The Management of Posttraumatic Stress Disorder and Acute Stress Disorder: Synopsis of the 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline.

DESCRIPTION: The U.S. Department of Veterans Affairs (VA) and Department of Defense (DoD) worked together to revise the 2017 VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder. This article summarizes the 2023 clinical practice guideline (CPG) and its development process, focusing on assessments and treatments for which evidence was sufficient to support a recommendation for or against. METHODS: Subject experts from both departments developed 12 key questions and reviewed the published literature after a systematic search using the PICOTS (population, intervention, comparator, outcomes, timing of outcomes measurement, and setting) method. The evidence was then evaluated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method. Recommendations were made after consensus was reached; they were based on quality and strength of evidence and informed by other factors, including feasibility and patient perspectives. Once the draft was peer reviewed by an external group of experts and their inputs were incorporated, the final document was completed. RECOMMENDATIONS: The revised CPG includes 34 recommendations in the following 5 topic areas: assessment and diagnosis, prevention, treatment, treatment of nightmares, and treatment of posttraumatic stress disorder (PTSD) with co-occurring conditions. Six recommendations on PTSD treatment were rated as strong. The CPG recommends use of specific manualized psychotherapies over pharmacotherapy; prolonged exposure, cognitive processing therapy, or eye movement desensitization and reprocessing psychotherapy; paroxetine, sertraline, or venlafaxine; and secure video teleconferencing to deliver recommended psychotherapy when that therapy has been validated for use with video teleconferencing or when other options are unavailable. The CPG also recommends against use of benzodiazepines, cannabis, or cannabis-derived products. Providers are encouraged to use this guideline to support evidence-based, patient-centered care and shared decision making to optimize individuals' health outcomes and quality of life.

A clinician's guide to the 2023 VA/DoD Clinical Practice Guideline for Management of Posttraumatic Stress Disorder and Acute Stress Disorder.

A clinical practice guideline (CPG) is a rigorously established set of recommendations based on currently available evidence about the efficacy, safety, acceptability, and feasibility of interventions to assist with clinical decision-making. The 2023 Department of Veterans Affairs /Department of Defense Clinical Practice Guideline for Management of Posttraumatic Stress Disorder and Acute Stress Disorder is described herein. The CPG recommendations are accompanied by a clinical algorithm, which incorporates principles of evidence-based practice, shared decision-making, and functional and contextual assessments of goals and outcomes. An overview of the CPG recommendations is combined with a discussion of questions that clinicians and patients may face in implementing the CPG and suggestions for how to effectively work with the CPG.

Clinical Outcomes of Intravenous Ketamine Treatment for Depression in the VA Health System.

Objective/Background: Intravenous (IV) ketamine is effective for reducing symptoms of major depressive disorder in short-term clinical trials; this study characterized clinical outcomes of repeated infusions in routine clinical practice and the frequency and number of infusions used to sustain symptom improvement.Methods: Records of IV ketamine infusions for depression and associated Patient Health Questionnaire-9 (PHQ-9) scores were identified from Veterans Health Administration (VA) electronic medical records for patients treated in Fiscal Year 2020 and up to 12 months following the date of their first infusion.Results: Sample patients (n = 215) had a mean baseline PHQ-9 score of 18.6 and a mean of 2.1 antidepressant medication trials in the past year and 6.1 antidepressant trials in the 20 years prior to their first ketamine infusion. Frequency of infusions decreased from every 5 days to every 3-4 weeks over the first 5 months of infusions, with a mean of 18 total infusions over 12 months. After 6 weeks of treatment, 26% had a 50% improvement in PHQ-9 score (response) and 15% had PHQ-9 score ≤ 5 (remission). These improvements were similar at 12 and 26 weeks. No demographic characteristics or comorbid diagnoses were associated with 6-week PHQ-9 scores.Conclusions: While only a minority of patients treated with IV ketamine for depression experienced response or remission, symptom improvements achieved within the first 6 weeks were sustained over at least 6 months with decreasing infusion frequency. Further study is needed to determine optimal infusion frequency and potential for adverse effects with repeated ketamine infusions for depression.