Episode Transcript
[00:00:02] Speaker A: Welcome to Unburdening a mountainorth Podcast where we unburden mental health topics from stigma like a prolonged construction project unburdening a mid century house from asbestos.
I bring up construction because there is currently work being done on my apartment. If you hear any stray noises in the background, I apologize, but that is what is going on right now.
So our topic today is the benzodiaphamine or benzo epidemic. I've been wanting to do an episode
[00:00:38] Speaker B: on this for a while because as
[00:00:40] Speaker A: someone who came of age in the early 2000s, my life and my community was directly impacted by the over prescription of things like Klonopin, Xanax, Ativan.
We'll start with some history and cultural context about this class of anti anxiety medications and why they were so aggressively marketed towards women, especially mothers, but they were also over prescribed to many sensitive and creative men.
A lot of people diagnosed with anxiety disorders are high in conscientiousness traits.
They care about their impact on others. They care about being a good parent, being a good friend, having a positive impact on the world.
But sometimes that sensitivity can turn against them, especially during life transitions when routine is disrupted. And in many instances, these medications helped people manage their anxiety and get through tough times.
So if you are someone listening to this who is prescribed one of these medications, please know I am not coming for you. I actually have been prescribed one of these medications just a few years ago
[00:01:58] Speaker B: to help with my anxiety when it
[00:02:01] Speaker A: came to flying on a plane and it really didn't do anything for me.
But I know people it has worked for in this context. I also know people whose lives it has completely burned up.
So this is really a moment for critical thinking. Okay, more than any medication, what determines what happens is our relationship to it, both physiologically, psychologically and the conditions it's prescribed under.
There's an old saying that says the difference between medicine and poison is dosage and that is especially true when it comes to benzos.
So we're going to get into that.
Then we'll get into the heart of this episode which is an interview with Morgan Ward, who is a psychiatric nurse practitioner at Mount north who specializes in helping parents navigate the postpartum period.
Because I lived through the benzo epidemic and because I have dear friends whose lives were derailed or even even lost due to their relationship with prescription drugs, I am someone who has a lot of medication hesitancy.
That said, I can truly say that knowing Morgan has helped me find trust in the reality that there are good and competent and caring psychiatric prescribers out there who not only do their homework, but see their clients holistically. And if you are someone listening to this, wondering if medications might be right for you, I'd definitely listen to what Morgan has to say because she explains what a good psychiatric relationship should really look like.
And just as a reminder, nothing said on this podcast is medical advice. If you want that, I encourage you. Talk to your doctor. Everything here is just for educational or entertainment purposes.
So let's get into it.
I want to take us back in time imagine it is 2010, 16 years ago now at this time, I am 19 years old. I'm in college.
The song Kids by MGMT has a chokehold on the local radio station.
Millennial fashion is in full swing, so everyone is in those high waisted skinny jeans, the band shirt, crop tops, the cat eyeliner.
So there I am in 2010, dressed like a mini adult, but inside I still feel like a child.
I'm reading fantasy novels, making inappropriate jokes, and testing my limits.
I don't know what being grown up is supposed to feel like, what I'm supposed to feel like.
I remember people telling me that young adulthood is supposed to be the prime of life, but if I'm honest, I spent a lot of my college days consumed with the anxiety of change.
I was being asked to grow more specifically to grow up, but it's like the next version of myself was out of reach, a blurry figure in a dream.
I didn't know her yet.
And into that vacuous space between childhood dependency and adult responsibility poured my racing thoughts, my insomnia, that nagging feeling that I just wasn't going to make it in this world.
At the time, my friends were also struggling with this kind of adolescent anxiety, and I would say more than a few, maybe half of my friends with anxiety were prescribed benzos.
In those days, Klonopin was an especially popular Benzo.
It was so popular in my hometown that there was a local punk band called King Klonopin.
And like a lot of punk bands, they were a conduit for the strong or taboo emotions the community was dealing with.
Though I'm sure if you asked them about any of that, they would have brushed off this analysis, as was the style of cool kids at the time.
So the years go by, the medications are tapered up, and music enters a new era of soundcloud rappers. People like Lil Peep and Lil Xan. That's short for Xanax, by the way.
These guys reflected the heartbreak of what was happening. Benzos wove their way into the lives of sensitive kids looking for a cope with the task of maturing.
And benzos wove their way onto the street where they were mixed and pressed with other drugs, namely fentanyl.
And this is when people started really dying.
The reckless over prescription of benzos got people hooked up.
Then when they turned to the streets because they needed something to keep the withdrawal at bay, or because they lost health insurance, or because they just couldn't sleep at night, they were unknowingly given a mix of street drugs that caused overdoses.
I know people who died this way.
In fact, almost everyone I know knows at least one person who died this way.
That's the definition of an epidemic.
During my college years, I witnessed a few friends struggle with dependence to benzos.
Little by little their doses were tapered up by their physicians until they couldn't sleep without Klonopin. Xanax or Ativan couldn't function without it.
By the time they realized it was a problem, it was too late. They were hooked.
Getting off a high dose of Klonopin after long term use is painful and frankly dangerous.
As my friends struggled to taper down, I remember sweat just pouring down their faces. The depression, the raw, gut wrenching despair.
When I look back on this, it feels like pure luck that I didn't have to go through this myself.
There really wasn't much of a difference between my friend's anxiety and my anxiety.
Except they were prescribed benzos and I wasn't. I don't know why I wasn't. Maybe I had a different doctor or maybe I coped in other ways that weren't so great.
I guess I want to drive home the point that this could really happen to anyone.
Rich, poor, nice, mean, compassionate, selfish, it really doesn't matter.
Given enough exposure to a drug, anyone can develop a tolerance.
And this is because in psychology we say what is repeated gets reinforced.
No matter the type of person you are, if you're around something a lot, whether you're around it because your doctor is prescribing it to you, or your friends are doing it, or your parents are doing it, or your community is doing it, it's going to reinforce itself. And there's really no amount of willpower that can overcome that.
This is why people often have to go away to rehab to literally get out of their environments to before they can begin to get back to themselves.
A lot of people in Klonopin withdrawal say their bodies feel on fire, caught in an electrical storm.
The writer Melissa Bond describes this Feeling as the Blood Orange Night.
This is the title she gives her memoir about her benzo addiction and recovery.
I read Melissa's memoir to prepare for this episode.
Melissa was prescribed benzos to help with postpartum insomnia. Over time, she is tapered up again and again by a doctor she calls Dr. Amazing because at the beginning, that's what these drugs feel like.
Amazing.
She can finally sleep through the night.
So of course, she builds a tolerance and a reliance on benzos. And it builds becomes dangerous.
With a lot of work and community support, she gathers the resources to taper down and she goes through the gambit of withdrawal symptoms, pain, psychosis, stroke, depression, anxiety.
She almost died.
And all of this was happening to her during the early stages of motherhood when she had two young kids.
So I want to disclose that I'm not a parent myself, so I don't know what it's really like to be inside of the type of experience Melissa was having. But becoming a parent is a threshold experience.
What I mean by that is that it marks the end of one phase of life and the beginning of another.
Anytime we have a threshold moment, we are called to take on more responsibilities, shed old ways of being, AKA to grow up, and not a little, but a lot.
And at every threshold, we are presented with a fork in the road, the path of avoidance or the path of anxiety.
If we take the avoidance path, we. We literally avoid the task of making our dreams come true. We get depressed, we get stuck, and we suffer arrested development or overdependence on others.
We may also use substances or behavioral addictions, gambling, sex, the stupid phone, whatever, to literally avoid the discomfort of growth.
So if we want to grow into ourselves, we need to embrace the path of anxiety and change.
But we need to feel supported in this choice.
And our culture has few templates for this.
This is why so many people develop crippling anxiety and seek psychiatric help when transitioning from high school to college, when leveling up in their career, when becoming parents.
These developmental tasks cause massive tectonic shifts in our psyche, our bodies, our identities.
And there is an overall lack of trustworthy mentorship to help us navigate this. And now it's out there, right? If you look hard enough. But we shouldn't have to look so hard.
I want to highlight two examples of people in the public eye who were prescribed benzos during their own threshold moments.
One is Lindsay Clancy, who at the time of this recording, is undergoing a massive public trial for the murder of her children.
The other is the late Chris Cornell, known For his otherworldly voice as the singer for the band Soundgarden.
I want to play a clip of Cornell's raw vocals from his song Black Hole sun so you can just hear what a powerhouse this guy was.
[00:14:00] Speaker C: In my shoes walking sleep in my youth I pray to keep Heaven send hell away no one sings like you anymore.
[00:14:20] Speaker A: Oh my God. Like you can just feel what a conduit this man was for emotion.
It takes training to sing like this, but I'd argue it also takes the willingness to create over and over with each performance the shape of these emotions in your body.
Artists in the public eye can be vulnerable to addiction because they are vulnerable to anxiety. Generally, this is for a few reasons, but the main ones are, is that public figures have a very compelling reason to quiet their anxiety as quickly as possible.
[00:14:59] Speaker B: Their whole job is being in front
[00:15:01] Speaker A: of people, performing or interacting with the public. And nothing is going to help them quiet their anxiety in those moments, like a fast acting drug. Another reason is that once someone gets to a certain level of fame, very few people are going to want to tell them no. It gets harder and harder to have those maybe not nice, but kind conversations when you're looking out for someone, right?
Because for every real friend who's willing to have that conversation with a rock star, there are like 20 fake friends who will gladly just enable him.
And for a long time, the music industry, especially in the early 2000s, was notorious for enabling these life draining behaviors.
So think about it, it's a perfect storm. A creative personality that feels deeply undergoes the enormous stress of public scrutiny, the separation of healthy routine due to touring, and the momentous threshold moment of growing into not just a person, but a cultural icon.
And all of this happens in a demanding and often exploitive industry.
When Cornell was prescribed Ativan due to Difficulty sleeping in 2016, he had been sober for 14 years.
He had struggled tremendously with addictions, mostly to alcohol in his past, but went to rehab and got sober at the urging of his bandmates.
So here he is in 2016, sober for 14 years, unable to sleep. His wife Vicky said that he was in a lot of pain from his shoulder surgery. It was waking him up at night.
And so he was prescribed this benzodiaphamine to help him sleep.
Vicki remembers though, that he quickly succumbed to that old addictive, compulsive pattern with the benzo.
So in a seven day period, he took 20 something pills and in a nine day period, 33. Which is a lot, right?
And so he is in a full relapse on May 18, 2017, when he dies by suicide.
And the toxology report reveals high levels of barbiturates, but also Ativan, the benzo, and, you know, a few other things in his system.
So after this toxology report comes out, Vicki, Chris Cornell's wife, tries to sue the prescribing doctor.
It was a heartbreaking lawsuit that was eventually settled. But while it was happening, I remember feeling pangs of compassion for this grieving family that knew these medications likely contributed to the dips in Chris's mood, but struggled to, quote, unquote, prove it legally.
And I have to be honest, I kind of side with the family here.
I don't think anyone with a strong addiction history as substantial as Chris Cornell should be prescribed a highly addictive medication on an ongoing basis. That's just dangerous.
So this brings me to the other legal situation involving benzodiaphamines. At least in part, this is the case of Lindsay Clancy. For those who don't know, Lindsay Clancy stands accused of murdering her three young children in 2023.
[00:18:55] Speaker B: The trial is interesting in that it
[00:18:57] Speaker A: centers not on whether Lindsay killed her children, but on the state of her
[00:19:03] Speaker B: mind at the time.
[00:19:05] Speaker A: The defense argues she should not be held criminally responsible because she was suffering from postpartum psychosis.
While prosecutors say she planned the killings and knew what she was doing.
If they determine she's a criminal, she'll go to prison. If they decide she's mentally ill, she'll go to a state mental facility for the rest of her life.
So starting in the fall of 2022, Lindsay's mother in law said she noticed a change in Lindsay. Lindsay was becoming increasingly anxious, paranoid, even suicidal.
Lindsay had sent texts saying that she feared she had developed a dependence on benzodiaphamines, but she couldn't sleep without taking them.
Lindsay's exact words were that the medications are destroying my mind.
Now, Lindsay's case is psychiatrically complicated, to say the least.
In addition to the benzos and Ativan, Valium, Klonopin, she was prescribed many other medications, including antidepressants, sleep aids, an antipsychotic.
And because she was so sleep deprived, it seemed she was also struggling to take the medications as prescribed and honestly was living in agony.
She had reached out for help many times for severe mental health problems and even went into a psychiatric hospital for a while.
In their case, Lindsay's lawyers are focused on proving that her care was disjointed, that she was denied higher levels of care when she needed them, and that Due to medical negligence. She became one of many in that statistic of women who just, quote, unquote, fall through the cracks.
And her lawyers, they have a compelling case.
Lindsay carried out the killings only 19 days after being discharged from a psychiatric hospital, where she talked about the hallucinations that were telling her to kill her children and herself.
The six months after an inpatient discharge can be a very vulnerable time for people.
In fact, this is when many completed suicides occur.
And Lindsay did try to take her own life after taking the lives of her children.
She didn't die, but she was paralyzed from the waist down.
I just find this case so heartbreaking.
No matter what's legally decided here, it's clear Lindsay was struggling with one of the most stigmatized and socially isolating mental health conditions a person can deal with, which is a break of reality.
Clearly, her care teams were frantic to treat the insomnia that was likely exasperating her psychosis, which might explain all the benzo prescriptions.
Also, I need to say it seems mental health only enters the public conversation seriously when violence is involved.
This is a double edged sword because while this awareness can revitalize efforts in preventative screening, I worry about how conflating postpartum psychosis with murder might impact women seeking care.
Would they, for example, avoid getting evaluated for fear that they'll be seen as a potential murderer?
For fear that they could lose custody of their children?
So if you, like me, are following this public case, I encourage you to use it not as the end, but the beginning of researching a very nuanced mental health topic.
Okay, so now that I've laid the groundwork for our topic, I want to transition into the interview portion of our show. Today you're going to hear my conversation with my Morgan Ward, who is a professional nurse practitioner specializing in postpartum care. We talk about everything from Morgan's experience of motherhood because she is a mom herself, to the science behind benzodiaphamines, what they're literally doing inside the brain.
And we wrap up our conversation just talking about what a good psychiatric relationship should look and feel like.
So, yeah, I'll let her take it away.
So welcome, Morgan, to the podcast.
[00:23:50] Speaker C: Thank you. Thank you.
[00:23:52] Speaker B: Tell us who you are and what you do.
[00:23:56] Speaker C: My name is Morgan Ward.
I am one of the psychiatric prescribers at Mount North. So I'm a PMHMP psychiatric mental health nurse practitioner.
After I graduated nursing school, I started in the emergency department, Children's emergency department. And it was also a dual role of.
I worked A couple of days in the regular medical emergency department and a couple of days in behavioral health crisis department for adolescent and Child psychiatry.
And I really loved that. Again, it was all child and adolescent.
So there were. There were some challenging moments for sure, but really, really enjoyed my time there. And then my husband and I moved out of state and I worked on an inpatient unit for child and adolescent mental health.
This was all still nursing.
Finished my nurse practitioner degree and that took some time for sure. But now I am at Mount north and I see mostly adults telehealth remotely and I've been really, really enjoying it.
[00:25:17] Speaker B: Yeah, you have a lot of experience here and I know your clients can feel that when you work with them.
I'm curious about your origin story. I always like to know about the beginning.
[00:25:30] Speaker A: What drew you to the profess?
[00:25:32] Speaker C: I think maybe a common theme. I might be overstepping over generalizing, but I think maybe a common theme of those of us who are drawn towards mental health. It's just from our own experience of it in our lives. You know, whether that's us, ourselves going through it or whether it's watching a family member struggle. And that's my, my story as well. So just kind of seeing mental health play out in my life really drew me to the field.
And yeah, very first day I stepped into the.
The psychiatric crisis department, I really felt at home. I felt like that was my place. I grew up in a time I remember.
I'm not trying to say I'm like, you know, how old I am, but I grew up in a time when we just did not talk about these things.
And no one talked about these things. We didn't really talk about them in school.
My friends and I didn't talk about it growing up. And that felt really stigmatizing. I think we've done a lot of work in recent years to destigmatize and try and make things more open. Just something that we don't have to feel stigmatized and ashamed about.
And I love being a part of that. I love being a part of helping people, number one. Just to get into a more mentally well space and to help them feel like they have a place and it's okay to talk about the things that they struggle with. Doesn't make them weak. Doesn't make them any less.
[00:27:09] Speaker B: Yeah, I know a lot of us who work in the helping professions relate to that. I know I do.
And the book learning counts for a lot. You know, the education counts for a lot of. There's also the life experience, the Experiential learning, which is its own education.
Right. And I think too, when you carry that into the room with you, people can almost sense it and it helps them relax a little, you know, just knowing you're not going to judge them. You have been in the trenches or some version, maybe not the exact same ones.
[00:27:45] Speaker A: Right.
[00:27:46] Speaker B: But I think that presence creates a lot of warmth here and that, yeah, we shouldn't be afraid of that connection.
So what do you find most rewarding about the work that you're doing?
[00:28:00] Speaker C: Nothing feels better to me than seeing a client progress toward the goals that they tell me they want to achieve. Nothing feels better than heading into a follow up and having a patient look at me and say, almost in disbelief, like, I'm doing better, I'm doing a lot better. I they'll even be hesitant to say they're doing better because they don't want to jinx it or whatever the case. But something clicked. They're finally moving in the direction of their goals. And I think that feels amazing. And the longer you're with a client, the more rewarding it gets. Regardless of what that treatment looks like, there's ups and downs always.
And just staying steady in a patient's corner throughout all of that.
It's incredibly rewarding. I think it's hard to describe unless you are on the side in the field kind of working with patients, but yeah, just seeing patients truly start to feel better.
[00:29:11] Speaker B: So I want to talk about the population. That is your specialty. I know you work with a lot of new moms and you are a newish parent yourself, right?
[00:29:23] Speaker C: Yes.
[00:29:24] Speaker B: So can you explain why this phase of life can be so tough for so many in terms of anxiety management?
[00:29:34] Speaker C: Yeah.
Until you experience a child, whatever that looks like a child coming into your life, you are the main caregiver.
You are the one responsible for everything. Specifically in the case of a birthing mom.
[00:29:54] Speaker B: Right.
[00:29:55] Speaker C: There really is nothing that can prepare you for that until it happens. So you, leading up to birth, you have a whole nine months and you're doing your best, but it's completely unexpected, completely unknown until I feel like you step into that role.
And when you do, when it happens, your life does a complete 180.
Things change literally in the blink of an eye overnight.
So number one, that uncertainty that we all like to feel in control, competent, like we have a grasp on things.
And in parenthood, I feel like that may not ever be something that you feel fully in control and capable of. It's constant learning, continuous learning, you're learning your child. If you have more than one child, you're learning the, the other children. And so it's really full of unknowns. And then there's a lot of the physical components of being a new parent as well, which is lack of sleep, there's safety. You're constantly fearing for your child's safety. You might fear for your safety if you had a really complicated birth or a really complicated pregnancy. High risk pregnancy. I just think there's a lot of fragility involved in caring for a newborn and yourself in the process. And this isn't just moms too. The dads experience a lot, a lot of this as well if they're involved in the care. So yeah, there's, it's very complex. But I think the unknowns of it and just the, the change that significant, significant overnight 180 that your body, your mind, your soul goes through.
I'm. I haven't experienced anything quite like it in my life, so. Comes with a lot of anxiety.
[00:31:52] Speaker B: And something I talk to my own clients about is that for almost all people, anxiety can be driven by three basic things. One is uncertainty. We don't know what's going to happen.
The other is a perceived lack of control.
And the third is our own belief that we may not be able to handle it, especially if there's something we haven't proved to ourself yet.
Parenthood is all three of those things.
[00:32:22] Speaker C: Yeah, I was just gonna say that's the check, check, check.
It's true.
[00:32:27] Speaker B: So what are the most common concerns or problems that you help pregnant or new mothers with?
[00:32:36] Speaker C: Definitely anxiety. I would say postpartum anxiety hasn't made it into our DSM yet, but it certainly is a very prevalent heavy weight after birth. And so that's, that's a big one. And anxiety does not just present as our standard what we experience anxiety as it can include rage and irritability. And a lot of times moms will experience. New moms will experience symptoms and they're like, I've, I've never experienced that emotion before in my life. And that provokes more anxiety because that's scary.
So anxiety is a big one. Anxiety itself causes insomnia number one. You're not sleeping very well as a new parent.
My first didn't sleep for about eight months. He just, that wasn't his thing.
So we weren't sleeping very well for a while. But when you get the chance to sleep, your mind doesn't really want to shut off because you're, you're thinking and you're thinking and you're worried about your baby and if they're okay, and are you doing things right? And again, like you said, am I. Am I cut out for this? Am I. Am I capable of doing this? It's a constant cycling, and I. I find this to be especially prevalent at night. So that's where the insomnia, trouble sleeping can come in.
And then depression. Your hormones shift in dramatic, dramatic ways from the beginning to the end of pregnancy and through birth. And so there's a couple of different ways that this can present. There's. There's baby blues, and then there's postpartum depression, which comes with a whole host of symptoms, but really just the intense, intense sadness, mood swings, trouble bonding with your baby, and that can progress into even more serious territory, like suicidal ideation. So it can be a really scary thing to experience, especially when you're trying to care for another tiny human. I would say those are. Those are the biggest, most common things.
[00:34:44] Speaker A: Yeah.
[00:34:45] Speaker B: I read in Gabor Mate's new book, the Myth of Normal, about some of the preventative factors for postpartum depression, and he talked about the support system and the support of the partner being number one.
And in so many ways, do you find that to be true generally?
[00:35:10] Speaker C: Absolutely. Support system in the partner, like you said, primarily number one. That's huge. To be able to have someone in your corner working with you, working on your side, working toward the same goal, which is making a healthy human, that's huge. And then also I find just your. Your village, whatever that looks like, they say it takes a village, and that really is the way I feel it's designed to be. You need support. And again, I feel dads need support as well in that time. And so the village can really step in and make a huge difference in a postpartum experience. If you can come in, do a load of laundry, bring them a meal, they might not be in the space where they're ready for that, and that's okay. But, you know, just continuing to show up and offer and be there and listening when the mom or the dad feels they need to be listened to, that's. That makes a huge difference. So, yeah, postpartum support is actually. It is a marker for postpartum depression risk.
So if a mom has a real, true lack of support system in a partner or a village, whatever that look like, that is a risk factor for developing postpartum depression.
[00:36:33] Speaker B: Yeah. And from a therapeutic perspective, I'm thinking
[00:36:36] Speaker A: of what a huge identity shift this
[00:36:38] Speaker B: is for both parents, the mom and the dad.
And their relationship and their relationship to other people and how much comes up with that. Maybe even reckoning their own childhoods, reckoning what it means to. To be a parent.
[00:36:56] Speaker C: Right.
[00:36:56] Speaker B: So big meaningful time of life.
[00:37:01] Speaker C: Yes, absolutely.
[00:37:03] Speaker B: You were talking about sleep earlier, and I want to circle back to that.
[00:37:08] Speaker C: Okay.
[00:37:09] Speaker B: Not just for postpartum anxiety, but for general maintenance of mental health.
I feel like something I.
I always am harping on, and the advice I am always harping on myself on and is how much sleep matters.
I used to be one of those people who would stay up until like four working on something and try to just white knuckle the next day. But as I get older, the consequences are pretty obvious.
I'm trying to keep an eye on that.
But, you know, I'm blessed to, at this point in my life, not struggle with chronic insomnia. And I know this can be something. And sleep disorders in general can be something difficult to treat. And I wanted to get your point of view on.
[00:38:01] Speaker A: What do you think makes insomnia difficult?
[00:38:05] Speaker C: So, in my experience, a large portion of the time, insomnia is not just insomnia. Right. It's an extremely complex web of mental, emotional, physical pieces that overlap. So a lot of times it can be due to an underlying physical or mental health condition.
What makes it even harder to treat for patients, I think, is in general, our behaviors and our thoughts or our attitudes toward our sleep can actually perpetuate worsened insomnia. So patients will end up spending. If they've been having trouble sleeping.
True insomnia, like, just they can't fall asleep or they're waking up multiple times a night. They end up spending a lot of their day thinking about how tired they are. They're worried that they're not going to sleep well at night.
Then they get into bed and they're stressed about how they're not sleeping, and they're looking at their clock and they're more stressed they're not sleeping. It can be a really vicious cycle. Right. Our behaviors, our thoughts can really perpetuate the sleep disorder. So gold standard for insomnia is actually cbt. And that makes sense to me because it's seeing someone who has a deep understanding of, like, how to treat the disorder is crucial. And when you think of cbt, right. Our thoughts, our behaviors, our actions, they all influence each other. And so I think that's a huge component of insomnia. And medications can be useful temporarily, but often they're really just covering up the symptom. Right. They're making you feel Sleepy. But we're not getting to the root cause of why they're experiencing trouble sleeping in the first place, which can be really complicated and can take some time.
Nobody wants to wait that long, right? If you are not sleeping, that feels really, really heavy, and that's hard. So a lot of times patients are looking for something that's going to help them right now, which I fully understand.
But sometimes it. It can be a little more complicated than that. And I talk to my patients a lot about that, that, you know, medications for insomnia really are just covering up the symptom. But there's probably deeper roots to that. And a lot of my patients, when they come to me with anxiety or depression symptoms, they will also have insomnia. And as we start to treat the underlying anxiety and depression, naturally, they will start to sleep better. They'll start to rely less on sleep aids and stuff. So just. That's just one, one example of how insomnia is a little more complex, I think, than we all realize complex.
[00:40:49] Speaker B: And it takes time, which is tough when you're in agony, right? Being sleepless is being in agony. It's light on hard mode. And anyone who has been there knows what it's like. I had a friend struggling in college with chronic insomnia who would hallucinate a little bit like you would. The way he described it was. It was like when you were playing Nintendo 64 and the Walls would glitch or. Yeah, through a wall a little bit. Right. And yeah, all of that went away once he started sleeping.
So when you are working with folks who are pregnant, breastfeeding, what are some things that you keep in mind? Because I know as a medication provider, this can be something that takes some figuring out.
[00:41:46] Speaker C: Number one thing I usually will talk to patients about, and this is generally what I see patients most concerned about, is how is this going to impact the baby? Right. They want to make sure any medication that they might take would be safe, or at least they want to know the risk versus benefit ratio so that they can make an informed decision.
I am huge on this, being a mom myself. When you're pregnant, you can't even take ibuprofen. You. You have to consider. And everything you put in your body, you have to consider, like, is this safe?
There's listeria outbreaks in lettuce, so you have to think about the, the food you're eating, and there's. You have to wash it a certain way. There's. There's so much concern for what you put in your body.
And number one, there's a natural medication hesitancy that I find in patients, which is fully understandable to me. So number one, they're already baseline dealing with some medication hesitancy. Frequently, often.
And then also they have the added factor that they're pregnant. So first thing I'll do, I'll bring up pregnancy categories. So there's pregnancy categories A through X, A being the safest, X being completely contraindicated. So I like to bring up the pregnancy categories to patients just to let them know where any medication falls. And then I'll also bring up a website and kind of go through it with them. It's called Mother to Baby.
It's got really good evidence based information on it about considerations of a specific medication in every step of the way. So could this increase my risk of a miscarriage? Could this increase my risk of a birth defect in my child?
Could this increase risk of any long term neurodevelopmental effects in my child?
And then with breastfeeding moms, is there any, any part of this medication that might make it into breast milk? What would that risk look like if it did make it into breast milk? There's even lactation categories too. So I'll bring those up too if a mom's breastfeeding to talk about where a medication might fall in terms of safety for the baby, how much of it would make it into breast milk, things like that. So that's number one, the safety considerations for mom and the baby. But just to naturally kind of talk through some of that medication hesitancy too.
Generally when a mom has come to see me, there's reasoning behind that, right? She's gotten to a place where she feels like this is a good option for her. So just talking through that medication hesitancy and framing it in a way of you also deserve to be taken care of every step of the way. And that maybe doesn't feel natural to you, but that's why I'm here to convince you that you deserve to be taken care of every step of the way too.
And if we can find a medication that can help you in any way to experience more joy, more lightness, more mental wellness and in your pregnancy, then that's what I want to get to.
And also we do have to sometimes bring in obese, right, the obstetrician for the pregnant person and just talking to them, or I'll always suggest to a new mom that's maybe breastfeeding, hey, you know, this is something you can absolutely bring up to your pediatrician. As well. So that way, if you do notice any sort of symptoms or side effects of potential medication going into your breast milk, that's something you can talk to your pediatrician about, too.
So kind of that collaborative approach to medication, I think, is really big for pregnant and breastfeeding our new moms.
[00:45:34] Speaker B: I love that you sit down with
[00:45:37] Speaker A: your patients and you go through with
[00:45:39] Speaker B: them step by step, the risks and the benefits of what they're thinking about.
I think giving them that information can be so empowering.
And, yeah, it's important not to gloss over that, because what might right for one person might not be right for someone else, depending on their history or their context or absolutely dealing with.
So I like that you are giving them all the information they need to make a choice that's going to be right for them.
[00:46:10] Speaker C: Yeah.
[00:46:12] Speaker B: Something I've seen a lot of folks struggle with just in my own life is sometimes they'll have a medication that, for whatever reason, it's not working for them. Either they're getting side effects that don't feel great, or just something about it is causing them unease.
If you had a patient come to you and they were to say, you
[00:46:38] Speaker A: know, you gave me this clinical recommendation,
[00:46:40] Speaker B: it is not working with me, how would you help them solve that problem?
[00:46:44] Speaker C: That does happen, certainly. And I.
I always set the groundwork before.
It's important to me that my patients make an informed decision about the medication that they're going to take. So I always will go through. Sometimes a patient will be like, okay, that's a little bit too much. But I always go through any side effects they could expect, you know, and how long they might expect to experience those things. So I, number one, I really work hard to set that groundwork before we ever try a medication, just so that they know what they could possibly expect.
So that way, if they do experience a side effect or, you know, something that was really undesirable in the initiation phase, we can work through that, but they don't feel blindsided.
So that's one component of it, but it depends on the medication. So let's say we start an ssri, a selective serotonin reuptake inhibitor. That's our primary class we use with depression and anxiety.
Those medications generally take about four to six weeks to achieve baseline efficacy. That is at least the duration of time, the minimum duration of time that would be considered like an adequate trial. So if a patient comes to me three weeks into being on, you know, an ssri, then, and they're saying, hey, I'm not Really feeling like this is working.
Number one, I want them to know, I hear you.
And also it can take a little bit more time for these medications to achieve a full baseline efficacy.
So I'll kind of talk them through again. Still, having laid that groundwork, I do let my patients know these medications take about four to six weeks. Just so they know. But just kind of talking that through with them again, this is a little bit to be expected. Let's give it some more time.
If they're not having any intolerable side effects, we can always talk about dosage changes. After we have reached that minimum amount of time that we would give it for an adequate trial, we can talk about dosage adjustments.
But I tell every one of my patients, you are never stuck on a medication. We can always make changes.
And I feel very strongly and I want my patients to be very comfortable and confident in the medication that we choose and in the decisions that we make in our treatment. Because that's just number one, that's basic, basic patient care. These decisions I don't take lightly. I don't take starting patients on medications lightly. That's what I do all day. But I don't take it lightly. It's a big deal and I see it that way as well.
I would want someone to take it seriously if they were providing to my family. So we're never stuck. We can always make a switch, make a dosage change, but we'll find the one that works. It might just take some time.
[00:49:47] Speaker B: It sounds like you have this collaborative approach to client care, which I think should be standard everywhere.
[00:49:55] Speaker C: Right, Me too.
[00:49:57] Speaker B: Yes.
But I hear horror stories and like, as someone who has been through meat grinders myself in the mental health care system when I was younger, I believe those stories.
But I think there can be a lot of repair and healing that happens when someone has a relationship with a provider where they feel heard and in control.
And I think, you know, what you're doing is going a long way in terms of empowering people to make decisions that are going to be good for their health, their well being and their families.
[00:50:35] Speaker C: Yes.
[00:50:36] Speaker B: So I wanted to at this point transition to talking about the benzos since we're talking about medications here.
[00:50:48] Speaker C: Yeah.
[00:50:49] Speaker B: And because I know these are prescribed and often over prescribed in situations where they should not be.
But I think it would be helpful for listeners to get a baseline understanding of what this medication is and how it works.
[00:51:05] Speaker C: Yeah.
[00:51:06] Speaker B: Can you explain how a benzo. So that's going to be Xanax, Klonopin, things In that class, how do they function in the body? Like how does this medication work on anxiety?
[00:51:21] Speaker C: So benzodiazepines, I'll refer to them as benzos like you mentioned, Klonopin, Xanax, Ativan, they work by slowing down the activity in your brain and your nervous system. So kind of think about hitting the brakes on a car, kind of hits the brakes a little bit on your brain and your nervous system.
So they work to enhance the effect of gaba, that's a neurotransmitter in our brain.
So GABA is a inhibitory neurotransmitter in the brain. So benzos will bind to GABA receptors which essentially has the overall effect of quieting nerve signals. So that's going to cause our classic side effects of anti anxiety sedation. It can make patients feel pretty sleepy and also anticonvulsant and muscle relaxant effects.
So a little bit more physiological, but that's, that's how it works. It's really our primary inhibitory neurotransmitter.
So the benzos enhances what kind of
[00:52:28] Speaker B: problems or what kind of anxiety would a benzo be suited for treating safely?
[00:52:35] Speaker C: That's an area where I tread a little lightly.
So I would say talking about what, what benzos are suited to treat safely just in general. So they're really effective at treating like medical conditions. We're talking about seizures, some more of our severe effects of alcohol withdrawal.
They even are used to provide muscle relaxation in the event of like procedural sedation, like a surgery. They are FDA approved to treat anxiety and insomnia.
But I think it gets a little tricky there.
We can talk about a little bit more. I don't necessarily know if that's the safest way to use them.
Based on their intense addiction potential, especially for chronic insomnia, chronic generalized anxiety.
I don't see their place or their role in treating those possibly like some severe specific phobias that patients maybe aren't exposed to on daily regular basis. For example, air travel in a plane. Right. Benzos can definitely be helpful on those one off kind of short term anxious triggers. But there's, there's limited use in, in my opinion for their role in anxiety.
[00:53:58] Speaker B: Yeah. And what you're saying echoes a lot of my own research and things I've heard from people who do activism erratmus that typically benzos are good for when someone needs a hammer.
So those medical situations he brought up, but there was one study that said their efficacy can wane after one week and that as those Weeks go on, folks are actually building a tolerance just as they would to alcohol opiates.
And so they start to experience withdrawal symptoms.
And I think again, this study, I was able to find it. But that's not something that unless a provider like sits down and talks with someone, that's not something the general public is going to be able to fish out.
[00:54:52] Speaker C: Right.
[00:54:53] Speaker B: You know, and again, I'm just so glad you sit down with your clients and go over all of this stuff because before I took a statistics class, I had no idea how to read these studies. Right. I would see, okay, I can use this, it's fine. But that's really not what the study is literally saying. Usually there's limitations behind how any medication or any treatment. This goes for therapy treatments too.
[00:55:20] Speaker C: Absolutely.
[00:55:21] Speaker B: Can be used and how they should be used and taking the time with someone to talk about, okay, here's what the research says, here's the risks, here are the, here are the benefits.
So what are some of the contraindications for benzo use? Like when should someone strongly consider that this just might not be the right medication for them?
[00:55:45] Speaker C: So I'll give more kind of general, broad categories. There's certainly some medical, like specific medical conditions that you could, your provider would have to assess. But overall, broad, general contraindications, especially in mental health, what we look at would be prior substance abuse issues. So if you have a history of addiction or substance abuse problems, that would be a contraindication. Or if you're pregnant or breastfeeding, that's a contraindication.
In patients who have severe respiratory illnesses like COPD or severe sleep apnea in elderly patients, these medications are known to cause respiratory, respiratory depression or like a slowing of your, your breathing. And so further slowing down your breathing in a patient who already has compromised respiratory system is not a great idea.
And there's some more like specific, like narrow angle glaucoma and my gravis, which is like a neuromuscular condition.
Again, there's more specific medical conditions that you could get into, but those are kind of more of the, the broad overarching. And specifically in my world, what I see. Right. Is the substance abuse or pregnancy and breastfeeding.
[00:57:03] Speaker B: And just to clarify for listeners who
[00:57:06] Speaker A: might be wondering, okay, if benzos are contraindicated for folks with a history of substance use disorders, why are they used
[00:57:15] Speaker B: to help with alcohol withdrawal? It's because a lot of folks in alcohol withdrawal can be a seizure risk.
[00:57:20] Speaker C: Yes.
[00:57:20] Speaker B: So the benzos are helping to mitigate that dramatic withdrawal symptom.
[00:57:26] Speaker A: And the goal for most people withdrawing
[00:57:29] Speaker B: is that they get off the benzo as well. So again, it's a short term intervention to get someone through a very dark period.
[00:57:38] Speaker C: Right. And that, in that, in that case, it's more. We have to prioritize the physical safety because there are a lot of physical health considerations when a patient's going through alcohol withdrawal.
So in that event, a benzo would be used as like a rescue or an as needed medication to prioritize the patient's safety in the event of like a seizure or something along those lines.
[00:58:01] Speaker B: Benzos work with GABA in our brain, right? They sit on those receptors. Those are the same receptors alcohol sits on.
So something to think about. Right. Because just as when you have a drink, you know this right away, right. That you know you've been physically impacted in some way, benzos are impacting that same system that alcohol is. Right. So that's another reason why that addiction risk can be there. And alcohol withdrawal can be deadly. So can benzo withdrawal.
[00:58:38] Speaker C: Absolutely.
[00:58:39] Speaker B: So just some things to keep in mind with this stuff.
Um, so on that note, what might be some of the red flags someone can look out for in themselves in terms of benzo use? Like, might be a sign that someone's use has stopped being helpful or even crossed the line into dangerous territory for them.
[00:59:03] Speaker C: So benzos are controlled substances. The, that means that they're tightly regulated by a federal regulatory agency, the dea.
The reason they're so tightly regulated is because they have such an incredibly high risk for abuse tolerance, psychological dependence. Okay. So if you're taking these medications on a long term basis, they can have severe withdrawal, like you said, deadly withdrawal symptoms if someone takes them on a regular, long term basis. So anyone who starts to develop any signs of those things like abuse tolerance, dependence, that would hopefully be a huge red flag for providers. And I think a lot of times providers are on the front lines, they are refilling the medication so they can really start to see those red flags, maybe even before a patient can see it in themselves.
But things like asking for refills early on a consistent basis, visiting multiple providers to ask for the same prescription, taking the medication not as prescribed or more than prescribed, or feeling like they need to, or just in life in general, having an increasing inability to like, meet the demands of their life, work, school, home life due to the medication. I find there's some evidence that shows that really long term use of these medications can actually increase anxiety in the long term, some sort of, you know, in a paradoxical effect. So A lot of those behaviors would be kind of the first red flags you would see.
And just in a patient themselves, feeling like you cannot go throughout the day without taking your medication or feeling like you need to take more than you're prescribed, those would be some red flags for sure.
[01:00:53] Speaker B: All of those make sense. And so much of that boils down to when you notice yourself not acting like yourself.
And something I'm thinking about as we talk is over the decades, benzos have reinvented and rebranded themselves.
They were Valium back in the 50s, 60s and they were branded specifically towards women and specifically mothers.
[01:01:20] Speaker C: Yeah, like they were mom's little helper.
[01:01:22] Speaker B: Right? Mom's little helper. This despite the fact that this medication is especially risky for that population.
So I have my own thoughts on this that I'll share, but I also want to hear your take.
[01:01:39] Speaker A: What do you think makes this class
[01:01:41] Speaker B: of medication so appealing to both clients and to providers who write these scripts
[01:01:48] Speaker A: despite the known risks?
[01:01:50] Speaker C: Now I'll speak to my field specifically in psychiatric care. First, I want to really empathize with why patients are usually seeking these medications out in a psychiatric setting. So a lot of times patients will come to a provider and they're experiencing debilitating anxiety that's already preventing them from being able to meet the demands or the expectations of their lives. Okay. And that's so heavy. I don't want to, I don't want to gloss over that. That's extremely heavy. That's a really hard place to be in patients.
Maybe initially they'll be prescribed these medications. Sometimes it can come from a primary care provider.
They'll start taking these medications.
Benzodiazepines do work quickly and effectively to decrease anxiety.
That's why they're so addictive, but so subjectively. Patients are going to report they feel relieved of their panic or their phobia or their generalized anxiety, whatever type of anxiety it might be after they take these medications. So the patient will experience that relief. And of course they want to continue with that treatment because that's what's providing them relief in the here and now. It's not in four to six weeks like some of our other psychiatric medications. The issue though comes when these medications are taken regularly and on a long term basis. Like you said, there's, there's can be evidence of decreased efficacy after one week.
That's, that's fast.
So physical and psychological dependence on benzos can happen very quickly. The issue at that point is there's true safety considerations like we talked about when we look at benzo withdrawal, seizures, psychosis, suicidal ideation.
I recently read a memoir of a woman who was working really hard to come off of long term benzodiazepine use and she experienced too many strokes.
So as a provider, if you have a patient coming to you and they've been on benzodiazepines for a long time, someone's been refilling them, what might have started as a genuine attempt to help someone through their anxiety?
Because as providers, we want to help, we want to fix. Absolutely. So what might have started as a genuine attempt to just relieve someone of their debilitating anxiety has now turned into a really serious safety consideration. And these medications cannot be stopped cold turkey. It's a very slow process and many patients don't want to come off of them. Sometimes they do, but it's again hard to want to come off of a medication that has proven to be effective in relieving your anxiety, even when you're faced with issues of tolerance and abuse, independence and increasingly higher dosages. I mean, we know addiction is extremely complicated, so a lot of patients don't want to come off of them. And so that can be really challenging for providers as well. There's the safety considerations and then there's also the patient, their willingness to do it. So it can be pretty, pretty complex, I feel.
[01:04:58] Speaker A: Yeah.
[01:04:59] Speaker B: And I'm just thinking about coming off of these is a full time job.
Right. Just like coming off of any other serious substance or behavior we might be addicted to. Most people go away for a month to do that.
And if you have to work, if you have kids, you know, taking the time to do that, it's going to be so difficult, not to mention the physical hell you have to go through.
Absolutely withdrawing and all that uncertainty. Right?
[01:05:30] Speaker C: Yeah.
[01:05:30] Speaker B: Coming back and just to echo some of what you've said, I know most Americans and I'm like this, we wait until a problem is really bad before we seek help, before we see a doctor, a psychiatrist or a therapist.
And this is not to blame or shade because I am guilty of this. And we all have so much going on, it can be hard to prioritize ourselves in that way. But I think by the time someone comes into our offices, they have been struggling so much for so long that understandably they want it to go away. And I've been there. And I think one of the hardest things we have to do as providers, but it is the most honest, ethical thing is to sit down with someone and say, I know you have been struggling so hard and so long and there is no magic cure.
[01:06:26] Speaker C: Yes.
[01:06:27] Speaker B: It'll take time.
That's tough. Especially when there's people out there who will sell them the fake magic cure.
[01:06:34] Speaker C: Right, right, right. Yes.
[01:06:36] Speaker B: I think it's just tough. And that goes for therapy. There's no, like, therapeutic practice that works overnight.
Goes for medication. You might get this more than I do just because you prescribe literal pills. So it fits the magic pill metaphor, right?
[01:06:51] Speaker C: Absolutely.
[01:06:52] Speaker B: Right.
[01:06:52] Speaker C: We have to set a lot of expectations in our first appointment. And anytime we make a switch, there's a lot of expectation. Setting. Yeah, yeah.
[01:07:01] Speaker B: And this isn't to say there isn't hope. Right. But that, of course, it takes time and effort and there's just no way the cheat code past it. There isn't. And if someone is trying to convince you that they have the cure and that it'll work quickly, that's a red flag.
[01:07:21] Speaker C: I would run. Yes, that is a red flag right there.
[01:07:24] Speaker B: Yep.
Yeah. You know, you should have a provider who's going to give you some hope, but they're going to be real with you, but they're going to be there with you as you're going through it. You don't have to go through that journey alone.
[01:07:38] Speaker C: Absolutely.
[01:07:39] Speaker B: So I want to be conscious of our time, so I know they have to begin wrapping up. Is there anything you'd like to say, any closing remarks before we. Yeah.
[01:07:48] Speaker A: Wrap up here?
[01:07:50] Speaker C: These things do take time, but there absolutely is hope. That's what we're here for. We are here to partner with you, to be your cheerleader and also to speak truth and to be real with you.
There are providers, many, many providers out there who feel the same and want to work with you and be on your team and be your biggest support.
If you are not thinking that maybe you are having the right fit with your current provider, that's okay. Like I said, there are providers out there who are.
They really want to be on your team, and they want you to be comfortable and confident in the treatment decisions that you make together.
So just to kind of.
Yeah. Give some encouragement to patients.
These things do take time, but there absolutely is hope. And there are providers out there who are excited and more than willing to go on the journey with you.
[01:08:50] Speaker A: Thank you for your time here.
[01:08:51] Speaker B: This has been awesome.
[01:08:54] Speaker C: Thank you for having me.
[01:08:56] Speaker B: And just listening to how thoughtful you are with how you work with your clients, that gives me a lot of hope and hope for those who might want to seek some psychiatric assistance with
[01:09:09] Speaker A: whatever they're going through.
[01:09:11] Speaker B: Right. Knowing that there's someone out there who's going to sit down with them, make sure that they're in control of the process, and just give them the information they need to make up their minds here. So.
Yeah. Well, thank you, Morgan.
[01:09:29] Speaker C: Sam.
