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APNA 29th Annual Conference Session 4025: October 31, 2015 Stuart 1

Practicing within VA/DoD Clinical Practice Guidelines (CPGs) for the Management of PTSD: A Case Review & Outcomes from a Civilian Provider Serving Military Personnel in Europe

Catherine Stuart, APRN, CNS, FPMHNP

catherine.stuart@va.gov

# 4025

Disclosure Statements

 The presenter has no real or potential conflict of

interest related to the VA/DoD Clinical Practice Guidelines; or the related medications and psychotherapies in this presentation.

 Off-label use of medication will be identified as

discussed.

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Learning Objectives

Objective 1: Appreciate the challenges and importance of integrating Clinical Practice Guidelines for PTSD into an ethos that would prevent one from doing otherwise. Objective 2: Review 1st and 2nd line EBT for PTSD with and without comorbid conditions as well as adjuncts for medical management Objective 3: Introduce the changes in criteria for PTSD for DSM-5 and related developments in psychometrics. Objective 4: Recognize that outcome measurement can be good for the patient as well as the provider and organization.

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APNA 29th Annual Conference Session 4025: October 31, 2015 Stuart 2

Number of Veterans with Mental Disorders in OEF/OIF/OND Veterans Evaluated at VA Facilities since FY 2002 - 1st Qtr 2014

4 VA Health Care Utilization among OEF/ OIF/ OND Veterans Cumulative from 1st Qtr FY 2002-1st Qtr FY 2014, Released March 2014

Diagnosis (ICD-9-CM) Veterans(OEF/OIF/OND)

Post-Traumatic Stress Disorder (309.81) 311,688 Depressive Disorders (311) 248,891

Neurotic Disorders (300) 229,361 Affective Disorders (296) 152,587 Alcohol Dependence Syndrome (303) 72,055 Abuse of Drugs 53,839 Drug Dependence 40,630

As of March 2014, there were 34,657 incident cases of PTSD in the US military for people who had not previously deployed. Among people who had been deployed, there were 121,014 incident cases of PTSD.

Monthly Surveillance Medical Report, (2014) Armed Forces Health Surveillance Center, Vol. 19, No 6, p. 14

5 Permission granted for photo- CPL D. Stuart USMC

Symptoms common to both…

 mTBI  Insomnia  Memory Deficits  Poor Concentration  Depressed Mood  Anxiety  Irritability  Headache  Dizziness  Fatigue  Noise/Light Intolerance  PTSD  Insomnia  Memory Deficits  Poor Concentration  Depressed Mood  Anxiety  Irritability  Intrusive symptoms  Emotional Numbing  Hyper-arousal  Avoidance behavior

6 Kennedy, J.E., Jaffee, M.S., Leskin, G.A., Stokes, J.W., Leal, F.O., & Fitzpatrick, P.J. (2007). Posttraumatic stress disorder and posttraumatic stress disorder-like symptoms and mild traumatic brain injury. Journal of Rehabilitation Research and Development, 44(7), 895-920.

APNA 29th Annual Conference Session 4025: October 31, 2015 Stuart 3

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PTSD in DSM-5

1. American Psychiatric Association. (2013a). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA 2. Jones et al, (2014) Trauma Redefined in the DSM-5: Rationale and Implications for Counseling Practice The Professional Counselor 4: 3, 257–271

• 1. Re-experiencing covers spontaneous memories of the trauma,

recurrent dreams, flashbacks or intense/ prolonged distress. Avoidance refers to distressing memories, thoughts, feelings or external reminders of the event.

• 2. Negative cognitions and mood represents feelings, from a

persistent/ distorted sense of guilt, to a markedly diminished interest in activities or others, to not remembering aspects of the event.

• 3. Arousal is marked by aggressive, reckless or self-destructive

behavior, sleep disturbances, or hyper-vigilance. DSM IV emphasized the “flight” aspect associated with PTSD; the criteria

• f DSM-5 also accounts for the “fight” reaction often seen.

Va/DoD Clinical Guideline Meds

1st Line Medications Med Class Dose

Sertraline (Zoloft) SSRI 50 mg – 200 mg daily Paroxetine (Paxil) SSRI 20 mg – 60 mg daily Fluoxetine (Prozac) SSRI 20 mg – 60 mg daily Venlafaxine (Effexor) SNRI 75 mg – 300 mg daily

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2nd Line Medications

Indication Medication Class Dosage

Hyperarousal: Mood, irritability, rage, impulse control, h/a prophylaxis divalproic acid lamotrigine, topomax Anticonvulsant 250-100mg 100-300mg 100-200mg Re-experiencing: Nightmares, flashbacks, insomnia, sleep latency Somatic symptoms: Post trauma headache, IBS symptoms, pelvic pain prazosin propanolol cyproheptadine trazodone nortriptyline, amitriptyline desipramine A1 blocker Beta blocker Antihistamine Tetracyclic Tricyclic Tricyclic Tricyclic 1-15mg 10-40mg 4-12mg 50-200mg 25-150mg 50-100mg 100-200mg Negative Symptoms: decreased libido, energy focus/concentration bupropion venlafaxine NDRI SNDRI 75-300mg 75-225mg

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APNA 29th Annual Conference Session 4025: October 31, 2015 Stuart 4

Discouraged/contraindicated….

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Atypical anti-psychotics: Not recommended unless clinically indicated (paranoia, hallucinations, irrationality, disassociation, co-morbid bi-polar illness, etc.). Risperdone is “contraindicated for use as an adjunctive agent –potential harm (side effects) exceeds benefit” Psychostimulants: insufficient evidence to recommend as an adjunctive agent.

BENZODI AZEPI NES: STRONGLY DI SCOURAGED. SEE CPG for m ultiple w arnings “evidence against” “significant adverse effects” “significant risk of dependency”

1 .w w w .healthquality.va.gov/ guidelines/ MH/ ptsd/ CPGSum m ary FI NALMgm tofPTSDfinal0 2 1 4 1 3 .pdf( pages 4 8 -5 2 ) 2 . Oct, 2 0 1 0 VA/ DoD CPG for Managem ent of PTSD Module 1 -2 Treatm ent I nterventions For PTSD page 1 5 4

Essentials of Prolonged Exposure Therapy

In Vivo Exposure

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• Manual
• Trained provider
• Recording device
• Worksheets
• Clock
• PCLs

2 Types of Exposures

Imaginal Exposure

McLean & Foa (2014) The use of prolonged exposure therapy to help patients with post

• traumatic. Clinical Practice 11(2): 233-241.

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Behavioral Health Data Portal

• 1. http: / / armymedicine.mil/ Pages/ BHDP
• 2. http: / / www.nextgov.com/ cloud-computing/ 2013/ 10/ pentagon-

directs-defensewide-use-armys-mental-health-data-portal/ 72953

Includes 24 questions measuring mental health distress and six subscales for the following: Depression and Functioning, Relationships, Self-Harm, Emotional labiality, Psychosis, and Substance Abuse. Completed on every visit.

• The PHQ-9: self-report screening tool developed to aid in quickly

diagnosing depression, monitoring depression symptom severity through treatment and validating remission.

• GAD-7: For Generalized Anxiety Disorder with higher scores that

were strongly associated with interviewer validated functional impairment.

• PCL-C: Reliable and routinely used for

PTSD diagnosis and to track progress

APNA 29th Annual Conference Session 4025: October 31, 2015 Stuart 5

http://www.mirecc.va.gov/docs/visn6/3_PTSD_CheckList_and_Scoring.pdf

Re-experiencing Avoidance Hyper arousal 1/ 5 3/ 6 2/ 6

P C L

Patient Checklist for PTSD (PCL) Changes

DSM IVR PCL

• PCL for DSM-IV has three

versions, PCL-M (military), PCL-C (civilian), and PCL-S (specific)

• Vary slightly in wording of

instructions and referring to the index event

• All versions are a 17-item

questionnaire and rely on a 1-5 rating scale

DSM 5 PCL

• PCL has only one

version: PCL-5

• PCL-5 is most similar to

the PCL-S (specific) version.

• The PCL-5 is a 20-item

questionnaire, based on DSM-5 symptom criteria for PTSD.

• New versions relies on a

0-5 rating scale The earlier versions of the PCL and PCL-5 are not interchangeable!

http: / / www.ptsd.va.gov/ professional/ assessment/ adult-sr/ ptsd-checklist.asp

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26 yr. old male USA SSG, TIS: 8 yrs. Deployments: 3 (2 OIF, 1 OEF)

CC: “I'm always angry... and I don't want to be like my stepfather” Seen at base clinic 2 days post d/c from a local hospital after a suicidal attempt/gesture. Psych/Social Hx: PTSD, new dx of ADHD w/o hx of scholastic/behavior problems during childhood or pre-military. Physical abuse from step-father in adolescence. Alcohol abuse after deployment. Current relational difficulties with pregnant wife of 2nd child. Relevant Medical Hx: mTBI with hx of seizure, chronic headaches, nml

• BMI. New dx of mild hypertension untreated, cervicalgia

Meds: sertraline 100mg, tramadol 50mg prn; both d/c'd after seizure 6 months

• prior. Amphetamine/dextroamphetamine XR 20mg qam and 10mg at noon.

alprazolam 0.5mg prn for "panic” 3-4 times daily prn.

A Case Study demonstrating results of care turned around with treatment under the umbrella of VA/ DoD CPGs for PTSD

APNA 29th Annual Conference Session 4025: October 31, 2015 Stuart 6

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A Case Study (continued) Subjective Symptoms: Anger with poor impulse control, irritability, nightmares, attention/concentration, anxiety and hopelessness Objective Data: PCL- C totaled 63 with high scores in hyper arousal and avoidance symptoms, moderate scores for re experiencing. Medical Management

• 1. Citalopram with quick titration to 40mg over 2 weeks. D/C’d amphetamine.
• 2. Conversion of alprazolam to clonazepam with reductions of 0.25mg per week , then D/C’d.
• 2. Divalproex 500 mg for mood stabilization and headache prophylaxis
• 3. Prazosin for nightmares with eventual titration to 6 mg. Trazadone prn for sleep.

Psychotherapy

• 1. Prolonged Exposure Therapy 5 sessions over 2 months
• 2. Cognitive-Behavioral Couples Therapy for Posttraumatic Stress Disorder (CBCT for PTSD)

9 sessions over 8 months

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I m provem ent of PTSD sym ptom s in SSG w ith VA/ DoD CPG Med MGMT and Psychotherapy

• 1. H/ A’s decreased to 1-2 per month from 3-4 per week
• 2. Sleep duration increased from 2-3 hrs. to 6-7 hours per night
• 3. Marriage satisfaction scores increased by 40%

Monson, C et al. Effect of cognitive-behavioral couple therapy for PTSD: a randomized controlled trial. JAMA August 2012 308: 7

Improvement of overall functioning

N=48

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0.5 1 1.5 2 2.5 3 3.5 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 Initial Last Seen

Patients completing BHDP with > 2 visits from 4.30.13 - 10.01.13

APNA 29th Annual Conference Session 4025: October 31, 2015 Stuart 7

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10 20 30 40 50 60 70 80 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49

PTSD Checklist Scores N=32

Initial PCL Current PCL 81% of patients receiving treatment for PTSD a reduction in PLC-C scores 53% experienced a significant reduction in PCL-C scores AD SM seen at SHCF for PTSD from 04.01 to 10.01 2013

Putting it all together and doing the right thing….

Provider Performance

Patient Compliance

Tracking Progress

1st Line Medications FI RST! 1. SSRI 2. SNDRI Psychotherapy when Ready 1. PE 2. CPT

• 3. EMDR
• 4. SI

Consult Guidelines for 1. Substance Abuse 2. Depression 3. TBI Make use of Adjuncts 1. Nightmares/ Sleep 2. Mood Stability 3. H/ A or GI

Clinical Practice Guidelines

Assists 16

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Permission granted: CPT J.P. Stuart

Other Clinical Practice Guidelines MENTAL HEALTH Major Depressive Disorder (MDD) Bipolar Disorder in Adults Substance Use Disorder Concussion mTBI Post Deployment Health (PDH) Post Traumatic Stress Disorder (PTSD) Assessment and Management of Patients at Risk for Suicide (new!)

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www.healthquality.va.gov/guidelines

Asthma Dyslipidemia CHF Stroke Rehabilitation Kidney Disease (updated!) Post Operative Pain COPD (updated!) Pregnancy Knee & Hip Arthritis (new!) Lower Back Pain Opioid Therapy Diabetes Mellitus Ischemic Heart Disease Obesity & Overweight (updated!)

APNA 29th Annual Conference Session 4025: October 31, 2015 Stuart 8

VA/ DoD Clinical Practice Guidelines (CPGs) for PTSD serve to

 Guide practice with EBT “rules & tools”  Produce predictable outcomes.  Foster confidence/competency in both provider and patient  Enhance perceptions of the capability and expertise

• f Psychiatric Nurse Providers.

Summary

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Acknowledgements

Special thanks to the following people who assisted with the work or served as mentors in my training as well as those who have Served or continue to Serve in our Nations Military.

 “Cap’n Jack”, CAPT John Golden USPHS, DoD: DHCC Defense Center of Excellence for

Psychological Health, former Chief of PH Directorate, Silver Spring MD

 COL Christine Piper USA (Retired) of Kailua, Hawaii formerly BH Chief, Scoffield Barracks, HI  COL Charles Engel USA (Retired) Senior Health Scientist, Behavioral and Policy Science,

RAND Corporation, Arlington, VA

 Joseph Etherege PsyD, BH Chief, SHAPE Healthcare Facility; Supreme Headquarters Allied

Powers of Europe, Mons, Belgium

 Keri Crisotti, RN, MSN Psychiatric Nurse Practitioner Board Eligible, Stoneybrook University NY  CAPT William McDaniel, USN (Retired) Psychiatrist MD at VAMC, Hampton, VA  CAPT Thomas Goddard USN (Retired) former Professor at NVCC, Alexandria, VA

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References

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• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders

(5th ed.). Arlington, VA

• Armed Forces Health Surveillance Center. “Mental Disorders and Mental Health Problems, Active

Component, U.S. Armed Forces.” Monthly Surveillance Medical Report 19: 6, March 2014

• Correll, D. (2013) "Terrifying Our Soldiers: Stimulant- I nduced PTSD in the Armed Forces". The

Trinity Papers. Trinity College Digital Repository, Hartford, CT. http: / / digitalrepository.trincoll.edu/ trinitypapers/ 19

• Jeffries M. A Clinicians Guide to Medications for PTSD (2010)

http: / / www.ptsd.va.gov/ professional/ treatment/ overview/ clinicians-guide-to medications-for- PTSD.asp, accessed February 2014

• Jones et al. (2014) Trauma Redefined in the DSM-5: Rationale and I mplications for Counseling

Practice The Professional Counselor, 4(3): 257–271

• McLean B & Foa E. (2014) The use of prolonged exposure therapy to help patients with post
• traumatic. Clinical Practice 11(2): 233-241.
• Nappi et al. (2012) Treating nightmares and insomnia in posttraumatic stress disorder: a review
• f the current evidence. Neuropharmacology62(2): 576-585
• Prescott MR, et al.(2014) Validation of lay administered mental health assessments in a large

Army National Guard cohort Int J Methods Psych Res. 23(1): 109-19.

• Watts BV et al, (2013) Meta-analysis of the efficacy of treatments for post traumatic stress

disorder J Clinical Psychiatry 74: 6

• http:/ / w w w .healthquality.va.gov/ guidelines accessed February 2 0 1 5