The Department of Veterans Affairs (VA) and Department of Defense (DoD) issued a revised PTSD Clinical Practice Guideline (CPG) in 2010 that established evidence-based recommendations that foster well-being among Veterans with PTSD. Beyond recommendations, the CPG cautioned against long-term use of benzodiazepines to manage core PTSD symptoms due to an absence of efficacy data and growing literature documenting potential harms.
Despite the guidance, VA providers routinely continue to prescribe benzodiazepines to Veterans with PTSD. In fiscal year 2009, our research group determined that over 30% of Veterans with PTSD seen in VA facilities received a benzodiazepine prescription. It is clear a gap exists between evidence-based practice for Veterans with PTSD and the clinical care they receive. What was unique about this research was that we were developing strategies to decrease the use of a clinical practice rather than trying to increase one.
The goal of this research was to develop strategies for the design and implementation of a training intervention program to decrease the use of benzodiazepines in PTSD with four specific aims:
(1) Characterized the patterns and extent of variability between VA facilities in benzodiazepine prescribing practices for PTSD patients over the past 11 years.
(2) Examined the prescribing patterns of other medications (e.g., atypical antipsychotic agents) to explore alternative drug treatment strategies to benzodiazepines in PTSD.
(3) Identified VA providers' perceptions about the barriers and facilitators of adherence to CPG recommendations regarding benzodiazepines for PTSD through semi-structured qualitative interviews with VA prescribers.
(4) Sought expert guidance to develop a training intervention to decrease prescribing of benzodiazepines for treatment of PTSD.
This study utilized a mixed methods approach. For Aims 1 & 2 secondary data analyses of VA pharmaceutical data was used to examine variation in local benzodiazepine utilization frequency for all patients with a PTSD diagnosis between FY99 and FY09. Both qualitative and quantitative methodology was employed for Aim 3. First we conducted semi-structured interviews with VA prescribers (26 prescribers from 11 VAMCs and 2 CBOCs) to identify the barriers and facilitators to adherence to the CPG recommendations regarding benzodiazepine prescribing in PTSD patients. The information obtained during the interviews was then used to inform a questionnaire that was used in a national online survey of VA prescribers (384 prescribers representing all 50 states and DC). To address Aim 4, all data was presented at an Expert Panel Meeting on September 6th. The panel reviewed the findings and helped to inform a training intervention program.
We found that the number of veterans receiving care for PTSD in the VA increased from 170,685 in 1999 to 498,081 in 2009. The proportion of individuals receiving a benzodiazepine decreased during this time period from 36.7% to 30.6%. We found that the proportion of Veterans receiving either of the two CPG-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% in 1999 to 13.9% in 2009. Hypnotic prescribing tripled when zolpidem was added to the formulary in 2008. Buspirone prescribing decreased steadily, while prazosin prescribing, which was possibly the big story here, expanded nearly 7-fold.
When we looked at demographic data on who was receiving benzodiazepines, we saw a significant gender difference. We learned that women were more likely than men to receive psychotropic medication across all classes except for 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%). The most notable gender discrepancy, however, 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%. This work, along with our other papers, suggested potential intervention targets. We sought through qualitative interviews to identify VA providers' perceptions about the barriers and facilitators to adherence to the PTSD CPG recommendations regarding the use of benzodiazepines. As far as their current practices, they have made conscious efforts to decrease new starts but indicate that they "inherit" patients who have long been taking benzodiazepines and don't want to stop them. They indicated that they would benefit from educational materials to help support them and also needed information on how to wean patients and alternative medication choices. The primary facilitator they identified was access to other resources including availability of evidence-based psychotherapy treatments. Conversely, the primary barrier was lack of access to specialty care services. We also learned that many prescribers did not know about the PTSD CPG or where to find it. Our online survey with prescribers indicated that they know the first-line treatment recommendations but are confused as to what to do next when those treatments are not effective. That is then when they begin to use medications that are not recommended.
We think that this project has been tremendously effective in identifying the state of prescribing in veterans with PTSD as well as identifying specific targets for an intervention project. The anticipated impact is an improvement in the quality of clinical care for veterans with PTSD and improved management for the VA health care system.
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- Bernardy NC, Lund BC, Alexander B, Friedman MJ. Increased polysedative use in veterans with posttraumatic stress disorder. Pain medicine (Malden, Mass.). 2014 Jul 1; 15(7):1083-90.
- Bernardy NC, Lund BC, Alexander B, Jenkyn AB, Schnurr PP, Friedman MJ. Gender differences in prescribing among veterans diagnosed with posttraumatic stress disorder. Journal of general internal medicine. 2013 Jul 1; 28 Suppl 2:S542-8.
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- Lund BC, Abrams TE, Bernardy NC, Alexander B, Friedman MJ. Benzodiazepine prescribing variation and clinical uncertainty in treating posttraumatic stress disorder. Psychiatric services (Washington, D.C.). 2013 Jan 1; 64(1):21-7.
- Bernardy NC, Lund BC, Alexander B, Friedman MJ. Prescribing trends in veterans with posttraumatic stress disorder. The Journal of clinical psychiatry. 2012 Mar 1; 73(3):297-303.
- Lund BC, Bernardy NC, Alexander B, Friedman MJ. Declining benzodiazepine use in veterans with posttraumatic stress disorder. The Journal of clinical psychiatry. 2012 Mar 1; 73(3):292-6.
- Lund BC, Kaboli PJ. Increased Risk for Potentially Inappropriate Prescribing among Rural Elder Veterans. Poster session presented at: VA HSR&D National Meeting; 2011 Feb 16; National Harbor, MD.