3.1 Barriers to Guideline-Concordant Benzodiazepine Use in Veterans with PTSD
3.1.1 .Organizational barriers . The most common organizational barrier mentioned by both primary care and mental health prescribing clinicians was “inheriting” large caseloads of patients on chronic benzodiazepines. Many clinicians placed responsibility of initial prescriptions onto “older” prescribing clinicians who retired. Clinicians discussed facing caseloads that included many older-era veterans with PTSD maintained on benzodiazepines and unwilling to give them up. For example, a psychiatrist based in Mental Health reported, “I could almost see a patient and just look at what meds they are on and make a good guess as to which older physician had been treating them.”
Although most prescribing clinicians who had been in their jobs for a decade on average agreed that the inherited caseloads of patients on benzodiazepines were problematic, they did not agree on how to treat them. Some clinicians who reported that they never or rarely write initial benzodiazepine prescriptions, argued they did not necessarily believe that discontinuation or tapering for the older “inherited” patients was imperative. They questioned the necessity of trying to taper the patient if it appeared that the patient was doing well for the time-being.
We’ve got a few prescribers [who have] been around here a while. It seems like everybody they see is on something like that or they’re continuing or starting it. A lot of it is the older prescribers and the patient already has 100% disability. They get started on these medications and at this point, it’s not going to hurt them to stay on them. [Psychiatrist, MH]
Some clinicians reported that they did not feel their facility leadership supported efforts to decrease the prescribing of benzodiazepines.
In the past, if you had a patient who was unhappy with you, they would just run upstairs to the ‘QUAD’ and talk to the leadership secretary. Next thing you know, I’m getting call saying either give them the benzo or give them another provider. [Physician’s Assistant, MH]
Most primary care providers said they believe that it is chiefly mental health’s responsibility to make the decision to maintain or taper benzodiazepines and questioned the necessity of discontinuation in older veterans who are doing well. This is in part because primary care providers believe they do not have the time or resources to devote to this time-intensive work.
I don’t want to step on Mental Health’s area and yet there is so much of an overlap between what we do and what they do. But in these areas, like maybe sleep problems, where it is kind of theirs and kind of mine, there’s sort of a song and dance there. I send a lot of emails suggesting maybe you consider prescribing something else. [Physician, PC]
Organizational factors such as documentation burdens and decreased time prescribing clinicians now have available with their patients may also play a role.
We need more time with the patients and the VA seems to be continually adding new screens and forms and making it harder for us. It’s sort of like you are running a 400-meter dash and they want you to run faster, but they then keep adding 5-kilogram weights to the backpack you are carrying. [Psychiatrist, MH]
3.1.2. Provider barriers . Provider factors that contributed to both increased incidence and prevalence of benzodiazepine prescriptions included the belief that there are complex symptoms best managed by these agents. Sleep and anxiety problems were prominent symptoms mentioned in the interviews as reasons to prescribe benzodiazepines but none of the providers intended to keep patients on them for long-term. There were concerns that depression and anxiety associated with PTSD increase the risk of suicide and that a benzodiazepine would decrease that risk.
They come back and say that they still have insomnia and look exhausted. We use Ambien® [zolpidem] … and that will be for sleep; then trazodone is our backup medication. For anxiety, then I’ll use lorazepam and explain to the patient that it is temporary, we don’t plan to keep them on it for years. [Psychiatrist, MH] I do sometimes prescribe clonazepam for someone who has suicidal thoughts. There is evidence that using something like clonazepam or an atypical can take the edge off the anxiety and help with suicide. So, I don’t use it a lot, but I do when that is a concern. [Psychiatrist, MH]
Prescribing clinicians mentioned that they occasionally use benzodiazepines to “kick-start” an SSRI, particularly in Primary Care where patients cannot be seen again for several months. Providers said that they use the benzodiazepines until they can get the patient into a psychotherapy treatment. Providers also report that they have their own concerns about the guideline-recommended antidepressants. They indicated concerns about patients not receiving full therapeutic dosage levels and about how these drugs might affect women, especially in pregnancy.
One of the things that we sometimes struggle to know is whether they have had an adequate trial before they’ve been moved on to other medications, or other medications have been added on top of the SSRI.” [Psychiatrist, MH] Pharmaceutical and medical fields have not given strong and consistent recommendations about these agents, in particular SSRIs, in pregnancy, using them, not using them, which to use, which not to use, etc. So it is really nervous-making.” [Psychiatrist, MH]
Finally, clinicians mentioned a lack of awareness about other effective treatment options in their own hospitals. They discussed discomfort about a severe “type” of PTSD, lack of knowledge regarding complex comorbidities, and the fact that the CPG does not go far enough to help. The providers made specific requests for education and guidance in these areas. This need was especially true for those new to the VA healthcare system and those within PC rather than MH.
Initially, I was just looking for some guidance. I was rather confused just first coming to the VA and trying to understand where you start treating somebody with PTSD pharmacologically. [Psychiatrist, MH] There’s also the factor that no one on my team I really feel is competent to do that [follow-up with patient by phone regarding medication management] as well as far as I could ask a nurse to do that for diabetes. I don’t even go there with my nurse trying to figure out what to do with the PTSD. [Physician, PC]
3.1.3 . Patient barriers. Patient factors that the clinicians identified included patient requests for benzodiazepines and concerns about antidepressants side effects. First and foremost was the concern that for many patients, antidepressant medications are stigmatizing. Younger patients did not want to be on long-term medication.
I think one of the biggest obstacles as far as – well, not necessarily initiating SSRIs, other than the patient being hesitant to start a med if they have never been on one before– I think there’s a lot of stigma associated with the antidepressant medication to this day. [Behavioral Health Pharmacist, PC]
Finally, because the US VA system provides benefits for service-connected disabilities there may be perceived economic disincentives for deprescribing medications. Many veterans fear that if they show improvement indicated by a reduction in medications, they will lose their benefits.
Who knows how true it is, but truth doesn’t matter; it’s the rumor that exists, that creates this scare of somebody even documenting just in the notes…of somebody getting better and this person having their benefits reduced. [Psychiatrist, MH].
Although this may appear to be a VA specific problem, it could generalize to any system that serves patients whose healthcare coverage depends on a disability or other type of diagnosis such as American patients who receive Social Security Disability payments and associated medical insurance. Of course, in countries where there is universal healthcare, this barrier would not arise.