Aligning Clinical Practice to PTSD Treatment Guidelines: Medication Prescribing by Provider Type

Psychiatric services (Washington, D.C.) (Impact Factor: 1.99). 02/2013; 64(2):142-8. DOI: 10.1176/
Source: PubMed

ABSTRACT OBJECTIVE Veterans with posttraumatic stress disorder (PTSD) are frequently prescribed psychiatric medications that are currently not supported by a guideline developed by the U.S. Department of Veterans Affairs and the U.S. Department of Defense. To better understand this practice, this study examined prescribing frequencies for three classes of psychiatric medications and the proportion of prescribing attributable to various provider types. METHODS This cross-sectional study analyzed fiscal year 2009 electronic pharmacy data from the Veterans Health Administration (VHA) for 356,958 veterans with PTSD who were receiving medications from VHA prescribers. Veterans had at least one VHA encounter with a diagnostic code of PTSD and evidence of continuous medication use. Medications of interest were selective serotonin-norepinephrine reuptake inhibitors (SSRI/SNRIs), second-generation antipsychotic medications, and benzodiazepines. Analyses described the proportion of prescribing attributable to mental health care providers and primary care providers for each medication class. RESULTS In 2009, among all veterans with PTSD who had continuous VA medication use, 65.7% were prescribed SSRI/SNRIs, and 70.2% of this prescribing was attributable to mental health care providers. Second-generation antipsychotics were prescribed for 25.6% of these veterans, and 80.2% of the prescribing was attributable to mental health care providers. Benzodiazepines were prescribed for 37.0% of the sample, and 68.8% of the prescribing was attributable to mental health care providers. CONCLUSIONS The findings indicate that veterans with PTSD were frequently prescribed medications not supported by existing guidelines. Most of these prescriptions were written by mental health care providers. Interventions to align prescribing with PTSD treatment guidelines should emphasize provider type.


Available from: Nancy C Bernardy, Jul 25, 2014
1 Follower
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objective: Recent military conflicts have generated significantly more demand for treatment of posttraumatic stress disorder (PTSD) as well as concerns about the adverse effects of stigma associated with specialty mental health care. This study examined the extent to which veterans diagnosed as having PTSD received treatment exclusively in primary care settings. Methods: Administrative data from the U.S. Department of Veterans Affairs (VA) Connecticut Healthcare System for fiscal year 2010 were used to compare the proportions and characteristics of veterans with PTSD (N=4,144) who were treated exclusively in a primary care setting or a mental health specialty clinic. Results: Most (87%) veterans were treated in specialty mental health clinics, and 13% were treated exclusively in primary care. In contrast, 24% of veterans with any mental health diagnosis received treatment exclusively in primary care. Comorbid psychiatric diagnoses were much more prevalent among those treated in mental health specialty clinics than in primary care (86% versus 14%), and psychotropic medications were far more likely to be filled in mental health specialty clinics than in primary care (80% versus 36%). The percentage of veterans with service-connected disabilities did not differ between the two treatment settings. Conclusions: Despite the VA's successful expansion of mental health services in primary care, the vast majority of patients with PTSD received treatment in mental health specialty clinics. Stigma does not seem to keep veterans with PTSD from receiving care in specialty mental health settings in spite of the availability of services in primary care.
    Psychiatric services (Washington, D.C.) 07/2014; 65(10). DOI:10.1176/ · 1.99 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Abstract Objective: While there has been considerable concern about veterans dually diagnosed with both posttraumatic stress disorder (PTSD) and comorbid substance use disorders, a national study of clinical characteristics, service utilization and psychotropic medication use of such veterans in Veterans Affairs (VA) has yet to be conducted. We hypothesized that veterans having both PTSD and substance use disorder would have lower socioeconomic status, greater medical and psychiatric comorbidity, higher medical service utilization, and more psychotropic pharmacotherapy fills. Methods: National VA data from fiscal year 2012 were used to compare veterans dually diagnosed with PTSD and substance use disorder, to veterans with PTSD without substance use disorder on socio-demographic characteristics, psychiatric and medical comorbidities, mental health and medical service utilization and psychotropic pharmacotherapy. Comparisons were based on bivariate and Poisson regression analyses. Results: The sample included all 638,451 veterans who received the diagnosis of PTSD in the VA in fiscal year 2012: 498,720 (78.1%) with PTSD alone and 139,731 (21.9%) dually diagnosed with PTSD and a comorbid substance use disorder. Veterans with dual diagnoses were more likely to have been homeless and to have received a VA disability pension. Medical diagnoses that were more strongly associated with veterans who were dually diagnosed included seizure disorders, liver disease and human immunodeficiency virus (HIV). Psychiatric comorbidities that distinguished veterans with dual diagnoses included bipolar disorder and schizophrenia Veterans dually diagnosed with PTSD and substance use disorder also had a greater likelihood of having had mental health inpatient treatment. There were no substantial differences in other measures of service use or prescription fills for psychotropic medications. Conclusions: Several substantial differences were observed, each of which represented more severe medical and psychiatric illness among veterans dually diagnosed with PTSD and substance use disorder compared to those with PTSD alone. However, effective treatments are available for these disorders and special efforts should be made to ensure that veterans who are dually diagnosed receive them.
    Journal of Dual Diagnosis 12/2014; 11(1). DOI:10.1080/15504263.2014.989653 · 0.80 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Twenty-one states and the District of Columbia have passed legislation allowing for the use of medical cannabis for those individuals with qualifying medical conditions, which include posttraumatic stress disorder (PTSD) for a growing number of states. Little information is available regarding PTSD among medical cannabis patients. This study seeks to provide initial data on this topic by examining the prevalence and correlates of positive PTSD screens among a sample of patients seeking medical cannabis certification for the first time (n=186). Twenty-three percent (42/186; 95% confidence interval [CI] =17%-29%) of the patients in the study sample screened positive for PTSD. Moreover, the group that screened positive for PTSD had higher percentages of lifetime prescription opioid, cocaine, prescription sedative, and street opioid use, as well as a higher percentage of recent prescription sedative use, than the group that screened negative for PTSD. These findings highlight the relatively common use of other substances among medical cannabis patients with significant PTSD symptoms, even when compared with other patients seeking medical cannabis for the first time. As a growing number of states include PTSD among the list of qualifying medical conditions for medical cannabis, additional research is needed to better characterize the longitudinal relationship between medical cannabis use and PTSD symptoms.
    Addictive Behaviors 06/2014; 39(10):1414-1417. DOI:10.1016/j.addbeh.2014.05.022 · 2.44 Impact Factor