RESUMO
Posttraumatic stress disorder (PTSD) and comorbid mild traumatic brain injury (mTBI) are highly prevalent in veterans who served in Iraq [Operation Iraqi Freedom/Operation New Dawn] and Afghanistan [Operation Enduring Freedom]. Complicated psychotropic medications are used for treatment of PTSD and comorbid mTBI symptoms lead to polypharmacy related complications. Primary care providers (PCPs) working in Community Based Outpatient Clinics (CBOCs) are usually burdened with the responsibility of managing this complicated medication regimen or relevant side effects. The PCPs do not feel equipped to provide this complicated psychopharmacological management. Thus, there is a need for a comprehensive yet concise tool for the medication management of PTSD in veterans with comorbid mTBI. (1) To conduct focus groups of interdisciplinary team of experts and other stake holders to assess need, (2) To carefully review current VA/Department of Defense practice guideline to identify content, (3) To develop an evidence based, user friendly, and concise pocket guide for the PCP's. Content was identified by review of current guidelines and available literature and was finalized after input from stakeholders, multidisciplinary team of experts, and review of qualitative data from focus groups/interviews of clinicians working in remote CBOCs. The pocket tool was formatted and designed by multimedia service. A pocket guide in the form of a bi-fold, 4â³ × 5.5â³ laminated card was developed. One thousand hard copies were distributed in the local VA medical center. This product is available online for download at the South-Central Mental Illness Research, Education, and Clinical Center website ( https://www.mirecc.va.gov/VISN16/ptsd-and-mtbi-pocket-card.asp ). This pocket card provides PCPs an easy to carry and user-friendly clinical decision-making tool to effectively treat veterans with PTSD and comorbid mTBI.
Assuntos
Concussão Encefálica/complicações , Concussão Encefálica/tratamento farmacológico , Conduta do Tratamento Medicamentoso , Atenção Primária à Saúde , Transtornos de Estresse Pós-Traumáticos/complicações , Transtornos de Estresse Pós-Traumáticos/tratamento farmacológico , Veteranos/psicologia , Campanha Afegã de 2001- , Humanos , Guerra do Iraque 2003-2011 , PolimedicaçãoRESUMO
(i) To describe an integrated model of psychiatric care for the treatment of posttraumatic stress disorder (PTSD) in veterans with mild traumatic brain injury (mTBI). (ii) To evaluate access to and engagement in psychiatric care among veterans with comorbid PTSD and mTBI after implementation of an Integrated Care (IC) model compared to the previous Usual Care (UC). 100 randomly selected charts, 50 from each of UC and IC were reviewed in this non-concurrent case- control study. Polytrauma Network Site (PNS), an outpatient rehabilitation clinic, for veterans who suffered from brain and other traumatic injuries at an urban VA Polytrauma Rehabilitation Center. Veterans receiving treatment for mTBI symptoms by the rehabilitation team were referred for medication management for PTSD to UC and IC. Co-located access to psychiatric care for medication management as part of the interdisciplinary team with the goal of expediting rehabilitation and functional recovery. Number of consults for psychiatric care for medication management scheduled and completed within 30 days, and number of veterans offered, initiating, and completing evidence-based psychotherapies for PTSD in UC compared to IC. After implementation of IC there were significant improvements in timely completion of consults and patient engagement with a psychiatrist. There also were improvements in number of referrals, initiation, and completion of evidence-based psychotherapies for the treatment of PTSD. IC within the PNS shows promise as an effective care model for increasing access and engagement in care for veterans with comorbid PTSD/mTBI. Future research is needed to examine the utility of this model in other sites.
Assuntos
Concussão Encefálica/reabilitação , Prestação Integrada de Cuidados de Saúde , Acessibilidade aos Serviços de Saúde , Serviços de Saúde Mental , Avaliação de Processos em Cuidados de Saúde , Transtornos de Estresse Pós-Traumáticos/terapia , Veteranos , Adulto , Concussão Encefálica/epidemiologia , Comorbidade , Prestação Integrada de Cuidados de Saúde/estatística & dados numéricos , Feminino , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Humanos , Masculino , Serviços de Saúde Mental/estatística & dados numéricos , Pessoa de Meia-Idade , Transtornos de Estresse Pós-Traumáticos/tratamento farmacológico , Transtornos de Estresse Pós-Traumáticos/epidemiologia , Veteranos/estatística & dados numéricosRESUMO
BACKGROUND: Selective serotonergic reuptake inhibitors (SSRIs) are first-line pharmacologic treatments for patients with posttraumatic stress disorder (PTSD), but must be given over extended period of time before the onset of action. The use of SSRIs in PTSD patients with mild traumatic brain injury (mTBI) is problematic since SSRIs could exacerbate post-concussion syndrome (PCS) symptoms. VA/DOD guidelines identify trauma-focused psychotherapy as the best evidence-based treatment for PTSD, but overall effectiveness is limited by reduced levels of patient engagement and retention. A previous study from this research group suggested that quetiapine monotherapy, but not risperidone or valproate, could increase engagement in trauma-focused psychotherapy. METHODS: We report the study protocol of a pilot study funded under the South-Central Mental Illness Research, Education, and Clinical Center pilot study program from the U.S. Department of Veterans Affairs. This randomized, open-label study was designed to evaluate the feasibility of completing a randomized trial of quetiapine vs. treatment as usual to promote patient engagement in PTSD patients with a history of mTBI. DISCUSSION: We expect that the success of this ongoing study should provide us with the preliminary data necessary to design a full-scale randomized trial. Positive efficacy results in a full- scale trial should inform new VA guidelines for clinical practice by showing that quetiapine-related improvements in patient engagement and retention may be the most effective approach to assure that VA resources achieve the best possible outcome for veterans. TRIAL REGISTRATION: NCT04280965 .
Assuntos
Concussão Encefálica/tratamento farmacológico , Fumarato de Quetiapina/farmacologia , Transtornos de Estresse Pós-Traumáticos/tratamento farmacológico , Veteranos/psicologia , Concussão Encefálica/fisiopatologia , Humanos , Terapia Implosiva/métodos , Projetos Piloto , Fumarato de Quetiapina/uso terapêutico , Transtornos de Estresse Pós-Traumáticos/fisiopatologia , Texas , Resultado do Tratamento , Veteranos/estatística & dados numéricosRESUMO
The authors report a case of self inflicted bilateral corneal abrasions and skin damage due to ophthalmic and cutaneous delusional parasitosis. A male in his 50s presented with a 10 year history of believing that parasites were colonizing his skin and biting into his skin and eyes. The patient had received extensive medical evaluations that found no evidence that symptoms were due to a medical cause. He was persistent in his belief and had induced bilateral corneal abrasions and skin damage by using heat lamps and hair dryers in an attempt to disinfect his body. The patient was treated with olanzapine along with treatment for his skin and eyes. His delusional belief system persisted but no further damage to his eyes and skin was noted on initial follow-up.