PTSD Evidence Based Practice Recommendations

Transcription

1 PTSD Evidence ased Practice Recommendations Jason's ox est Practice Group Dr. Sam Moreno, Michelle Schnack Compilation & consolidation of the research and recommendations located in: The VA/DoD Clinical Practice Guideline for the Management of Post-Traumatic Stress (2010) For the full version: For the summary: The VA s National Center for PTSD, Clinician s Guide to Medications for PTSD The International Society for Traumatic Stress Studies Treatment Guidelines for PTSD (2005) For links to the treatment guidelines: 1

2 I. First, an explanation of the ratings used in recommendations SR A C D I Evidence Rating System A strong recommendation that clinicians provide the intervention to eligible patients. evidence was found that the intervention improves important health outcomes and concludes that benefits substantially outweigh harm. A recommendation that clinicians provide (the service) to eligible patients. At least fair evidence was found that the intervention improves health outcomes & concludes that benefits outweigh harm No recommendation for or against the routine provision of the intervention is made. At least fair evidence was found that the intervention can improve health outcomes but concludes that the balance of benefits and harms is too close to justify a general recommendation. Recommendation is made against routinely providing the intervention to asymptomatic patients. At least fair evidence was found that the intervention is ineffective or that the harms outweigh benefits. The conclusion is that the evidence is insufficient to recommend for or against routinely providing the intervention. Evidence that the intervention is effective is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined. SR = Strength of recommendation I I Fair Poor At least one properly done RCT Level of Evidence (LE) Well-designed controlled trial without randomization Well-designed cohort or case-control analytic study, preferably from more than one source Multiple time series evidence with/without intervention, dramatic results of uncontrolled experiment Opinion of respected authorities, descriptive studies, case reports, and expert committees Overall Quality [QE] High grade evidence (I or -1) directly linked to health outcome High grade evidence (I or -1) linked to intermediate outcome; or Moderate grade evidence (-2 or -3) directly linked to health outcome Level I evidence or no linkage of evidence to health outcome Final Grade of Recommendation [SR] The Net enefit of the Intervention Quality of Evidence Substantial Moderate Small Zero or Negative A C D Fair C D Poor I I I I 2

3 . Screening Recommendations All new patients should be screened for symptoms of PTSD initially & then annually, or more frequently, if clinically indicated. [] There is insufficient evidence to recommend one PTSD screening tool versus another. The following screening tools have been validated and should be considered for use: - Primary Care PTSD Screen (PC-PTSD) - PTSD rief Screen - Short Screening Scale for DSM IV PTSD - PTSD Checklist (PCL) Evidence Sources LE QE SR 1 Screening all patients for PTSD symptoms. reslau et al., 1999a -2 Fair Leskin & Westrup, 1999 Prins et al., 1999 Taubman et al., Screening tools: Primary Care PTSD Screen PTSD rief Screen Short Screening Scale for DSM IV PTSD Checklist (PCL) reslau et al., 1999a Leskin & Westrup, 1999 Prins et al., 1999 Terhakopian, et al Fair All patients with PTSD should be assessed for safety & dangerousness including current risk to self or others, and historical patterns of risk: - SI or HI, intent, means, history, behaviors, co-morbidities (substance use, medical conditions) - Family and social environment including risks to the family - Ongoing health risks or risk-taking behavior - Medical/psychiatric co-morbidities or unstable medical conditions Recommendation Sources LE QE SR 1 Assess for dangerousness including suicidal or homicidal ideation, intent, means, history, behaviors, and comorbidities 2 Assess family, social environment including risks for family 3 Assess ongoing health risks or risktaking behaviors 4 Assess medical or psychiatric comorbidities or unstable medical condition reslau, 2000 ullman & Kang, 1994 Ferrada-Noli et al., 1998 Kaslow et al., 2000 Marshall et al., 2001 Prigerson & Slimack, 1999 Swanson et al., 2002 Zivin, 2007 Seng, 2002 Swanson, 2002 Acierno et al., 1996 Hutton et al., 2001 Vieweg et al., 2006 Davidson et al., 1991 Farrell et al., 1995; Weisberg et al., 2002 Hoge et al., 2007; Gill et al., 2009 LE = Level of Evidence; QE = Quality of Evidence; SR= Recommendation I -2 I -2-2 I -2-2 I I 3

4 I. Treatment Recommendations A. EARLY INTERVENTIONS TO PREVENT PTSD SR Early Interventions after Exposure to Trauma (<4 days after exposure) Significant enefit Some enefit I -- Psychological First Aid Psychoeducation & normalization Social support alance of enefit and Harm Unknown enefit Spiritual support -- No enefit / Potential Harm D Psychological debriefing SR A C D I Early Interventions after Exposure to Trauma (4-30 days after exposure) Significant enefit rief CT (4-5 sessions) alance of enefit and Harm Some enefit Unknown enefit No enefit Social support Psychoeducation & normalization Imipramine Propranolol, Prazosin Other Antidepressants Anticonvulsants Atypical Antipsychotics as Adjunct (except risperidone)* Spiritual support Psychological First Aid 4 Individual psychological debriefingw Formal psychotherapy for asymptomatic survivors W enzodiazepines, Typical Antipsychotics, risperidone* W Atypical antipsychotics as Monotherapy* Group psychological debriefing *VA/DoD Clinical Practice Guideline has been revised as follows: 1) atypical antipsychotics are not recommended as mono therapy for PTSD, 2) risperidone is contraindicated for use as an adjunctive agent (potential for harm), and 3) there is insufficient evidence to recommend any other atypical antipsychotic as an adjunctive agent for PTSD (

5 . TREATMENT INTERVENTIONS FOR PTSD Providers should explain to all patients with PTSD all available & effective options for PTSD. Patient education is recommended for all patients with PTSD & their family members. [C] Patient and provider preferences should drive the selection of evidence-based psychotherapy and/or evidence-based pharmacotherapy as the first line treatment. Psychotherapies should be provided by practitioners trained in the method of treatment. All clinicians should be trained in trauma-informed care. A collaborative care approach to therapy administration, with care management, may be considered, although supportive evidence is lacking specifically for PTSD. Psychotherapy Interventions for Treatment of PTSD alance enefit and Harm SR Significant enefit Some enefit Unknown enefit A C Trauma-focused psychotherapy that includes component of exposure and/or cognitive restructuring (i.e., CT, EMDR, Exposure Therapy, etc.) ; or, Stress Inoculation training Patient Education Imagery Rehearsal Therapy Psychodynamic Therapy Hypnosis Relaxation Techniques Group Therapy I Family Therapy Web-based CT Acceptance and Commitment Therapy Dialectical ehavior Therapy 5

6 Adjunctive Problem-Focused Method/Services for PTSD If patient: Is not fully informed about aspects of health needs & does not avoid high-risk behaviors Does not have sufficient self-care & independent living skills Does not have safe, decent, affordable, stable housing that is consistent with treatment goals Does not have a family that is actively supportive and/or knowledgeable about treatment for PTSD Is not socially active Does not have a job that provides adequate income and/or fully uses his or her training & skills Is unable to locate & coordinate access to services Does not request spiritual support OTHER CONDITIONS Has a borderline personality disorder with parasuicidal behaviors Has concurrent substance abuse problem Service/Training Provide patient education Refer to self-care/independent living skills training services Use and/or refer to supported housing services Implement family skills training Implement social skills training Implement vocational rehabilitation training Use case management services Provide access to religious/spiritual advisors and/or other resources Consider DT Integrated PTSD substance abuse treatment (i.e., Seeking Safety) Symptom Response by Drug Class and Individual Drug (based on controlled trials) Global Improvement Reexperiencing Avoidance/ Numbing Hyperarousal SSRI Fluoxetine X X X X Sertraline X X X X Paroxetine X X X X SNRI Venlafaxine X X X X TCAs Amitriptyline/ X X X Imipramine MAOIs Phenelzine X X X Sympatholytics Prazosin X X X Other Antidepressants Mirtazapine X X X Nefazodone X X X *VA/DoD Clinical Practice Guideline has been revised as follows: 1) atypical antipsychotics are not recommended as mono therapy for PTSD, 2) risperidone is contraindicated for use as an adjunctive agent (potential for harm), and 3) there is insufficient evidence to recommend any other atypical antipsychotic as an adjunctive agent for PTSD ( 6

7 Pharmacotherapy for PTSD alance of enefit and Harm SR Significant Some enefit Unknown No enefit A C D I SSRIs SNRIs Mirtazapine Prazosin (for sleep/nightmares) TCAs Nefazodone [Caution] MAOIs (phenelzine) X Prazosin (for global PTSD) Atypical antipsychotic, as adjunct (besides risperidone which is contraindicated)* Typical antipsychotics uspirone Non-benzodiazepine hypnotics upropion Trazodone (adjunctive) Gabapentin Lamotrigine Propranolol Clonidine 7 enzodiazepines[harm] Tiagabine Guanfacine Valproate Topiramate Risperidone, as adjunct [Harm] * Atypical antipsychotics, as monotherapy * SR = Strength of recommendation (see Introduction); X= Attention to drug to-drug and dietary interactions *VA/DoD Clinical Practice Guideline has been revised as follows: 1) atypical antipsychotics are not recommended as mono therapy for PTSD, 2) risperidone is contraindicated for use as an adjunctive agent (potential for harm), and 3) there is insufficient evidence to recommend any other atypical antipsychotic as an adjunctive agent for PTSD (

8 Monotherapy: Strongly recommend that patients with PTSD be offered SSRIs, for which fluoxetine, paroxetine, or sertraline have strongest support, or SNRIs, for which venlafaxine has strongest support. [A] Recommend mirtazapine, nefazodone, TCAs, amitriptyline & imipramine, or MAOIs (phenelzine). [] Recommend against guanfacine, anticonvulsants (tiagabine, topiramate, valproate) as monotherapy [D] Existing evidence does not support the use of bupropion, buspirone, and trazodone, anticonvulsants (lamotrigine or gabapentin) or atypical antipsychotics as monotherapy in the management of PTSD. [I] There is evidence against the use of benzodiazepines, atypical antipsychotics as monotherapy,*** and risperidone as adjunct*** in management of PTSD. [D] Insufficient evidence to support the use of prazosin as monotherapy in the management of PTSD. [I] Augmented Therapy for PTSD: Recommend adjunctive treatment with prazosin for sleep/nightmares. [] Insufficient evidence to recommend a sympatholytic, anticonvulsant, or atypical antipsychotic (besides risperidone, which is contraindicated)*** as an adjunct. [I] Step Patient Condition 1 Initial Treatment 2 Non response to initial dose 3 Failed second trial of antidepressant 4 Failed three trials including augmentation Treatment Response and Follow-Up Psychotherapy AND/OR SSRI/SNRI Assess adherence Increase dose Consider longer duration Switch to another SSRI or SNRI Add psychotherapy Consider referral to specialty care 8 Options Switch to another SSRI/SNRI or mirtazapine Add psychotherapy Augment with prazosin (sleep/nightmare) Re- evaluate diagnosis and treatment Switch to TCA If no response consider nefazodone (monitoring side effects), or phenalzine (with careful consideration of risks) Consider referral to specialty care Reassess at:* 2 weeks **/ 4 weeks 4-6 weeks 8-12 weeks > 12 weeks * Times are general guidelines and may vary considerably / **If treatment is not tolerable, switch to another antidepressant. ***VA/DoD Clinical Practice Guideline has been revised as follows: 1) atypical antipsychotics are not recommended as mono therapy for PTSD, 2) risperidone is contraindicated for use as an adjunctive agent (potential for harm), and 3) there is insufficient evidence to recommend any other atypical antipsychotic as an adjunctive agent for PTSD (