Implementation strategies to improve posttraumatic stress disorder care in rural veterans.

PURPOSE: Prior research has noted treatment inequalities in the care of rural veterans with posttraumatic stress disorder (PTSD). This project sought to increase the delivery, or reach, of recommended PTSD treatments in 2 rural health care systems of the Department of Veterans Affairs (VA) using implementation facilitation. METHODS: The quality improvement project involved 6 months of facilitation to 2 low-reach PTSD clinics within 2 VA health care systems. The clinics were matched to a control clinic at another regional system similar in reach, rurality, and patient volume. We compared the delivery of evidence-based psychotherapies (EBPs) for PTSD at 3 timepoints: baseline, 6 months, and 1 year using difference-in-difference effect estimation. Facilitators and barriers of EBP reach were identified through interviews with clinic staff and informed specific implementation plans. We also measured reductions in benzodiazepine prescriptions and polypharmacy to determine the impact of an academic detailing intervention aimed at improving PTSD prescribing practices at the 2 sites. FINDINGS: EBP reach at 6 months more than doubled in the 2 PTSD clinics that received facilitation, while our control clinic experienced a decrease in EBP reach (DID = 24.6; SE = 6.71%). Both intervention clinics identified similar administrative barriers to the delivery of EBPs, offering useful information for improvement at other rural clinics. The use of academic detailing as part of our facilitation intervention further appears to have positively impacted care. CONCLUSIONS: In this preliminary work, facilitation is a promising strategy for increasing the delivery of PTSD EBPs to veterans seen in under-resourced rural VA clinics.

Deimplementation of Benzodiazepine Prescribing in Posttraumatic Stress Disorder in the Veterans Health Administration.

Objective: Our objective was to characterize benzodiazepine prescribing changes among veterans with posttraumatic stress disorder (PTSD) and inform efforts to deimplement low-value prescribing practices.Methods: This retrospective observational study used national Veterans Health Administration (VHA) administrative databases to examine annual period prevalence and incidence of benzodiazepine prescribing from 2009 through 2019 in veterans with PTSD. International Classification of Diseases (ICD-9/10) codes were used to identify PTSD. Temporal trends in discontinuation rates, incidence rates, and prevalent prescribing among patients newly engaged in PTSD care were measured.Results: Benzodiazepine prevalence in veterans with PTSD declined from 31.3% in 2009 to 10.7% in 2019, and incidence decreased from 11.4% to 2.9%, along with a 30% decrease in daily doses. Increasing discontinuation rates accounted for 21.0% of the decline in prevalence, while decreasing incidence among existing patients accounted for 36.8%, and decreased prevalence among new PTSD cohort entrants accounted for 42.2%. Women received benzodiazepines more commonly than men (odds ratio [OR] = 1.67; 95% CI, 1.64-1.70). The proportion of older adults increased over time among both existing (2009: 14.5%; 2019: 46.5%) and new (2009: 8.6%; 2019: 24.3%) benzodiazepine recipients.Conclusions: Benzodiazepine prescribing in VHA among veterans with PTSD showed changes driven by decreases in prevalence among new PTSD cohort entrants, with smaller changes in discontinuation and decreased incidence among existing patients. Educational initiatives may have curtailed benzodiazepine prescribing through promotion of effective alternative treatment options and supporting discontinuation through various tapering strategies. These initiatives offer resources and lessons to other health care systems to deimplement inappropriate benzodiazepine prescribing and other potentially harmful practices through patient-centered approaches that promote viable treatment alternatives.

Gender differences in medication prescribing patterns for veterans with posttraumatic stress disorder: A 10-year follow-up study.

Women veterans with posttraumatic stress disorder (PTSD) have historically received more psychiatric medications than men. The current analysis identified prescribing trends of medications recommended for (i.e., select antidepressants) and against (i.e., benzodiazepines, select antidepressants, antipsychotics, and select anticonvulsants) use in PTSD treatment among women and men in 2010-2019. All veterans receiving care for PTSD in 2019 were identified using national U.S. Department of Veterans Affairs (VA) administrative data. Multivariable logistic regression analyses, adjusted for demographic characteristics and psychiatric comorbidities, were used to contrast the likelihood of receiving a medication class across genders. Sensitivity analyses using identical selection methods were conducted for the calendar years 2010, 2013, and 2016. In 2019, 877,785 veterans received treatment for PTSD within the VA, 13.5% of whom were women. Across medication classes and years, women were more likely to receive all psychiatric medications of interest. Relative to men, women were slightly more likely to receive antidepressants recommended for PTSD in 2019, adjusted odds ratio (aOR) = 1.07, 95% CI [1.06, 1.09]. However, gender differences for medications recommended against use for PTSD were notably larger, including benzodiazepines, aOR = 1.62, 95% CI [1.59, 1.65]; anticonvulsants. aOR = 1.41, 95% CI [1.38, 1.44]; and antidepressants recommended against use for PTSD, aOR = 1.26, 95% CI [1.19, 1.33]. To inform tailored intervention strategies, future work is needed to fully understand why women receive more medications recommended against use for PTSD.

Investigation of Therapist Effects on Patient Engagement in Evidence-Based Psychotherapies for Posttraumatic Stress Disorder in the Veterans Health Administration.

The present study examined whether certain Veterans Health Administration (VHA) therapists have more success than others in keeping patients engaged in evidence-based psychotherapies for posttraumatic stress disorder (PTSD). Our objective was to use multilevel modeling to quantify the variability between therapists in two indicators of patient engagement: early dropout (i.e., < 3 sessions) and adequate dose (i.e., ≥ 8 sessions). The phenomenon of systematic variability between therapists in patients' treatment experience and outcomes is referred to as "therapist effects." The sample included the 2,709 therapists who provided individual cognitive processing therapy (CPT) or prolonged exposure (PE) to 18,461 veterans with PTSD across 140 facilities in 2017. Data were extracted from administrative databases. For CPT, therapist effects accounted for 10.9% of the variance in early dropout and 8.9% of the variance in adequate dose. For PE, therapist effects accounted for 6.0% and 8.8% of the variance in early dropout and adequate dose, respectively. Facility only accounted for an additional 1.1%-3.1% of the variance in early dropout and adequate dose. For CPT, patients' odds of receiving an adequate dose almost doubled, OR = 1.41/0.72 = 1.96, if they were seen by a therapist in the highest compared with the lowest retention decile. For PE, the odds of a patient receiving an adequate dose were 84% higher, OR = 1.38/0.75 = 1.84, when treated by a therapist in the highest compared with the lowest retention decile. Therapist skills and work environment may contribute to variability across therapists in early dropout and adequate dose.

Rural differences in psychiatric medication prescribing in veterans with posttraumatic stress disorder.

PURPOSE: Disparities in the treatment of posttraumatic stress disorder (PTSD) for rural veterans have been noted in prior research. The objective was to examine rural differences in prescribing for veterans with PTSD, and changes over time, in the Department of Veterans Affairs (VA) health care system. METHODS: Prescribing prevalence in veterans with PTSD during 2009 and 2019 was determined using national VA administrative pharmacy data according to the joint VA-Department of Defense clinical practice guideline as medications recommended for use in PTSD and those recommended against use. Multivariable logistic regression was used to contrast patient residence (urban vs rural) and site of PTSD care (medical center, urban clinic, or rural clinic), while adjusting for clinical covariates. FINDINGS: Recommended medications were prescribed significantly less often to patients of rural clinics, relative to medical centers in 2009 (OR = 0.91; 95% CI: 0.89-0.94) but reached equivalence in 2019 (OR = 1.01; 95% CI: 0.99-1.03). In addition, rural clinics had significantly lower prescribing of recommended against medications (OR = 0.86; 95% CI: 0.84-0.87) in 2019. Prescribing of medications recommended against the use for PTSD was higher among rural residents, relative to urban residents in 2009 (OR = 1.14; 95% CI: 1.12-1.16), which declined toward equivalence by 2019 (OR = 1.06; 95% CI: 1.05-1.07). CONCLUSIONS: While some clinically meaningful differences in prescribing for rural veterans with PTSD were observed in 2009, these differences shifted toward equivalency within the following decade. In 2019, we failed to observe any systematic prescribing deficiencies for veterans receiving PTSD care at rural clinics.

Central nervous system polytherapy among veterans with posttraumatic stress disorder: changes across a decade.

OBJECTIVE: The study objectives were to investigate rates and patterns of polytherapy among veterans with PTSD across time (in 2009 and 2019), describe features of polytherapy prescribing, and identify demographic and clinical factors associated with polytherapy. METHODS: Veterans Affairs (VA) administrative data were used to build cohorts of all VA-served veterans with PTSD in 2009 (N = 458,620) and 2019 (N = 877,785). Frequency of CNS active drug classes, rates of polytherapy (≥5 concurrent CNS drugs), clinical features associated with polytherapy, number of prescribers, and patterns of co-prescribed medications were examined. RESULTS: The 12-month period prevalence of CNS polytherapy declined from 12.1% in 2009 to 6.9% in 2019. However, polytherapy rates increased from 3.3% in 2009 to 4.1% in 2019, when opioids and benzodiazepines were excluded. In multivariable regression analysis, CNS polytherapy was more common among women, White people, middle-age veterans (45-64 years), rural residents, veterans receiving care at a medical center, and those with psychiatric comorbidities. CNS polytherapy regimens involved a mean of 2.3 prescribers and the majority (86.6%) included at least one medication commonly prescribed for pain management. CONCLUSIONS: CNS polytherapy declined among veterans with PTSD from 2009 to 2019 and was wholly attributable to decreases in opioid and benzodiazepine prescribing.

Taking the message to the rural patient: evidence-based PTSD care.

The Department of Veterans Affairs and Department of Defense (VA/DoD) Clinical Practice Guideline for PTSD recommends against the use of benzodiazepines. Despite the recommendation, clinicians continue potentially inappropriate benzodiazepine prescribing practices for veterans with PTSD. We designed an educational product aimed at decreasing benzodiazepine use in PTSD care. Using VA data, the booklet was mailed to over 1300 New England veterans. Veterans were advised to discuss the booklet's information with their medical provider on their next appointment. The intervention resulted in a significant decrease in benzodiazepine use in veterans with PTSD, with 66% of the sample showing a dose reduction from pre- to post-booklet time points. Longitudinal analyses noted that rural veterans were significantly more likely to reduce benzodiazepine use than those in urban settings. Direct to consumer education appears to be an effective strategy to empower rural veterans to improve benzodiazepine prescribing safety and quality.

Evaluation of an Implementation Intervention to Increase Reach of Evidence-Based Psychotherapies for PTSD in US Veterans Health Administration PTSD Clinics.

To evaluate an implementation intervention to increase the uptake, referred to as reach, of two evidence-based psychotherapies (EBP) for posttraumatic stress disorder (PTSD) in Veterans Health Administration (VHA) PTSD specialty clinics. The implementation intervention was external facilitation guided by a toolkit that bundled strategies associated with high EBP reach in prior research. We used a prospective quasi-experimental design. The facilitator worked with local champions at two low-reach PTSD clinics. Each intervention PTSD clinic was matched to three control clinics. We compared the change in EBP reach from 6-months pre- to post-intervention using Difference-in-Difference (DID) effect estimation. To incorporate possible clustering effects and adjust for imbalanced covariates, we used mixed effects logistic regression to model the probability of EBP receipt. Analyses were conducted separately for PTSD and other mental health clinics. 29,446 veterans diagnosed with PTSD received psychotherapy in the two intervention and six control sites in the two 6-month evaluation periods. The proportion of therapy patients with PTSD receiving an EBP increased by 16.98 percentage points in the intervention PTSD clinics compared with .45 percentage points in the control PTSD clinics (DID = 16.53%; SE = 2.26%). The adjusted odd ratio of a patient receiving an EBP from pre to post intervention was almost three times larger in the intervention than in the control PTSD clinics (RoR 2.90; 95% CI 2.22-3.80). EBP reach was largely unchanged in other (not PTSD specialty) mental health clinics within the same medical centers. Toolkit-guided external facilitation is a promising intervention to improve uptake of EBPs in VHA. Toolkits that pre-specify targets for clinic change based on prior research may enhance the efficiency and effectiveness of external facilitation. Trial registration ISRCTN registry identifier: ISRCTN65119065. Available at https://www.isrctn.com/search?q=ISRCTN65119065 .

Which patients initiate cognitive processing therapy and prolonged exposure in department of veterans affairs PTSD clinics?

The United States Department of Veterans Affairs (VA) provides Cognitive Processing Therapy (CPT) and Prolonged Exposure therapy (PE) for PTSD at all of its facilities, but little is known about systematic differences between patients who do and do not initiate these treatments. VA administrative data were analyzed for 6,251 veterans receiving psychotherapy over one year in posttraumatic stress disorder (PTSD) specialty clinics at nine VA medical centers. CPT and PE were initiated by 2,173 (35%) patients. Veterans' probability of initiating either CPT or PE (considered together) was 29% lower (adjusted odds ratio = .61) if they had a psychiatric hospitalization within the same year, and 15% lower (AOR = .78) if they had service-connected disability for PTSD. Veterans' probability of starting CPT or PE was 19% lower (AOR = .74) if they were Hispanic or Latino, 10% lower (AOR = .84), if they were male rather than female, and 9% lower (AOR = .87) if they were divorced, separated or widowed rather than currently married. Probability of receiving CPT or PE was also lower if verans had more co-occurring psychiatric diagnoses (AOR per diagnosis = .88), were older (AOR per every five years = .95), or lived further away from the VA clinic (AOR per every ten miles = .98). Nonetheless, most patients initiating CPT or PE had two or more comorbidities and were service-connected for PTSD. Observed gender, age and ethnic differences in initiation of CPT and PE appear unrelated to clinical suitability and warrant further study.

The Influence of Team Functioning and Workload on Sustainability of Trauma-Focused Evidence-Based Psychotherapies.

OBJECTIVE: It has been over a decade since the U.S. Department of Veterans Affairs (VA) began formal dissemination and implementation of two trauma-focused evidence-based psychotherapies (TF-EBPs). The objective of this study was to examine the sustainability of the TF-EBPs and determine whether team functioning and workload were associated with TF-EBP sustainability. METHODS: This observational study used VA administrative data for 6,251 patients with posttraumatic stress disorder (PTSD) and surveys from 78 providers from 10 purposefully selected PTSD clinical teams located in nine VA medical centers. The outcome was sustainability of TF-EBPs, which was based on British National Health System Sustainability Index scores (possible scores range from 0 to 100.90). Primary predictors included team functioning, workload, and TB-EBP reach to patients with PTSD. Multiple linear regression models were used to examine the influence of team functioning and workload on TF-EBP sustainability after adjustment for covariates that were significantly associated with sustainability. RESULTS: Sustainability Index scores ranged from 53.15 to 100.90 across the 10 teams. Regression models showed that after adjustment for patient and facility characteristics, team functioning was positively associated (B=9.16, p<.001) and workload was negatively associated (B=-.28, p<.05) with TF-EBP sustainability. CONCLUSIONS: There was considerable variation across teams in TF-EBP sustainability. The contribution of team functioning and workload to the sustainability of evidence-based mental health care warrants further study.

Pharmacological management of posttraumatic stress disorder.

Posttraumatic stress disorder (PTSD) has been conceptualized as an inability to cope with overwhelming stress that is followed by a distinctive pattern of symptoms. This concept has made it possible to develop therapeutic approaches for PTSD that include medication and psychotherapy options. In this article we summarize research studies on pharmacotherapies for PTSD and review new findings in the neurobiology of PTSD that are promoting the development of targeted treatment options. Research findings that have improved our understanding of psychobiological abnormalities associated with PTSD offer clinicians improved treatment strategies. We review those findings, the developments in the medication management of PTSD and common co-occurring disorders, and new areas of pharmacological research on PTSD treatment.

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.

Context Matters: Team and Organizational Factors Associated with Reach of Evidence-Based Psychotherapies for PTSD in the Veterans Health Administration.

Evidence-based psychotherapies for PTSD are often underused. The objective of this mixed-method study was to identify organizational and clinic factors that promote high levels of reach of evidence-based psychotherapies for PTSD 10 years into their dissemination throughout the Veterans Health Administration. We conducted 96 individual interviews with staff from ten outpatient PTSD teams at nine sites that differed in reach of evidence-based psychotherapies for PTSD. Major themes associated with reach included clinic mission, clinic leader and staff engagement, clinic operations, staff perceptions, and the practice environment. Strategies to improve reach of evidence-based psychotherapies should attend to organizational and team-level factors.

Trends in Opioid Use Disorder Diagnoses and Medication Treatment Among Veterans With Posttraumatic Stress Disorder.

OBJECTIVE: Despite long-standing interest in posttraumatic stress disorder (PTSD) and opioid use disorder comorbidity, there is a paucity of data on the prevalence of opioid use disorder in patients with PTSD. Therefore, there is limited understanding of the use of medications for opioid use disorder in this population. We determined the prevalence of diagnosed opioid use disorder and use of medications for opioid use disorder in a large cohort of patients with PTSD. METHODS: We obtained administrative and pharmacy data for veterans who initiated PTSD treatment in the Department of Veterans Affairs (VA) between 2004 and 2013 (N = 731,520). We identified those with a comorbid opioid use disorder diagnosis (2.7%; n = 19,998) and determined whether they received a medication for opioid use disorder in the year following their initial clinical PTSD diagnosis (29.6%; n = 5,913). Using logistic regression, we determined the predictors of receipt of opioid use disorder medications. RESULTS: Comorbid opioid use disorder diagnoses increased from 2.5% in 2004 to 3.4% in 2013. Patients with comorbid opioid use disorder used more health services and had more comorbidities than other patients with PTSD. Among patients with PTSD and comorbid opioid use disorder, use of medications for opioid use disorder increased from 22.6% to 35.1% during the same time period. Growth in the use of buprenorphine (2.0% to 22.7%) was accompanied by relative decline in use of methadone (19.3% to 12.7%). Patients who received buprenorphine were younger and more likely to be rural, White, and married. Patients who received methadone were older, urban, unmarried, from racial and ethnic minorities, and more likely to see substance abuse specialists. While use of naltrexone increased (2.8% to 8.6%), most (87%) patients who received naltrexone also had an alcohol use disorder. Controlling for patient factors, there was a substantial increase in the use of buprenorphine, a substantial decrease in the use of methadone, and no change in use of naltrexone across years. CONCLUSIONS: Opioid use disorder is an uncommon but increasing comorbidity among patients with PTSD. Patients entering VA treatment for PTSD have their opioid use disorder treated with opioid agonist treatments in large and increasing numbers. There is a need for research both on the epidemiology of opioid use disorder among patients with PTSD and on screening for opioid use disorder.

Cultivating change door to door: Educational outreach to improve prescribing practices in rural veterans with posttraumatic stress disorder.

BACKGROUND: Clinical guidelines for the management of posttraumatic stress disorder (PTSD) recommend against the use of benzodiazepines. Benzodiazepines and PTSD are both associated with addiction-related risks. The Department of Veterans Affairs (VA) prescribing trends show continued use of benzodiazepines and polysedative use in veterans with PTSD, particularly in rural areas. The authors examine the use of an educational intervention to improve pharmacologic management of veterans with PTSD in rural clinics. METHODS: The VA Academic Detailing Service Informatics Toolset provides prescribing, demographic and risk factor data for veterans with PTSD treated at the White River Junction VA Medical Center (WRJ VA) and affiliated rural clinics in Vermont and New Hampshire. Individualized academic detailing visits were provided to clinicians identified by the informatics tool with the aim of increasing guideline-concordant care. Other educational efforts included traditional, didactic group education on evidence-based PTSD care and the development and dissemination of educational materials for clinicians and patients. Prescribing trends of benzodiazepines, off-label atypical antipsychotics, and prazosin were collected quarterly for 3 years (October 1, 2013, to September 30, 2016). RESULTS: Prescribing rates of benzodiazepines during the educational intervention decreased from 13% to 9.3%. Use of off-label atypical antipsychotics, a class of medications not recommended for PTSD, stayed relatively flat at about 10%. Prescribing of prazosin, a medication recommended for treatment of trauma nightmares, increased from 9.8% to 14.3%. CONCLUSIONS: Academic detailing and other educational programming appear to be effective for addressing gaps and lag in quality PTSD care and are associated with a positive trend of decreased benzodiazepine use. Efforts will continue, now with added focus on concurrent use of benzodiazepines and opioids and the use of off-label atypical antipsychotics in rural veterans with PTSD.

Considering future pharmacotherapy for PTSD.

Posttraumatic stress disorder (PTSD) is a prevalent, disabling, and often chronic condition that may develop following exposure to a traumatic event. Despite the immense social and economic ramifications of PTSD, there has been relatively little recent development of new pharmacotherapies. The majority of pharmacological randomized clinical trials (RCTs) that has been conducted are now dated. Existing treatments for PTSD primarily have come out of research that tested medications developed for other disorders such as antidepressants, anti-hypertensives, antipsychotics, anticonvulsants, and anxiolytics. With an improved understanding of the complex pathophysiology of PTSD, we consider why it has taken so long to identify important targets to advance the field by addressing the underlying pathophysiology in pharmacological interventions. Exciting developments include research into PTSD-related abnormalities associated with dysregulation of adrenergic, hypothalamic-pituitary-adrenocortical, monoaminergic, peptide, glutamatergic, GABAergic, cannabinoid, opioid, and other neurotransmitter and neuroendocrine systems. Yet, this is a broad list and there are many unanswered questions. Current research on biomarkers associated with different clinical phenotypes of PTSD should lead to novel and more specific pharmacotherapeutic strategies. In this brief review, we consider key questions regarding current knowledge on pharmacological treatments for PTSD and highlight evolving practices in future research.

Desired Involvement in Treatment Decisions Among Adults with PTSD Symptoms.

UNLABELLED: Most medical patients want to be involved in decisions about their care. Whether this is true for people with posttraumatic stress disorder (PTSD)-a disorder characterized by avoidance of trauma-related discussions-is unknown. We conducted an online survey assessing preferences for involvement in PTSD treatment decisions (level of control, timing) and information about PTSD treatment (content, format). Adults who screened positive for possible PTSD (N = 301) were recruited from a large online survey panel representative of the U. S. POPULATION: Virtually all respondents (97.3%) desired involvement in treatment decisions; two thirds (67.8%) wanted primary responsibility for decisions. Most (64.2%) wanted 30-60 minutes to learn about treatments and 80.1% wanted at least 1-3 days to consider their options. Respondents expressed more interest in informational content on treatment effectiveness and side effects than any other topic. In-person discussion with a provider was preferred more than other learning formats (e.g., websites, brochures). Results suggested that people with symptoms of PTSD want involvement in decisions about their treatment and want to discuss treatment options with their provider. Providers may wish to prioritize information about effectiveness and side effects, and should expect that many patients will need several days after their visit to make a decision.

Geographical diffusion of prazosin across Veterans Health Administration: Examination of regional variation in daily dosing and quality indicators among veterans with posttraumatic stress disorder.

Posttraumatic stress disorder (PTSD) is a high-priority treatment area for the Veterans Health Administration (VHA), and dissemination patterns of innovative, efficacious therapies can inform areas for potential improvement of diffusion efforts and quality prescribing. In this study, we replicated a prior examination of the period prevalence of prazosin use as a function of distance from Puget Sound, Washington, where prazosin was first tested as an effective treatment for PTSD and where prazosin use was previously shown to be much greater than in other parts of the United States. We tested the following three hypotheses related to prazosin geographic diffusion: (1) a positive geographical correlation exists between the distance from Puget Sound and the proportion of users treated according to a guideline recommended minimum therapeutic target dose (>/=6 mg/d), (2) an inverse geographic correlation exists between prazosin and benzodiazepine use, and (3) no geographical correlation exists between prazosin use and serotonin reuptake inhibitor/serotonin norepinephrine reuptake inhibitor (SSRI/SNRI) use. Among a national sample of veterans with PTSD, overall prazosin utilization increased from 5.5 to 14.8% from 2006 to 2012. During this time period, rates at the Puget Sound VHA location declined from 34.4 to 29.9%, whereas utilization rates at locations a minimum of 2,500 miles away increased from 3.0 to 12.8%. Rates of minimum target dosing fell from 42.6 to 34.6% at the Puget Sound location. In contrast, at distances of at least 2,500 miles from Puget Sound, minimum threshold dosing rates remained stable (range, 18.6 to 17.7%). No discernible association was demonstrated between SSRI/SNRI or benzodiazepine utilization and the geographic distance from Puget Sound. Minimal threshold dosing of prazosin correlated positively with increased diffusion of prazosin use, but there was still a distance diffusion gradient. Although prazosin adoption has improved, geographic differences persist in both prescribing rates and minimum target dosing. Importantly, these regional disparities appear to be limited to prazosin prescribing and are not meaningfully correlated with SSRI/SNRI and benzodiazepine use as indicators of PTSD prescribing quality.

Early discontinuation and suboptimal dosing of prazosin: a potential missed opportunity for veterans with posttraumatic stress disorder.

OBJECTIVE: Clinical Practice Guidelines issued by the US Department of Veterans Affairs (VA) and the Department of Defense recommend prazosin for sleep/nightmares for veterans with posttraumatic stress disorder (PTSD). As existing literature suggests this novel treatment option to be underutilized, we examined a cohort of veterans with PTSD initiating prazosin to characterize their typical duration of use and dosing patterns. METHOD: Administrative data from fiscal year 2010 were used to identify veterans with PTSD according to ICD-9 codes extracted from inpatient and outpatient encounters. The longitudinal course of prazosin use following initiation was examined using refill data, and estimated prazosin doses were calculated based upon total milligrams and the day's supply dispensed. RESULTS: A total of 12,844 veterans with PTSD initiated prazosin during 2010. Twenty percent of veterans never refilled the initial prescription, and 37.6% persisted on the drug for at least 1 year. Patients more likely to remain on prazosin for at least 1 year were older (ages 40-59 years [OR = 1.28; 95% CI, 1.15-1.45] and ages ≥ 60 years [OR = 1.25; 95% CI, 1.12-1.40]) relative to younger patients and taking more medications (4-6 [OR = 1.40; 95% CI, 1.27-1.55], 7-9 [OR = 1.73; 95% CI, 1.56-1.94], and ≥ 10 [OR = 2.04; 95% CI, 1.83-2.29]) relative to 0-3 medications. The mean maximum prazosin dose reached in the first year of treatment was 3.6 mg/d, and only 14.1% of patients reached the minimum guideline recommended dose of 6 mg/d. CONCLUSIONS: Of patients with PTSD newly initiated on prazosin in 2010, < 40% were still taking the drug 1 year later, and < 20% received the minimum recommended dose according to current VA guidelines. Further investigation is required to determine the precise clinical factors underlying these prescribing patterns and overcome barriers to guideline-concordant treatment.