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.

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 .

Community Clinicians and the Veterans Choice Program for PTSD Care: Understanding Provider Interest During Early Implementation.

BACKGROUND: In 2014, the Department of Veterans Affairs (VA) implemented the Veterans Choice Program (VCP) to provide reimbursement for community-based care to eligible veterans. Inadequate networks of participating providers may impact the utility of VCP for veterans with posttraumatic stress disorder (PTSD), a complex condition occurring at lower frequency among civilians. OBJECTIVES: To compare characteristics and attitudes of community-based primary care and mental health providers reporting interest or no interest in VCP participation during early implementation; and to examine perceptions and experiences of VCP among "early adopters." RESEARCH DESIGN: Cross-sectional surveys with 2 samples: a stratified random sample of mental health and primary care prescribers and psychotherapists drawn from state licensing boards (Community Sample); and a stratified random sample of prescribers and psychotherapists identified as VCP-authorized providers (VCP-Authorized). SUBJECTS: Five hundred fifty-three respondents in the Community Sample and 115 in the VCP-Authorized (total, n=668; 21.1% response). MEASURES: Surveys assessed provider and practice characteristics, attitudes to VA and VCP, and experiences and satisfaction with the VCP; an open-ended survey item assessed providers' reasons for interest or lack of interest in VCP participation. RESULTS: Few providers reported VCP participation during this period. Interest in VCP participation was associated across provider groups with factors including being a veteran and receiving VA reimbursement; currently providing treatment for PTSD was associated with interest in VCP participation among psychotherapists, but not prescribers. CONCLUSIONS: Developing networks of VCP providers to serve Veterans with PTSD is likely to require targeting more receptive provider groups, reducing barriers to participation, and more effectively communicating the value of VCP participation to providers.

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.

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.

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.

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.

Psychopharmacological strategies in the management of posttraumatic stress disorder (PTSD): what have we learned?

There have been significant advancements in the pharmacologic management of posttraumatic stress disorder (PTSD) in the past two decades. Multisite randomized clinical trials (RCTs) have noted the efficacy of selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNR Is) for PTSD treatment. Unfortunately, there have been no new medications approved to treat PTSD in the past 10 years. Although there have been exciting new findings in our knowledge of the neurobiology of PTSD, clinical trials testing new medications have lagged. This review summarizes recent research that builds on the unique pathophysiology of PTSD and suggests ways to move the field forward.

Increased polysedative use in veterans with posttraumatic stress disorder.

BACKGROUND: Posttraumatic stress disorder (PTSD) treatment is often complicated in veterans by co-occurring conditions including pain, insomnia, brain injury, and other mental disorders. Pharmacologic approaches to these conditions can produce an accumulation of sedating medications with potential for safety concerns. OBJECTIVE: The objective of this study was to characterize polysedative prescribing among veterans with PTSD over an 8-year period. DESIGN: National Department of Veterans Affairs (VA) data were used to identify veterans with PTSD using International Classification of Diseases, Ninth Revision codes among regular medication users. Prescribing of benzodiazepines, hypnotics, atypical antipsychotics, opioids, and muscle relaxants was determined annually. Prevalence and incidence rates were determined for each medication class from 2004 through 2011. Polysedative use was determined from longitudinal refill patterns that indicated concurrent use across sedative classes. RESULTS: In 2004, 9.8% of veterans with PTSD concurrently received medications from three or more sedative classes. By 2011, the prevalence of concurrent use involving three or more classes increased to 12.1%. Polysedative use varied across demographic subgroups, with higher rates observed among women, rural residents, younger adults, Native Americans and Whites. The most common combination was an opioid plus a benzodiazepine, taken concurrently by 15.9% of veterans with PTSD. CONCLUSIONS: Important trends in polysedative use among veterans with PTSD illustrate the complexity of treating an intersecting cluster of symptoms managed by sedative medications. As the VA seeks to improve care by focusing on non-pharmacologic options, our findings emphasize the need for a comprehensive approach that encompasses overlapping conditions of relevance to veterans with PTSD.

What's Gender Got to Do With It: Accounting for Differences in Incident Guideline Discordant Prescribing for PTSD Among Women and Men Veterans.

Objectives: Women veterans are more likely than men veterans to receive medications that Department of Veterans Affairs clinical practice guidelines recommend against to treat posttraumatic stress disorder (PTSD). To understand this difference, we examined potential confounders in incident prescribing of guideline discordant medications (GDMs) in veterans with PTSD.Methods: Veterans receiving care for PTSD during 2020 were identified using Veterans Health Administration administrative data. PTSD diagnosis was established by the presence of at least 1 ICD-10 coded outpatient encounter or inpatient hospitalization during the calendar year 2020. Incident GDM prescribing was assessed during 2021, including benzodiazepines, antipsychotics, select anticonvulsants, and select antidepressants. Log-binomial regression was used to estimate the difference in risk for GDM initiation between men and women, adjusted for patient, prescriber, and facility-level covariates, and to identify key confounding variables.Results: Of 704,699 veterans with PTSD, 16.9% of women and 10.1% of men initiated a GDM, an increased risk of 67% for women [relative risk (RR) = 1.67; 95% CI, 1.65-1.70]. After adjustment, the gender difference decreased to 1.22 (95% CI, 1.20-1.24) in a fully specified model. Three key confounding variables were identified: bipolar disorder (RR = 1.60; 95% CI, 1.57-1.63), age (<40 years: RR = 1.20 [1.18-1.22]; 40-54 years: RR = 1.13 [1.11-1.16]; ≥65 years: RR = 0.64 [0.62-0.65]), and count of distinct psychiatric medications prescribed in the prior year (RR = 1.14; 1.13-1.14).Conclusions: Women veterans with PTSD were 67% more likely to initiate a GDM, where more than half of this effect was explained by bipolar disorder, age, and prior psychiatric medication. After adjustment, women veterans remained at 22% greater risk for an incident GDM, suggesting that other factors remain unidentified and warrant further investigation.

Gender differences in prescribing among veterans diagnosed with posttraumatic stress disorder.

OBJECTIVE: The Department of Veterans Affairs (VA) and Department of Defense (DoD) issued a revised posttraumatic stress disorder (PTSD) Clinical Practice Guideline (CPG) in 2010 with specific pharmacotherapy recommendations for evidence-based quality care. The authors examined prescribing frequencies over an 11-year period prior to the release of the new guideline to determine gender differences in pharmacotherapy treatment in veterans with PTSD. METHOD: National administrative VA data from 1999 to 2009 were used to identify veterans with PTSD using ICD-9 codes extracted from inpatient discharges and outpatient clinic visits. Prescribing of antidepressants, antipsychotics and hypnotics was determined for each year using prescription drug files. RESULTS: Women were more likely than men to receive medication across all classes except prazosin where men had higher prescribing frequency. The proportion of women receiving either of the first-line pharmacotherapy treatments for PTSD, selective serotonin reuptake inhibitors (SSRI) and serotonin-norepinephrine reuptake inhibitors (SNRI), increased from 56.4 % in 1999 to 65.7 % in 2009, higher rates than seen in men (49.2 % to 58.3 %). Atypical antipsychotic prescriptions increased from 14.6 % to 26.3 % and nonbenzodiazepine hypnotics increased from 3.8 % to 16.9 % for women, higher frequencies than seen in men for both medications (OR = 1.31, 1.43 respectively). The most notable gender discrepancy was observed for benzodiazepines where prescriptions decreased for men (36.7 % in 1999 to 29.8 % in 2009) but steadily increased for women from 33.4 % to 38.3 %. CONCLUSION: A consistent pattern of increased prescribing of psychotropic medications among women with PTSD was seen compared to men. Prescribing frequency for benzodiazepines showed a marked gender difference with a steady increase for women despite guideline recommendations against use and a decrease for men. Common co-occurring disorders and sleep symptom management are important factors of PTSD pharmacotherapy and may contribute to gender differences seen in prescribing benzodiazepines in women but do not fully explain the apparent disparity.

A formative evaluation of two evidence-based psychotherapies for PTSD in VA residential treatment programs.

Between July 2008 and March 2011, 38 U.S. Department of Veterans Affairs (VA) residential treatment programs for posttraumatic stress disorder (PTSD) participated in a formative evaluation of their programmatic services, including evidenced-based treatments (EBTs). Face-to-face qualitative interviews were conducted with over 250 staff by an independent psychologist along with onsite participant observations. This evaluation coincided with a national VA dissemination initiative to train providers in two EBTs for PTSD: prolonged exposure (PE) and cognitive processing therapy (CPT). A substantial proportion of eligible (based on professional background) residential treatment providers received training in PE (37.4%) or CPT (64.2%), with 9.5% completing case consultation or becoming national trainers in each therapy respectively. In semistructured interviews, providers reported that their clinical programs had adopted these EBTs at varying levels ranging from no adoption to every patient receiving the full protocol. Suggestions for improving the adoption of PE and CPT are noted, including distilling manualized treatments to essential common elements.

Comparison of mental health outcomes of augmenting medications for patients with posttraumatic stress disorder: A national veterans affairs study.

RATIONALE: Posttraumatic stress disorder (PTSD) is highly prevalent among veterans. Many veterans with PTSD respond well to serotonin reuptake inhibitors (SRIs). Nonresponders may be prescribed augmenting medications, which are not as well-studied in PTSD. AIMS AND OBJECTIVES: We used Veterans Health Administration electronic records to compare mental health outcomes (PTSD symptoms and rates of mental health hospitalizations and psychiatric emergency room visits) in patients with PTSD who were prescribed four different groups of augmenting medications (atypical antipsychotics, mirtazapine, prazosin or tricyclic antidepressants) in addition to SRIs-from the year before to the year after the start of the augmenting medication. METHOD: We included data from 169,982 patients with a diagnosis of PTSD (excluding patients with comorbid bipolar or psychotic disorders) seen in Veterans Affairs care from 2007 to 2015 who were taking an SRI and filled a new prescription for one of the four augmenting medications for at least 60 days. RESULTS: Patients evidenced minimal (<2%) reduction in PTSD symptoms and a larger reduction in psychiatric hospitalizations and psychiatric emergency room visits after receiving augmenting medications; this effect was largely similar across the four medication groups. Initiating augmenting medications was preceded by increases in PTSD symptoms, psychiatric hospitalizations and psychiatric emergency room visits. After initiating an augmenting medication, PTSD symptoms/hospitalizations/emergency room visits returned to baseline levels (before the start of the augmenting medication), but generally did not improve beyond baseline. CONCLUSION: Importantly, these effects could be explained by regression to the mean, additional interventions or confounding. These findings should be further explored with placebo controlled randomized clinical trials.

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.

Treatment of posttraumatic stress disorder with prolonged exposure for primary care (PE-PC): Effectiveness and patient and therapist factors related to symptom change and retention.

Prolonged exposure (PE) is a first-line treatment for posttraumatic stress disorder (PTSD) available in specialty mental health. PE for primary care (PE-PC) is a brief version of PE adapted for primary care mental health integration, composed of four-eight, 30-min sessions. Using retrospective data of PE-PC training cases from 155 Veterans Health Administration (VHA) providers in 99 VHA clinics who participated in a 4- to 6-month PE-PC training and consultation program, we examined patients' PTSD and depression severity across sessions via mixed effects multilevel linear modeling. Additionally, hierarchical logistic regression analysis was conducted to assess predictors of treatment dropout. Among 737 veterans, medium-to-large reductions in PTSD (intent-to-treat, Cohen's d = 0.63; completers, Cohen's d = 0.79) and small-to-medium reductions in depression (intent-to-treat, Cohen's d = 0.40; completers, Cohen's d = 0.51) were observed. The modal number of PE-PC sessions was five (SD = 1.98). Providers previously trained in both PE and cognitive processing therapy (CPT) were more likely than providers who were not trained in either PE or CPT to have veterans complete PE-PC (OR = 1.54). Veterans with military sexual trauma were less likely to complete PE-PC than veterans with combat trauma (OR = 0.42). Asian American and Pacific Islander veterans were more likely than White veterans to complete treatment (OR = 2.93). Older veterans were more likely than younger veterans to complete treatment (OR = 1.11). (PsycInfo Database Record (c) 2023 APA, all rights reserved).

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.

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.