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The Department of Veterans Affairs and Department of Defense (VA/DoD) Clinical Practice Guideline for PTSD recommends against the use of benzodiazepines. Despite the recommendation, clinicians continue potentially inappropriate benzodiazepine prescribing practices for veterans with PTSD. We designed an educational product aimed at decreasing benzodiazepine use in PTSD care. Using VA data, the booklet was mailed to over 1300 New England veterans. Veterans were advised to discuss the booklet's information with their medical provider on their next appointment. The intervention resulted in a significant decrease in benzodiazepine use in veterans with PTSD, with 66% of the sample showing a dose reduction from pre- to post-booklet time points. Longitudinal analyses noted that rural veterans were significantly more likely to reduce benzodiazepine use than those in urban settings. Direct to consumer education appears to be an effective strategy to empower rural veterans to improve benzodiazepine prescribing safety and quality., Author(s): Nancy C. Bernardy [sup.1] [sup.2] , Macgregor Montano [sup.1] [sup.3] , Lisa-Ann Cuccurullo [sup.1] , Kristen Breen [sup.1] , Bernard F. Cole [sup.4] Author Affiliations: (1) grid.413726.5, 0000 0004 [...]

Purpose: Prior research has noted treatment inequalities in the care of rural veterans with posttraumatic stress disorder (PTSD). This project sought to increase the delivery, or reach, of recommended PTSD treatments in 2 rural health care systems of the Department of Veterans Affairs (VA) using implementation facilitation. Methods: The quality improvement project involved 6 months of facilitation to 2 low‐reach PTSD clinics within 2 VA health care systems. The clinics were matched to a control clinic at another regional system similar in reach, rurality, and patient volume. We compared the delivery of evidence‐based psychotherapies (EBPs) for PTSD at 3 timepoints: baseline, 6 months, and 1 year using difference‐in‐difference effect estimation. Facilitators and barriers of EBP reach were identified through interviews with clinic staff and informed specific implementation plans. We also measured reductions in benzodiazepine prescriptions and polypharmacy to determine the impact of an academic detailing intervention aimed at improving PTSD prescribing practices at the 2 sites. Findings: EBP reach at 6 months more than doubled in the 2 PTSD clinics that received facilitation, while our control clinic experienced a decrease in EBP reach (DID = 24.6; SE = 6.71%). Both intervention clinics identified similar administrative barriers to the delivery of EBPs, offering useful information for improvement at other rural clinics. The use of academic detailing as part of our facilitation intervention further appears to have positively impacted care. Conclusions: In this preliminary work, facilitation is a promising strategy for increasing the delivery of PTSD EBPs to veterans seen in under‐resourced rural VA clinics. [ABSTRACT FROM AUTHOR]

Rationale: Posttraumatic stress disorder (PTSD) is highly prevalent among veterans. Many veterans with PTSD respond well to serotonin reuptake inhibitors (SRIs). Nonresponders may be prescribed augmenting medications, which are not as well‐studied in PTSD. Aims and Objectives: We used Veterans Health Administration electronic records to compare mental health outcomes (PTSD symptoms and rates of mental health hospitalizations and psychiatric emergency room visits) in patients with PTSD who were prescribed four different groups of augmenting medications (atypical antipsychotics, mirtazapine, prazosin or tricyclic antidepressants) in addition to SRIs—from the year before to the year after the start of the augmenting medication. Method: We included data from 169,982 patients with a diagnosis of PTSD (excluding patients with comorbid bipolar or psychotic disorders) seen in Veterans Affairs care from 2007 to 2015 who were taking an SRI and filled a new prescription for one of the four augmenting medications for at least 60 days. Results: Patients evidenced minimal (<2%) reduction in PTSD symptoms and a larger reduction in psychiatric hospitalizations and psychiatric emergency room visits after receiving augmenting medications; this effect was largely similar across the four medication groups. Initiating augmenting medications was preceded by increases in PTSD symptoms, psychiatric hospitalizations and psychiatric emergency room visits. After initiating an augmenting medication, PTSD symptoms/hospitalizations/emergency room visits returned to baseline levels (before the start of the augmenting medication), but generally did not improve beyond baseline. Conclusion: Importantly, these effects could be explained by regression to the mean, additional interventions or confounding. These findings should be further explored with placebo controlled randomized clinical trials. [ABSTRACT FROM AUTHOR]

Purpose: Disparities in the treatment of posttraumatic stress disorder (PTSD) for rural veterans have been noted in prior research. The objective was to examine rural differences in prescribing for veterans with PTSD, and changes over time, in the Department of Veterans Affairs (VA) health care system. Methods: Prescribing prevalence in veterans with PTSD during 2009 and 2019 was determined using national VA administrative pharmacy data according to the joint VA‐Department of Defense clinical practice guideline as medications recommended for use in PTSD and those recommended against use. Multivariable logistic regression was used to contrast patient residence (urban vs rural) and site of PTSD care (medical center, urban clinic, or rural clinic), while adjusting for clinical covariates. Findings: Recommended medications were prescribed significantly less often to patients of rural clinics, relative to medical centers in 2009 (OR = 0.91; 95% CI: 0.89‐0.94) but reached equivalence in 2019 (OR = 1.01; 95% CI: 0.99‐1.03). In addition, rural clinics had significantly lower prescribing of recommended against medications (OR = 0.86; 95% CI: 0.84‐0.87) in 2019. Prescribing of medications recommended against the use for PTSD was higher among rural residents, relative to urban residents in 2009 (OR = 1.14; 95% CI: 1.12‐1.16), which declined toward equivalence by 2019 (OR = 1.06; 95% CI: 1.05‐1.07). Conclusions: While some clinically meaningful differences in prescribing for rural veterans with PTSD were observed in 2009, these differences shifted toward equivalency within the following decade. In 2019, we failed to observe any systematic prescribing deficiencies for veterans receiving PTSD care at rural clinics. [ABSTRACT FROM AUTHOR]

A randomized controlled trial of female veterans and active-duty personnel with posttraumatic stress disorder (PSTD) was conducted to compare the effect of prolonged exposure, a cognitive behavioral therapy, with present-centered therapy, a supportive intervention, for treatment of PSTD. It was observed that prolonged exposure was more effective than present-centered therapy for treating PSTD, possible to be implemented across a range of clinical settings.

Posttraumatic stress disorder (PTSD) is a highly prevalent disorder in both clinical and community populations. This article reviews current knowledge about PTSD in order to assist clinicians in the diagnosis and treatment of reactions to traumatic life events. First, research findings are presented, followed by guidelines for the assessment of trauma and PTSD. Topics discussed include epidemiology, course, and comorbidity, as well as information processing and psychobiology. The review is limited to information about PTSD in adults, although some of the material may generalize to child and adolescent populations. Keywords: posttraumatic stress disorder; psychological trauma; assessment

The present study examined whether certain Veterans Health Administration (VHA) therapists have more success than others in keeping patients engaged in evidence-based psychotherapies for posttraumatic stress disorder (PTSD). Our objective was to usemultilevelmodeling to quantify the variability between therapists in two indicators of patient engagement: early dropout (i.e., < 3 sessions) and adequate dose (i.e., = 8 sessions). The phenomenon of systematic variability between therapists in patients' treatment experience and outcomes is referred to as "therapist effects." The sample included the 2,709 therapists who provided individual cognitive processing therapy (CPT) or prolonged exposure (PE) to 18,461 veterans with PTSD across 140 facilities in 2017. Data were extracted from administrative databases. For CPT, therapist effects accounted for 10.9% of the variance in early dropout and 8.9% of the variance in adequate dose. For PE, therapist effects accounted for 6.0% and 8.8% of the variance in early dropout and adequate dose, respectively. Facility only accounted for an additional 1.1%-3.1% of the variance in early dropout and adequate dose. For CPT, patients' odds of receiving an adequate dose almost doubled, OR = 1.41/0.72 = 1.96, if they were seen by a therapist in the highest compared with the lowest retention decile. For PE, the odds of a patient receiving an adequate dose were 84% higher, OR = 1.38/0.75 = 1.84, when treated by a therapist in the highest compared with the lowest retention decile. Therapist skills and work environment may contribute to variability across therapists in early dropout and adequate dose. [ABSTRACT FROM AUTHOR]