"Our own implicit biases come into play at times whether we like it or not, especially when it comes to frequently controversial medications."
The tele-geropsychiatry new patient consultation appointment started. The patient and his wife were on camera. The patient was able to answer most of the interview questions himself, with his wife chiming in intermittently. The patient was a very pleasant man living with Parkinson disease. We talked about where the patient and his wife live, their children, the patient’s time in the military, and the state of his mood. Then I asked about eating and sleeping and started the review of medications. Here we go, I said to myself.
The consult was a referral from the patient’s primary care physician noting anxiety and that “wife requests refill for patient’s clonazepam 1.0 mg qhs.” The consult mentioned that clonazepam was the only medication to assist with the patient’s mood and sleep. It also mentioned that the primary care physician had recommended trazodone but that the prescription was never filled.
Naturally, I thought about clonazepam and the fall risk for the patient—an older gentleman with Parkinson disease—and about how clonazepam is the “only medication that assists the patient,” according to the consult. I was eager to talk with the patient and his wife and curious about whether there might be pushback when discussing the adverse effects of such a medication, especially in a patient with Parkinson disease.
I was prepared to discuss the risks and benefits of using clonazepam at this dose in an individual with dizziness and falls, compounded by a neurodegenerative disease. Then came a natural pause—one of the moments in the psychiatric interview that can often be just a moment to hold space with the patient.
“He used to thrash in his sleep,” the patient’s wife said.
“Thrash?” I asked.
“Yes,” she said.
“Could you tell me a little bit more?” I asked.
The patient’s wife then described years in which the patient would become agitated during the night, moving his legs and arms and sometimes striking his wife during these episodes. The only medication that the patient had used over the last 12 years was clonazepam. When he trialed quetiapine, the thrashing got worse.
I thought to myself: Thrashing…in someone with Parkinson disease…got worse with quetiapine…Could this in fact be rapid eye movement sleep behavior disorder (RBD)? I quickly went to UpToDate and searched for “treatment” and “first line: clonazepam 0.5 to 1.0 mg qhs.” Then came the “ah-ha” moment.
The patient and his family were never told the actual medical name for “thrashing.” They were never told that the clonazepam was to lessen these episodes. There was no documentation of this diagnosis anywhere in the patient’s direct access chart. It was through digging back 11 years in a remote medical chart and finding one neurology note that said—albeit in 3 letters—“RBD,” with no subsequent explanation, that I realized this was what the patient was experiencing. Could it be true?
This was not about benzodiazepines. It was not about overuse or misuse of the drug. It was about the first-line FDA-approved drug for RBD1—and the only one that worked for this patient. RBD is a disorder in which patients act out their dreams, which is commonly seen with comorbid Parkinson disease.2 This diagnosis was never discussed with the patient and his family, who were also never given a diagnosis to explain the years of sleep disruption. It never made it into the patient’s formal diagnosis list, so it never got carried forward on his problem list.
I immediately wondered how many times this patient must not have been listened to because his wife was asking only for clonazepam. What would have happened if his wife had never mentioned thrashing during sleep in this patient encounter? This certainly could have gone very differently.
Today, when doctors are targeted for irresponsible prescribing practices, how many physicians are hesitant to prescribe what turns out to be the first-line treatment for a legitimate medical condition? Ultimately, that is where the buck stops.
Sometimes this is due to preconceived notions or scenarios we often play out in our head prior to engaging with patients. Sometimes it is because we do not dig deep enough into medical charts and then make assumptions. And then, there is a staunch reminder that the patient’s story is the center of the encounter. We need to keep an open mind about the patient’s narrative and ensure that it is what remains front and center.
Our own implicit biases come into play at times whether we like it or not, especially when it comes to frequently controversial medications. If we do not ask, if we do not explore, and if we do not engage in those moments of holding space with patients, our biases can cloud our judgment and divert patient care in very different directions than intended. Listening to patients, asking them questions, and maintaining an open mind throughout the conversation can be key not only to preventing our implicit biases from taking over, but also to providing more effective patient care.
Dr Massoudi is a PGY2 psychiatry resident at Nova Southeastern University College of Medicine/Bay Pines VA Healthcare System. Ms Piotrowska is a medical student at Nova Southeastern University College of Medicine. Dr Behbahani is associate training director of the general adult psychiatry residency program and geriatric psychiatry site director at Nova Southeastern University College of Medicine.
1. Anderson KN, Shneerson JM. Drug treatment of REM sleep behavior disorder: the use of drug therapies other than clonazepam. J Clin Sleep Med. 2009;5(3):235-239.
2. Howell M, Schenck CH. Rapid eye movement sleep behavior disorder. UpToDate. Updated August 18, 2022. Accessed September 25, 2022. https://www.uptodate.com/contents/rapid-eye-movement-sleep-behavior-disorder/print#:~:text=INTRODUCTION%20Rapid%20eye%20movement%20(REM,thrashing%2C%20punching%2C%20and%20kicking