Prescribing Trends in Veterans With Posttraumatic Stress Disorder

ArticleinThe Journal of Clinical Psychiatry 73(3):297-303 · March 2012with128 Reads
DOI: 10.4088/JCP.11m07311 · Source: PubMed
Abstract
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.
    • "The high rate of benzodiazepine prescriptions is TREATMENT FOR PTSD AND COMORBID MDD not in line with the treatment guidelines, which do not recommend benzodiazepine use for PTSD patients (e.g., [7]). However, it has been reported that more than 30% of veterans in the USA with PTSD continue to receive benzodiazepines [28,29]. Female, older age, and longer time since PTSD diagnosis were independently associated with benzodiazepine use in veterans [29]. "
    [Show abstract] [Hide abstract] ABSTRACT: Major depressive disorder (MDD) has been associated with stressful life events and with posttraumatic stress disorder (PTSD). PTSD and MDD comorbidity was also reported to be associated with greater symptom severity and lower levels of functioning. However, the characteristics of pharmacotherapy for PTSD with MDD are not fully understood. To understand this relationship, we conducted a retrospective review using medical charts at the Department of Neuropsychiatry, Kurume University Hospital. Information from 55 patients with PTSD was analyzed. Five cases were excluded after re-evaluation of the PTSD diagnosis. A higher rate of type II trauma was observed in the PTSD with MDD group (50.0%) than in the PTSD-only group [13.6%; χ2 (1, n =50) = 7.26, p<0.01]. Patients with comorbid MDD were significantly older, had more severe PTSD symptomatology, and a longer duration of treatment. They also received higher doses of psychotropic drugs, regardless of the type (antidepressants, antipsychotics, benzodiazepines), than the PTSD-only group. Our results showed that comorbid MDD is associated with higher doses of psychotropic drugs, suggesting difficulties in treatment.
    Full-text · Article · Feb 2016
    • "We defined PTSD according to the International Classification of Diseases-9th Revision (ICD-9), using 309.81 as the ICD-9 code. This case definition was used in the original prazosin diffusion article and in several subsequent studies of PTSD prescribing practices in VA6791011. Each patient was assigned to a single VHA medical center based on the site of a majority of their PTSD coded encounters. "
    [Show abstract] [Hide abstract] ABSTRACT: Posttraumatic stress disorder (PTSD) is a high-priority treatment area for the Veterans Health Administration (VHA), and dissemination patterns of innovative, efficacious therapies can inform areas for potential improvement of diffusion efforts and quality prescribing. In this study, we replicated a prior examination of the period prevalence of prazosin use as a function of distance from Puget Sound, Washington, where prazosin was first tested as an effective treatment for PTSD and where prazosin use was previously shown to be much greater than in other parts of the United States. We tested the following three hypotheses related to prazosin geographic diffusion: (1) a positive geographical correlation exists between the distance from Puget Sound and the proportion of users treated according to a guideline recommended minimum therapeutic target dose (>/=6 mg/d), (2) an inverse geographic correlation exists between prazosin and benzodiazepine use, and (3) no geographical correlation exists between prazosin use and serotonin reuptake inhibitor/serotonin norepinephrine reuptake inhibitor (SSRI/SNRI) use. Among a national sample of veterans with PTSD, overall prazosin utilization increased from 5.5 to 14.8% from 2006 to 2012. During this time period, rates at the Puget Sound VHA location declined from 34.4 to 29.9%, whereas utilization rates at locations a minimum of 2,500 miles away increased from 3.0 to 12.8%. Rates of minimum target dosing fell from 42.6 to 34.6% at the Puget Sound location. In contrast, at distances of at least 2,500 miles from Puget Sound, minimum threshold dosing rates remained stable (range, 18.6 to 17.7%). No discernible association was demonstrated between SSRI/SNRI or benzodiazepine utilization and the geographic distance from Puget Sound. Minimal threshold dosing of prazosin correlated positively with increased diffusion of prazosin use, but there was still a distance diffusion gradient. Although prazosin adoption has improved, geographic differences persist in both prescribing rates and minimum target dosing. Importantly, these regional disparities appear to be limited to prazosin prescribing and are not meaningfully correlated with SSRI/SNRI and benzodiazepine use as indicators of PTSD prescribing quality.
    Full-text · Article · Oct 2015
    • "There is currently not enough evidence to support their use as monotherapy or adjunctive therapy, and concerns about their costs and harmful side effects remain an important consideration [3]. Overall, the SSRI and SNRI antidepressants have been found to decrease core PTSD symptoms but too often, there is little improvement noted in sleep-related disturbances and it is thought that this contributes to the use of medications such as benzodiazepines and the atypical antipsychotics [44, 61]. The use of the alpha-adrenergic antagonist, prazosin, has proven to be an effective treatment for PTSD-related night- mares [62, 63]. "
    [Show abstract] [Hide abstract] ABSTRACT: There have been significant advancements in the pharmacologic management of posttraumatic stress disorder (PTSD) in the past two decades. Multisite randomized clinical trials (RCTs) have noted the efficacy of selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNR Is) for PTSD treatment. Unfortunately, there have been no new medications approved to treat PTSD in the past 10 years. Although there have been exciting new findings in our knowledge of the neurobiology of PTSD, clinical trials testing new medications have lagged. This review summarizes recent research that builds on the unique pathophysiology of PTSD and suggests ways to move the field forward.
    Full-text · Article · Apr 2015
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