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