11-Year Study Shows Increase in Proportion of Veterans with PTSD Prescribed Guideline-Concordant Medications
To address the critical need for appropriate management of PTSD among Veterans, VA and the DoD issued a PTSD clinical practice guideline (CPG) in 2010, which was an update of the original 2004 guideline. The updated CPG provides evidence-based psychotherapy and pharmacotherapy treatment recommendations, as well as alternative and augmentation treatment strategies that best improve outcomes for patients with PTSD. This study sought to characterize prescribing trends among Veterans with PTSD over the past decade. Using VA data from FY99 through FY09, investigators identified Veterans who were diagnosed with PTSD (primary or secondary diagnosis) and who used VA healthcare services (inpatient and outpatient). Investigators then examined outpatient prescriptions for all Veterans with PTSD, including antidepressants, benzodiazepines, and atypical antipsychotics, as well as prazosin, an inexpensive alpha-1 blocker used to treat hypertension and considered by the CPG to have some benefit for targeting PTSD-related sleep problems and nightmares.
- The number of Veterans being treated for PTSD in the VA healthcare system increased nearly 3-fold — from 170,685 in FY1999 to 498,081 in FY2009. The majority of these Veterans (80%) received one of the medications recommended in the CPG for the treatment of this disorder.
- The proportion of Veterans receiving either of the two CPG-recommended first-line pharmacotherapy treatments for PTSD — selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) — increased from 50% in 1999 to 59% in 2009. This increase represents more than 46,000 Veterans receiving first-line, guideline recommended medications.
- The overall frequency of antipsychotic use declined by 6% — from 20% in 1999 to 14% in 2009, and there also was a reduction in benzodiazepine prescriptions (the CPG cautions against prescribing benzodiazepines to manage core PTSD symptoms). However, non-benzodiazepine hypnotic drug prescribing tripled when zolpidem (Ambien) was added to the VA national formulary.
- Prazosin use increased more than 6-fold, from 1% in 1999 to 9% in 2009, suggesting that it is now more widely prescribed to Veterans with PTSD.
- While investigators were able to describe prescribing trends among Veterans with PTSD using VA administrative data, they could not determine whether these agents were used for PTSD.
- This study points to a need to supplement work with administrative data with a qualitative examination of PTSD prescribing from interviews with providers to better understand the strategies used to make medication management decisions.
This study was partly funded by VA/HSR&D's Mental Health Quality Enhancement Research Initiative (QUERI; RRP 11-001). Dr. Bernardy is part of the Executive Division at the National Center for PTSD, White River Junction, VT, and Dr. Lund is part of HSR&D's Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City, IA.
Bernardy N, Lund B, Alexander B, and Friedman M. Prescribing Trends in Veterans with Post-Traumatic Stress Disorder. Journal of Clinical Psychiatry March 2012;73(3):297-303.