Clinical Summary: Prescription Patterns in Canadian Operational Stress Injury Clinics: An In-Depth Examination of Posttraumatic Stress Disorder Treatment Practices
Patients with military-related posttraumatic stress disorder in operational stress injury clinics often have chronic symptoms, multiple comorbidities, and long prior treatment histories, making straightforward first-line prescribing difficult in day-to-day care. This study shows how psychiatrists in Canadian operational stress injury clinics are actually treating posttraumatic stress disorder, including how often care extends beyond guideline-first antidepressants into polypharmacy and symptom-targeted adjunctive treatment.
Key Findings
- Medication treatment was nearly universal: of 438 patients, 432 were prescribed at least 1 medication (98.6%), with an average of 3.69 (SD = 1.78) medications prescribed per patient for any condition and 3.04 (SD = 1.65) specifically for PTSD.
- Chronic and comorbid illness was common: the average chronicity of PTSD was 8.15 years (SD = 5.27), 62.6% (n = 274) had received pharmacologic treatment for PTSD for ≥5 years, and 78.3% (n = 343) had at least 1 comorbid mental health condition.
- PTSD pharmacotherapy commonly included antidepressants and hypnotics: among patients prescribed ≥1 antidepressant (n = 394), 96.4% (n = 380) were for PTSD; among those prescribed ≥1 hypnotic (n = 283), 94.0% (n = 266) were for PTSD; among those prescribed ≥ 2 hypnotics (n = 77), 96.1% had them prescribed for PTSD.
- Sleep-targeted and adjunctive agents were among the most common PTSD-indicated medications, including low-dose trazodone used as a hypnotic (n = 116), zopiclone (n = 112), zolpidem (n = 82), doxazosin (n = 81), and quetiapine (n = 78).
- Prescribing patterns differed significantly across clinics: significant differences (P < .001) by site were observed across most classes and subclasses, indicating substantial variability in prescribing patterns.
In Canadian operational stress injury clinics, selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors remain the pharmacologic foundation for posttraumatic stress disorder, but real-world care is dominated by chronic treatment, polypharmacy, and frequent use of adjunctive agents for sleep and other persistent symptoms. Clinicians treating military and veteran populations should expect complex regimens rather than antidepressant monotherapy alone.
Practice Implications
- Review full medication burden routinely in posttraumatic stress disorder care, because patients were prescribed a mean of 3.04 (SD = 1.65) PTSD-indicated medications and 98.6% received at least 1 medication.
- Assess insomnia and nightmares directly at follow-up, as low-dose trazodone used as a hypnotic (n = 116), zopiclone (n = 112), zolpidem (n = 82), and doxazosin (n = 81) were among the most common PTSD-indicated agents.
- Use selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors as core treatments, while recognizing that many patients with 8.15 years (SD = 5.27) average PTSD chronicity and 62.6% with ≥5 years of pharmacologic treatment will need symptom-targeted augmentation.
- Where local practice varies, consider shared case review and quality-improvement approaches, because significant differences (P < .001) by site were observed across most medication classes and antidepressant subclasses.
