Revised Framework to Assess and Treat Patients with Acute Stress Disorder/Posttraumatic Stress DisorderPsychological Health Center of Excellence, Defense Health Agency, Silver Spring, MD USA

TREATMENT OF PTSD ALTERNATIVE TREATMENTS FOR PTSD?

FOR MORE INFORMATION

DOWNLOAD THE CLINICAL PRACTICE GUIDELINE AND CLINICAL SUPPORT TOOLS https://www.healthquality.va.gov/guidelines/MH/ptsd/ https://www.qmo.amedd.army.mil/QMOCPGShopCart/products.asp?cat=19

References: Goldstein, R. B., Smith, S. M., Chou, S. P., Saha, T. D., Jung, J., Zhang, H., . . . Grant, B. F. (2016). The epidemiology of DSM-5 posttraumatic stress disorder in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions-III. Social Psychiatry and Psychiatric Epidemiology, 51(8), 1137-1148. doi:10.1007/s00127-016-1208-5 . Kok, B. C., Herrell, R. K., Thomas, J. L., & Hoge, C. W. (2012). Posttraumatic Stress Disorder Associated With Combat Service in Iraq or Afghanistan. The Journal of Nervous and Mental Disease, 200(5), 444-450. doi:10.1097/nmd.0b013e3182532312 Management of Posttraumatic Stress Disorder Work Group. (2017). VA/DoD clinical practice guideline for the management of posttraumatic stress disorder and acute stress disorder (Version 3.0). Washington, DC: Veterans Health Administration, Department of Defense. Ramchand, R., Rudavsky, R., Grant, S., Tanielian, T., & Jaycox, L. (2015). Prevalence of, Risk Factors for, and Consequences of Posttraumatic Stress Disorder and Other Mental Health Problems in Military Populations Deployed to Iraq and Afghanistan. Current Psychiatry Reports, 17(5). doi:10.1007/s11920-015-0575-z Wisco, B. E., Marx, B. P., Wolf, E. J., Miller, M. W., Southwick, S. M., & Pietrzak, R. H. (2014). Posttraumatic Stress Disorder in the US Veteran Population. The Journal of Clinical Psychiatry, 1338-1346. doi:10.4088/jcp.14m09328

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Poster presented at the AMSUS Annual Meeting in November 2017. For more information, please contact alia.h.creason.ctr@mail.mil. The views expressed in this presentation are those of the authors and do not necessarily represent the official policy or position of the Psychological Health Center of Excellence, Defense Health Agency, Department of Defense, Department of Veterans Affairs, or any U.S. government agency. (PUID# 4714)

DIAGNOSIS AND ASSESSMENT OF PTSD

CLINICAL SUPPORT TOOLS FOR PROVIDERS

Insufficient evidence to recommend for or against: Repetitive transcranial magnetic stimulation (rTMS) Electroconvulsive therapy (ECT) Hyperbaric oxygen therapy (HBOT) Stellate ganglion block (SGB) Vagal nerve stimulation (VNS)

Insufficient evidence to recommend as primary treatment:

Acupuncture Meditation/mindfulness Yoga Mantram meditation

A useful, quick reference summary for providers of algorithms and recommendations

for treating patients with PTSD and related

conditions

PTSD and co-occurring conditions: presence of co-occurring disorder(s), to include substance use disorder (SUD) should not prevent patients from receiving PTSD treatment

Patients with sleep problems: undergo independent sleep assessment, particularly when problems pre-date PTSD onset or remain following successful completion of a course of treatment Cognitive Behavioral Therapy for Insomnia (CBT-I) is recommended to

treat insomnia in patients with PTSD unless underlying etiology or severe sleep deprivation warrants immediate use of medication to prevent harm

Empirically-supported trauma-focused psychotherapies use cognitive, emotional, or behavioral techniques to facilitate processing a traumatic experience

Involve 8-16 sessions with the following core techniques: Exposure to traumatic images or memories through narrative or

imaginal exposure Exposure to avoided or triggering cues in vivo or through

visualization Cognitive restructuring techniques focused on enhancing meaning

and shifting problematic appraisals stemming from the traumatic experience

Effective trauma-focused approaches for treatment of PTSD: Prolonged Exposure (PE) Cognitive Processing Therapy (CPT) Eye Movement Desensitization and Reprocessing (EMDR) Brief Eclectic Psychotherapy (BEP) Narrative Exposure Therapy (NET)

Less evidence to support, but better than receiving no treatment: Stress Inoculation Training (SIT) Present-Centered Therapy (PCT) Interpersonal Psychotherapy (IPT) Group therapy internet-based cognitive behavioral therapy (iCBT)

PSYCHOTHERAPY

System-wide goal of developing evidence-based guidelines is to improve the patient’s health and well-being by guiding health care providers who are taking care of patients with PTSD along the management pathways that are supported by evidence

Current PTSD CPG updated in 2017 by the VA/DoD Evidence-Based Practice Work Group

based on evidence and best practice as of March 2016

VA/DOD PTSD CLINICAL PRACTICE GUIDELINE (CPG)

GENERAL GUIDELINES AND PREVENTION

A reference for patients on understanding PTSD

and treatment recommendations and

resources

THE SCOPE OF POSTTRAUMATIC STRESS DISORDER (PTSD)

In U.S. Adult Population: PTSD prevalence rates of 6.1% (lifetime prevalence) and 4.7% (current prevalence) per findings from Wave 3 of National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) based on DSM-5 criteria (Goldstein et al., 2016). In Department of Defense (DoD): PTSD prevalence estimates range from 5.5% to 13.2% based on multiple studies of U.S. Operation Enduring Freedom and

Operation Iraqi Freedom Veterans (Kok et al., 2012) Combat exposure is the strongest predictor of mental health problems among those deployed to Iraq and Afghanistan

(Ramchand et al., 2015) Similar prevalences found by service, branch, or rank adjusted for combat exposure (Ramchand et al., 2015)

In Department of Veterans Affairs (VA): Precise PTSD prevalence estimates in the current population of U.S. Veterans overall have yet to be established A recent survey of a nationally representative U.S. Veteran sample found 8% lifetime and 5% current PTSD prevalence rates

(Wisco et al., 2014)

No evidence to recommend use of medication in the early period following a trauma to prevent development of PTSD

Initial pharmacological approach should include a first-line monotherapy trial of sufficient time for response

Providers should monitor patients for outcomes and side effects

Providers should consider patient’s response or side effect history, and comorbidities, when choosing medication and dosage

Selective serotonin reuptake inhibitors (SSRIs) and serotonin

norepinephrine reuptake inhibitors (SNRIs) are the only medication classes strongly recommended Recommended SSRIs include fluoxetine, paroxetine, or sertraline Recommended SNRI is venlafaxine

Medications not suggested/recommended: Anticonvulsants or atypical antipsychotics as a monotherapy Divalproex Tiagabine Risperidone Benzodiazepines Ketamine Hydrocortisone D-cycloserine

Cannabis is not recommended given lack of evidence, known adverse effects, and associated risks

A quick reference for providers that

summarizes the PTSD CPG

GENERAL CLINICAL MANAGEMENT 1. Engage patients in shared decision making

(SDM), which includes educating patients about effective treatment options.

2. For patients with PTSD who are treated in primary care, use collaborative care interventions that facilitate active engagement in evidence-based treatments.

PREVENTION OF PTSD Insufficient evidence to recommend trauma-

focused psychotherapy or pharmacotherapy in the immediate post-trauma period

Patients with acute stress disorder (ASD): Use an individual trauma-focused

psychotherapy that includes a primary component of exposure and/or cognitive restructuring

Insufficient evidence to recommend pharmacotherapy

Perform periodic screening for PTSD using validated measures such as Primary Care PTSD Screen (PC-PTSD) or the PTSD Checklist (PCL)

Patients with suspected PTSD: diagnostic evaluation should include determination of DSM criteria, acute risk of harm to self or others, functional status, medical history, past treatment history, and relevant family history

Patients with a diagnosis of PTSD: use a quantitative self-report measure of PTSD severity, such as the PCL-5, in initial treatment planning and to monitor treatment progress

Includes objective, evidence-based information on management of PTSD and related conditions to assist health care

providers in all aspects of patient care, including diagnosis, treatment, and follow-up

Intended for VA and DoD health care practitioners including primary care physicians, nurse practitioners, physician assistants, psychiatrists, psychologists, social workers, nurses, pharmacists, chaplains, addiction counselors, and others involved in the care of service members or veterans with PTSD

**CPGs are not standard of care and use of guidelines must be considered within the context of a

provider’s clinical judgment and patient values and preferences for the care of an individual patient**

Booklet that describes symptoms and

treatment options and provides additional

resources

Brochure that describes symptoms and

treatment options and offers healthy coping

strategies and resources for family members of those

diagnosed with PTSD

Tabbed guide to help providers assess and diagnose symptoms

and to treat PTSD and ASD and co-occurring

conditions as recommended in the 2017 clinical practice

guideline

WHAT ABOUT PRAZOSIN?

Suggest against use as a mono- or augmentation therapy

Insufficient evidence to

recommend for or against using Prazosin to treat nightmares associated with PTSD

CLINICAL SUPPORT TOOLS FOR PATIENTS AND FAMILIES

Clinician Summary

Pocket Guide

Pocket Card

Patient Summary

Patient Guide

Family Guide

PHARMACOTHERAPY

THE FIRST LINE OF TREATMENT FOR PTSD SHOULD BE AN INDIVIDUAL, MANUALIZED TRAUMA-FOCUSED PSYCHOTHERAPY. Trauma-focused psychotherapies impart greater change and longer lasting improvements in the core symptoms of PTSD when compared to

pharmacotherapies. However, when unavailable or not preferred by the patient, pharmacotherapy or individual non-trauma focused psychotherapy are still recommended as viable alternatives.