A few months ago I performed an inpatient consultation on a non-incarcerated patient. His psychiatric care was being managed by a neurologist in another community.

I was shocked and disappointed when his family informed me that the neurologist told them that if the patient sought a medical opinion elsewhere, the neurologist would no longer treat the patient.

Even on a bad day I cannot fathom exuding such arrogance and insecurity! Hopefully this doctor’s attitude about second opinions is the exception and not the rule among physicians. However, this situation sparked my curiosity about second opinions.

Throughout my career, I’ve often encouraged my patients to obtain second opinions, either when they have questioned my diagnoses or treatments or when I have given them serious diagnoses such as schizophrenia.

In other situations I have specifically arranged for them to see trusted colleagues for second opinions when I have been clinically perplexed or have needed another psychiatrist’s input for risk management purposes.

In correctional work it tends to occur more in the context of risk management. For example, if an inmate strongly disagrees with the treatment I am providing, having him see another psychiatrist lends credibility to my treatment and helps to protect me legally if he tries to initiate legal action.

Interestingly, regardless of treatment setting, I’ve never had a patient see another psychiatrist for a second opinion and decide not continue his or her treatment with me. I don’t think that the reason has anything to do with my having superior knowledge or treatment approaches. I would bet it is due to the fact that I honestly try to collaborate with patients, and I’m not afraid to say, “I don’t know.”

Until now, I really hadn’t thought much about if, when, and how often other physicians, regardless of specialty, request second opinions on their own patients.

If you are a physician, do you ever request second opinions on your own patients? Under what circumstances? Do you ever try to discourage patients from obtaining second opinions?

If you are a patient, have you had any experiences, positive or negative, with second opinions that you would like to share?

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 I entered the foreign land of correctional health care. If one prescribes benzodiazepines liberally in a prison setting, he or she will become the unwitting victim of droves of drug-seeking inmates and the archenemy of already-skeptical security staff. Controlled substances in a correctional setting are problematic for numerous reasons that are beyond the scope of this article.

As a result of my experiences in various settings, I have developed some guidelines that I believe can be helpful in prescribing benzodiazepines. My goal is simply to provide excellent clinical care while simultaneously managing risk.

1. Develop your own practice protocol for benzodiazepines. I believe the key to providing good care and avoiding trouble revolves around the seeming paradox of being consistent with how and when you prescribe these medications yet ensuring that you individualize the care you are providing. It may be prudent to provide patients who are receiving their first benzodiazepine prescriptions from you with your own oral and/or written guidelines so that they know your “rules” up front. Then, if you suspect misuse it is much easier to take them off the medication. Decide ahead of time how you will handle “lost” prescriptions, early refill requests, or suspicions of abuse or diversion. Consider informing patients that a condition of your prescribing these medications to them is that they obtain the prescriptions only from you. Some doctors request that their patients bring their medication bottles into each appointment so that they can verify the correct remaining quantity of pills.

2. Obtain and document clear informed consent. In addition to the common side effects, be sure not to leave out the potential risk for physiological dependence, serious withdrawal, and potential impairment when driving or operating machinery. Doctors have been sued by patients who have become “addicted” to benzodiazepines.

3. Consider non-benzodiazepine alternatives. It is not typically necessary to use benzodiazepines first-line for anxiety disorders. Selective serotonin reuptake inhibitors (SSRI’s) such as escitalopram, citalopram, sertraline, paroxetine, and fluoxetine as well non-SSRI’s such as venlafaxine XR, buspirone, and others are used as first-line agents for treating various anxiety disorders (some FDA-indicated and some off-label, depending on the diagnosis). Note: Use extreme caution when prescribing antidepressants to patients with bipolar disorder.

4. Avoid very short-acting benzodiazepines. Alprazolam (Xanax) and triazolam (Halcion) have very short half-lives and consequently are more prone to causing problems with rebound anxiety, physiological dependence, and withdrawal. To read an interesting and very popular post entitled “Why Docs Don’t Like Xanax,” head over to Shrink Rap.

5. Aim for short term use. Some patients will need indefinite treatment with benzodiazepines for chronic anxiety disorders. However, when possible use non-benzodiazepine alternatives in these patients (see #3 above), and use the benzodiazepines in patients with acute transient stressors or to counteract the usually temporary insomnia or restlessness that may occur when SSRI’s are initially started. Try to limit use to a few days or a few weeks.

6. Be very cautious treating patients with suspected or documented substance abuse histories. Some will say never to prescribe benzodiazepines to this group. My personal opinion is that it is ideal to avoid prescribing to them when possible, but in reality there still may be select cases where doing so is providing the best care. I would strongly recommend using a written treatment contract with such patients. If you do prescribe to these patients (unless you are treating alcohol withdrawal), never prescribe to those actively drinking or using drugs. Consider limiting prescription quantities to one week in less trustworthy patients.

7. Try to avoid benzodiazepines in the elderly. This was a point heavily emphasized in my geriatric psychiatry fellowship. Benzodiazepines, especially in the elderly, can cause falls, sedation, and cognitive impairment. Of course, since always and never are usually the wrong answers, if you must prescribe these medications to elderly patients, do so rarely, and avoid long-acting agents such as diazepam and clonazepam. An intermediate-acting agent such as lorazepam used at extremely low doses for a brief duration is probably best.

8. Expand the field if necessary. If you feel that you are out of your comfort zone with a specific case, then consider referring the patient for a second opinion (even if you are a psychiatrist).

9. Prepare not to be liked by some patients. KevinMD.com recently featured a post by physician writer, Dr. Edwin Leap, entitled “Good Doctors Sometimes May Make Patients Unhappy.” This article nicely expands on my point that responsibly providing quality medical care occasionally requires setting limits and disappointing some patients.

What are your thoughts about prescribing benzodiazepines? Please share your comments.

*Please note that this article is intended to provide information and my personal opinions to the medical community and other interested readers. It is not intended to be used by anyone as medical advice. Do not stop or change any medication as a result of any information contained in this article. Please consult with your own physician or other health care professional if you have concerns or questions about your own medications.

Many non-correctional health care providers will also treat inmates from time to time. This may occur in the office or hospital. How can one best approach the challenges of working with the incarcerated in order to deliver the best possible care while simultaneously managing risk?

1. Treat the patient with respect. Not submissive respect, but mutual respect — the way we all want to be treated. I believe that this principle alone goes a long way towards helping one to establish a therapeutic alliance and to minimize interpersonal conflict and hostility. Inmates are people, too. Those who do not agree with this statement should steer clear of treating them.

2. Listen attentively. It may be tempting to get this shackled person (who you may secretly be embarrassed to have in your office) out as expediently as possible. Squelch that temptation, and listen actively as you would to any patient. All patients want their concerns taken seriously. Inmates are no exception. I believe you minimize problems for yourself in the long run (and provide better care) if you ensure that  patients’ concerns are heard, especially if they seem to have more challenging personality styles.

3. Be honest. If there is a particular reason why you think something the patient is requesting is inappropriate, then politely tell them so. If you believe they have a particular diagnosis, psychiatric or not, then respectively inform them of your opinion. For some reason, I’ve gotten the impression that clinicians are more likely to be dishonest with inmates than with other patients. I don’t know why. Whatever you do, never lie to an inmate.

4. Maintain appropriate boundaries. While you may briefly mention something about your family or personal life to your long-term patients (depending on your specialty), never do so with offenders. Stick to the task at hand, and don’t answer personal questions. You want a professional, not a personal, relationship with them.

5. Avoid the defensive medicine temptation. Inmates sue doctors at a higher rate than does the rest of the population. Understandably, some physicians will believe they must practice more defensively to protect themselves. Despite such fears, do not order more tests, procedures, or medications for the incarcerated than you would order for other patients. Thorough documentation and caring are, in my opinion, your best defenses in these situations (see #7 below). Remember that your goal is to provide appropriate health care, not placation. (For some reassurance from a malpractice plaintiffs’ attorney that practicing defensive medicine is not the way to manage risk but caring and respect are, read this letter to the editor of Current Psychiatry.)

6. Focus on what you can do for them, not on what you cannot do. It’s always better to be positive. If you and the patient are having trouble reaching a mutually agreeable workup or treatment for their complaints, emphasize what you are willing to do to help them and why. Emphasizing the limits you want to set with them will only fuel animosity.

7. Document, document, document. Generally speaking, medical care documentation for inmates does not need to be different than that for non-inmates. However, it is crucial to be extra-thorough if you believe the inmate is in any way disappointed or angry about their medical encounter with you. Document not only your thorough history and physical but also your interpersonal interaction with the inmate, the fact that they were dissatisfied, and then justify your treatment plan as though it is being reviewed in court. If something frivolous is filed against you, it will be much easier for a judge to quickly dismiss before it goes anywhere if you have clearly demonstrated your thoughtfulness in providing care.

As always, thank you for reading. Please share your comments.

(The following is a fictional vignette based on thousands of real patient encounters. Any resemblance to an actual person is purely coincidental.)

The heavy door slammed with an echo he’d never forget. He thought he could trust her, but he had been proven wrong. He should’ve known not to trust anybody in prison. In fact, throughout most of his life he’d known only a few people he ever could trust. Naked, cold, humiliated and feeling as though he had been violated again, “David” now wanted to die more than ever. He didn’t care how; it didn’t matter if it hurt. He just needed to end it all. But, he would soon realize that it would be nearly impossible to do. Nearly ever imaginable method of suicide had been removed from him. He was now “safe” in the eyes of the prison, but he sunk into a deeper depression.

It was David’s first time in prison. He had spent a few days in jail prior to his current age of 22, but it was remarkable that he hadn’t gotten himself into more trouble. His father was a career criminal who had repeatedly emotionally, physically, and sexually abused him as he was growing up. David had grown up far too fast. He had had few boundaries and rules and almost no adult supervision in his younger years. He started smoking cigarettes at age 10, started drinking at 12, and was using marijuana regularly by 13.

Despite having the deck stacked against him, David was a kind person who wanted a better life for himself and his new family. Tina was his girlfriend of three years, and they had a 2 year-old daughter together. They were planning to be married soon.

Unfortunately, though, David violated the rules of his probation. Revealing his recent use of marijuana, a urine test had been positive for THC. He knew he had broken the law and the rules of his probation, but he had never imagined that he would not only end up in prison for 2 years but in his current unimaginable state of hell.

He was being successfully treated for depression and post traumatic stress disorder with psychotherapy and an antidepressant medication in the community. Unfortunately, during his brief stay in the county jail prior to coming to prison, the medication was stopped. He could not afford it and was therefore not allowed to have it. When he arrived in prison 2 weeks later, he was placed on the list to see the psychiatrist, the doctor who would assess whether to restart David’s usual medication, but that appointment had not yet occurred.

Today he had seen the psychologist, Dr. Cook, for the second time. She had first seen him the day after he arrived in prison. She was aware of his mental health history and the fact that he was off his medication. David believed he could trust mental health professionals. He was therefore honest with Dr. Cook and revealed to her that he was not coping well. He was slipping quickly into a deeper depression and was thinking of hanging himself. He was frightened by these thoughts because he had previously believed that suicide was a selfish act. He had not wanted to hurt his family emotionally.

Dr. Cook cringed inside when she realized what she had to do. She had to follow protocol. Her patient was suicidal. As counter-therapeutic as she knew it would be, she placed David on suicide watch. She hated this part of her job.

All of his property was taken away from him. Initially he was naked but then offered a paper gown. He had a thin mattress with no sheets on a concrete floor. He was now in an observation cell that felt more like a fish bowl. Officers checked on him every 15 minutes. He knew they were just doing their jobs, but he hated them for their intrusiveness.

Other inmates on the segregation wing where his suicide observation cell was located jeered David from their cells and yelled derogatory comments about him to each other in an effort to further demean him. He had seen more difficult times in his young life than most other 22 year-olds, but now he was at rock-bottom.

Two days later, he did what he had to do. He repeatedly lied and successfully convinced Dr. Cook that he was no longer suicidal. In reality he still was, but fortunately he did not act on his thoughts. Finally he was allowed to return to a regular general population cell. Never again would he admit to a mental health professional that he was thinking of harming himself.

Unfortunately, the above scenario is played out hundreds of times every day inside U.S. jails and prisons. Prisoners who are believed to be at risk of harming themselves are thrown into segregation cells naked or nearly so, and are not allowed access to most of their own property. They are watched closely. Correctional institutions face litigation anytime inmates commit suicide.

While understandable that jails and prisons need to manage risk, I find the manner in which suicidal inmates are kept “safe” to be repulsive. The current system in most facilities around the country discourages inmates from speaking up and admitting to anyone that they need help. Just when they are at their lowest point, they are stripped of their dignity.

Outside of correctional facilities, we mental health professionals routinely make sure that patients who may harm themselves have responsible friends or family members with whom to stay. We never want patients who are severely depressed to be alone. Likewise, I believe that in prisons and jails, inmates who may be suicidal should be kept in cells with other inmates. I wish I could propose a comprehensive solution to this vexing problem, but I don’t have one. I’ve been stumped by this issue for years.

What do you think about this issue? Do you have any novel ideas? Please share your comments.