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Military providers seek tailored approach to treating PTSD

The VA/DoD clinical practice guideline for managing post-traumatic stress disorder and acute stress disorder recommends against prescribing benzodiazepines. (U.S. Air Force photo by Airman 1st Class Joseph Pick) The VA/DoD clinical practice guideline for managing post-traumatic stress disorder and acute stress disorder recommends against prescribing benzodiazepines. (U.S. Air Force photo by Airman 1st Class Joseph Pick)

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Mental Health Care | Military Hospitals and Clinics | Posttraumatic Stress Disorder

FALLS CHURCH, VA — A new reporting tool developed by the Defense Health Agency’s Pharmacy Operations Division is helping ensure Military Health System providers follow best practices in prescribing medications for patients diagnosed with post-traumatic stress disorder.

The PTS Provider Prescribing Profile lists all providers at military treatment facilities who are treating patients with PTSD or acute stress disorder, said Sushma Roberts, Ph.D., a clinical psychologist and senior program manager for DoD/VA Integrated Behavioral Health, Clinical Communities Support Section, Clinical Support Division. The tool also documents the medications providers are prescribing. 

According to the Psychological Health Center of Excellence, PTSD is a medically diagnosed mental health condition that may develop after experiencing, witnessing, or learning the details of a traumatic event such as combat, a natural disaster, sexual assault, or a terrorist attack. 

From February 2000 to February 2018, about 223,000 active-duty service members were diagnosed with PTSD, Roberts said, adding that 75 percent were diagnosed following a deployment of 30 days or longer. 

Currently, the focus is on benzodiazepines, or benzos. The clinical practice guideline released in 2017 recommended against prescribing benzos for PTSD patients, she noted. 

Benzos, also known as tranquilizers, act on the brain and central nervous system to produce a calming effect. People can easily develop a tolerance to benzos, health care experts say, needing higher doses and increased frequency to achieve the same effects. People also may suffer withdrawal symptoms, including insomnia, irritability, anxiety, panic attacks, and seizures.

It’s dangerous to combine benzos with alcohol or other medications such as opioids. In 2015, 23 percent of people who died of an opioid overdose also tested positive for benzo use, according to the Centers for Disease Control and Prevention. 

“Benzos aren’t necessarily bad,” said Army Lt. Col. Dennis Sarmiento, a psychiatrist and chair of the DHA’s Behavioral Health Clinical Community. “There are indications for their use. Short-term, they can help with anxiety, panic, and sleep. Treating such symptoms can help providers engage patients in care and better establish or reinforce rapport.”

Studies have shown a large percentage of service members and veterans who may benefit from treatment for PTSD may not seek care or complete treatment, Sarmiento said.

But medications other than benzos are recommended for treating PTSD because they’re more effective. For example, antidepressants such as Zoloft, Paxil, Prozac, and Effexor raise the brain’s level of serotonin, a chemical that reduces symptoms of depression and anxiety. 

“In contrast to benzodiazepines, these medications [antidepressants] can be used with trauma-focused psychotherapy,” Sarmiento said. Those therapies include talking or writing about traumatic events, or learning and practicing meditation or deep-breathing exercises to manage anxiety.

“Treatment should be tailored to the individual patient,” Sarmiento said. 

Sarmiento notes that throughout the MHS, benzo prescriptions have been on a downward trend since peaking in 2012. “And from available pharmacy data, we know that the medications recommended for PTSD are appropriately trending upward,” he said.

Roberts said a prototype of the reviewing and monitoring tool was developed in February 2017. It was updated in September to reflect the revised VA/DoD clinical practice guideline for the management of PTSD and acute stress disorder. The tool generates quarterly reports that the DHA Pharmacy Operations Division sends to the three service surgeon general staffs to distribute to military treatment facility leaders.

“MTF commanders have the information to know what the prescribing practices are for PTSD patients at their particular facility,” Roberts said. 

According to the tool, the number of benzos prescriptions for MHS beneficiaries diagnosed with PTSD dropped from 1,922 in the first quarter of fiscal year 2017 to 1,749 in the fourth quarter, a decline of about 9 percent. Data for the first quarter of FY 2018 was released this month. It shows the number dropped again — to 1,651.

“In June, we’ll assess trends based on second-quarter data,” Sarmiento said. “If the prescribing rate doesn’t continue declining, we’ll implement one-on-one education between clinical leadership and their high-prescribing providers.”

Meanwhile, Sarmiento encourages patients who’ve been diagnosed with PTSD to talk with their providers. “We want them to feel empowered to ask questions and understand their individual treatment plan,” he said. 


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This retrospective study estimated the rates of seizures diagnosed among deployed and non-deployed service members to identify factors associated with seizures and determine if seizure rates differed in deployment settings. It also attempted to evaluate the associations between seizures, traumatic brain injury (TBI), and post-traumatic stress disorder (PTSD) by assessing correlations between the incidence rates of seizures and prior diagnoses of TBI and PTSD. Seizures have been defined as paroxysmal neurologic episodes caused by abnormal neuronal activity in the brain. Approximately one in 10 individuals will experience a seizure in their lifetime. Line graph 1: Annual crude incidence rates of seizures among non-deployed service members, active component, U.S. Armed Forces data •	A total of 16,257 seizure events of all types were identified among non-deployed service members during the 10-year surveillance period. •	The overall incidence rate was 12.9 seizures per 10,000 person-years (p-yrs.) •	There was a decrease in the rate of seizures diagnosed in the active component of the military during the 10-year period. Rates reached their lowest point in 2015 – 9.0 seizures per 10,000 p-yrs. •	Annual rates were markedly higher among service members with recent PTSD and TBI diagnoses, and among those with prior seizure diagnoses. Line graph 2: Annual crude incidence rates of seizures by traumatic brain injury (TBI) and recent post-traumatic stress disorder (PTSD) diagnosis among non-deployed active component service members, U.S. Armed Forces •	For service members who had received both TBI and PTSD diagnoses, seizure rates among the deployed and the non-deployed were two and three times the rates among those with only one of those diagnoses, respectively. •	Rates of seizures tended to be higher among service members who were: in the Army or Marine Corps, Female, African American, Younger than age 30, Veterans of no more than one previous deployment, and in the occupations of combat arms, armor, or healthcare Line graph 3: Annual crude incidence rates of seizures diagnosed among service members deployed to Operation Enduring Freedom, Operation Iraqi Freedom, or Operation New Dawn, U.S. Armed Forces, 2008 – 2016  •	A total of 814 cases of seizures were identified during deployment to operations in Iraq and Afghanistan during the 9-year surveillance period (2008 – 2016). •	For deployed service members, the overall incidence rate was 9.1 seizures per 10,000 p-yrs. •	Having either a TBI or recent PTSD diagnosis alone was associated with a 3-to 4-fold increase in the rate of seizures. •	Only 19 cases of seizures were diagnosed among deployed individuals with a recent PTSD diagnosis during the 9-year surveillance period. •	Overall incidence rates among deployed service members were highest for those in the Army, females, those younger than age 25, junior enlisted, and in healthcare occupations. Access the full report in the December 2017 MSMR (Vol. 24, No. 12). Go to www.Health.mil/MSMR

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