PTSD: A Primary Care Management Approach

LTC J. Brian Lanier, MD, FAAFP

“The views expressed in this presentation are those of the author and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.” I have no financial or personal conflicts of interest.

Learning Objectives

• Be able to recognize the patient presenting to a primary care setting with potential PTSD

• Initiate management of the patient presenting to primary care with PTSD

• Coordinate care of patients with PTSD in a PCMH setting

Brief History

• PTSD symptoms long described in the history of war – Classic Literature – DaCosta’s Syndrome (Soldier’s Heart) – Shell Shock

• PTSD first recognized as a diagnosis in 1980 (DSM-III)

– Response to external stressor rather than an inherent individual weakness

– Catastrophic stressor

• Initial treatments regiments were developed in studies of survivors of natural disasters or sexual assault

• More than a decade of military conflict involving US Soldiers has enhanced our understanding and treatment leading to significant diagnostic changes

• Epidemiology – 5.0% and 10.4% in American men and women (National

Comorbidity Survey) – 4%-31% in US military personnel returning from deployment

Onset and Course

• Onset and Course – More than ½ of Americans are exposed to a traumatic event – Onset varies considerably

• Military studies have shown an increase in symptom development 3-6 months post-deployment

– Lifetime prevalence around 10% in the US, one-year incidence around 5% – Role of combat

• 1.5% prevalence in Servicemembers without combat • 14% in those with combat

– Spontaneous recovery usually occurs • Early identification and treatment improves prognosis • Up to 1/3 may develop chronic symptoms if not treated

– Oftentimes not primary reason for visit or symptoms attributed to another condition

– As many as 1 in 5 attempt suicide

Risk and Protective Factors

Factors associated with Risk

• Low SES • Low intelligence • Childhood abuse and other

maltreatment • Family psych history • Life stress (Bevin, Andrews and Valentine, 2000)

Protective Factors

• Being in a relationship • Fewer psychosocial difficulties • Greater perception of purpose • Family support • Positive affect • (military specific)—positive military

experiences (Orsello and Alfonso, 2012)

Diagnostic Changes

• An anxiety disorder

• Traumatic Event – Requires direct personal

experience – Feelings of helplessness and

hopelessness

• Three categories of symptoms – Re-experiencing – Hyper-arousal – Avoidance

• A trauma and stress disorder

• Traumatic Event – May be direct exposure, witnessed,

event occurred to close relative, or repeated exposure to details of the event

– No A2 criteria

• Four categories of symptoms – Intrusion – Avoidance – Negative alterations in cognition

and mood – Marked alterations in arousal and

reactivity

• No chronic specifier

DSM IV-TR DSM V

DSM-V

• Exposure to actual or threatened death, serious injury, or sexual violence – Directly experiencing the traumatic event – Witnessing, in person, the event as it occurred to others – Learning that the event occurred to a close family member – Experiencing repeated or extreme exposure to aversive details of the traumatic events

• Presence of 1 or more of the following intrusion symptoms

– Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s) – Recurrent distressing dreams in which the content and/or affect of the dream are related – Dissociative reactions in which the individual feels or acts as if the event is recurring – Intense or prolonged psychological distress at exposure to internal /external cues that

symbolize the event – Marked physiological reactions to internal/external cues that symbolize/resemble the event

DSM-V

• Persistent avoidance of stimuli associated with the

traumatic events (1 or both) – Avoidance of or efforts to avoid distressing memories, thoughts,

or feelings about or closely associated with the event – Avoidance of or efforts to avoid external reminders that arouse

distressing memories, thoughts, or feelings about or associated with the event

DSM-V

• Negative alterations in cognition and mood associated with the event (2 or more) – Inability to remember an important aspect of the event – Persistent or exaggerated negative beliefs or expectations about oneself,

others, or the world – Persistent, distorted cognitions about the cause or consequences of the

event leading to self blame – Persistent negative emotional state (e.g. fear, horror, anger, guilt, or

shame) – Markedly diminished interest in participating in significant activities – Feelings of detachment or estrangement from others – Persistent inability to experience positive emotions

DSM-V

• Marked alterations in arousal and reactivity associated with the

event (2 or more) – Irritable behavior and angry outbursts – Reckless or self-destructive behavior – Hyper vigilance – Exaggerated startle response – Problems with concentration – Sleep disturbances

• Duration: Symptoms must be present for more than a month

Take Aways

• Antecedent traumatic event

• 4 key symptom clusters – Intrusive thoughts – Avoidance behavior – Negative changes in cognition and mood – Changes in arousal

• Signs/Symptoms – Anxiety with somatic manifestations (palpitations, tremors, sweating) – Insomnia – Combative behavior – Withdrawn – Other symptoms related to co-morbid conditions (depression)

Evaluation and Management Patient with a history of trauma exposure (e.g. combat, domestic/criminal assault, abuse, natural disaster,

terrorist attack)

Use PTSD Screening Tool

Assess for Suicide Risk

+

- No further action required.

Refer for immediate intervention

+

Interview and Assess DSM V

Criteria

Provide Supportive Treatment and Assess for

Other Disorders

PTSD Not Met

PTSD Criteria Met

-

Evaluation

• Screening and diagnostic questionnaires – Universal vs targeted screening

• 4 item PTSD screener: Asks about a traumatic experience and symptoms within the past month – Had any nightmares about it or thought about it when you did not

want to? – Tried hard not to think about it or went out of your way to avoid

situations that remind you of it? – Were constantly on guard, watchful, or easily startled? – Felt numb or detached from others, activities, or your surroundings?

• Yes on 2 questions indicated further assessment necessary

Evaluation

• PTSD Symptom Checklist (PCL) – Revised for DSM V (PCL-5) – 20 questions based on symptom clusters – Scored 0-4 – Provisionally score of 38 is associated with PTSD

• More research needed with revised version

• Assess all for suicidality

Evaluation and Management

Assess for co-morbid physical/psychiatric conditions (e.g. substance abuse, mood disorders, traumatic brain injury, etc)

Conduct education of both patient and family about PTSD symptoms, co-morbid conditions and treatments

Develop multidisciplinary treatment plan and initiate trauma focused psychotherapy and/or pharmacotherapy (SSRI/SNRI)

PTSD Criteria Met

Evaluation and Management • Co-Morbidity

– Up to 80% have a co-morbid psychiatric condition

• Co-Morbid Conditions – Major Depressive Disorders (48%) – Dysthymia (22%) – Generalized Anxiety Disorder (16%) – Simple Phobia (30%) – Panic Disorder (F-12.6%, M-7.3%) – Agoraphobia (F-22.4%, M-16.1%) – Alcohol Abuse (M-51.9%, F-27.9%) – Substance Abuse (M-34.5%, F-26.9%) – Conduct Disorder (M-43.3%, F-15.4%) – Traumatic Brain Injury

Evaluation and Management

Develop multidisciplinary treatment plan and initiate trauma focused psychotherapy and/or

pharmacotherapy (SSRI/SNRI)

Reassess PTSD and

Safety Symptoms

Continue treatment

and continue to monitor

Maximize monotherapy, consider adjunctive treatments, change to a different medication if not

tolerating or showing no response after appropriate time period. Refer to mental health provider.

Not Improving/ Side Effects Present/ Safety Concerns

Improving/ Tolerating w/o Significant Side

Effects or Safety Concerns

Management • First Line Treatments for PTSD

– Psychotherapy • Trauma Focused Therapy (Cognitive

Processing, Eye Movement Desensitization Reprocessing, Prolonged Exposure)

– Pharmacotherapy • SSRIs/SNRIs • Sertraline and Paroxetine have FDA

indications • May take 6-8 weeks to achieve full

therapeutic benefit

• Augmenting Agents – Prazosin – alleviates sleep disturbance – Antihistamines or Hypnotics – can use for

short term – Other antidepressants are second line

agents

• Agents to Avoid – Buspirone – insufficient data – Benzodiazepines – abuse, dissociative, and

disinhibition – Mood Stabilizers – limited benefit vs.

risks/lab monitoring – Atypical Antipsychotics – studies have

shown no benefit

• Other Considerations – Support systems – Alternative therapies – Physical therapy with co-morbid pain

Psychotherapy

• Exposure-based – Prolonged Exposure

• Cognitive-Based – Cognitive Processing Therapy

• Symptom Education • Awareness of thoughts/feelings • Skills to challenge maladaptive thoughts • Understanding changes in beliefs (safety, trust, esteem)

– Stress Management Therapy – Eye Movement Desensitization and Reprocessing (EMDR)

• Brief sequential doses of emotionally disturbing material while focusing on an external stimulus such as lateral eye movements

• Allows access to traumatic memories and reassociation with more adaptive memories or information

• Insufficient data to determine superiority of exposure-based to cognitive-based methods

Pharmacotherapy

• SSRI’s – NNT for response in 11 weeks

• Paroxetine 4.3 • Sertraline 4.5 • Fluoxetine 6.0

• SNRI’s – Venlafaxine ER effective in treatment and remission at 6 months

• Average dose 221.5 mg/day – Not superior to sertraline

• Dosing – Paroxetine—20-60 mg/day – Sertraline—50-200 mg/day – Fluoxetine—20-60 mg/day – Citalopram—20-40 mg/day – Escitalopram—20-30 mg/day – Venlafaxine –37.5-300 mg/day

Pharmacotherapy

• Alpha-adrenergic antagonists – For nightmares – Prazosin effective over 15 weeks

• Mean effective dose 4 mg for men, 1.7 mg for women – Orthostatic hypotension – Rebound hypertension on discontinuation

• Cannabinoids – Mostly observational, lack of RCT data – Higher use in those diagnosed – May be beneficial with hyperarousal symptoms – Trend towards increased cannabis use disorder in those using cannabis to

treat PTSD symptoms – Not enough data to recommend use

Pharmacotherapy

• Versus psychotherapy – No direct comparisons

• Combining pharmacotherapy with psychotherapy – Limited evidence does not conclusively show additional benefit

• Duration of treatment – 6-8 week trial to assess response – 6 months to a year to prevent recurrence

• 28 weeks of maintenance treatment after 12 weeks of initial therapy with sertraline (5 percent relapse) more effective than placebo maintenance (26 percent relapse)

Doing This in Primary Care

• RESPECT-MIL Program – Based on 3 component model of care

• Trained Primary care provider able to make an initial diagnosis and treatment • Care facilitator

– Monitors response – Follows-up with patient – Communicates with clinician

• Psychiatrist – Supervises care facilitator – Can offer treatment advice and informal feedback to primary care manager – Arranges for specialty consultation when necessary

– Universal screening of all Soldiers presenting for primary care visit for depression and PTSD (using 4 question screener)

• Screen positive Soldiers administered full PCL • Every 4 weeks repeat instrument administered

Doing This in Primary Care

• 16 month feasibility in primary care setting found following – 4,159 Soldiers completed screening process – 404 screens positive (~10%)

• 320 depression alone • 81 depression and PTSD • 3 PTSD alone • ~2% prevalence of PTSD

– 80 Soldiers ultimately enrolled in Respect-MIL • Others preferred traditional models of care or were already established in care

– 21 of SM’s followed for PTSD had a follow-up PCL by 6-10 weeks • 14 (67%) had at least a 5 point drop

– By 12 weeks, 13/16 (81%) had at least a 5 point drop – No suicide attempts

Evolution into PCMH

• All Soldiers screened in Primary care practice • If screen positive, full instrument administered by screener

before provider sees patient • Provider notified of positive results

– Option to engage clinic’s Internal Behavioral Health Consultant (psych NP or LCSW typically) immediately or in short-term follow-up

• Provider’s nurse will facilitate initial contact at direction of provider – IBHC will follow patient for up to 4 visits with feedback to provider

• “sticky note” or other internal communication in EMR – If ongoing care needed, IBHC will refer to specialty care – Nurse case manager serves as care facilitator and provides ongoing

follow-up – Psychiatrist provides clinical supervision for IBHC’s

Can we prevent PTSD?

• Military structure of unit cohesion and vigorous exercise effective – Additional training has not been shown to be effective – Newer efforts (resiliency training in Active Duty)

• Potential for early outpatient therapy (prolonged exposure) to prevent development of PTSD in those exposed to a causative event

Questions

References • Bevin CR, Andrews B and Valentine JD. Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. J Consulting and Clin

Psychology. 2000;68:748-766. • Davidson J, Baldwin D, Stein DJ, et al. Treatment of posttraumatic stress disorder with venlafaxine extended release: a 6-month randomized controlled

trial. Arch Gen Psychiatry. 2006;63(10):1158 • Davidson J, Pearlstein T, Londborg P, et al. Efficacy of sertraline in preventing relapse of posttraumatic stress disorder: results of a 28-week double-blind,

placebo-controlled study. Am J Psychiatry. 2001;158(12):1974. • Davidson J, Rothbaum BO, Tucker P, Asnis G, Benattia I, Musgnung JJ. Venlafaxine extended release in posttraumatic stress disorder: a sertraline- and

placebo-controlled study. J Clin Psychopharmacol. 2006;26(3):259. • Engel CC, Oxman T, Yamamoto C, et al. RESPECT-Mil: feasibility of a systems-level collaborative care approach to depression and post-traumatic stress

disorder in military primary care. Mil Med 2008 Oct;173(10):935-40. • Orsello CA and Alfonzo CA. Prevention of post traumatic stress disorder among military health care workers: a systematic review. J Healthcare Sci and

Humanities. 2012;2:17-29. • Raskind MA, Peterson K, Williams T, et al. A trial of prazosin for combat trauma PTSD with nightmares in active-duty soldiers returned from Iraq and

Afghanistan. Am J Psychiatry. 2013;170(9):1003 • Sareen J. Posttraumatic stress disorder in adults: epidemiology, pathophysiology, clinical manifestations, course, and diagnosis.

http://www.uptodate.com/contents/posttraumatic-stress-disorder-in-adults-epidemiology-pathophysiology-clinical-manifestations-course-and-diagnosis?source=machineLearning&search=PTSD+symptoms&selectedTitle=1%7E150&sectionRank=1&anchor=H10#H10. Accessed 24 Feb 2016.

• Stein DJ, Ipser JC, Seedat S. Pharmacotherapy for post traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD002795. DOI: 10.1002/14651858.CD002795.pub2

• Stein MB. Pharmacotherapy for posttraumatic stress disorder in adults. http://www.uptodate.com/contents/pharmacotherapy-for-posttraumatic-stress-disorder-in-adults?source=search_result&search=ptsd+treatment+adult&selectedTitle=1%7E150#H5614705. Accessed 24 Feb 2016.

• Warner CH, Appenzeller GN, Warner CM, Hoge CW. Identification and Management of Posttraumatic Stress Disorder in the Primary Care Office. American Family Physician, 2013; 88(12): 827-34.

• Veterans Affairs (VA)/Department of Defense (DoD) Clinical Practice Guideline for Management of Post-Traumatic Stress, VA, DoD, The Management of Post-Traumatic Stress Working Group, Version 2.0, October 2010.

• Ursano RJ, Bell C, Eth S, Friedman M, Norwood A, Pfefferbaum B, Pynoos RS, Zatzick DF, Benedek D. Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Am J Psychiatry 2004; 161(Suppl 11): 3-31.

• Yarnell S. The use of medicinal marijuana for posttraumatic stress disorder: a review of the current literature. Prim Care Companion CNS Disord. 2015;17(3): 10.4088/PCC.15r01786.