As a psychiatrist who has now been practicing for over a decade, I think back to the days of residency and fellowship and realize how much my approach to prescribing benzodiazepines has changed.
One of the key faculty members in my psychiatry residency program was considered an expert in treating anxiety disorders. He was very liberal with his prescription of benzodiazepines, the anti-anxiety class of medications including diazepam (Valium), clonazepam (Klonopin), lorazepam (Ativan), alprazolam (Xanax) and others.
Having no other frame of reference, I naively adopted his unsparing prescription-writing habit of these not-so-benign medications. I unquestioningly steered down this path for the first couple years of my post-training practice.
Then I had the good fortune of working with a very competent group of experienced psychiatrists who were in full-time clinical practice. Regularly collaborating on cases with them helped to initiate my transformation to more conservative, and in my opinion, more appropriate, prescribing habits.
My prescription style inevitably evolved further when
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The Archives of General Psychiatry published an article this month entitled, “Metabolic Testing Rates in 3 State Medicaid Programs After FDA Warnings and ADA/APA Recommendations for Second-Generation Antipsychotic Drugs.”
The retrospective analysis examines how frequently the recommended metabolic testing for second generation antipsychotic drugs (SGA’s) was performed in Medicaid patients in 3 different states. The conclusion was that the monitoring was not being done nearly as frequently as recommended. Less than one-third of patients treated with these medications, which can cause metabolic syndrome, undergo serum glucose or lipid monitoring.
Obviously this is not good news. In recent years, we’ve learned that the risks associated with SGA’s is higher than originally thought. My intent in this post, though, is not to focus on this study itself as much as to examine an ethical dilemma related to it that I have never heard discussed.
What I’ve been wondering: Is it ever appropriate to prescribe SGA’s to severely mentally ill patients who have no financial means to obtain the necessary blood monitoring tests? I’ll explain.
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