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Pharmacotherapy of PTSD in the U.S. Department of Veterans Affairs: Diagnostic- and Symptom-Guided Drug Selection
Somaia Mohamed, M.D., Ph.D., and Robert A. Rosenheck, M.D.
Background: Although increasing numbers of war veterans are seeking treatment for posttraumatic stress disorder (PTSD) at the U.S. Department of Veterans Affairs (VA), information on the role of psychotropic pharmacotherapy in their treatment has not been available.
Method: Records of psychotropic prescriptions for all VA patients diagnosed with ICD-9 PTSD (N = 274,297) in fiscal year 2004 (October 1, 2003, to September 30, 2004) were examined. Descriptive statistics and multivariable logistic regression were used to identify veteran characteristics and measures of service use that were associated with receipt of any psychotropic medication and, among users of such medications, with use of each of 3 medication classes: antidepressants, anxiolytics/sedative-hypnotics, and antipsychotics.
Results: Most veterans diagnosed with PTSD received psychotropic medication (80%), and among these, 89% were prescribed antidepressants, 61% anxiolytics/sedative-hypnotics, and 34% antipsychotics. Greater likelihood of medication use was associated with greater mental health service use and comorbid psychiatric disorders. Among comorbidities, medication-appropriate comorbid diagnoses were the most robust predictors of use of each of the 3 medication subclasses, i.e., depressive disorders were associated with antidepressant use, anxiety disorders with anxiolytic/sedative-hypnotic use, and psychotic disorders with antipsychotic use. Use of anxiolytics/sedative-hypnotics and antipsychotics in the absence of a clearly indicated diagnosis was substantial.
Conclusion: Diverse psychotropic medication classes are extensively used in the treatment of PTSD in the VA. While disease-specific use for both PTSD and comorbid disorders is common, substantial use seems to be unrelated to diagnosis and thus is likely to be targeted at specific symptoms (e.g., insomnia, anxiety, nightmares, and flashbacks) rather than diagnosed illnesses. A new type of efficacy research may be needed to determine symptom responses to psychotropic medications as well as disorder responses, perhaps across diagnoses.
(J Clin Psychiatry
2008;69:959-965. Online Ahead of Print June 3, 2008.)
Received Oct. 10, 2007; accepted Nov. 11, 2007. From New England Mental Illness Research, Education, and Clinical Center, U.S. Department of Veterans Affairs (VA) Connecticut Health Care System, West Haven, and the Department of Psychiatry, Yale University School of Medicine, New Haven, Conn.
Conclusions and opinions expressed in this article are those of the authors and do not necessarily reflect the position or policy of the U.S. Department of Veterans Affairs.
Dr. Rosenheck has received research support from Eli Lilly, Janssen, AstraZeneca, and Wyeth and has been a consultant to GlaxoSmithKline, Bristol-Myers Squibb, Organon, and Janssen. Dr. Mohamed reports no financial affiliations or other relationships relevant to the subject of this article.
Corresponding author and reprints: Somaia Mohamed, M.D., Ph.D., Northeast Program Evaluation Center, Department of Psychiatry, Yale University School of Medicine, VA Connecticut Health Care System, 950 Campbell Ave., West Haven, CT 06516 (e-mail: Somaia.Mohamed@yale.edu).