Patients with primary
psychiatric comorbidity and sedative-hypnotic use disorders | Patients with primary substance use comorbidity | Patients with abuse of or dependence on multiple
drugs or alcohol | Patients with coexisting psychiatric disorders
Patients who present with adverse effects secondary to sedative-hypnotic
medications require a thorough evaluation, including an appraisal
of whether adverse effects outweigh benefits of continuing treatment.
Adverse effects include the development of excessive sedation or
memory problems that interfere with functioning or increase risk
of falls in the elderly, potential for adverse interaction with
alcohol or other sedative medications, and compulsive/uncontrollable side
effects involved in maintenance therapy with alternative antianxiety
medications such as antidepressants, mood stabilizers, or neuroleptics.
In the instances when adequate symptom control cannot be achieved
without adverse effects, the alternative treatment strategy is warranted.
This might include 1) conversion to and stabilization on the equivalent
dose of an alternative benzodiazepine with a slower onset and a
longer duration of effect (e.g., conversion from alprazolam to clonazepam);
2) conversion to and stabilization on the lower dose of the alternative
benzodiazepine; 3) complete discontinuation of benzodiazepines and stabilization
on an alternative GABAergic agent with a more favorable safety profile
(e.g., carbamazepine or valproate); or 4) discontinuation of medication
and implementation of behavioral treatment strategies (see Figure 16–2 for the suggested treatment strategies).