Anxiolytics and hypnotics — cross-table viva · Psych Vivas

Prompt

Examiner draws columns: Class / Mechanism / Dependence risk / Elderly risk / One exam dose pattern. Cards: alprazolam, zolpidem, buspirone, pregabalin, hydroxyzine, melatonin, LOT, EMPOWER, Sun opioid+BZD, Beers, flumazenil.

Station structure

Time: 8–10 minutes. Depth: consultant teaching registrar. Expect mechanism maps, duration limits, elderly harm, interaction literacy, and taper craft without marketing slogans.[1][9]

Core questions and model points

1. Map the classes by mechanism

BZD/Z-drugs: GABA-A PAM / BZ-site agonists.[1][8]
Buspirone: 5-HT1A partial agonist; delayed; no withdrawal cover.[6]
Pregabalin: α2δ Ca channel; GAD RCT support.[7]
Hydroxyzine: H1; melatonin: MT1/MT2 modest sleep effects.

2. Why not long-term alprazolam for GAD?

Rapid relief but dependence, interdose anxiety, hard taper; durable care is SSRI/SNRI + CBT.[9][1]

3. Elderly and Z-drugs

Glass risk–benefit; Beers potentially inappropriate; falls, cognition, residual impairment — Z-drugs not safe loopholes.[2][5][8]

4. Opioid combination

Sun: concurrent opioids + BZD associated with overdose; avoid stacking.[3]

5. Taper scaffold

Gradual 10–25% reductions; convert short-acting high-potency; never abrupt continuous users; reinstate if seizure.[1]

6. EMPOWER one-liner

Patient education reduces inappropriate long-term BZD use in older adults (cluster RCT).[4]

7. Flumazenil trap

Not routine; seizure risk in dependent/mixed OD; airway first.[1]

Pass behaviours

Names LOT in liver disease.
Distinguishes buspirone from GABA cover.
Writes exit plan into any short-term script.
Links Beers + Glass without ageism slogans.[2][5][6][9]

Fail behaviours

"Z-drugs never cause dependence."
Routine opioid + BZD without risk discussion.
Abrupt stop advice after years of use.
Flumazenil for every coma.[1][3][8]

References

[1]Soyka M Treatment of Benzodiazepine Dependence N Engl J Med, 2017.PMID 28328330
[2]Glass J, Lanctôt KL, Herrmann N, et al. Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits BMJ, 2005.PMID 16284208
[3]Sun EC, Dixit A, Humphreys K, et al. Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis BMJ, 2017.PMID 28292769
[4]Tannenbaum C, Martin P, Tamblyn R, et al. Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial JAMA Intern Med, 2014.PMID 24733354
[5]By the 2023 American Geriatrics Society Beers Criteria Update Expert Panel American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults J Am Geriatr Soc, 2023.PMID 37139824
[6]Chessick CA, Allen MH, Thase M, et al. Azapirones for generalized anxiety disorder Cochrane Database Syst Rev, 2006.PMID 16856115
[7]Rickels K, Pollack MH, Feltner DE, et al. Pregabalin for treatment of generalized anxiety disorder: a 4-week, multicenter, double-blind, placebo-controlled trial of pregabalin and alprazolam Arch Gen Psychiatry, 2005.PMID 16143734
[8]Gunja N The clinical and forensic toxicology of Z-drugs J Med Toxicol, 2013.PMID 23404347
[9]Baldwin DS, Anderson IM, Nutt DJ, et al. Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: a revision of the 2005 guidelines from the British Association for Psychopharmacology J Psychopharmacol, 2014.PMID 24713617

Prompt

Station structure

Time: 8–10 minutes. Depth: consultant teaching registrar. Expect mechanism maps, duration limits, elderly harm, interaction literacy, and taper craft without marketing slogans.[1][9]

Core questions and model points

1. Map the classes by mechanism

BZD/Z-drugs: GABA-A PAM / BZ-site agonists.[1][8]
Buspirone: 5-HT1A partial agonist; delayed; no withdrawal cover.[6]
Pregabalin: α2δ Ca channel; GAD RCT support.[7]
Hydroxyzine: H1; melatonin: MT1/MT2 modest sleep effects.

2. Why not long-term alprazolam for GAD?

Rapid relief but dependence, interdose anxiety, hard taper; durable care is SSRI/SNRI + CBT.[9][1]

3. Elderly and Z-drugs

Glass risk–benefit; Beers potentially inappropriate; falls, cognition, residual impairment — Z-drugs not safe loopholes.[2][5][8]

4. Opioid combination

Sun: concurrent opioids + BZD associated with overdose; avoid stacking.[3]

5. Taper scaffold

Gradual 10–25% reductions; convert short-acting high-potency; never abrupt continuous users; reinstate if seizure.[1]

6. EMPOWER one-liner

Patient education reduces inappropriate long-term BZD use in older adults (cluster RCT).[4]

7. Flumazenil trap

Not routine; seizure risk in dependent/mixed OD; airway first.[1]

Pass behaviours

Names LOT in liver disease.
Distinguishes buspirone from GABA cover.
Writes exit plan into any short-term script.
Links Beers + Glass without ageism slogans.[2][5][6][9]

Fail behaviours

"Z-drugs never cause dependence."
Routine opioid + BZD without risk discussion.
Abrupt stop advice after years of use.
Flumazenil for every coma.[1][3][8]

References

[1]Soyka M Treatment of Benzodiazepine Dependence N Engl J Med, 2017.PMID 28328330
[2]Glass J, Lanctôt KL, Herrmann N, et al. Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits BMJ, 2005.PMID 16284208
[3]Sun EC, Dixit A, Humphreys K, et al. Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis BMJ, 2017.PMID 28292769
[4]Tannenbaum C, Martin P, Tamblyn R, et al. Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial JAMA Intern Med, 2014.PMID 24733354
[5]By the 2023 American Geriatrics Society Beers Criteria Update Expert Panel American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults J Am Geriatr Soc, 2023.PMID 37139824
[6]Chessick CA, Allen MH, Thase M, et al. Azapirones for generalized anxiety disorder Cochrane Database Syst Rev, 2006.PMID 16856115
[7]Rickels K, Pollack MH, Feltner DE, et al. Pregabalin for treatment of generalized anxiety disorder: a 4-week, multicenter, double-blind, placebo-controlled trial of pregabalin and alprazolam Arch Gen Psychiatry, 2005.PMID 16143734
[8]Gunja N The clinical and forensic toxicology of Z-drugs J Med Toxicol, 2013.PMID 23404347
[9]Baldwin DS, Anderson IM, Nutt DJ, et al. Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: a revision of the 2005 guidelines from the British Association for Psychopharmacology J Psychopharmacol, 2014.PMID 24713617