PTSD Evidence Based Practice Recommendations

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PTSD Evidence Based Practice Recommendations

Jason's Box Best Practice Group

Dr. Sam Moreno, Michelle Schnack

Compilation & consolidation of the research and recommendations located in:

The VA/DoD Clinical Practice Guideline for the Management of Post-Traumatic Stress

(2010)

For the full version:

http://www.healthquality.va.gov/PTSD-FULL-2010c.pdf

For the summary:

http://www.healthquality.va.gov/ptsd/ptsd-sum_2010a.pdf

The VA’s National Center for PTSD, Clinician’s Guide to Medications for PTSD

http://www.ptsd.va.gov/professional/pages/clinicians-guide-to-medications-for-ptsd.asp

The International Society for Traumatic Stress Studies Treatment Guidelines for PTSD

(2005)

For links to the treatment guidelines:

http://www.istss.org/TreatmentGuidelines/3337.htm

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I. First, an explanation of the ratings used in recommendations…

Evidence Rating System

SR

A A strongrecommendation that clinicians provide the intervention to eligible patients. Good evidence was found that the intervention improves important health outcomes and concludes that benefits substantially outweigh harm.

B A recommendation that clinicians provide (the service) to eligible patients. At least fair evidence was found that the intervention improves health outcomes & concludes that benefits outweigh harm

C No recommendation for or against the routine provision of the intervention is made. At least fair evidence was found that the intervention can improve health outcomes but concludes that the balance of benefits and harms is too close to justify a general recommendation.

D Recommendation is made against routinely providing the intervention to asymptomatic patients. At least fair evidence was found that the intervention is ineffective or that the harms outweigh benefits.

I The conclusion is that the evidence is insufficient to recommend for or against routinely providing the intervention. Evidence that the intervention is effective is lacking, of poor quality, or

conflicting, and the balance of benefits and harms cannot be determined. SR  =  Strength  of  recommendation  

 

Level of Evidence (LE)

I At least one properly done RCT

II-1 Well-designed controlled trial without randomization

II-2 Well-designed cohort or case-control analytic study, preferably from more than one source

II-3 Multiple time series evidence with/without intervention, dramatic results of uncontrolled experiment

III Opinion of respected authorities, descriptive studies, case reports, and expert committees

Overall Quality [QE]

Good High grade evidence (I or II-1) directly linked to health outcome

Fair High grade evidence (I or II-1) linked to intermediate outcome; or Moderate grade evidence (II-2 or II-3) directly linked to health outcome

Poor Level III evidence or no linkage of evidence to health outcome

Final Grade of Recommendation [SR]

The Net Benefit of the Intervention

Quality of Evidence Substantial Moderate Small Zero or Negative

Good A B C D

Fair B B C D

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II. Screening Recommendations

All new patients should be screened for symptoms of PTSD initially & then annually, or more

frequently, if clinically indicated. [B]

There is insufficient evidence to recommend one PTSD screening tool versus another. The following

screening tools have been validated and should be considered for use:

- Primary Care PTSD Screen (PC-PTSD)

- PTSD Brief Screen

- Short Screening Scale for DSM IV PTSD

- PTSD Checklist (PCL)

Evidence   Sources   LE QE SR

1 Screening all patients for PTSD symptoms. Breslau et al., 1999a Leskin & Westrup, 1999 Prins et al., 1999

Taubman et al., 2001

II-2 Fair B

2 Screening tools:

Primary Care PTSD Screen PTSD Brief Screen

Short Screening Scale for DSM IV PTSD Checklist (PCL)

Breslau et al., 1999a Leskin & Westrup, 1999 Prins et al., 1999

Terhakopian, et al 2008

II-2 Fair B

All patients with PTSD should be assessed for safety & dangerousness including current risk to self or

others, and historical patterns of risk:

- SI or HI, intent, means, history, behaviors, co-morbidities (substance use, medical conditions)

- Family and social environment – including risks to the family

- Ongoing health risks or risk-taking behavior

- Medical/psychiatric co-morbidities or unstable medical conditions

Recommendation Sources LE QE SR

1 Assess for dangerousness including suicidal or homicidal ideation, intent, means, history, behaviors, and co-morbidities

Breslau, 2000

Bullman & Kang, 1994 Ferrada-Noli et al., 1998 Kaslow et al., 2000 Marshall et al., 2001 Prigerson & Slimack, 1999 Swanson et al., 2002 Zivin, 2007 III II-2 III II-2 II II II II-2 Good B

2 Assess family, social environment – including risks for family

Seng, 2002 Swanson, 2002

III II

Good B

3 Assess ongoing health risks or risk-taking behaviors Acierno et al., 1996 Hutton et al., 2001 Vieweg et al., 2006 II-2 II II-2 Good B

4 Assess medical or psychiatric co-morbidities or unstable medical condition

Davidson et al., 1991

Farrell et al., 1995; Weisberg et al., 2002 Hoge et al., 2007; Gill et al., 2009

II III III

Good B

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III. Treatment Recommendations

A. EARLY INTERVENTIONS TO PREVENT PTSD

Early Interventions after Exposure to Trauma (<4 days after exposure)

Balance of Benefit and Harm

SR Significant

Benefit

Some Benefit Unknown

Benefit

No Benefit / Potential Harm

I -- Psychological First Aid

Psychoeducation & normalization Social support

Spiritual support --

D -- -- -- Psychological debriefing

Early Interventions after Exposure to Trauma (4-30 days after exposure)

Balance of Benefit and Harm

SR Significant

Benefit

Some Benefit Unknown Benefit No Benefit

A Brief CBT (4-5 sessions) B

C Social support

D Individual psychological debriefingW

Formal psychotherapy for asymptomatic survivors W Benzodiazepines, Typical Antipsychotics, risperidone* W Atypical antipsychotics as Monotherapy* I Psychoeducation & normalization Imipramine Propranolol, Prazosin Other Antidepressants Anticonvulsants Atypical Antipsychotics as Adjunct (except risperidone)* Spiritual support

Psychological First Aid

Group psychological debriefing

*VA/DoD Clinical Practice Guideline has been revised as follows: 1) atypical antipsychotics are not recommended as

mono therapy for PTSD, 2) risperidone is contraindicated for use as an adjunctive agent (potential for harm), and 3) there is insufficient evidence to recommend any other atypical antipsychotic as an adjunctive agent for PTSD

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B. TREATMENT INTERVENTIONS FOR PTSD

Providers should explain to all patients with PTSD all available & effective options for PTSD.

Patient education is recommended for all patients with PTSD & their family members. [C]

Patient and provider preferences should drive the selection of evidence-based psychotherapy and/or

evidence-based pharmacotherapy as the first line treatment.

Psychotherapies should be provided by practitioners trained in the method of treatment.

All clinicians should be trained in trauma-informed care.

A collaborative care approach to therapy administration, with care management, may be considered,

although supportive evidence is lacking specifically for PTSD.

Psychotherapy Interventions for Treatment of PTSD

Balance Benefit and Harm

SR Significant Benefit Some Benefit Unknown Benefit

A Trauma-focused psychotherapy that includes component of exposure and/or cognitive restructuring (i.e., CBT, EMDR, Exposure Therapy, etc.) ; or,

Stress Inoculation training B

C Patient Education

Imagery Rehearsal Therapy Psychodynamic Therapy Hypnosis

Relaxation Techniques Group Therapy

I Family Therapy Web-based CBT

Acceptance and Commitment Therapy Dialectical Behavior Therapy

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Adjunctive Problem-Focused Method/Services for PTSD

If patient: Service/Training

Is not fully informed about aspects of health needs & does not avoid high-risk behaviors

Provide patient education Does not have sufficient self-care & independent living

skills

Refer to self-care/independent living skills training services

Does not have safe, decent, affordable, stable housing that is consistent with treatment goals

Use and/or refer to supported housing services Does not have a family that is actively supportive and/or

knowledgeable about treatment for PTSD Implement family skills training

Is not socially active Implement social skills training

Does not have a job that provides adequate income and/or fully uses his or her training & skills

Implement vocational rehabilitation training Is unable to locate & coordinate access to services Use case management services

Does not request spiritual support Provide access to religious/spiritual advisors and/or other resources

OTHER CONDITIONS

Has a borderline personality disorder with parasuicidal behaviors

Consider DBT

Has concurrent substance abuse problem Integrated PTSD substance abuse treatment (i.e., Seeking Safety)

Symptom Response by Drug Class and Individual Drug (based on controlled trials)

Global Improvement Re-experiencing Avoidance/ Numbing Hyper-arousal SSRI Fluoxetine X X X X Sertraline X X X X Paroxetine X X X X SNRI Venlafaxine X X X X TCAs Amitriptyline/ Imipramine X X X MAOIs Phenelzine X X X Sympatholytics Prazosin X X X Other Anti-depressants Mirtazapine X X X Nefazodone X X X

*VA/DoD Clinical Practice Guideline has been revised as follows: 1) atypical antipsychotics are not recommended as

mono therapy for PTSD, 2) risperidone is contraindicated for use as an adjunctive agent (potential for harm), and 3) there is insufficient evidence to recommend any other atypical antipsychotic as an adjunctive agent for PTSD

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Pharmacotherapy for PTSD

Balance of Benefit and Harm

SR Significant Some Benefit Unknown No Benefit A SSRIs SNRIs B Mirtazapine Prazosin (for sleep/nightmares) TCAs Nefazodone [Caution] MAOIs (phenelzine) X

C Prazosin (for global PTSD)

D Benzodiazepines[Harm] Tiagabine Guanfacine Valproate Topiramate Risperidone, as adjunct [Harm] * Atypical antipsychotics, as monotherapy * I Atypical antipsychotic, as

adjunct (besides risperidone which is contraindicated)* Typical antipsychotics Buspirone Non-benzodiazepine hypnotics Bupropion Trazodone (adjunctive) Gabapentin Lamotrigine Propranolol Clonidine

SR = Strength of recommendation (see Introduction); X= Attention to drug to-drug and dietary interactions

*VA/DoD Clinical Practice Guideline has been revised as follows: 1) atypical antipsychotics are not recommended as

mono therapy for PTSD, 2) risperidone is contraindicated for use as an adjunctive agent (potential for harm), and 3) there is insufficient evidence to recommend any other atypical antipsychotic as an adjunctive agent for PTSD

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Monotherapy:

Strongly recommend that patients with PTSD be offered SSRIs, for which fluoxetine, paroxetine, or

sertraline have strongest support, or SNRIs, for which venlafaxine has strongest support. [A]

Recommend mirtazapine, nefazodone, TCAs, amitriptyline & imipramine, or MAOIs (phenelzine). [B]

Recommend against guanfacine, anticonvulsants (tiagabine, topiramate, valproate) as monotherapy [D]

Existing evidence does not support the use of bupropion, buspirone, and trazodone, anticonvulsants

(lamotrigine or gabapentin) or atypical antipsychotics as monotherapy in the management of PTSD. [I]

There is evidence against the use of benzodiazepines, atypical antipsychotics as monotherapy,*** and

risperidone as adjunct*** in management of PTSD. [D]

Insufficient evidence to support the use of prazosin as monotherapy in the management of PTSD. [I]

Augmented Therapy for PTSD:

Recommend adjunctive treatment with prazosin for sleep/nightmares. [B]

Insufficient evidence to recommend a sympatholytic, anticonvulsant, or atypical antipsychotic (besides

risperidone, which is contraindicated)*** as an adjunct. [I]

Treatment Response and Follow-Up

Step Patient

Condition

Options Reassess

at:*

1 Initial

Treatment • Psychotherapy AND/OR _{• SSRI/SNRI} 2 weeks **/ 4 weeks 2 Non response

to initial dose • Assess adherence _{• Increase dose} • Consider longer duration • Switch to another SSRI or SNRI • Add psychotherapy

• Consider referral to specialty care

4-6 weeks

3 Failed second trial of

antidepressant

• Switch to another SSRI/SNRI or mirtazapine • Add psychotherapy

• Augment with prazosin (sleep/nightmare)

8-12 weeks

4 Failed three trials including augmentation

• Re- evaluate diagnosis and treatment • Switch to TCA

• If no response consider nefazodone (monitoring side effects), or phenalzine (with careful consideration of risks)

• Consider referral to specialty care

> 12 weeks

* Times are general guidelines and may vary considerably / **If treatment is not tolerable, switch to another antidepressant.

***VA/DoD Clinical Practice Guideline has been revised as follows: 1) atypical antipsychotics are not recommended as

mono therapy for PTSD, 2) risperidone is contraindicated for use as an adjunctive agent (potential for harm), and 3) there is insufficient evidence to recommend any other atypical antipsychotic as an adjunctive agent for PTSD