2017 VA/DoD Clinical Practice Guideline for the · PDF file“Medically Ready ForceReady Medical Force” 3 . Resources Available for Download . Today’s presentation and resources

Psychological Health Webinar

2017 VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder

and Acute Stress Disorder - A Revised Framework to Assess and Treat Patients

1-2:30 p.m. Dec. 14, 2017

Presenters

Paula Schnurr, Ph.D.

Executive Director of the National Center for Posttraumatic Stress Disorder White River Junction, Vermont

Professor of Psychiatry Geisel School of Medicine at Dartmouth

Hanover, New Hampshire

David Riggs, Ph.D. Professor/Chair, Department of Medical and Clinical Psychology

Executive Director, Center for Deployment Psychology Uniformed Services University of the Health Sciences

Bethesda, Maryland

Corinne K.B. Devlin MSN, RN, FNP-BC Chief, Evidence Based Practice U.S. Army Medical Command

Clinical Performance Assurance Directorate (CPAD) Office of Evidence Based Practice

Fort Sam Houston, Texas

“Medically Ready Force…Ready Medical Force” 2

Moderator

Holly O’Reilly, Ph.D. Senior Clinical Psychologist, Evidence-Based Practice

Psychological Health Center of Excellence (PHCoE) Silver Spring, Maryland


Resources Available for Download

Today’s presentation and resources are available for download in the “Files” box on the screen, or visit http://www.pdhealth.mil/education-and-training/dcoe-webinars


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Webinar Details

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Submit questions via the Q&A box


Continuing Education Details

All who wish to obtain continuing education (CE) credit or certificate of attendance, and who meet eligibility requirements, must register by 3 p.m.(ET) Dec. 14, 2017 to qualify for the receipt of credit.

DCoE’s awarding of CE credit is limited in scope to health care providers who actively provide psychological health and traumatic brain injury care to active-duty U.S. service members, reservists, National Guardsmen, military veterans and/or their families.

The authority for training of contractors is at the discretion of the chief contracting official. – Currently, only those contractors with scope of work or with

commensurate contract language are permitted in this training.


Continuing Education Accreditation (continued)

This continuing education activity is provided through collaboration between DCoE and Professional Education Services Group (PESG).

Credit Designations include: – 1.5 AMA PRA Category 1 credits – 1.5 ACCME Non Physician CME credits – 1.5 ANCC Nursing contact hours – 1.5 CRCC – 1.5 APA Division 22 contact hours – 0.15 ASHA Intermediate level, Professional area – 1.5 CCM hours – 1.5 AANP contact hours – 1.5 AAPA Category 1 CME credit – 1.5 NASW contact hours



Physicians This activity has been planned and implemented in accordance with the essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME). Professional Education Services Group is accredited by the ACCME as a provider of continuing medical education for physicians. This activity has been approved for a maximum of 1.5 hours of AMA PRA Category 1 Credits. Physicians should only claim credit to the extent of their participation. Nurses Nurse CE is provided for this program through collaboration with the Professional Education Services Group (PESG). Professional Education Services Group is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. This activity has been approved for a maximum of 1.5 contact hours of nurse CE credit. Nurses should only claim credit to the extent of their participation. Occupational Therapists (ACCME Non Physician CME Credit) For the purpose of recertification, The National Board for Certification in Occupational Therapy (NBCOT) accepts certificates of participation for educational activities certified for AMA PRA Category 1 Credit from organizations accredited by ACCME. Occupational Therapists may receive a maximum of 1.5 hours for completing this live program. Physical Therapists Physical Therapists will be provided a certificate of participation for educational activities certified for AMA PRA Category 1 Credit. Physical Therapists may receive a maximum of 1.5 hours for completing this live program.

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Psychologists This Conference is approved for up to 1.5 hours of continuing education. APA Division 22 (Rehabilitation Psychology) is approved by the American Psychological Association to sponsor continuing education for psychologists. APA Division 22 maintains responsibility for this program and its content. Physical Therapists Physical Therapists will be provided a certificate of participation for educational activities certified for AMA PRA Category 1 Credit. Physical Therapists may receive a maximum of 1.5 hours for completing this live program. Psychologists This Conference is approved for up to 1.5 hours of continuing education. APA Division 22 (Rehabilitation Psychology) is approved by the American Psychological Association to sponsor continuing education for psychologists. APA Division 22 maintains responsibility for this program and its content. Rehabilitation Counselors The Commission on Rehabilitation Counselor Certification (CRCC) has pre-approved this activity for 1.5 clock hours of continuing education credit. Speech-Language Professionals This activity is approved for up to 0.15 ASHA CEUs (Intermediate level, Professional area).

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Case Managers This program has been pre-approved by The Commission for Case Manager Certification to provide continuing education credit to CCM board certified case managers. The course is approved for up to 1.5 clock hours. PESG will also make available a General Participation Certificate to all other attendees completing the program evaluation. Nurse Practitioners Professional Education Services Group is accredited by the American Academy of Nurse Practitioners as an approved provider of nurse practitioner continuing education. Provider number: 031105. This course if offered for 1.5 contact hours (which includes 0 hours of pharmacology). Physician Assistants This Program has been reviewed and is approved for a maximum of 1.5 hours of AAPA Category 1 CME credit by the Physician Assistant Review Panel. Physician Assistants should claim only those hours actually spent participating in the CME activity. This Program has been planned in accordance with AAPA’s CME Standards for Live Programs and for Commercial Support of Live Programs. Social Workers This Program is approved by The National Association of Social Workers for 1.5 Social Work continuing education contact hours. Other Professionals Other professionals participating in this activity may obtain a General Participation Certificate indicating participation and the number of hours of continuing education credit.

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Webinar Overview

Since the 2010 release of the U.S. Department of Veterans Affairs (VA) and Department of Defense (DoD) clinical practice guideline for the management of posttraumatic stress disorder (PTSD), a growing body of research has expanded the general knowledge and understanding of PTSD and other stress related disorders. Improved recognition of the complexities of acute stress reaction (ASR), acute stress disorder (ASD), and PTSD has led to the adoption of new and/or refined strategies to manage and treat patients with these conditions. The revised VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder was released in June 2017 to provide health care providers with a framework to evaluate, treat, and manage the needs and preferences of patients with PTSD and ASD. The new guideline incorporates current diagnostics as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (2013) and evidence-informed recommendations from the VA/DoD Management of PTSD Work Group. This presentation will briefly review the purpose of a CPG and discuss the its key recommendations. In addition, the presentation will focus on the importance of patient-centered treatment planning and shared decision-making; the provision of trauma-informed psychotherapy, and over-arching pharmacology treatment recommendations. The presentation will conclude by identifying new clinical support tools available for providers, patients, and family members to help attendees implement these evidence-informed recommendations in their practice.


Webinar Overview (continued)

At the conclusion of this session, the participant will be able to: 1. Explain who participates in the development of a VA/DoD clinical practice guideline.

2. Determine key recommendations from the VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder. 3. Identify first-line PTSD treatment recommendations. 4. Examine clinical support tools that align with the clinical practice guideline that are available for providers, patients, and family members.


Corinne K.B. Devlin, MSN, RN, FNP-BC

“Medically Ready Force…Ready Medical Force”

Mrs. Devlin is the Chief, Evidenced-Based Practice, U.S. Army Medical Command, a board certified Family Nurse Practitioner, and active DoD primary care provider. She retired from the Army Nurse Corps as a lieutenant colonel after 24 years of distinguished service. She was the recipient of a ROTC scholarship and was commissioned with the rank of second lieutenant in 1988. She received her Bachelor’s and Masters of Science in nursing degrees from Georgia Southern University.

Mrs. Devlin deployed with the 2nd Mobile Army Surgical Hospital (MASH) in support of Operation Desert Shield/Desert Storm and deployed to Tikrit, Iraq (COB Speicher) as the Chief, Clinical Services with the 21st Combat Support Hospital (CSH) in support of Operation Iraqi Freedom, January to July 2010.

Mrs. Devlin is a member of the American Association of Nurse Practitioners and the National Honor Society of Nursing, Sigma Theta Tau International, Mu Kappa Chapter. Her awards include the Legion of Merit and Order of Military Medical Merit.

14

David Riggs, Ph.D.


Dr. David Riggs, clinical and research psychologist, is a Professor and Chair of the Department of Medical and Clinical Psychology (MCP) in the Herbert School of Medicine at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. He leads the doctoral program to train active-duty psychologist for the military services as well as civilian clinical psychologists who train as scientist-practitioners to deliver outstanding patient care and contribute to clinically-relevant science in psychology.

Dr. Riggs also serves as the Executive Director of the Center for Deployment Psychology (CDP) where he oversees the development and delivery of training seminars for behavioral health professionals to prepare them to provide for the needs of warriors and their families.

Much of Dr. Riggs’ work has focused on trauma, violence and anxiety with particular interest in the impact of PTSD and other anxiety disorders on the families of those directly affected. He has trained and supervised numerous students and mental health professionals in techniques for treating PTSD, obsessive compulsive disorder (OCD) and other anxiety disorders. This included training professionals in ways to address emotional and psychological needs of survivors of combat, international terror, natural disasters, and sexual and physical assault.

Dr. Riggs earned his doctorate degree at the State University of New York at Stony Brook and completed a clinical psychology internship at the Medical University of South Carolina. To date, Dr. Riggs has published more than 80 articles and book chapters and presented more than 250 papers and workshops on topics including PTSD, domestic violence, and behavioral therapy.

15

Paula Schnurr, Ph.D.


Dr. Schnurr is the Executive Director of the National Center for Posttraumatic Stress Disorder and previously served as Deputy Executive Director of the center since 1989. She is a Research Professor of Psychiatry at the Geisel School of Medicine at Dartmouth and Editor of the Clinician's Trauma Update-Online. She has investigated risk and resilience factors associated with the long-term physical and mental health outcomes of exposure to traumatic events. She is an expert on psychotherapy research and has conducted a number of clinical trials of PTSD treatment, including a multi-site trial of Prolonged Exposure for female veterans and active-duty personnel with PTSD and of group psychotherapy for PTSD in Vietnam veterans. Her most current studies on treatment include a comparative effectiveness trial of Prolonged Exposure and Cognitive Processing Therapy and another trial of Acceptance and Commitment Therapy.

Dr. Schnurr received her doctorate in Experimental Psychology at Dartmouth College in 1984 and then completed a post-doctoral fellowship in the Department of Psychiatry at the Geisel School of Medicine at Dartmouth. Dr. Schnurr is Past-President of the International Society for Traumatic Stress Studies and is a fellow of the American Psychological Association and of the Association for Psychological Science. She previously served as Editor of the Journal of Traumatic Stress.

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DHA Presentation 12/14/17

David S. Riggs, PhD (DoD) Paula P. Schnurr, PhD (VA)

Corinne K.B. Devlin, MSN, RN, FNP-BC (DoD)

Disclosures & Acknowledgements

Corinne Devlin, Paula Schnurr, and David Riggs have no relevant financial relationships to disclose relating to the content of this activity.

The views expressed in this presentation are those of the author and do not necessarily reflect the official policy or position of the Department of Defense, nor the U.S. Government.

This continuing education activity is managed and accredited by Professional Education Services Group (PESG) in collaboration with the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE). PESG, DCoE as well as all accrediting organizations, do not support or endorse any product or service mentioned in this activity.

PESG, DCoE staff, activity planners and reviewers have no relevant financial or non financial interest to disclose. Commercial support was not received for this activity.


Disclosures & Acknowledgements

Support for the work described in this presentation has been provided by DVBIC, USUHS, the U.S. Army Medical Research and Materiel Command Award #W81XWH-13-1-0095, and the Center for Neuroscience and Regenerative Medicine.

Selected technology described in this presentation is included in U.S. Patent Application No. 61/779,801, U.S. Patent Application No. 14/773,987, European Patent Application No. 14780396.9, and International Patent Application No. PCT/US2014/022468 (rights assigned to USUHS).


Polling Question

My primary discipline is: Counselor Case Manager Nurse Pharmacist Physical Therapist Physician (non-psychiatrist) Physician Assistant/ Nurse Practitioner Psychiatrist Psychologist Social Worker Other clinical staff Other non-clinical staff


V A / D o D C l in ic a l P r a c t i c e G u id e l in e f o r t h e M a n a g e m e n t o f Co n c u s s io n - m i ld T r a u m a t ic B r a in I n j u r y VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

Agenda

• Scope of the Problem

• Update of a Complex Clinical Practice Guideline

• Guideline Working Group and Project Team

• Goals of the Guideline

• Scope of the Guideline

• Evidence-based Clinical Practice Guideline Development Process

• Grading Recommendations

• Updating and Categorizing Recommendations

• Evidence-based Clinical Practice Recommendations

• Algorithm

• Discussion

21


Scope of the Problem

• U.S. General population The Wave 3 National Epidemiologic Survey on Alcohol and Related Conditions study found a

lifetime PTSD prevalence of 6.1% and current prevalence of 4.7%. (Goldstein, et al., 2016)

Military Personnel

A meta-analysis of studies of Operations Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) Veterans reported current PTSD prevalence as 5.5% overall and 13.2% among operational infantry units (Kok, et al., 2012).

During FY2015, 2.2% of the active-duty population was estimated to meet criteria for PTSD based on administrative medical data of the DoD direct care system (Armed Forces Health Surveillance Branch, 2017).

• Veterans In a recent survey of a nationally representative sample of U.S. Veterans, lifetime PTSD

prevalence was 8% and current PTSD prevalence was 5%. (Wisco, et al., 2014). According to VA administrative data, 10.6% of VA health care users in FY2016 had PTSD

(Greenberg & Hoff, 2016); among OEF/OIF users in 2015, 26.7% had PTSD (Harpaz-Rotem & Hoff, 2015).

22


Update of a Complex Clinical Practice Guideline

• VA/DoD 2010 CPG was outdated Included nearly 213 “recommendations,” many based on expert opinion only

• Guideline was updated with evidence published from January 2009 – March 2016

• Guideline was updated to evaluate new evidence and establish evidence-based recommendations in the following key areas: Psychotherapy, pharmacotherapy, and biological treatments for PTSD Efficacy of combined or augmented treatment approaches Complementary and integrative treatments Group and peer treatment approaches Treatments for acute stress disorder (ASD) Technology-based care modalities

23


Guideline Work Group

Department of Veterans Affairs Department of Defense

Nancy C. Bernardy, PhD (Champion) Charles W. Hoge, MD (Champion)

Matthew J. Friedman, MD, PhD (Champion) David S. Riggs, PhD (Champion)

Paula P. Schnurr, PhD (Champion) Megan J. Ehret, PharmD, MS, BCPP

Kathleen M. Chard, PhD Maj Joel T. Foster, PhD

Lori Davis, MD COL Shawn F. Kane, MD, FAAFP, FACSM

Bradford Felker, MD Kate McGraw, PhD

Jessica L. Hamblen, PhD CDR Jeffrey Millegan, MD, MPH, FAPA

Matthew Jeffreys, MD Elaine P. Stuffel, BSN, MHA, RN

Sonya Norman, PhD COL Lisa A. Teegarden, PsyD

Mary Jo Pugh, RN, PhD, FACMPH CDR Meena Vythilingam, MD

Sheila A.M. Rauch, PhD, ABPP COL Wendi M. Waits, MD

Todd P. Semla, MS, PharmD, BCPS, FCCP, AGSF Jonathan Wolf, MD

24


Project Team

Office of Quality, Safety and Value, Department of Veterans Affairs

Office of Evidence Based Practice, MEDCOM

Eric Rodgers, PhD, FNP-BC James Sall, PhD, FNP-BC

Rene Sutton, BS, HCA

Corinne K. B. Devlin, MSN, RN, FNP-BC Elaine P. Stuffel, BSN, MHA, RN

The Lewin Group ECRI Institute

Clifford Goodman, PhD Christine Jones, MS, MPH, PMP

Erin Gardner, BS Anjali Jain, MD

James Reston, MPH, PhD Amy Tsou, MD, MSc

Rebecca Rishar, MLIS Jeff Oristaglio, PhD

Savvas Pavlides, PhD

Sigma Health Consulting, LLC Duty First Consulting

Frances Murphy, MD, MPH Anita Ramanathan, BA Megan McGovern, BA

25


Goals of the Guideline

• Enhance assessment of the patient’s condition and determine the best treatment method in collaboration with the patient and, when possible and desired, the patient’s family and caregivers

• Optimize the patient’s health outcomes and improve quality of life

• Minimize preventable complications and morbidity

• Emphasize the use of patient-centered care

26


Scope of the Guideline

• Population Patients (men and women) aged 18 years or older with PTSD and

related conditions (e.g., ASD) Excludes children or adolescents

• Interventions Pharmacotherapy Trauma-focused and non-trauma-focused psychotherapies Non-pharmacologic biological treatments Complementary and integrative treatments Group psychotherapy Collaborative or integrative care Technology-based modalities Peer support

27


VA/DoD Guideline Development Process

• Strict approach to conflicts of interest • Multidisciplinary development teams • Identification of key questions • Evidence review for key questions • Groups review evidence, apply grading • Development of recommendations and treatment

algorithms • Review from trained external & internal subject

matter experts • Final CPG reviewed and approved by VA/DoD EBP

Working Group

28


Guideline Development Process

Topic selection

by EBPWG

Development of key

questions

Evidence review

In-person workshop

Draft products

Second in-person workshop

Final products

24 subject matter experts from

VA/DoD

• Iterative process • Includes peer review

• Evidence-based CPG • Algorithm • Toolkit

29


VA/DoD Clinical Practice Guidelines

• Routinely updated every 3-5 years • Immediate Update • Any recommendation identified as harmful • Pharmaceutical Recall/Black Box • Device Recall

30


Grading Recommendations - GRADE

• Evidence-based clinical practice recommendations were developed based on the evidence review

• GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology assigning recommendations:

• Relative strength (Strong or Weak)

• Direction (For or Against)

• Decision domains (4) used to determine strength and direction

31


Strength of a Recommendation

• Strength of a recommendation on a continuum:

Strong For (or “We recommend offering this option …”)

Weak For (or “We suggest offering this option …”)

Weak Against (or “We suggest not offering this option …”)

Strong Against (or “We recommend against offering this option …”)

• Note: Weak (For or Against) recommendations may also be termed “conditional,” “discretionary,” or “qualified”

Recommendations may be conditional based on patient values and preferences, the resources available, or the setting in which the intervention will be implemented

Recommendations may be at the discretion of the patient and clinician

Recommendations may be qualified with an explanation about the issues that would lead decisions to vary

(Andrew, et al., 2013)

32


Grading Recommendations - GRADE

Decision Domains (4)

Balance of desirable and undesirable outcomes

Confidence in the quality of the evidence

Values and preferences

Other implications, as appropriate, e.g.:

• Subgroup considerations

• Acceptability

• Feasibility

• Equity

• Resource use

33


Structure of the Clinical Practice Guideline

• Importance and consideration of patient preferences, safety, and education is reflected throughout the CPG, in the background, recommendations, and appendices

• Patient-centered care and shared decision making are described in the background section and referenced throughout the document to emphasize their use

• Recommendations were made taking into consideration all four GRADE domains

34


Clinical Practice Recommendations

Recommendations are organized into the following groups: • General Clinical Management • Diagnosis and Assessment of PTSD • Prevention of PTSD • Treatment of PTSD • Treatment of PTSD with Co-occurring Conditions

35



Recommendation Strength Category

General Clinical Management

1. We recommend engaging patients in shared decision making (SDM), which includes educating patients about effective treatment options.

Strong for Not Reviewed, Amended

2. For patients with posttraumatic stress disorder (PTSD) who are treated in primary care, we suggest collaborative care interventions that facilitate active engagement in evidence-based treatments.

Weak for Reviewed, New-replaced

36




Diagnosis and Assessment of PTSD

3. We suggest periodic screening for PTSD using validated measures such as the Primary Care PTSD Screen (PC-PTSD) or the PTSD Checklist (PCL).

Weak for Not Reviewed, Amended

4. For patients with suspected PTSD, we recommend an appropriate diagnostic evaluation that includes determination of DSM criteria, acute risk of harm to self or others, functional status, medical history, past treatment history, and relevant family history. A structured diagnostic interview may be considered.

Strong for Not Reviewed, Amended

5. For patients with a diagnosis of PTSD, we suggest using a quantitative self-report measure of PTSD severity, such as the PTSD Checklist for DSM-5 (PCL-5), in the initial treatment planning and to monitor treatment progress.

Weak for Not Reviewed, Amended

37




Prevention of PTSD

Selective Prevention of PTSD

6. For the selective prevention of PTSD, there is insufficient evidence to recommend the use of trauma-focused psychotherapy or pharmacotherapy in the immediate post-trauma period.

N/A Reviewed, New-replaced

Indicated Prevention of PTSD and Treatment of ASD

7. For the indicated prevention of PTSD in patients with acute stress disorder (ASD), we recommend an individual trauma-focused psychotherapy that includes a primary component of exposure and/or cognitive restructuring.

Strong for Reviewed, New-replaced

8. For the indicated prevention of PTSD in patients with ASD, there is insufficient evidence to recommend the use of pharmacotherapy.


38




Treatment of PTSD

Treatment Selection

9. We recommend individual, manualized trauma-focused psychotherapy (see Recommendation 11) over other pharmacologic and non-pharmacologic interventions for the primary treatment of PTSD.

Strong for Reviewed, New-added

10. When individual trauma-focused psychotherapy is not readily available or not preferred, we recommend pharmacotherapy (see Recommendation 17) or individual non-trauma-focused psychotherapy (see Recommendation 12). With respect to pharmacotherapy and non-trauma-focused psychotherapy, there is insufficient evidence to recommend one over the other.

Strong for Reviewed, New-added

39




Treatment of PTSD (cont.)

Psychotherapy

11. For patients with PTSD, we recommend individual, manualized trauma-focused psychotherapies that have a primary component of exposure and/or cognitive restructuring to include Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), Eye Movement Desensitization and Reprocessing (EMDR), specific cognitive behavioral therapies for PTSD, Brief Eclectic Psychotherapy (BEP), Narrative Exposure Therapy (NET), and written narrative exposure.


12. We suggest the following individual, manualized non-trauma-focused therapies for patients diagnosed with PTSD: Stress Inoculation Training (SIT), Present-Centered Therapy (PCT), and Interpersonal Psychotherapy (IPT).


40


Clinical Practice Recommendations Recommendation Strength Category


Psychotherapy (cont.)

13. There is insufficient evidence to recommend for or against psychotherapies that are not specified in other recommendations, such as Dialectical Behavior Therapy (DBT), Skills Training in Affect and Interpersonal Regulation (STAIR), Acceptance and Commitment Therapy (ACT), Seeking Safety, and supportive counseling.


14. There is insufficient evidence to recommend using individual components of manualized psychotherapy protocols over or in addition to the full therapy protocol.

N/A Reviewed, New-added

15. We suggest manualized group therapy over no treatment. There is insufficient evidence to recommend using one type of group therapy over any other.


16. There is insufficient evidence to recommend for or against trauma-focused or non-trauma-focused couples therapy for the primary treatment of PTSD.

N/A Reviewed, Amended

41





Pharmacotherapy

17. We recommend sertraline, paroxetine, fluoxetine, or venlafaxine as monotherapy for PTSD for patients diagnosed with PTSD who choose not to engage in or are unable to access trauma-focused psychotherapy.


18. We suggest nefazodone, imipramine, or phenelzine as monotherapy for the treatment of PTSD if recommended pharmacotherapy (see Recommendation 17), trauma-focused psychotherapy (see Recommendation 11), or non-trauma-focused psychotherapy (see Recommendation 12) are ineffective, unavailable, or not in accordance with patient preference and tolerance. (NOTE: Nefazodone and phenelzine have potentially serious toxicities and should be managed carefully.)


42



43



Pharmacotherapy (cont.)

19. We suggest against treatment of PTSD with quetiapine,olanzapine, and other atypical antipsychotics excludingrisperidone (see Recommendation 20), citalopram,amitriptyline, lamotrigine, or topiramate as monotherapydue to the lack of strong evidence for their efficacy and/orknown adverse effect profiles and associated risks.

Weak against

Reviewed, New-replaced

20. We recommend against treating PTSD with divalproex,tiagabine, guanfacine, risperidone, benzodiazepines,ketamine, hydrocortisone, or D-cycloserine, as monotherapydue to the lack of strong evidence for their efficacy and/orknown adverse effect profiles and associated risks.

Strong

against

Reviewed,

New-

replaced

21. We recommend against treating PTSD with cannabis orcannabis derivatives due to the lack of evidence for theirefficacy, known adverse effects, and associated risks.

Strong

against

Reviewed,

New-

added

V A / D o D C l in ic a l P r a c t i c e G u id e l in e f o r t h e M a n a g e m e n t o f Co n c u s s io n - m i ld T r a u m a t ic B r a in I n j u r y


44 VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder



Pharmacotherapy (cont.)

22. There is insufficient evidence to recommend for or againstmonotherapy or augmentation therapy for the treatment ofPTSD with eszopiclone, escitalopram, bupropion,desipramine, doxepin, D-serine, duloxetine, desvenlafaxine,fluvoxamine, levomilnacipran, mirtazapine, nortriptyline,trazodone, vilazodone, vortioxetine, buspirone, hydroxyzine,cyproheptadine, zaleplon, and zolpidem.


Augmentation Therapy

23. We suggest against the use of topiramate, baclofen, orpregabalin as augmentation treatment of PTSD due toinsufficient data and/or known adverse effect profiles andassociated risks.

Weak

against

Reviewed,

New-

replaced

24. We suggest against combining exposure therapy with D-cycloserine in the treatment of PTSD outside of the researchsetting.

Weak

against

Reviewed,

New-

added



45



Augmentation Therapy (cont.)

25. We recommend against using atypical antipsychotics,benzodiazepines, and divalproex as augmentation therapyfor the treatment of PTSD due to low quality evidence orthe absence of studies and their association with knownadverse effects.

Strong

against

Reviewed,

New-

replaced

26. There is insufficient evidence to recommend thecombination of exposure therapy with hydrocortisoneoutside of the research setting.

N/A

Reviewed,

New-

added

27. There is insufficient evidence to recommend for or againstthe use of mirtazapine in combination with sertraline forthe treatment of PTSD.

N/A Reviewed,

New-

replaced






Prazosin

28a. For global symptoms of PTSD, we suggest against the use of prazosin as mono- or augmentation therapy for the treatment of PTSD.

Weak

against

Reviewed,

New-

replaced

28b. For nightmares associated with PTSD, there is insufficient evidence to recommend for or against the use of prazosin as mono- or augmentation therapy.

N/A

Reviewed,

New-

replaced

Combination Therapy

29. In partial- or non-responders to psychotherapy, there isinsufficient evidence to recommend for or againstaugmentation with pharmacotherapy.

N/A

Reviewed,

New-

replaced

30. In partial- or non-responders to pharmacotherapy, there isinsufficient evidence to recommend for or againstaugmentation with psychotherapy.

N/A

Reviewed,

New-

replaced






Combination Therapy (cont.)

31. There is insufficient evidence to recommend for or againststarting patients with PTSD on combinationpharmacotherapy and psychotherapy.

N/A

Reviewed,

New-

added

Non-pharmacologic Biological Treatments

32. There is insufficient evidence to recommend for or againstthe following somatic therapies: repetitive transcranialmagnetic stimulation (rTMS), electroconvulsive therapy(ECT), hyperbaric oxygen therapy (HBOT), stellate ganglionblock (SGB), or vagal nerve stimulation (VNS).

N/A

Reviewed,

New-

replaced






Complementary and Integrative Treatments

33. There is insufficient evidence to recommend acupuncture asa primary treatment for PTSD. N/A

Reviewed,

New-

replaced

34. There is insufficient evidence to recommend anycomplementary and integrative health (CIH) practice, suchas meditation (including mindfulness), yoga, and mantrammeditation, as a primary treatment for PTSD.

N/A

Reviewed,

New-

replaced

Technology-based Treatment Modalities

35. We suggest internet-based cognitive behavioral therapy(iCBT) with feedback provided by a qualified facilitator as analternative to no treatment.

Weak for

Reviewed,

New-

replaced

36. We recommend using trauma-focused psychotherapies thathave demonstrated efficacy using secure videoteleconferencing (VTC) modality when PTSD treatment isdelivered via VTC.

Strong for Reviewed,

Amended





Treatment of PTSD with Co-occurring Conditions

37. We recommend that the presence of co-occurringdisorder(s) not prevent patients from receiving otherVA/DoD guideline-recommended treatments for PTSD.

Strong for

Reviewed,

New-

added

38. We recommend VA/DoD guideline-recommendedtreatments for PTSD in the presence of co-occurringsubstance use disorder (SUD).

Strong for

Reviewed,

New-

replaced

39. We recommend an independent assessment of co-occurringsleep disturbances in patients with PTSD, particularly whensleep problems pre-date PTSD onset or remain followingsuccessful completion of a course of treatment.

Strong for

Reviewed,

New-

replaced

40. We recommend Cognitive Behavioral Therapy for Insomnia(CBT-I) for insomnia in patients with PTSD unless anunderlying medical or environmental etiology is identifiedor severe sleep deprivation warrants the immediate use ofmedication to prevent harm.

Strong for Reviewed,

Amended


Module A: Acute Stress Reaction/Disorder

50


Module A: Acute Stress Reaction/Disorder (Boxes 1-6)

Note: Boxes 7-14 and Sidebar 3 are depicted on the next slide • Box 6 connects to Box 7

51


Module A: Acute Stress Reaction/Disorder (Boxes 7-14) Note: Boxes 1-6 and Sidebars 1 and 2 are depicted on the previous slide; Sidebar 4 is depicted on the next slide • Boxes 4 and 5 connect to Box 6

52


Module A: Acute Stress Reaction/Disorder (Sidebar 4)

53


Module B: Assessment and Diagnosis of PTSD

54


Module B: Assessment and Diagnosis of PTSD (Boxes 1-5)

Note: Boxes 6-10 are depicted on the next slide • Box 5 (No) connects to Box 8 • Box 5 (Yes) connects to Box 6

55


Module B: Assessment and Diagnosis of PTSD (Boxes 6-10) Note: Boxes 1-5 and Sidebar 5 are depicted on the previous slide; Sidebar 6 is depicted on the next slide • Box 3 (No) and

Box 4 connect to Box 5

56


Module B: Assessment and Diagnosis of PTSD (Sidebar 6)

57


Module C: Management of PTSD

58


Module C: Management of PTSD (Boxes 1-4)

Note: Boxes 5-9 are depicted on the next slide • Box 4 (Yes) connects to Box 5 • Box 4 (No) connects to Box 7 • Box 8 (Yes) and Box 9 connect to Box 2

59


Module C: Management of PTSD (Boxes 5-9) Note: Boxes 1-4 and Sidebars 7 and 8 are depicted on the previous slide • Box 3 connects

to Box 4 • Box 8 (Yes) and

Box 9 connect to Box 2

60


Provider Tools to Support the PTSD Guideline

www.healthquality.va.gov www.qmo.amedd.army.mil

61

https://www.healthquality.va.gov/

http://www.qmo.amedd.army.mil/


Patient Tools to Support the PTSD Guideline

www.healthquality.va.gov

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https://www.healthquality.va.gov/


Key Take-Aways

• For patients with suspected PTSD, we recommend an appropriate diagnostic evaluation that includes determination of DSM criteria, acute risk of harm to self or others, functional status, medical history, past treatment history, and relevant family history.

• For the indicated prevention of PTSD in patients with acute stress disorder (ASD), we recommend an individual trauma-focused psychotherapy that includes a primary component of exposure and/or cognitive restructuring.

• For patients with PTSD, we recommend individual, manualized

trauma-focused psychotherapies that have a primary component of exposure and/or cognitive restructuring.

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Key Take-Aways

• We recommend individual, manualized trauma-focused psychotherapy over other pharmacologic and non-pharmacologic interventions for the primary treatment of PTSD.

• When individual trauma-focused psychotherapy is not readily available or not preferred, we recommend pharmacotherapy or individual non-trauma-focused psychotherapy. With respect to pharmacotherapy and non-trauma-focused psychotherapy, there is insufficient evidence to recommend one over the other.

• With regard to pharmacotherapies, we recommend sertraline, paroxetine, fluoxetine, or venlafaxine as monotherapy for PTSD for patients diagnosed with PTSD who choose not to engage in or are unable to access trauma-focused psychotherapy.

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References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). (5th ed.).

Arlington, VA: American Psychiatric Association.

Armed Forces Health Surveillance Branch. (2017). Mental health conditions among active component U.S. Armed

forces. Defense Medical Surveillance System (DMSS). Public Health Division, Defense Health Agency.

Andrew, J.C., Holger, J.S., Oxman, A.D., Pottie, K., Meerpohl, J.J., Coello, P.A., . . . Guyatt, G. (2013). GRADE

guidelines: 15. Going from evidence to recommendation—determinants of a recommendation's direction

and strength. Journal of Clinical Epidemiology, 66(7), 726-735. doi:

http://dx.doi.org/10.1016/j.jclinepi.2013.02.003

Friedman, M.J., Kilpatrick, D.G., Schnurr, P.P., & Weathers, F.W. (2016). Correcting misconceptions about the

diagnostic criteria for posttraumatic stress disorder in DSM-5. JAMA Psychiatry, 73(7), 753-754.

doi:10.1001/jamapsychiatry.2016.0745

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http://dx.doi.org/10.1016/j.jclinepi.2013.02.003


References (cont.)

Goldstein, R.B., Smith, S.M., Chou, S.P., Saha, T.D., Jung, J., Zhang, H., . . . Grant, B.F. (2016). The epidemiology

of DSM-5 posttraumatic stress disorder in the United States: Results from the National Epidemiologic

Survey on Alcohol and Related Conditions-III. Social Psychiatry and Psychiatric Epidemiology, 51(8), 1137-

1148. doi: 10.1007/s00127-016-1208-5

Greenberg, G. & Hoff, R. (2016). Veterans with PTSD data sheet: National, VISN, and VAMC tables. Northeast

Program Evaluation Center. West Haven, CT: Northeast Program Evaluation Center.

Harpaz-Rotem, I., & Hoff, R. (2015). FY2015 overview of PTSD patient population data sheet. VA Office of

Mental Health Operations. West Haven, CT: Northeast Program Evaluation Center.

Kok, B.C., Herrell, R.K., Thomas, J.L., & Hoge, C.W. (2012). Posttraumatic stress disorder associated with combat

service in Iraq or Afghanistan: Reconciling prevalence differences between studies. Journal of Nervous

and Mental Disorder, 200(5), 444-450. doi: 10.1097/NMD.0b013e3182532312

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References (cont.)

U.S. Department of Veteran Affairs, Department of Defense. (2013). Guideline for guidelines. Veterans Health

Administration, Office of Quality & Performance, Evidence Review Subgroup. Retrieved from

https://www.healthquality.va.gov/documents/cpgGuidelinesForGuidelinesFinalRevisions051214.docx

U.S. Department of Veteran Affairs, Department of Defense. (2017). VA/DoD clinical practice guideline for the

management of posttraumatic stress disorder and acute stress disorder, version 3.0. Posttraumatic Stress

Disorder and Acute Stress Disorder Working Group. Retrieved from

https://www.healthquality.va.gov/guidelines/MH/ptsd/VADoDPTSDCPGClinicianSummaryFinal.pdf

Wisco, B.E., Marx, B.P., Wolf, E.J., Miller, M.W., Southwick, S.M., & Pietrzak, R.H. (2014). Posttraumatic stress

disorder in the US Veteran population: Results from the national health and resilience in Veterans study.

Journal of Clinical Psychiatry, 75(12), 1338-1346. doi: 10.4088/JCP.14m09328

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https://www.healthquality.va.gov/documents/cpgGuidelinesForGuidelinesFinalRevisions051212.docx

https://www.healthquality.va.gov/guidelines/MH/ptsd/VADoDPTSDCPGClinicianSummaryFinal.pdf

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