end up at your baseline, then the antidepressant did work! In that case, the next step should be psychotherapy, not more meds.

These issues tie in with an idea discussed by H. Paul Putman III M.D. in the April 2024 issues of Psychiatric News. He points out that much of what is labeled “treatment resistance” is actually a treatment impasse, meaning the doctors have not done everything they needed to do with the antidepressant or ruled out other causes for the symptoms. They have perhaps not slowly raised the dose until the maximum, or if this becomes precluded by side effects, then trying the same strategy with a second antidepressant and then a third. 

Medical causes such as endocrine disorders have not been ruled out. Maybe there was a rupture in the alliance between the patient and the doctor. Or the patient has not been taking the prescribed antidepressant at full dose all along - or not taking it at all. Interactions with other medications have not been evaluated. Co-occurring psychiatric disorders that are complicating treatment have not been considered.

Putman says the term “difficult to treat” should be substituted for “treatment resistant.” But then Pharma might not make as much money.