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Psychiatry Practice Research Review

Released: September 29, 2021
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VAMC Study on Medication Prescription Trends for PTSD: 2009-2018

Holder N, et al. J Clin Psychiatry. 2021;82:20m13522.

Background
Posttraumatic stress disorder (PTSD) is a debilitating mental condition that disproportionately affects military veterans, with the Veterans Health Administration (VHA) providing effective treatment for more than 600,000 veterans with PTSD. This study evaluated longitudinal prescription practice trends for patients diagnosed with PTSD in VHA care from 2009-2018.

Methods
Using ICD-9 and ICD-10 codes to determine diagnoses, 1,353,416 patients diagnosed with PTSD in VHA care were retrospectively identified who were not diagnosed with a bipolar or psychotic spectrum disorder. Veterans were included in the analytic sample starting in the year of their first PTSD diagnosis for each year that they were active in VHA care. Outpatient prescription records were examined from 2009-2018 for medications that are commonly used as recommended (selective serotonin reuptake inhibitors [SSRIs], serotonin–norepinephrine reuptake inhibitors [SNRIs]) or second-line/adjunctive atypical antipsychotics (AAPs), mirtazapine, prazosin, trazodone, tricyclic antidepressants, and non-benzodiazepine hypnotics medications for PTSD. Benzodiazepine prescriptions were also examined.

Results
From 2009-2018, the percentage of patients active in VHA care who received at least 1 of the recommended or second-line/adjunctive medications for PTSD in a calendar year declined by 9.0% (absolute change). The largest absolute change in rates of prescribing for medication classes during the past decade was observed among SSRIs (-12.3%) and SNRIs (+6.4%). AAP use decreased 5.4% from 2009-2018, with most of this change (-4.3%) occurring from 2009-2013.

Conclusions
Consistent with clinical practice guidelines, SSRIs/SNRIs were the most common prescriptions for patients in the current study. Reductions in the percentage of patients receiving PTSD medications may reflect concerns regarding effectiveness, adverse events, increases in access to evidence-based psychotherapy for PTSD, and/or symptom improvement such that medication was no longer needed.

Clinical Commentary
PTSD is a chronic and debilitating psychiatric illness with significant morbidity due to symptoms as well as comorbid drug and alcohol use. It is also associated with poor physical health and quality of life. It has a significant suicide risk. Military veterans are noted to be disproportionately diagnosed with PTSD. This is a retrospective study and has the limitation of such a study but includes a large sample with a longitudinal design over 9 years. A distinct limitation/advantage of this study (depending on perspective) is that it focuses on veterans, making it difficult to generalize these findings towards the civilian population. Another limitation of this study is attention not being paid to the kind of therapy used.

Clinical Insights

  • The number of veterans diagnosed with PTSD doubled from 2009-2018 whereas the percentage of veterans receiving pharmacotherapy declined.
  • SSRI use (recommended by clinical practice guidelines) decreased (the largest decrease) primarily because of discontinuation due to adverse events and not due to reduction in new prescriptions.
  • Other factors, such as the FDA warning of prolonged QT interval with citalopram, may have had an effect.
  • There was increased use of duloxetine because it became generic as well as its approval by the FDA for use in chronic pain.
  • Data suggested that patients preferred psychotherapy over pharmacotherapy and there was increased access to psychotherapy services at the VHA. The psychotherapies were time limited. More patients elected for first-time psychotherapy.
  • The prescription of AAP medications also decreased significantly due to a lack of substantial evidence of efficacy and risk of metabolic adverse events. Quetiapine was the most commonly prescribed AAP medication because of its sedating qualities.
  • There was also a significant decline in prazosin use possibly because of a large multicenter randomized trial that was negative.

Summary
As a healthcare professional, I conduct a thorough assessment of patients with PTSD including substance use disorder assessment and connect them with evidence-based psychotherapy programs for PTSD such as cognitive therapy or eye movement desensitization and reprocessing. I recommend using the SSRIs (with monitoring for adverse events and especially sexual adverse events) while being cautious about prescribing AAPs because of the lack of strong evidence of efficacy and the risk of metabolic adverse events and tardive dyskinesia. If nightmares are present, I would still use prazosin (despite the negative study) based on my own clinical experience, with monitoring of blood pressure. Cyproheptadine has also been shown to have efficacy for nightmares.

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