Prescribing Trends in Veterans With Posttraumatic Stress Disorder

National Center for PTSD, Veterans Affairs Medical Center, White River Junction, VT 05001, USA.
The Journal of Clinical Psychiatry (Impact Factor: 5.5). 03/2012; 73(3):297-303. DOI: 10.4088/JCP.11m07311
Source: PubMed


The revised Department of Veterans Affairs (VA) and Department of Defense Clinical Practice Guideline for Management of Post-Traumatic Stress recommends against long-term use of benzodiazepines to manage posttraumatic stress disorder (PTSD). An analysis of recent trends among veterans receiving care for PTSD in the VA noted a decreasing proportion receiving benzodiazepines. The authors examined prescribing patterns for other medications to better understand the general context in which the changes in benzodiazepine prescribing have occurred in the VA.
Administrative VA data from fiscal years 1999 through 2009 were used to identify veterans with PTSD using ICD-9 codes extracted from inpatient discharges and outpatient encounters. Prescribing of antidepressants, antipsychotics, and hypnotics was determined for each fiscal year using prescription drug files.
The proportion of veterans receiving either of the 2 Clinical Practice Guideline-recommended first-line pharmacotherapy treatments for PTSD, selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors, increased from 49.7% in 1999 to 58.9% in 2009. In addition to reduced benzodiazepine prescriptions, the overall frequency of antipsychotic use declined 6.1%, from 20.0% in 1999 to 13.9% in 2009. Nonbenzodiazepine hypnotic prescribing tripled when zolpidem was added to the VA national formulary in 2008. Buspirone prescribing decreased steadily, while prazosin prescribing expanded nearly 7-fold.
This work highlights several clinically important trends in prescribing over the past decade among veterans with PTSD that are generally consistent with the revised VA/Department of Defense Clinical Practice Guideline recommendations. However, the findings illustrate the limitations of administrative data and point to a need to supplement this work with a qualitative examination of PTSD prescribing from interviews with providers to better understand the strategies used to make medication management decisions.

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    • "Although benzodiazepines were once commonly used to manage acute PTSD symptoms, current evidence suggests that these medications show little benefit in reducing symptoms and can actually have deleterious effects on the trauma recovery process (VA/DOD, the Management of Post- Traumatic Stress Working Group, 2010). The rates of prescription use that we observed, particularly in the P3 group, were comparable with other recent VA pharmacy reviews that have reported similar rates of antidepressant, antipsychotic, and benzodiazepine use in veterans with PTSD (Bernardy et al., 2012; Lund et al., 2013). The work of Lund et al. suggested that although variation in benzodiazepine prescribing practices for veterans with PTSD may be declining with time, high rates of benzodiazepine use remain and seem to reflect a degree of clinical uncertainty among providers in terms of optimally managing PTSD. "
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    ABSTRACT: Persistent postconcussive symptoms (PPCS) are noted when a series of cognitive, emotional, and somatosensory complaints persist for months after a concussion. Clinical management of PPCS can be challenging in the veteran population because of the nonspecific nature of symptoms and co-occurrence with affective disturbances such as posttraumatic stress disorder (PTSD) and chronic pain. In this study, we compared health service and medication use patterns in a sample of 421 veterans with PPCS with an age-matched cohort of case controls. The results suggest that the veterans with PPCS showed high rates of medical and mental health service utilization during a mean treatment period of 2 years. Although chronic pain commonly co-occurs with PPCS in veterans, service use and medication prescribing trends seem to have been influenced more by the presence of PTSD than chronic pain. Our findings reinforce the overlap among PPCS, PTSD, and chronic pain and demonstrate the complexity inherent in treating these conditions in veterans.
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    • "Unfortunately, there are virtually no data concerning prescribing differences across genders in VA, despite the prominent role that pharmacotherapy plays in the management of PTSD. Approximately 60 % of privately insured patients with PTSD receive pharmacotherapy for the disorder,5 while close to 80 % of veterans receiving care for PTSD in VA are treated with psychiatric medications.6 In the privately insured patients, women were 1½ times more likely to receive psychotropic medications given a PTSD diagnosis than men, but we do not know if this is the case for women veterans treated in the VA.5 "
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    ABSTRACT: The Department of Veterans Affairs (VA) and Department of Defense (DoD) issued a revised posttraumatic stress disorder (PTSD) Clinical Practice Guideline (CPG) in 2010 with specific pharmacotherapy recommendations for evidence-based quality care. The authors examined prescribing frequencies over an 11-year period prior to the release of the new guideline to determine gender differences in pharmacotherapy treatment in veterans with PTSD. National administrative VA data from 1999 to 2009 were used to identify veterans with PTSD using ICD-9 codes extracted from inpatient discharges and outpatient clinic visits. Prescribing of antidepressants, antipsychotics and hypnotics was determined for each year using prescription drug files. Women were more likely than men to receive medication across all classes except prazosin where men had higher prescribing frequency. The proportion of women receiving either of the first-line pharmacotherapy treatments for PTSD, selective serotonin reuptake inhibitors (SSRI) and serotonin-norepinephrine reuptake inhibitors (SNRI), increased from 56.4 % in 1999 to 65.7 % in 2009, higher rates than seen in men (49.2 % to 58.3 %). Atypical antipsychotic prescriptions increased from 14.6 % to 26.3 % and nonbenzodiazepine hypnotics increased from 3.8 % to 16.9 % for women, higher frequencies than seen in men for both medications (OR = 1.31, 1.43 respectively). The most notable gender discrepancy was observed for benzodiazepines where prescriptions decreased for men (36.7 % in 1999 to 29.8 % in 2009) but steadily increased for women from 33.4 % to 38.3 %. A consistent pattern of increased prescribing of psychotropic medications among women with PTSD was seen compared to men. Prescribing frequency for benzodiazepines showed a marked gender difference with a steady increase for women despite guideline recommendations against use and a decrease for men. Common co-occurring disorders and sleep symptom management are important factors of PTSD pharmacotherapy and may contribute to gender differences seen in prescribing benzodiazepines in women but do not fully explain the apparent disparity.
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