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Benzodiazepine Use in America: A Growing Concern Over Over-Prescription and Long-Term Risks
The ease with which some Americans obtain prescriptions for benzodiazepines,commonly known as “benzos,” is raising alarms among healthcare professionals.For decades, many individuals have relied on these medications for sleep or anxiety, often without a full understanding of the potential consequences.One such individual, identified as Marcoux, recalls a time when obtaining a prescription was remarkably simple. “Got the prescription,and that’s it.Nobody was asking questions. I was not asking questions,” Marcoux recalls,highlighting a past culture of less stringent oversight.
Marcoux’s story underscores a significant issue: the potential for over-prescription and misuse of benzodiazepines, a class of drugs that has been around as 1955. After 35 years of nightly use, marcoux quit after a study linked long-term benzodiazepine use to cognitive impairment.
Benzodiazepines, often depicted in popular culture, including TV series, reflect their widespread use and societal perception.Though,the reality behind these medications is frequently enough more complex and concerning.A 2024 study published in the journal Sleep Medicine surveyed approximately 4,000 Canadians, revealing that 15% had used sleep medication. The study further indicated that one in four respondents aged 65 and older,and about one in ten between 36 and 49,had used prescribed sleep medication in the past year. While this study focused on Canadians, similar trends are observed in the United States, were sleep disorders and anxiety are prevalent.
According to a study published in the Canadian Journal of Public Health in 2023, benzodiazepine use ranges from 5% to 10% of the populations in Canada and the United States between 1996 and 2019. This consistent usage rate over decades suggests a persistent reliance on these drugs, despite growing awareness of their risks. This steady rate suggests a need for re-evaluation of prescribing practices and patient education in the U.S.Understanding Benzodiazepines: Uses and Risks
Benzodiazepines are prescription medications primarily intended for the short-term treatment of conditions like acute anxiety, panic attacks, and severe stress. They can also be prescribed to prevent seizures, provide temporary relief for sleep disorders, act as muscle relaxants, or manage alcohol withdrawal symptoms.Dr.Paxton Bach, an addictions medicine specialist at Vancouver’s St. Paul’s Hospital, emphasizes the importance of understanding the risks. “Its crucial to understand that these medications are intended for very brief use — typically only a few days to a week — as they can quickly lead to physical dependence.”
The risks associated with benzodiazepine use are significant:
Dependency: Habit formation can occur within days to weeks of regular use. This is a major concern, as dependency can lead to withdrawal symptoms and difficulty discontinuing the medication.
Withdrawal Symptoms: These range from increased anxiety and restlessness to life-threatening complications like seizures or coma. The severity of withdrawal symptoms underscores the importance of careful tapering under medical supervision.
side Effects: Sedation, decreased cognitive function, impaired reflexes, and increased fall risk are common. These side effects can significantly impact daily life and increase the risk of accidents,especially in older adults.
Tolerance: Long-term use can lead to tolerance, requiring higher doses for the same effect, making discontinuation more challenging than with opioids. This escalation of dosage can further exacerbate the risks and side effects.
Overdose Risk: combining benzodiazepines with other substances like opioids or alcohol dramatically increases the risk of overdose. This is a notably risky combination, as it can lead to respiratory depression and death.
The potential for dependency and severe withdrawal symptoms makes it crucial for both doctors and patients to carefully consider the risks and benefits before initiating benzodiazepine treatment.For example,a patient experiencing situational anxiety before a flight might benefit from a short course,but long-term use for chronic anxiety is generally discouraged.
The Over-Prescription problem and Safer Alternatives
Dr. Camille Gagnon, assistant director at the Canadian Medication Appropriateness and Deprescribing Network, points out the serious issue of benzodiazepines being over-prescribed. while they can be beneficial for patients with qualifying symptoms, she emphasizes that “these are not the best approach for patients, especially not long term.”
Gagnon recommends exploring alternatives to insomnia treatment, such as psychological therapy. however, she acknowledges barriers to accessing these options, including high costs and a lack of publicly funded psychotherapists. This frequently enough makes medication, whether prescribed or not, the more accessible option. In the U.S., similar barriers exist, with many individuals lacking adequate insurance coverage for mental health services.
Dr. Bach has observed that some patients are prescribed benzodiazepines without adequate communication about the risks, a critical factor in preventing dependency. “I hope that patients who’ve been on one of these medications long term have been communicating with their prescriber about the risks and benefits and whether or not it’s still the right medication for them.”
Safer Alternatives and the Path Forward
Given the risks associated with benzodiazepines, healthcare providers are increasingly exploring safer alternatives. These include:
cognitive Behavioral therapy for Insomnia (CBT-I): This therapy helps individuals identify and change negative thoughts and behaviors that contribute to insomnia.
Mindfulness-Based Stress Reduction (MBSR): This program teaches mindfulness techniques to reduce stress and improve sleep.
Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): These antidepressants can be effective in treating anxiety disorders without the same risk of dependency as benzodiazepines.
* Lifestyle Changes: Regular exercise, a healthy diet, and good sleep hygiene can also improve sleep and reduce anxiety.
The key to addressing the over-prescription problem lies in better education for both doctors and patients, increased access to alternative treatments, and more careful monitoring of benzodiazepine prescriptions. By prioritizing these measures, the U.S. can reduce the risks associated with these medications and improve the overall health and well-being of its citizens.
Addressing Potential Counterarguments
Some might argue that benzodiazepines are essential for managing severe anxiety or panic disorders when other treatments have failed. While this might potentially be true in certain cases, it’s crucial to weigh the potential benefits against the risks and to explore all other options first. Additionally, regular monitoring and careful tapering can help minimize the risk of dependency and withdrawal symptoms.
Conclusion
The reliance on benzodiazepines in the United States presents a complex challenge. While these medications can provide short-term relief for certain conditions,their potential for dependency and other adverse effects necessitates a more cautious and informed approach. By promoting safer alternatives, improving patient education, and addressing the underlying causes of anxiety and sleep disorders, the U.S. can move towards a more sustainable and effective approach to mental health care.
Benzodiazepines: Unveiling the Truth Behind Over-Prescription, Dependency, and the Path to Freedom
An exclusive interview with a leading expert on the hidden dangers and alternative solutions.
Interview: The Benzodiazepine Epidemic and Beyond
World-Today-News.com sits down with Dr. Evelyn Reed,a renowned addiction and mental health specialist with over 20 years of experience helping individuals navigate the complexities of benzodiazepine use and withdrawal.
World-Today-News.com: Dr. Reed, it’s estimated that millions worldwide have been prescribed benzodiazepines. Yet, as the recent Radio-canada *Enquête* report highlighted, many were never fully informed about the potential for devastating withdrawal symptoms. Is this a crisis of informed consent, and how did we get here?
Dr. Evelyn reed: “Absolutely.It’s a crisis of informed consent, and the history is complex.Benzodiazepines like diazepam (valium), alprazolam (Xanax), and others, were initially marketed as safer alternatives to barbiturates in the 1960s. The perception was that they were less addictive. This created a surge in prescriptions. Doctors, under pressure to address anxiety and sleep issues quickly, frequently prescribed them without fully explaining the risks of dependence. The long-term consequences,notably the potential for protracted withdrawal syndromes,cognitive impairments,and other serious side effects,weren’t always well-understood or adequately communicated. This resulted in a situation where many patients were initiated on these medications without a clear understanding of the long-term implications. Many practitioners didn’t fully realize the potential for the body to become reliant on these medications. This led to a reliance on these medications over a period of weeks or even months,a practice not encouraged in modern medicine.”
This echoes concerns raised across the United States, where similar prescribing patterns have led to widespread dependence. The Centers for Disease Control and Prevention (CDC) has issued guidelines urging caution in prescribing benzodiazepines, emphasizing the importance of exploring alternative treatments and carefully monitoring patients for signs of dependence. The over-prescription of opioids in the U.S. serves as a stark reminder of the potential consequences when medications are not carefully managed and patients are not adequately informed.
World-Today-News.com: You mentioned protracted withdrawal. Can you elaborate on the withdrawal symptoms and the challenges individuals face when they try to stop these medications?
Dr. Evelyn Reed: “The withdrawal symptoms are far-reaching and can be quite severe. it largely depends on the individual, the dosage they were taking, and the duration of use. Symptoms can range from mild anxiety, insomnia, and muscle tension to more severe complications like seizures, hallucinations, and suicidal ideation. Protracted withdrawal means that these symptoms can linger for weeks, months, or even years after the medication is discontinued. Some individuals experience what is called ‘kindling,’ where each attempt to withdraw or reduce the dose leads to more severe withdrawal symptoms. The process requires very measured, and supervised care.”
For many Americans, the fear of withdrawal is a significant barrier to discontinuing benzodiazepines. Stories abound of individuals struggling with debilitating symptoms for months or even years after stopping the medication. This fear is compounded by a lack of awareness among some healthcare providers about the complexities of benzodiazepine withdrawal, leading to inadequate support and guidance for patients attempting to taper off the drugs.[2]
Alternative Treatments for anxiety and Insomnia
World-Today-News.com: Given these risks, what alternative treatments for anxiety and insomnia do you recommend, and what are their benefits?
dr.Evelyn Reed: “We have a multitude of effective, non-pharmacological alternatives. Here are some evidence-based treatments that people can look into:”
- Cognitive Behavioral Therapy (CBT): “This is a form of psychotherapy that helps individuals identify and modify negative thought patterns and destructive behaviors related to their anxiety or insomnia. It provides long-term benefits and has no risk of dependency.”
- Mindfulness Meditation: “Practicing mindfulness involves focusing on the present moment without judgment. It’s an excellent method for reducing stress, anxiety, and improving overall sleep quality.”
- Regular Exercise: “Physical activity is a natural mood booster and helps reduce stress hormones. It enhances both physical and mental well-being.”
- Good Sleep Hygiene: “Establishing consistent sleep patterns, creating a relaxing bedtime routine, and optimizing the sleep habitat are cornerstones of healthy sleep. These practices can considerably reduce the reliance on medication.”
“These alternatives provide lasting benefits without the dangers associated with benzodiazepines.”
These alternatives are gaining traction in the United states as healthcare providers and patients alike seek safer and more sustainable approaches to managing anxiety and insomnia. for example, many insurance companies now cover CBT for insomnia, recognizing its effectiveness and cost-effectiveness compared to long-term medication use. Furthermore, the rise of mindfulness-based stress reduction (MBSR) programs across the country reflects a growing interest in non-pharmacological approaches to mental well-being.
| Alternative Treatments for Anxiety and Insomnia | Description | Benefits |
|---|---|---|
| Cognitive Behavioral Therapy (CBT) | A type of psychotherapy that helps individuals identify and change negative thinking patterns and behaviors. | Effective for anxiety and insomnia, long-term benefits, no risk of dependency. |
| Mindfulness Meditation | A practice that involves focusing on the present moment without judgment. | Reduces stress and anxiety, improves sleep quality, promotes relaxation. |
| Regular Exercise | Physical activity that improves mood and reduces stress hormones. | Reduces anxiety and depression, improves sleep, enhances overall well-being. |
| Good Sleep Hygiene | Practices that promote healthy sleep habits, such as maintaining a consistent sleep schedule and creating a relaxing bedtime routine. | Improves sleep quality,reduces reliance on medication,promotes natural sleep patterns. |
Quitting Benzodiazepines: A Gradual Process
World-Today-news.com: Many people worry about tapering prescriptions. What is the most effective approach to quitting benzodiazepines?
Dr. Evelyn Reed: “The most crucial aspect is a carefully planned,gradual tapering process,done under medical supervision. Quitting benzodiazepines abruptly can be extremely hazardous. The goal should be to reduce the dosage slowly over weeks or months, allowing the brain to adjust. This reduces the severity of withdrawal symptoms. Having a support system, including therapists or support groups, is also incredibly beneficial.this is not something anyone should do alone.”
This gradual tapering process is crucial to minimize the risk of severe withdrawal symptoms. [3] abrupt cessation can lead to seizures, delirium, and even death. The ashton Manual, a widely respected guide for benzodiazepine withdrawal, provides detailed tapering schedules and strategies for managing withdrawal symptoms.It emphasizes the importance of individualized treatment plans tailored to each patient’s specific needs and circumstances.
World-Today-News.com: What role does a doctor play in helping their patients safely discontinue benzodiazepines?
Dr. Evelyn Reed: “A doctor’s role is pivotal at every stage. They begin by thoroughly assessing the patient’s medical history, current medications, and the reasons for benzodiazepine use. They then work with the patient to develop a personalized tapering plan, closely monitoring for any withdrawal symptoms and providing support and guidance throughout the process.Doctors can also prescribe medications to manage specific withdrawal symptoms, such as anxiety or insomnia. Moreover, they can refer patients to therapists or support groups for additional support.”
The involvement of a educated and supportive physician is essential for prosperous benzodiazepine withdrawal. Regrettably, many patients report feeling dismissed or unsupported by their doctors, highlighting the need for improved training and awareness among healthcare professionals regarding the complexities of benzodiazepine dependence and withdrawal. The American Psychiatric Association and other medical organizations offer resources and training programs to help doctors better understand and manage these issues.
while benzodiazepines can be effective for short-term management of anxiety and insomnia,their potential for dependence and severe withdrawal symptoms necessitates careful prescribing practices and informed consent.Alternative treatments, such as CBT, mindfulness meditation, regular exercise, and good sleep hygiene, offer safer and more sustainable solutions for many individuals. For those seeking to discontinue benzodiazepines, a gradual tapering process under medical supervision is crucial to minimize the risk of adverse effects. Increased awareness, improved training for healthcare professionals, and greater access to alternative treatments are essential to address the benzodiazepine epidemic and help individuals reclaim their health and well-being.
Navigating Benzodiazepine Discontinuation: A Comprehensive Guide for U.S. Readers
World-Today-News.com, March 31, 2025 – As benzodiazepine prescriptions remain prevalent in the united States for managing anxiety, panic attacks, and insomnia [[[2]], understanding the complexities of safely discontinuing these medications is crucial. This article delves into the process of benzodiazepine withdrawal, offering expert insights and practical advice for a successful and supported journey to recovery.
the Challenge of Benzodiazepine Withdrawal
Benzodiazepines,while effective in the short term,can lead to physical dependence [[[2]]. Abrupt cessation can trigger a range of withdrawal symptoms, from mild anxiety and insomnia to severe and potentially life-threatening complications [[1]]. These symptoms underscore the importance of a carefully managed tapering process.
Sudden withdrawal can manifest as anxiety, panic, and insomnia [[1]]. In extreme instances, benzodiazepine and Z-drug withdrawal can pose a significant health risk [[1]]. This is why a gradual reduction, or tapering, is almost always recommended.
Consider the case of a 45-year-old woman from Chicago, Illinois, who had been taking lorazepam for anxiety for several years. When she attempted to stop “cold turkey,” she experienced severe rebound anxiety and insomnia, ultimately requiring hospitalization. This real-world example highlights the potential dangers of unsupervised benzodiazepine cessation and the necessity of medical guidance.
Dr. Evelyn reed on Safe Discontinuation Strategies
Dr. Evelyn reed, a leading expert in addiction and withdrawal management, emphasizes the importance of a personalized approach to benzodiazepine discontinuation. She advocates for a collaborative effort between the patient and their doctor, focusing on a gradual tapering schedule tailored to individual needs.
According to Dr. Reed, a doctor’s role involves “assessing the patient’s history, current medication, and the severity of their symptoms. The doctor then works with the patient to create a personalized tapering schedule. they also monitor the patient’s progress, adjust the taper if needed, and importantly, provide support and reassurance throughout the process. Sometimes, additional medications may be useful to manage withdrawal symptoms, and the doctor manages these as well. Moreover, a doctor can also assist with non-pharmacological alternatives discussed earlier to help create a healthier lifestyle.”
This comprehensive approach acknowledges that withdrawal is not solely a physical process but also involves psychological and lifestyle adjustments. The doctor’s role extends beyond medication management to encompass holistic support.
Tips for Benzodiazepine Freedom
World-Today-News.com: What general advice woudl give to someone who is currently taking benzodiazepines and contemplating quitting?
Dr. evelyn Reed: “My advice is to start by being honest with yourself and your doctor. Acknowledge the risks and the potential for withdrawal. Don’t try to quit cold turkey. Seek medical guidance. Collaborate with your doctor to create a tapering plan. Additionally, consider therapy or joining a support group to address the underlying anxiety or insomnia that led you to the medication in the first place.be patient,persistent,and kind to yourself during the process. Remember, with the right support and a well-structured plan, successful discontinuation is absolutely possible for most people. remember that recovery is an achievable goal, and many have been successful to achieve it.”
Dr. reed’s advice underscores the importance of honesty, collaboration, and self-compassion. The journey to benzodiazepine freedom requires a multifaceted approach that addresses both the physical and psychological aspects of dependence.
The Role of Support Systems
world-Today-News.com: What about support groups or other resources for those attempting to wean off the medication and manage their anxiety and insomnia?
Dr. Evelyn Reed: “Absolutely. There are several valuable resources available. The first and most significant is to consult a healthcare professional. other support systems include:
- Support Groups: Groups specifically designed to help individuals through benzodiazepine withdrawal. These offer peer support and share coping strategies.
- Therapists: Therapists familiar with benzodiazepine withdrawal can provide guidance and support. CBT, in particular, can be very effective.
- Online Forums and Communities: Many online communities offer a space for people to share their experiences and recieve support.”
These support systems provide a crucial network for individuals navigating the challenges of withdrawal. Peer support, professional guidance, and online communities offer different avenues for connection and shared experience.
Cognitive Behavioral Therapy (CBT), as mentioned by Dr. Reed, is a particularly effective therapeutic approach. CBT helps individuals identify and modify negative thought patterns and behaviors that contribute to anxiety and insomnia, providing long-term coping mechanisms beyond medication.
Benzodiazepine Dependency: An Expert unpacks the Crisis, Risks, and Paths to Recovery
A deep dive into the dangers of benzodiazepines with Dr. Evelyn reed – an addiction specialist.
The Benzodiazepine Dilemma: Understanding the Scope
World-Today-News.com: Dr. Reed, thank you for joining us. To start, benzodiazepines are still widely prescribed. What’s the core problem facing individuals on these medications, and how has it escalated into such a concerning issue?
Dr. Evelyn Reed: “The core problem stems from a perfect storm of factors, including over-prescription, a lack of patient education about the risks, and the inherent addictive potential of these medications. When benzodiazepines, such as alprazolam (Xanax), clonazepam (Klonopin), and diazepam (Valium), were introduced, they were initially hailed as safer alternatives to barbiturates. This led to widespread prescribing for anxiety, insomnia, and even muscle spasms. Unfortunately, the long-term consequences of chronic use – including dependency, tolerance, and severe withdrawal symptoms – were often downplayed or overlooked. This, combined with the ease of obtaining prescriptions, especially from less informed practitioners, created a vulnerable population. The situation was then and is now exacerbated by the tendency to use benzodiazepines as a quick fix rather than addressing the underlying causes of anxiety or sleep issues. Without a comprehensive understanding of the risks, many people became dependent without even realizing it. additionally, the physical adaptations to the medication mean it can become necessary to take the drug to avoid potentially life threatening situations.”
Over the past decade, awareness around benzodiazepine dependence has grown, yet the problem persists. The CDC reports that millions of Americans still recieve prescriptions each year, making this a growing health concern.
Unveiling the Dangers: The Risks and Consequences
World-Today-News.com: Can you elaborate on the specific risks associated with long-term benzodiazepine use? what are the most significant dangers that patients should be aware of?
Dr.Evelyn Reed: “The risks are multifaceted and can considerably impact a person’s life. The most significant dangers include:
- Tolerance and Dependence: with regular use, the body adapts, requiring higher doses to achieve the same effect. This leads to tolerance and, subsequently, dependence.
- Withdrawal Symptoms: Abrupt cessation or rapid tapering can trigger severe withdrawal symptoms, including heightened anxiety, panic attacks, insomnia, seizures, and, in certain specific cases, psychosis.
- Cognitive Impairment: Chronic use can lead to cognitive decline, impacting memory, concentration, and overall mental function. There’s increasing evidence linking long-term use to a higher risk of dementia.
- Increased Fall Risk: Benzodiazepines can cause drowsiness and impaired coordination, making older adults especially vulnerable to falls and related injuries.
- Overdose Risk: Combining benzodiazepines with alcohol or opioids drastically increases the risk of respiratory depression and potential fatality.
These risks underline the importance of informed decision-making, careful monitoring by medical professionals, and a strategic approach to tapering when discontinuing the medication.”
The severity of withdrawal, in particular, highlights the crucial need for medical supervision and support.
Paths to Recovery: Strategies and Support
world-Today-News.com: What recovery strategies do you recommend for individuals looking to break free from benzodiazepines, and what role does medical support play in this process?
dr. Evelyn Reed: “The most effective approach involves a combination of medical, psychological, and social support. The cornerstone of any recovery plan is a medically supervised tapering schedule. it’s crucial to work closely with a doctor who can gradually reduce the dosage with a carefully planned schedule, which can extend over several weeks or months to minimize the risk of withdrawal symptoms. In addition to medical supervision, there are several other methods that can be explored:
- Cognitive Behavioral Therapy (CBT): CBT is incredibly effective in addressing the underlying anxiety or insomnia that frequently enough led to benzodiazepine use. It equips individuals with coping mechanisms and helps them identify and modify negative thought patterns and behaviors that fuel their struggles, allowing for better long-term management beyond medication.
- Group Therapy and Support Groups: Connecting with others who are going through similar experiences can provide immense emotional support and reduce feelings of isolation. Online communities, 12-step programs, and mental health forums can also serve as valuable resources.
- Mindfulness and Relaxation Techniques: Practices like meditation, deep breathing exercises, and yoga can definitely help reduce stress and anxiety, providing calming effects which the benzodiazepines once did.
- Lifestyle Adjustments: Promoting sleep hygiene, a healthy diet, and regular exercise will improve overall well-being and will promote better sleep routines.
Medical support is not onyl critical for managing the tapering process but also for addressing any medical or psychological issues that may arise during withdrawal. This might involve the use of medications to manage withdrawal symptoms or address underlying mental health conditions. It is also very useful to work with a professional and establish a plan for any negative feelings that may arise. This highlights the importance of having a personalized approach that accounts for each individuals unique health status.”
Exploring Choice Treatments & Long-Term Management
World-Today-news.com: Aside from CBT, what other therapeutic and pharmacological alternatives are available for managing anxiety and insomnia, and what is the best approach to long-term management?
Dr. Evelyn Reed: “There are several other options for managing anxiety and insomnia that do not carry the same risk of dependence.For anxiety, these might also include:
- SSRI (Selective Serotonin Reuptake Inhibitors) and SNRI (Serotonin-Norepinephrine Reuptake Inhibitors) antidepressants: The use of these medications can be effective in treating, as an alternative to immediate sedation, anxiety or panic disorders.
- Certain Anticonvulsants: can be used to help with sleep and other anxiety disorders.
For sleep disorders, the following alternatives can be used:
- Melatonin: Often helps to regulate sleep cycles.
- Trazodone: This antidepressant is also used to treat insomnia by helping lower anxiety and promoting sleep.
- Other Medications: Sedative hypnotics can be used, but it’s very important to keep in touch with your primary provider on the potential risks.
Long-term management necessitates a multimodal approach. It involves consistent implementation of coping strategies learned in therapy, routine check-ins with a mental health professional, a focus on a balanced lifestyle, and, when necessary, maintenance medication as guided by these same specialists. This promotes a comprehensive approach to manage anxiety and any sleeping issues that may have existed. This ensures both short-term relief and long-term mental well-being.”
The Path Forward: Education, Awareness, and Action
World-Today-News.com: Final question Dr. Reed. How can we improve the system to prevent future problems related to benzodiazepine misuse and addiction?
Dr. Evelyn Reed: “We need a multi-pronged approach focusing on education, responsible prescribing, and improving access to alternative treatments.
- Enhanced Education: Providing comprehensive educational resources for both prescribers and patients about the risks and benefits of benzodiazepines. This can include detailed information about the effects, the risks of dependency, tolerance, and withdrawal symptoms.
- improved Prescribing Practices: Promoting the use of evidence-based guidelines for prescribing benzodiazepines, including the use of the lowest effective dose for the shortest duration of time.
- Expanding Access to Alternative treatments: Increasing the availability and affordability of CBT, therapy, support groups, and other non-pharmacological interventions.
- Mental Health Resources: improving services.
- Developing a culture of open dialog: Encouraging doctors and patients to be a team, focusing on well-being.
By prioritizing these measures, we can reduce the risks associated with benzodiazepines and create a more sustainable approach to mental health that prioritizes both immediate relief and long term health and well-being. the best way to improve results with mental health for any condition is to promote an open dialogue and work as a team to create a safe and healthy surroundings.”
