Integrative Psychiatry

Thursday 5/9/16 APNA CPI preconference discussion on benzo pitfalls: notes from the lecture

Benzo discussion Dr. Limandri:

My impression: great info, so much material to cover though so she mostly skimmed the surface. Lots of the info seemed to come from her own experience. Some material came from the UK — Ashton Manual which I refer to often and it’s full of good info.

Below are my mostly unedited notes from this session along with some lyrics from a famous Rolling Stones song relevant to subject.

  1. Women use this class of med more than men. 25-50 yr age range is highest; multitasking requirements for women in that age bracket; middle aged, white, wealthier higher utilizers of benzos. The Rolling Stones wrote a famous song about women using Valium, “Mother’s Little Helper” in the 1960s — here are the lyrics:

What a drag it is getting old
“Kids are different today, ”
I hear ev’ry mother say
Mother needs something today to calm her down
And though she’s not really ill
There’s a little yellow pill
She goes running for the shelter of a mother’s little helper
And it helps her on her way, gets her through her busy day

“Things are different today, ”
I hear ev’ry mother say
Cooking fresh food for a husband’s just a drag
So she buys an instant cake and she burns her frozen steak
And goes running for the shelter of a mother’s little helper
And two help her on her way, get her through her busy day

Doctor please, some more of these
Outside the door, she took four more
What a drag it is getting old

“Men just aren’t the same today”
I hear ev’ry mother say
They just don’t appreciate that you get tired
They’re so hard to satisfy, You can tranquilize your mind
So go running for the shelter of a mother’s little helper
And four help you through the night, help to minimize your plight

Doctor please, some more of these
Outside the door, she took four more
What a drag it is getting old

“Life’s just much too hard today, ”
I hear ev’ry mother say
The pusuit of happiness just seems a bore
And if you take more of those, you will get an overdose
No more running for the shelter of a mother’s little helper
They just helped you on your way, through your busy dying day

Notes con’t:

2. More deaths for those who were regular daily users v the infrequent.

3. 3 weeks is the longest time they should be prescribed, per the speaker. Most long term users stay at same dosages, but they have rebound anxiety and end up raising the dose over time. When your patient c/o anxiety while on a benzo — and you choose to up the dose — you’ve done opposite of what you were supposed to do.

4. Primary care providers are the bigger offenders, that is, prescribe benzos the most, possibly because they feel pressured to solve all the problems of their patients.

5. Studies are reporting on stats by psychiatrists and not NPs. Add the NPs and the stats would be different.  For many providers it’s much quicker to write the script than it is to  do MI or other counseling in an effort to back off the dose or taper off. There are providers out there that will write for benzos with no intent to stop because it’s lucrative work, sad to say.

6. GAD has so many somatic c/o so they end up in primary care and while there they end of getting a rx for benzo.

7. Best anxiolytics are SSRIs. Take a bz to bridge until they kick in, for 2-3 weeks, and then stop without taper.

8. DSM5: MDD with anxious distress… emphasize the last part and that it’s linked to the first, as say of encouraging someone to try and SSRI.

9. Why do many people with trauma dislike taking bzd? They feel a loss of control when on them, less reactive, less fight/flight.

10. Dementia and increased falls.

11. It’s expensive to treat all the collateral damage, eg, falls, car accidents, etc.

12. 2.5 x higher rate of suicide attempts: from a big study in Taiwan she mentioned (I don’t have the reference).

13. Anterograde amnesia (use midazolam in your teaching and why it’s used in medical procedures), dissociation, cognitive impairment, paradoxical anxiety that is proven in PET scans. It makes you not care about the anxiety, not care about possible risks. hinders fight/flight — exactly what trauma survivors don’t want.

14. Cognitive impairment makes it hard to learn the skills needed to curb anxiety.

15. COGNITIVE IMPAIRMENT IS WHY YOU DON’T GET WHAT I’M TELLING YOU.

16. CBT to get people off benzos: question why you think it’s helping your anxiety.

Questions from the audience:

State hospitals and volatile patients and common use of bzd’s: increases impulsivity but they’re slower and we can catch them. Use a different gaba med that’s not the benzo receptor: lamictal and gabapentin. both slow the firing and allow staff time to think. State hospitals may want to use benzo cause it’s cheaper.

Alternative anxiolytics: Effexor — more adrenergic at higher doses. 75mg is antidepressant. Fetzima more adrenergic at lower doses so better tolerated. Buspar helpful; others: lamitical and gabapentin. alpha and betas blockers: trauma clients do better on these and feel it right away.

Schizophrenia and benzos: no indication but had been used for akathisia.

Possible fewer PTSD diagnoses with DSM-5

The prevalence of post-traumatic stress disorder PTSD in US combat soldiers: a head-to-head comparison of DSM-5 versus DSM-IV-TR symptom criteria with the PTSD checklist : The Lancet Psychiatry.

The conclusion taken from the study:

Our findings showed the PCL-5 to be equivalent to the validated PCL-S. However, the new PTSD symptom criteria do not seem to have greater clinical utility, and a high percentage of soldiers who met criteria by one definition did not meet the other criteria. Clinicians need to consider how to manage discordant outcomes, particularly for service members and veterans with PTSD who no longer meet criteria under DSM-5.
Funding for this study: US Army Military Operational Medicine Research Program (MOMRP), Fort Detrick, MD.

Heroin Overdose Home Antidote Approved by FDA: Evzio

Evzio-kit

 

Press Announcements > FDA approves new hand-held auto-injector to reverse opioid overdose.

Evzio — Approved for use in April 2014, Evzio (naloxone hydrocloride injection) reverses opiate overdose in non-medical settings. Opiate overdoses are now the leading cause of death by injury in the US. Prior to the release of Evzio, in the event of an overdose, emergency response was by EMS or police, a huge barrier to treatment because of fears related to legal charges for criminal drug use.

Evzio needs to be seen as a harm-reduction tool, one that the public can become comfortable using, similar to needle exchange programs. Evzio can reduce the number of deaths and serious injury from overdose of prescription or non-prescription opiates, including heroin. Evzio works similarly to an epipen.

Evzio is injected into the muscle (intramuscular) or under the skin (subcutaneous). Once turned on, the device provides verbal instruction to the user describing how to deliver the medication, similar to automated defibrillators. Family members or caregivers should become familiar with all instructions for use before administering to known or suspected persons to have had an opioid overdose. Family members or caregivers should also become familiar with the steps for using Evzio and practice with the trainer device, which is included along with the delivery device, before it is needed.

1,892 American Flags Memorialize Veteran Suicides on National Mall

Using Flags to Focus on Veteran Suicides – NYTimes.com.

American Flags Memorialize Veteran Suicides

It’s hard to believe that 22 veterans take their own lives every day in the US. Some people probably believe those numbers can’t possibly be accurate.

The world places such stigma on the diagnosis of mental illness that coming up with a solution is not easy. The denial is enormous. Placing close to 2,000 American flags across the National Mall makes it hard to ignore, unless one questions the accuracy of the statistic.

Do the math: 1,892/90=21.02. The flags represent veteran suicides since January 1, 2014. That would be about 22 per day.

The stigma doesn’t lie just with people suffering from depression or other conditions. It prevents medical professionals from choosing to practice psychiatry as a medical specialty because they are stigmatized by their peers for choosing to practice psychiatry.

Why are we so ashamed of revealing emotions? To the extent that we’re willing to turn our cheeks while 22 American veteran’s kill themselves everyday?

Last year Washington made a cash infusion into mental health services in hopes of shoring up the ranks of psychiatric providers. Doing so only seems to have bought a little time, enough to say, ‘OK, we’re doing something to fix the problem’. But a year later we don’t seem to have made any progress.

Nurses are a group that’s poised to fill in the gaps of providers, if the number-crunchers would get to work.  Placing a mental health RN in every primary care practice will help — I guarantee.

I follow hiring trends at the Veterans Administration Medical Center in Western North Carolina and I rarely see mental health jobs posted (the process of getting hired at the Veterans Administration is abysmally outdated and time-consuming, so much so that I’ve heard of courses being offered in How To Get A Job At The Veterans Administration).

Until we can acknowledge the enormous White Elephant in the room that is “mental illness” we aren’t going to make much progress. Next time you are out with your friends look around, see and believe, that 1 in 4 of everyone around you has at one time or another had to seek help for emotional challenges.

I applaud the veterans and their caregivers who took the time to place those 1,892 little American flags on the National Mall in Washington, DC. Progress is rarely made by being silent.

 

 

 

 

 

Psychiatry’s Stigma In The Medical Profession

The stigma of becoming a psychiatrist.

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Today’s GML (Great Medical Link) has my brain wheels turning, so here’s my first 2014 post:

While working one of those long 12-hour shifts I used to pull while on staff at a university teaching hospital in SC as a registered nurse back in 2001, I found myself once again sitting with my patient/client/charge (nomenclature dilemma is fodder for a future post) just… talking. Excessive talking with patients isn’t smiled upon by the bean counters.

“You know?” my RN colleague said to me then. “Have you ever thought about becoming a psychiatric nurse? I think you’d be really good at it.” Hmm. No, not really. (more…)

Rules to Require Equal Coverage for Mental Ills – NYTimes.com

Rules to Require Equal Coverage for Mental Ills – NYTimes.com.

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In this article it’s stated that parity will help prevent gun killing sprees. But these “new” rules aren’t going to apply to Medicaid and Medicare recipients and those individuals are often the sickest and most at-risk. So go figure.

Senator Richard Blumenthal, Democrat of Connecticut, said the five-year delay in issuing a final rule had real-world consequences. “In mental health, uncertainty kills,” he said. “If an individual poses a threat to himself or others, he cannot be told he will get the care he needs as soon as his insurance company decides what ‘parity’ means.”

Can parity be achieved in a capitalist society?