Correction to: Measurement Strategies for Evidence-Based Psychotherapy for Posttraumatic Stress Disorder Delivery: Trends and Associations with Patient-Reported Outcomes.

The original version of this article unfortunately contained a mistake. The co-author name was incorrectly published with the middle initial in the author list.

Measurement Strategies for Evidence-Based Psychotherapy for Posttraumatic Stress Disorder Delivery: Trends and Associations with Patient-Reported Outcomes.

We sought to develop a quality standard for the delivery of psychotherapy for posttraumatic stress disorder (PTSD) that is both consistent with the underlying evidence supporting psychotherapy as a treatment for PTSD and associated with the best levels of symptom improvement. We quantified psychotherapy receipt during the initial year of PTSD treatment in a 10-year national cohort of Department of Veterans Affairs (VA) users who completed patient-reported outcome measurement as part of routine practice. We added progressively stringent measurement requirements. The most stringent requirement was associated with superior outcomes. Quality of psychotherapy for PTSD in the VA improved over time.

Causes of Excess Mortality in Veterans Treated for Posttraumatic Stress Disorder.

INTRODUCTION: Published research indicates that posttraumatic stress disorder (PTSD) is associated with increased mortality. However, causes of death among treatment-seeking patients with PTSD remain poorly characterized. The study objective was to describe causes of death among Veterans with PTSD to inform preventive interventions for this treatment population. METHODS: A retrospective cohort study was conducted for all Veterans who initiated PTSD treatment at any Department of Veterans Affairs Medical Center from fiscal year 2008 to 2013. The primary outcome was mortality within the first year after treatment initiation. In 2018, collected data were analyzed to determine leading causes of death. For the top ten causes, standardized mortality ratios (SMRs) were calculated from age- and sex-matched mortality tables of the U.S. general population. RESULTS: A total of 491,040 Veterans were identified who initiated PTSD treatment. Mean age was 48.5 (±16.0) years, 90.7% were male, and 63.5% were of white race. In the year following treatment initiation, 1.1% (5,215/491,040) died. All-cause mortality was significantly higher for Veterans with PTSD compared with the U.S. population (SMR=1.05, 95% CI=1.02, 1.08, p<0.001). Veterans with PTSD had a significant increase in mortality from suicide (SMR=2.52, 95% CI=2.24, 2.82, p<0.001), accidental injury (SMR=1.99, 95% CI=1.83, 2.16, p<0.001), and viral hepatitis (SMR=2.26, 95% CI=1.68, 2.93, p<0.001) versus the U.S. POPULATION: Of those dying from accidental injury, more than half died of poisoning (52.3%, 325/622). CONCLUSIONS: Veterans with PTSD have an elevated risk of death from suicide, accidental injury, and viral hepatitis. Preventive interventions should target these important causes of death.

A Retrospective Comparative Effectiveness Study of Medications for Posttraumatic Stress Disorder in Routine Practice.

OBJECTIVE: Fluoxetine, paroxetine, sertraline, topiramate, and venlafaxine have consistently shown efficacy for posttraumatic stress disorder (PTSD) in meta-analyses of randomized controlled trials. However, no study has compared the effectiveness of these agents in routine clinical practice. We conducted a retrospective comparative effectiveness study of these 5 medications using electronic medical record data. METHODS: We identified 2,931 Department of Veterans Affairs outpatients initiating treatment for PTSD between fiscal years 2004 and 2013 who received 1 of the 5 medications at an adequate dose and duration, combined with baseline and endpoint PTSD Checklist (PCL) measurements. Patients were identified based on clinical diagnoses of PTSD (DSM-IV criteria). We weighted participants in order to balance pretreatment characteristics. We compared continuous changes on total PCL score, symptom cluster scores, and sleep items, as well as categorical changes including reliable improvement and loss of PTSD diagnosis, using weighted regression analyses. We conducted exploratory analysis to determine whether any patient characteristics or service use variables predicted loss of PTSD diagnosis. RESULTS: Patients improved by a mean of 5-6 points on the PCL over approximately 6 months of treatment. While half of patients had a reliable improvement of 5 points or more on the PCL, less than a fifth achieved loss of PTSD diagnosis. There were no differences between medications. The only significant (P < .001) predictor of loss of PTSD diagnosis was concurrent treatment with evidence-based psychotherapy. CONCLUSIONS: Available evidence-based medications for PTSD are equally effective in clinical practice. Although effective, our data suggest that patients choosing medication treatment for PTSD should consider concurrent treatment with evidence-based psychotherapy in order to maximize their chances of meaningful improvement.

Anticonvulsant Medication Use in Veterans With Posttraumatic Stress Disorder.

OBJECTIVE: Anticonvulsants have been studied for many indications, including posttraumatic stress disorder (PTSD). The limited efficacy research on anticonvulsants for PTSD is mixed. However, anticonvulsants are prescribed widely to veterans with PTSD. Our objective was to measure trends and factors associated with anticonvulsant prescriptions among veterans with PTSD. METHODS: We obtained administrative and pharmacy data for veterans who initiated PTSD treatment in the US Department of Veterans Affairs (VA) between 2004 and 2013 (N = 731,520). We identified those who received anticonvulsants during the year following their initial clinical PTSD diagnosis and examined common indications for anticonvulsant use, patient characteristics, and service use characteristics. Using logistic regression, we determined the predictors of anticonvulsant initiation among those without an indication. RESULTS: Although 24.9% of patients in the cohort received an anticonvulsant during their initial year of PTSD treatment, 94.6% had an indication unrelated to PTSD and 51.2% initiated anticonvulsant use before their PTSD diagnosis. While there was growth in anticonvulsant initiation over the 10-year period, this was explained both by growth in indications unrelated to PTSD and by increased use of anticonvulsants for these indications. The rate of anticonvulsant initiation without an indication was stable at approximately 5% throughout the period, with patient and service use characteristics driving the selection of individual agents. CONCLUSIONS: A large and increasing proportion of veterans with PTSD receives anticonvulsant prescriptions. However, this may be appropriate use driven by increased prevalence of comorbid conditions that may be an indication for anticonvulsant use, including pain and headache disorders.

Suicidal Ideation is Associated With All-Cause Mortality.

Suicidal ideation may be associated with all-cause mortality. Available research shows that treatment of depression reduces the risk of all-cause mortality in patients with suicidal ideation. However, this finding has not been replicated in a clinical population, where patients have various mental health conditions. We examined the association between suicidal ideation and all-cause mortality in a clinical cohort. We stratified patients presenting to a mental health clinic from January 2005 through December 2007 based upon their degree of suicidal ideation and obtained vital status information through June 2015. We compared groups using survival analysis, adjusting for patient characteristics and treatment receipt. Among 1,869 patients who completed the initial assessment, there were 363 deaths. Patients with the highest levels of suicidal ideation died at increased rates. Cause-of-death data in the year following the initial assessment indicates that the difference in mortality is not likely attributable to suicide. Accounting for patient characteristics and treatment, which included medical care and mental health care, did not meaningfully diminish the relationship between suicidal ideation and all-cause mortality. Additional research is needed to determine specific treatment elements that may moderate the relationship between suicidal ideation and all-cause mortality.