On the Reading of the Week

Just a quick reminder: this week’s Reading is the second in a two-part, two-paper series. The selection was made with the editorial board of the International Psychiatry Twitter Journal Club, allowing us to consider these papers here, and to continue the conversation on Twitter.

And that conversation is going on today.


Interested? Follow @psychiatryJC.

On Last Week’s Reading

Last week, we looked at the new JAMA Psychiatry study considering benzodiazepine use in the United States, a paper that draws from an incredible data set, covering more than 60% of all US retail pharmacies.

That paper reminds me of the old joke of the doctor delivering bad news.

Doctor: I have bad news and really bad news. Which would you like to hear first?

Patient: Wow. Well, let’s start with the bad news.

Doctor: You have 24 hours to live.

Patient: I’m devastated. I don’t know what to say… what could possibly be worse?

Doctor: I’m running late and I’m sorry you’ve waited two hours to see me.

The bad news: Olfson et al. find that benzodiazepines are being prescribed often, way too often. The really bad news: what we want to avoid – prescribing to the elderly – is done commonly; in fact, Olfson et al. find that Valium and its sister drugs are prescribed three times more to the elderly than the non-elderly.

On This Week’s Reading

But this week’s Reading has a positive message: something can be done. That’s why I strongly encourage you to read: “Reduction of Inappropriate Benzodiazepine Prescriptions Among Older Adults Through Direct Patient Education: The EMPOWER Cluster Randomized Trial” by Tannenbaum et al. The JAMA Internal Medicine paper is relatively straight-forward and doesn’t require much of a summary here. (It’s attached in PDF format.)

Essentially, the paper asks a simple question: if we give patients information, can they make better decisions?

Here’s what the study authors did:

· In the Montreal area, they approached 165 pharmacies. They found 30 willing (and appropriate) to participate in the study.

· Older patients of these pharmacies who were on benzodiazepines long term were identified.

· Some patients were then provided with information on benzodiazepines and the problems of use, and information on a step-wise protocol for tapering out the medication (picture based, with large fonts, with a schedule of eliminating benzodiazepines over 21 weeks); other patients received their usual care.

The results? Tannenbaum et al. report:

· “62% initiated discussions about benzodiazepine therapy discontinuation with their physician and/or pharmacist, and 58% attempted discontinuation.”

· “The majority (72%) of participants desiring discontinuation opted to follow the tapering protocol provided.”

· At six months: “Adults in discussing the harms of benzodiazepine use with their physician and/or pharmacist yielded a benzodiazepine discontinuation rate of 27% compared with 5% in the control group.”

The authors conclude:

In an era of multimorbidity, polypharmacy, and costly therapeutic competition, direct-to-consumer education is emerging as a promising strategy to stem potential overtreatment and reduce the risk of drug harms.

This paper suggests that direct-to-consumer education – the term the study authors use – works, and works well.

It’s an interesting concept. And it speaks to an important and larger concept: empowering patients with information. In this study, the targeted population would seem quite adverse to change – that is, older patients on a medication they are used to and probably reluctant to give up. Yet, the data suggests that the majority were interested in weaning themselves off of benzodiazepines.

In health care, it’s easy to fall into the trap of continuing what we’ve been doing even if it’s less than ideal, resigning ourselves to the status quo. Easy, and unfortunate.

So, two quick questions:

1. About the system. The majority of pharmacies opted not to be in the study. Another example of providers not shouldering their responsibilities?

2. About your practice. How often do you provide hand-outs to your patients?

Reading of the Week. Every week I pick a reading — often an article or a paper — from the world of Psychiatry.