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APNA 29th Annual Conference Session 4025: October 31, 2015 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 # 4025 Catherine Stuart, APRN, CNS, FPMHNP catherine.stuart@va.gov 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. 2 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 1 st and 2 nd 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. . 3 Stuart 1

APNA 29th Annual Conference Session 4025: October 31, 2015 Number of Veterans with Mental Disorders in OEF/OIF/OND Veterans Evaluated at VA Facilities since FY 2002 - 1 st Qtr 2014 Diagnosis (ICD-9-CM) Veterans(OEF/OIF/OND) Post-Traumatic Stress 311,688 Disorder (309.81) 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 VA Health Care Utilization among OEF/ OIF/ OND Veterans Cumulative from 1st Qtr FY 2002-1st Qtr FY 2014, Released March 2014 4 Permission granted for photo- CPL D. Stuart USMC 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 . 5 Monthly Surveillance Medical Report , (2014) Armed Forces Health Surveillance Center, Vol. 19, No 6, p. 14 Symptoms common to both…  mTBI  PTSD  Insomnia  Insomnia  Memory Deficits  Memory Deficits  Poor Concentration  Poor Concentration  Depressed Mood  Depressed Mood  Anxiety  Anxiety  Irritability  Irritability  Headache  Intrusive symptoms  Dizziness  Emotional Numbing  Fatigue  Hyper-arousal  Noise/Light Intolerance  Avoidance behavior Kennedy, J.E., Jaffee, M.S., Leskin, G.A., Stokes, J.W., Leal, F.O., & Fitzpatrick, P.J. (2007). Posttraumatic 6 stress disorder and posttraumatic stress disorder-like symptoms and mild traumatic brain injury. Journal of Rehabilitation Research and Development, 44(7), 895-920. Stuart 2

APNA 29th Annual Conference Session 4025: October 31, 2015 PTSD in DSM-5 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 of DSM-5 also accounts for the “fight” reaction often seen. 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 7 Counseling Practice The Professional Counselor 4: 3, 257–271 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 8 2 nd Line Medications Indication Medication Class Dosage Hyperarousal: Mood, divalproic acid Anticonvulsant 250-100mg irritability, rage, impulse lamotrigine, 100-300mg control, h/a prophylaxis topomax 100-200mg Re-experiencing: prazosin A1 blocker 1-15mg Nightmares, flashbacks, propanolol Beta blocker 10-40mg insomnia, sleep latency cyproheptadine Antihistamine 4-12mg Somatic symptoms: Post trazodone Tetracyclic 50-200mg trauma headache, IBS nortriptyline, Tricyclic 25-150mg symptoms, pelvic pain amitriptyline Tricyclic 50-100mg desipramine Tricyclic 100-200mg Negative Symptoms: decreased libido, energy bupropion NDRI 75-300mg focus/concentration venlafaxine SNDRI 75-225mg 9 Stuart 3

APNA 29th Annual Conference Session 4025: October 31, 2015 Discouraged/contraindicated…. 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 10 Essentials of Prolonged Exposure Therapy • Manual 2 Types of Exposures • Trained provider • Recording device • Worksheets Imaginal Exposure In Vivo Exposure • Clock • PCLs McLean & Foa (2014) The use of prolonged exposure therapy to help patients with post traumatic. Clinical Practice 11(2): 233-241. 11 Behavioral Health Data Portal 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 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 12 Stuart 4

APNA 29th Annual Conference Session 4025: October 31, 2015 Re-experiencing Avoidance Hyper arousal P 1/ 5 C 3/ 6 L 2/ 6 http:// www.mirecc.va.gov/docs/visn6/3_PTSD_CheckList_and_Scoring.pdf Patient Checklist for PTSD (PCL) Changes DSM IVR PCL DSM 5 PCL • PCL for DSM-IV has three • PCL has only one versions, PCL-M (military), version: PCL-5 PCL-C (civilian), and PCL-S • PCL-5 is most similar to (specific) the PCL-S (specific) • Vary slightly in wording of version. instructions and referring to • The PCL-5 is a 20-item the index event questionnaire, based on • All versions are a 17-item DSM-5 symptom criteria questionnaire and rely on a for PTSD. 1-5 rating scale • 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 A Case Study demonstrating results of care turned around with treatment under the umbrella of VA/ DoD CPGs for PTSD 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 2 nd 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. 15 alprazolam 0.5mg prn for "panic” 3-4 times daily prn. Stuart 5