What approach should be taken for a patient with a history of anxiety or insomnia, currently taking benzodiazepines, who wants to consult a psychiatrist without tapering off their medication?

Managing a Patient on Benzodiazepines Who Wants Psychiatric Consultation Without Tapering

You should support the patient's psychiatric consultation while maintaining their current benzodiazepine regimen, as abrupt discontinuation or forced tapering can cause seizures and death, and psychiatric evaluation may actually facilitate eventual safe discontinuation if appropriate. 1, 2

Immediate Clinical Approach

Maintain the current benzodiazepine prescription while arranging psychiatric consultation. The FDA explicitly warns that abrupt discontinuation causes withdrawal symptoms including seizures, and after extended therapy, abrupt discontinuation should be avoided with a gradual tapering schedule followed only when clinically appropriate. 2 Physical dependence develops with chronic use even at therapeutic doses, making continuation safer than forced cessation. 2

Critical Safety Assessment Before Psychiatric Referral

Before proceeding, verify the following high-risk situations that require immediate specialist involvement rather than routine continuation:

• Check for concurrent opioid use - the combination increases risk of respiratory depression and death, and should be avoided whenever possible 1
• Screen for history of withdrawal seizures - these patients must be managed by specialists, not in primary care 1
• Assess for co-occurring substance use disorders - requires specialist management 1, 3
• Evaluate for unstable psychiatric comorbidities - needs specialist involvement before continuing benzodiazepines 1
• Review the Prescription Drug Monitoring Program (PDMP) to identify all controlled substances the patient is receiving 1

Rationale for Supporting Continued Use During Psychiatric Evaluation

Psychiatric consultation may actually improve long-term outcomes for several evidence-based reasons:

• Psychiatrists can offer evidence-based psychological therapies (particularly cognitive behavioral therapy) and specific approved antidepressants for anxiety as alternatives to benzodiazepines during any future reduction process 1
• CBT during benzodiazepine taper increases success rates to 70-80%, compared to only 5% success when patients attempt discontinuation alone and 25-30% with general practitioner support alone 4
• Patient agreement and interest in tapering is a key component of success - forcing unwilling patients to taper has poor outcomes 1

Documentation and Monitoring Requirements

While maintaining the prescription pending psychiatric evaluation:

• Follow up at least monthly during continued use 1, 3
• Monitor for signs of tolerance (dose escalation requests, early refill requests) which indicates problematic use 3, 5
• Screen for cognitive impairment and depression which develop with regular benzodiazepine use 3, 6
• Assess for mood changes and suicidal ideation at every visit 1
• Document the duration of current use - patients on benzodiazepines for more than 1 year have developed physical dependence and require extended tapering protocols if discontinuation is eventually pursued 1

Setting Expectations for the Psychiatric Consultation

Inform the patient that the psychiatrist will likely:

• Evaluate underlying anxiety or insomnia with evidence-based diagnostic criteria 7
• Assess whether they ever received first-line treatments (psychotherapy, relaxation techniques, sleep hygiene education, serotonergic agents) before benzodiazepines were prescribed 7
• Discuss long-term treatment options that may include maintaining benzodiazepines at the lowest effective dose, transitioning to alternatives, or eventual tapering with psychological support 1, 8
• Consider adjunctive medications like SSRIs (particularly paroxetine) for underlying anxiety, or buspirone which manages anxiety without dependence risk (though requires 2-4 weeks to become effective) 1, 3

Critical Pitfalls to Avoid

• Never force tapering on an unwilling patient - this destroys the therapeutic relationship and worsens outcomes 1
• Never abruptly discontinue benzodiazepines - this is equivalent to suddenly stopping antihypertensives or antihyperglycemics and can cause seizures and death 1, 2
• Do not abandon the patient even if they refuse tapering - maintain the therapeutic relationship and consider maintenance therapy as a legitimate long-term option for some patients with chronic anxiety 1
• Avoid prescribing additional CNS depressants during continued benzodiazepine use 1

Long-Term Perspective

About 50% of patients prescribed benzodiazepines continuously for 12 months develop dependence. 1 For patients already on long-term therapy, continuation at stable doses may be medically appropriate rather than constituting "abuse" - pharmacologic dependence is a predictable adaptation that differs from addiction. 8 The psychiatric consultation will help determine whether the patient has legitimate ongoing need for benzodiazepines versus problematic use requiring intervention. 8, 5

If eventual discontinuation becomes a shared goal after psychiatric evaluation, successful withdrawal typically results in improved psychomotor and cognitive functioning, particularly in memory and daytime alertness, with maintained improvement in anxiety symptoms and general well-being. 1, 6