Limitations
There are several limitations to our findings that we should note. First, our intent was to describe barriers and facilitators participants face in the use of benzodiazepines for PTSD, not to judge the correctness of individual decisions. Some use of benzodiazepines may be justified but the trend of continued prescribing in what might be considered “high risk” subgroups such as older patients warrants additional actions. Second, patients’ perspectives are critical. We had to rely on provider feedback about patient level barriers and facilitators, so patient voices should be reflected in future research. Finally, our findings are most applicable to providers working with military veterans who suffer from PTSD and are treated in the US VA health care system. As we observed above, however, we believe there are lessons learned from this work to help inform overall clinical decision making, especially for large national health systems which share some structural features with VA.
Conclusion
Due to the growing risks associated with benzodiazepines and their lack of efficacy in the treatment of PTSD, it is worthwhile for the VA and other healthcare systems to implement strategies that address the barriers and facilitators to guideline concordant treatment identified through this work. To do this, we must find ways, whenever possible, both to encourage tapering among patients already on these drugs and limit new prescriptions. Effective strategies to taper benzodiazepines exist but are time-consuming and providers need support to implement them.27 Hospital leadership needs to support culture changes and dissemination of evidence-based practices to encourage taking on this difficult task. VA has undertaken several steps to improve PTSD treatment practices that include dissemination of evidence-based psychotherapy, consultation for complex comorbid cases through the PTSD Consultation Program, and funding PTSD pharmacotherapy research to improve prescribing practices and discover new, safer alternatives to benzodiazepines. It will be essential as we continue to move forward to monitor the progress of these steps and the impact on care, particularly in older patients at greatest risk and who are least likely to be offered first-line psychotherapy treatments for PTSD.17 Ultimately, the results of these efforts should result in continued decreases in utilization of these medications and improved access to effective treatment alternatives among all patients with PTSD.