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2015 HSR&D/QUERI National Conference Abstract

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3174 — Symptom Presentation and VHA Prescription of Sleep Medications for Veterans with PTSD

Greenbaum MA, Sierra-Pacific (VISN 21) MIRECC; Neylan TC, San Francisco VA Medical Center; UC San Francisco; Sierra-Pacific MIRECC; Rosen CS, COIN - Palo Alto; National Center for PTSD, Dissemination and Training Division;

Objectives:
Insomnia and nightmares are common symptoms of PTSD. VA/DoD practice guidelines endorse use of trazodone (a serotonin antagonist and reuptake inhibitor) and zolpidem (a non-benzodiazepine hypnotic) for disturbed sleep, and prazosin (an alpha blocker), for nightmares. The study examines whether receipt of these medications by VHA patients with PTSD is associated with reported insomnia, nightmares, and overall PTSD symptoms.

Methods:
Participants were 357 veterans beginning or transitioning to a new phase of PTSD treatment at three VA facilities who had been recruited into a randomized telephone care management trial. Nightmares and other PTSD symptoms at intake were assessed with the PTSD Checklist (PCL). Insomnia at intake was assessed with one PCL item and one item from the Center for Epidemiological Studies-Depression Scale (CES-D). Prescriptions in the 4 months following intake were determined from VA pharmacy data. Logistic regression was used to model how receipt of each medication was predicted by insomnia, nightmares, and overall PTSD symptoms (excluding insomnia and nightmare items).

Results:
Half the Veterans reported both severe insomnia (7 to 8 on a 1-8 scale) and severe nightmares (4 to 5 on a 1-5 scale). Nearly half (45%) the patients received either Prazosin (20%), Zolpidem (13%), and/or Trazodone (23%) in the four months following intake. Receipt of Zolpidem was predicted by insomnia (OR = 1.2 to 4.8) but not by nightmares or other PTSD symptoms. Receipt of Trazodone was predicted by insomnia (OR = 1.0 to 2.5) but not by nightmares or other PTSD symptoms. Receipt of Prazosin was predicted by nightmares (OR = 1.9 to 4.4) but not by insomnia or other PTSD symptoms. Neither insomnia, nightmares, nor PTSD symptoms predicted receipt of an SSRI/SNRI.

Implications:
VA prescribers are appropriately using guideline-endorsed medications to address insomnia and nightmares in veterans with PTSD and prescribing in line with patients' clinical presentation. We could not assess whether patients were receiving recommended psychosocial interventions such as CBT for insomnia, or were adequately treated for physical causes such as apnea.

Impacts:
VHA prescribing of sleep medications for PTSD patients appears to generally be patient-centered and consistent with practice guidelines.