Treatment of schizophrenia 1999

Expert Consensus Guideline Series Treatment of Posttraumatic Stress Disorder Payment form for reprinting multiple copies of Foa EB, Davidson JRT, Frances A. The Expert Consensus Guideline Series: Treatment of Posttraumatic Stress Disorder. J Clin Psychiatry 1999;60 (Suppl 16). Single copies of this document can be printed free of charge. If you wish to reproduce multiple copies of the PTSD Guidelines, there is a reprint charge of $1.25/copy. Please mail this form with check or money order to: Judy Beach Physicians Postgraduate Press 6555 Quince Road, Suite 501 Memphis, TN 38119 Check or money order enclosed for _______ copies @ $1.25/copy = $_________ THE JOURNAL OF CLINICAL PSYCHIATRY VOLUME 60 1999 SUPPLEMENT 16 SUPPLEMENT The Expert Consensus Guideline Series TREATMENT OF POSTTRAUMATIC STRESS DISORDER EDITORS FOR THE GUIDELINES Edna B. Foa, Jonathan R. T. Davidson, and Allen Frances LETTERS TO THE EDITOR THE JOURNAL OF CLINICAL PSYCHIATRY VOLUME 60 1999 The Journal of Clinical Psychiatry (ISSN 0160-6689) is owned and published monthly by Physicians Postgraduate Press, Inc., P.O. Box 752870, Memphis, TN 38175-2870. Physicians Postgraduate Press, Inc., does not hold itself responsible for statements made by contributors in the Journal. The Journal of Clinical Psychiatry is indexed in Index Medicus, Excerpta Medica, Psychological Abstracts, Current Contents, Science Citation Index, Hospital Literature Index, Biological Abstracts, Cumulative Index of Allied Health and Nursing, International Nursing, Industrial Medicine, Chemical Abstracts, and Adolescent Mental Health Abstracts. The Journal of Clinical Psychiatry requires the express transfer of copyright to Physicians Postgraduate Press, Inc., so that the author(s) and Physicians Postgraduate Press, Inc., are protected from misuse of copyrighted material. All submissions must be accompanied by a copyright transfer signed by all authors. A $3.00 fee per article for photocopying material appearing in the Journal is payable to Physicians Postgraduate Press. This fee is waived in lieu of a specific charge to be determined on a case-bycase basis for classroom and library use; it is the responsibility of the institution or individual to obtain permission for such use. All advertising accepted conforms to high medical standards. Acceptance does not imply endorsement by Physicians Postgraduate Press, Inc. © Copyright 1999 Physicians Postgraduate Press, Inc. All rights reserved. BOARD OF EDITORS Editor in Chief ................................ Alan J. Gelenberg, M.D. Deputy Editor .................................. Eric M. Reiman, M.D. Deputy Editor .................................. Michael H. Ebert, M.D. EDITORIAL BOARD Geoffrey L. Ahern, M.D., Ph.D. Hagop S. Akiskal, M.D. Judith V. Becker, Ph.D. Joseph Biederman, M.D. Jonathan F. Borus, M.D. Rubin Bressler, M.D. Andrew W. Brotman, M.D. James L. Claghorn, M.D. Paula J. Clayton, M.D. Jonathan O. Cole, M.D. Pedro L. Delgado, M.D. William E. Falk, M.D. Ellen Frank, Ph.D. Jack M. Gorman, M.D. John H. Greist, M.D. George T. Grossberg, M.D. Bernard I. Grosser, M.D. John G. Gunderson, M.D. David B. Herzog, M.D. Robert M.A. Hirschfeld, M.D. James W. Jefferson, M.D. Dilip V. Jeste, M.D. John M. Kane, M.D. T. Byram Karasu, M.D. Paul E. Keck, Jr., M.D. Samuel J. Keith, M.D Martin B. Keller, M.D. Donald F. Klein, M.D. Philip W. Lavori, Ph.D. R. Bruce Lydiard, M.D., Ph.D. Stephen R. Marder, M.D. Susan L. McElroy, M.D. Herbert Y. Meltzer, M.D. Roger E. Meyer, M.D. Mark J. Mills, M.D., J.D. Erwin B. Montgomery, Jr., M.D. George B. Murray, M.D. Henry A. Nasrallah, M.D. Mark H. Pollack, M.D. Harrison G. Pope, Jr., M.D. Michael K. Popkin, M.D. Robert M. Post, M.D. Robert F. Prien, Ph.D. Frederic M. Quitkin, M.D. John C. Racy, M.D. Judith L. Rapoport, M.D. Steven A. Rasmussen, M.D. Elliott Richelson, M.D. Steven P. Roose, M.D. Patricia I. Rosebush, M.D., F.R.C.P.C. Jerrold F. Rosenbaum, M.D. A. John Rush, Jr., M.D. José M. Santiago, M.D. Nina R. Schooler, Ph.D. Mogens Schou, M.D. George M. Simpson, M.D. Gary W. Small, M.D. Susan E. Swedo, M.D. John A. Talbott, M.D. Michael E. Thase, M.D. Richard D. Weiner, M.D., Ph.D. Roger D. Weiss, M.D. PUBLICATION STAFF Publisher .......................................... John S. Shelton, Ph.D. Publisher Emeritus .......................... Irving Shelton Director of Operations .................... Judy Beach Managing Editor ............................. Meg M. Waters Senior Editor ................................... Kathryn Hedges Assistant Editor ............................... David M. Twombly Assistant Editor ............................... Jennifer L. Gentry Senior Proofreader .......................... Kathy E. Shassere Proofreader ...................................... David Spicer Graphic Arts Manager .................... Faye M. Green Graphics Assistant .......................... F. Grant Whittle Graphics Assistant .......................... Erik Adamec CME Coordinator ............................ Anne M. Bechard Publications Coordinator ................ Anna Kwapien Project Director ............................... Jane B. Eckstein Circulation Manager ....................... Sharon Landers Publications Manager ..................... C. J. Firestone Advertising Director ....................... J. Sherman LETTERS TO THE EDITOR Visit our web site at www.psychiatrist.com. SUPPLEMENT 16 Expert Consensus Guideline Series Treatment of Posttraumatic Stress Disorder Editors for the Guidelines Edna B. Foa, Ph.D., Jonathan R. T. Davidson, M.D., Allen Frances, M.D. Editor for the Primary Care Version Larry Culpepper, M.D., M.P.H. Consultant for Patient-Family Educational Materials Anxiety Disorders Association of America (ADAA) Editing and Design Ruth Ross, M.A., David Ross, M.A., M.C.E., Ross Editorial Disclaimer: Any set of guidelines can provide only general suggestions for clinical practice and practitioners must use their own clinical judgment in treating and addressing the needs of each individual patient, taking into account that patient’s unique clinical situation. There is no representation of the appropriateness or validity of these guideline recommendations for any given patient. The developers of the guidelines disclaim all liability and cannot be held responsible for any problems that may arise from their use. This project was supported by unrestricted educational grants from Abbott Laboratories Bristol-Myers Squibb Copyright © 1999 by Expert Consensus Guidelines, LLC, Eli Lilly and Co. all rights reserved. Janssen Pharmaceutica, Inc. PUBLISHED BY PHYSICIANS POSTGRADUATE PRESS, INC. Pfizer Inc For reprints of this Supplement, contact Solvay Pharmaceuticals. Physicians Postgraduate Press, Inc. THE JOURNAL OF CLINICAL PSYCHIATRY VOLUME 60 1999 SUPPLEMENT 16 Treatment of Posttraumatic Stress Disorder 4 The Expert Consensus Panels for PTSD 6 Introduction 7 How to Use the Guidelines GUIDELINES I. Diagnosis 10 Guideline 1: How to Recognize PTSD II. Selecting Initial Treatment Strategies 12 14 18 Guideline 2: Selecting the Overall Treatment Strategy Guideline 3: Selecting the Initial Psychotherapy Guideline 4: Selecting the Initial Medication III.What to Do After the Initial Trial 24 26 28 29 Guideline 5: When the Patient Has Had No Response Guideline 6: When the Patient Has Only a Partial Response Guideline 7: When the Patient Has Not Responded to Multiple Previous Treatments Guideline 8: When the Patient Has a Remission or Good Response: Strategies for the Maintenance Phase IV. Other Treatment Issues 30 31 31 Guideline 9: Medication Dosing Guideline 10: Enhancing Compliance Guideline 11: Prevention of PTSD and Avoiding Chronicity V. Primary Care 32 Primary Care Treatment Guide for Posttraumatic Stress Disorder SURVEY RESULTS 34 Survey Questions Answered by All the Experts 44 Survey Questions Answered Only by Psychotherapy Experts 52 Survey Questions Answered Only by Medication Experts 69 A GUIDE FOR PATIENTS AND FAMILIES Expert Consensus Guideline Series The Expert Consensus Panels for PTSD The recommendations in the guidelines are derived from the statistically aggregated opinions of the groups of experts and do not necessarily reflect the opinion of each individual expert on each question. Psychotherapy Experts The following participants in the Psychotherapy Expert Consensus Survey were identified from several sources: recent publications, recipients of research grants, and the membership of the International Society for Traumatic Stress Studies and the American Association of Behavioral Therapists. Of the 55 experts to whom we sent the PTSD psychotherapy survey, 52 (95%) replied. Gerald C. Davison, Ph.D. University of Southern California, Los Angeles Grant J. Devilly, M.C.P. University of Queensland, Australia Anke Ehlers, Ph.D. University of Oxford Donald Meichenbaum, Ph.D. University of Waterloo, Ontario Pallavi Nishith, Ph.D. University of Missouri Laurie Anne Pearlman, Ph.D. Traumatic Stress Institute, Center for Adult & Adolescent Psychotherapy, South Windsor, CT John A. Fairbank, Ph.D. Duke University Medical Center David Pelcovitz, Ph.D. NYU School of Medicine David H. Barlow, Ph.D. Boston University Jean Beckham, Ph.D. Duke University Medical Center, Durham VAMC Lucy Berliner, M.S.W. Harborview Center, Seattle Jonathan Bisson, B.M., M.R.C.Psych. Gabalfa Clinic, Cardiff, UK Arthur S. Blank, Jr., M.D. Uniformed Services University of Health Sciences and Washington Psychoanalytic Institute, Washington, DC Sandra L. Bloom, M.D. The Sanctuary, Horsham Clinic, Ambler, PA Patrick A. Boudewyns, Ph.D. Augusta VAMC Elizabeth Brett, Ph.D. Yale University School of Medicine John Briere, Ph.D. USC School of Medicine, Los Angeles Claude M. Chemtob, Ph.D. Stress Disorder Laboratory, Pacific Island Division, VA National Center for PTSD Marylene Cloitre, Ph.D. Cornell University Medical College Judy Cohen, M.D. Allegheny General Hospital, Pittsburgh Christine Courtois, Ph.D. Private Practice, Washington, DC Constance V. Dancu, Ph.D. Center for Cognitive and Behavior Therapy, Wilmington, DE 4 Sherry A. Falsetti, Ph.D. National Crime Victims Research & Treatment Center, Charleston, SC Charles Figley, Ph.D. Florida State University David W. Foy, Ph.D. Pepperdine University Berthold P. R. Gersons, M.D., Ph.D. University of Amsterdam Lisa H. Jaycox, Ph.D. RAND David Read Johnson, Ph.D. Post Traumatic Stress Center, New Haven, CT Richard J. Katz, Ph.D. Novartis Pharmaceuticals Terence M. Keane, Ph.D. Boston VAMC/Boston University School of Medicine Mary P. Koss, Ph.D. University of Arizona Janice Krupnick, Ph.D. Georgetown University Medical Center Andrew M. Leeds, Ph.D. Private practice, Santa Rosa, CA Jeffrey M. Lohr, Ph.D. University of Arkansas Isaac Marks, M.D. Institute of Psychiatry, London Richard J. McNally, Ph.D. Harvard University Elizabeth Meadows, Ph.D. Central Michigan University Patricia Resick, Ph.D. University of Missouri, St. Louis Heidi Resnick, Ph.D. Medical University of South Carolina Lizabeth Roemer, Ph.D. University of Massachusetts, Boston Susan Roth, Ph.D. Duke University Barbara Olasov Rothbaum, Ph.D. Emory University School of Medicine Philip Saigh, Ph.D. Educational Psychology, New York M. Tracie Shea, Ph.D. Brown University Medical School/Providence VAMC Mervin R. Smucker, Ph.D. Cognitive Therapy Institute of Milwaukee Larry D. Smyth, Ph.D. Post Traumatic Stress Clinic/Havre DeGrace, MD Susan Solomon, Ph.D. National Institutes of Health David Spiegel, M.D. Stanford University School of Medicine Sandra A. Wilson, Ph.D. Spencer Curtis Foundation, Colorado Springs Rachel Yehuda, Ph.D. Mount Sinai Hospital Center William Yule, Ph.D. Institute of Psychiatry, University of London Rose Zimering, Ph.D. Boston VAMC J Clin Psychiatry 1999;60 (suppl 16) Treatment of Posttraumatic Stress Disorder Medication Experts The following participants in the Medication Expert Consensus Survey were identified from several sources: recent publications, recipients of research grants, and the membership of the International Society for Traumatic Stress Studies, the Society for Biological Psychiatry, and the American Society for Clinical Psychopharmacology. Of the 61 experts to whom we sent the PTSD medication survey, 57 (93%) replied. Mark B. Hamner, M.D. Charleston VAMC Michael A. Hertzberg, M.D. Durham VAMC Rudolf Hoehn-Saric, M.D. Johns Hopkins University Are Holen, M.D., Ph.D. Norwegian University of Science and Technology Mardi J. Horowitz, M.D. Langley Porter Psychiatric Inst., San Francisco Lisa Amaya-Jackson, M.D., M.P.H. Duke University Medical Center Dewleen Baker, M.D. Johan E. Hovens, M.D., Ph.D. Delta Psychiatric Hospital, Poortugaal, Netherlands Dallas VAMC Roger K. Pitman, M.D. VAMC Manchester, NH Mark Pollack, M.D. Massachusetts General Hospital Frank W. Putnam, M.D. Children’s Hospital Medical Center, Cincinnati Scott L. Rauch, M.D. Massachusetts General Hospital Richard J. Ross, M.D., Ph.D. Philadelphia VAMC Pierre-Alain Savary, M.D. Cincinnati VAMC Kenneth O. Jobson, M.D. H. Stefan Bracha, M.D. Frederick Petty, M.D., Ph.D. Psychiatry and Psychopharm Services, Knoxville, TN Commission de psychiatrie de guerre et de catastrophe, Nyon, Switzerland National Center for PTSD, VAMROC, Honolulu Paul E. Keck, Jr., M.D. Kathleen Brady, M.D., Ph.D. University of Cincinnati College of Medicine Arieh Shalev, M.D. Hadassah University Hospital, Jerusalem Medical University of South Carolina John H. Krystal, M.D. J. Douglas Bremner, M.D. VA Connecticut Healthcare System Steven M. Southwick, M.D. Yale University School of Medicine Yale Psychiatric Institute Harold Kudler, M.D. Timothy Brewerton, M.D. Duke University Medical Center, Durham VAMC Vladan Starcevic, M.D., Ph.D. Institute of Mental Health, Belgrade, Yugoslavia Medical University of South Carolina Bernard Lerer, M.D. Marian I. Butterfield, M.D., M.P.H. Hadassah-Hebrew University Medical Center Dan J. Stein, M.D. University of Stellenbasch, South Africa Durham VAMC Michael R. Liebowitz, M.D. Alexander Bystritsky, M.D. New York State Psychiatric Institute Suzanne M. Sutherland, M.D. Duke University Medical Center University of California Los Angeles Hadar Lubin, M.D. Dennis S. Charney, M.D. Yale University School of Medicine Stuart Turner, M.D. The Traumatic Stress Clinic, London Yale University School of Medicine John March, M.D. Kathryn M. Connor, M.D. Duke University Medical Center Duke University Medical Center Robert Ursano, M.D. Uniformed Services University School of Medicine, Kensington, MD Randall D. Marshall, M.D. Nicholas J. Coupland, M.B., Ch.B. Columbia University University of Alberta Bessel van der Kolk, M.D. Boston University Alexander C. McFarlane, M.D. Daniela David, M.D., M.Sc. University of Adelaide, Australia University of Miami Wybrand Op den Velde, M.D. St. Lucas Andreas Hospital, Amsterdam Patrick McGorry, Ph.D., F.R.A.N.Z.C.P. Rodrigo Escalona, M.D. University of New Mexico Matthew Friedman, M.D., Ph.D. National Center for PTSD, White River Junction, VT Ulrich Frommberger, M.D. Freiburg Medical School, Germany J. Christian Gillin, M.D. University of California San Diego, San Diego VAMC John H. Greist, M.D. Healthcare Technology Systems, Madison, WI J Clin Psychiatry 1999;60 (suppl 16) Center for Young People’s Mental Health, Australia Thomas A. Mellman, M.D. University of Miami School of Medicine Charles B. Nemeroff, M.D., Ph.D. Emory University School of Medicine I. P. Burges Watson, M.R.C. Psych., F.R.A.N.Z.C.P. University of Tasmania Lars Weisaeth, M.D. University of Oslo Sidney Zisook, M.D. University of California San Diego Thomas C. Neylan, M.D. University of California, San Francisco H. George Nurnberg, M.D. University of New Mexico 5 Expert Consensus Guideline Series Introduction H ow often have you wished that you had an expert on hand to advise you on how best to help a patient who is not responding well to treatment or is having a serious complication? Unfortunately, of course, an expert is usually not at hand, and even if a consultation were available, how would you know that any one expert opinion represents the best judgment of our entire field? This is precisely why we began the Expert Consensus Guidelines Series. Our practical clinical guidelines for treating the major mental disorders are based on a wide survey of the best expert opinion. These are meant to be of immediate help to you in your everyday clinical work. Let’s begin by asking and answering four questions that will help put our effort in context. How do these Expert Consensus Guidelines relate to (and differ from) the other guidelines that are already available in the literature? Each of our guidelines builds upon existing guidelines but goes beyond them in a number of ways: 1. We focus our questions on the most specific and crucial treatment decisions for which detailed recommendations are usually not made in the more generic guidelines that are currently available. 2. We survey the opinions of a large number of the leading experts in each field and have achieved a remarkably high rate of survey response (over 90% for these PTSD guidelines), ensuring that our recommendations are authoritative and represent the best in current expert opinion. 3. We report the experts’ responses to each question in a detailed and quantified way (but one that is easy to understand) so that you can evaluate the relative strength of expert opinion supporting the guideline recommendations. 4. The guidelines are presented in a simple format. It is easy to find where each patient’s problem fits in and what the experts would suggest you do next. 5. To ensure the widest possible implementation of each of the guidelines, we are undertaking a number of educational activities and research projects, consulting with policy makers in the public sector and in managed care, and maintaining a web page (www.psychguides.com). Why should we base current treatment decisions on expert consensus instead of the relevant treatment studies in the research literature and evidence-based guidelines? There are three reasons why expert consensus remains an important addition: 1. Most research studies are difficult to generalize to everyday clinical practice. The typical patient who causes us the most concern usually presents with comorbid disorders, has not responded to previous treatment efforts, and/or requires a number of different treatments delivered in combination or sequentially. Such individuals are almost universally excluded from clinical trials. We need practice guidelines for help with those patients who would not meet the narrow selection criteria used in most research studies. 2. The available controlled research studies do not, and cannot possibly, address all the variations and contingencies that arise in clinical practice. Expert-generated guidelines are needed because clinical practice is so complicated that it is 6 constantly generating far too many questions for the clinical research literature to ever answer comprehensively with systematic studies. 3. Changes in the accepted best clinical practice often occur at a much faster rate than the necessarily slower-paced research efforts that would eventually provide scientific documentation for the change. As new treatments become available, clinicians often find them to be superior for indications that go beyond the narrower indications supported by the available controlled research. For all these reasons, the aggregation of expert opinion is a crucial bridge between the clinical research literature and clinical practice. How valid are the expert opinions provided in these guidelines, and how much can I trust the recommendations? We should be better able to answer this question when our current research projects on guideline implementation are completed. For now, the honest answer is that we simply don’t know. Expert opinion must always be subject to the corrections provided by the advance of science. Moreover, precisely because we asked the experts about the most difficult questions facing you in clinical practice, many of their recommendations must inevitably be based on incomplete research information and may have to be revised as we learn more. Despite this, the aggregation of the universe of expert opinion is often the best tool we have to develop guideline recommendations. Certainly the quantification of the opinions of a large number of experts is likely to be much more trustworthy than the opinions of any small group of experts or of any single person. Why should I use treatment guidelines? First, no matter how skillful or artful any of us may be, there are frequent occasions when we feel the need for expert guidance and external validation of our clinical experience. Second, our field is becoming standardized at an ever more rapid pace. The only question is, who will be setting the standards? We believe that practice guidelines should be based on the very best in clinical and research opinion. Otherwise, they will be dominated by other less clinical and less scientific goals (e.g., pure cost reduction, bureaucratic simplicity). Third, it should be of some comfort to anyone concerned about losing clinical art under the avalanche of guidelines that the complex specificity of clinical practice will always require close attention to the individual clinical situation. Guidelines can provide useful information but are never a substitute for good clinical judgment and common sense. Our guidelines are already being used throughout the country and seem to be helpful not only to clinicians but also to policy makers, administrators, case managers, mental health educators, patient advocates, and clinical and health services researchers. Ultimately, of course, the purpose of this whole enterprise is to do whatever we can to improve the lives of our patients. It is our hope that the expert advice provided in these guidelines will make our treatments ever more specific and effective. Allen Frances, M.D. J Clin Psychiatry 1999;60 (suppl 16) Treatment of Posttraumatic Stress Disorder How to Use the Guidelines T he Expert Consensus Guidelines for the Treatment of Posttraumatic Stress Disorder (PTSD) are based on surveys of 52 experts on the psychotherapy treatment and 57 experts on the medication treatment of PTSD. We thank all the experts who gave of their time and expertise in participating in the surveys. Analyzing and Presenting the Results The actual questions and results of the medication and psychotherapy treatment surveys are presented in the second half of this publication (pp. 34–68). As an example, the results of Psychotherapy Survey Question 20 are presented graphically as shown on the next page. For most questions, we present: METHOD OF DEVELOPING EXPERT CONSENSUS GUIDELINES x the question as it was posed to the experts x the treatment options ordered as they were rated by the experts x a bar chart depicting the confidence intervals for each of the choices x a table of mean scores and frequency distributions Creating the Surveys We first created a skeleton algorithm based on the existing 1 research literature and other guidelines to identify key decision points in the everyday treatment of patients with PTSD. We highlighted important clinical questions that had not yet been 2,3 adequately addressed or definitely answered. We then developed two written questionnaires, one on medication treatments and one on psychotherapy treatments. The Rating Scale The survey questionnaires used a 9-point scale slightly modified from a format developed by the RAND Corporation for 4 ascertaining expert consensus. We presented the rating scale to the experts with the following anchor points: Extremely Inappropriate 1 2 3 4 5 6 7 8 9 Extremely Appropriate 9 = extremely appropriate: this is your treatment of choice 7–8 = usually appropriate: a 1st line treatment you would often use 4–6 = equivocal: a 2nd line you would sometimes use (e.g., patient/family preference or if 1st line treatment is ineffective, unavailable, or unsuitable) 2–3 = usually inappropriate: a treatment you would rarely use 1 = extremely inappropriate: a treatment you would never use Below is Psychotherapy Survey Question 20 as an example of our question format. 20. Please rate the appropriateness of each of the following formats for psychotherapy sessions during the initial phase (first 3 months) of treatment for PTSD. Individual 1 2 3 4 5 6 7 8 9 Family 1 2 3 4 5 6 7 8 9 Therapist-led PTSD group 1 2 3 4 5 6 7 8 9 Self-help PTSD group 1 2 3 4 5 6 7 8 9 Combination of individual and group therapy 1 2 3 4 5 6 7 8 9 Combination of individual and family therapy 1 2 3 4 5 6 7 8 9 J Clin Psychiatry 1999;60 (suppl 16) In some cases, to save space, we present only the numerical results in a tabular form or summarize the results verbally. Complete results for these questions are available from the editors on request. 95% Confidence Intervals. In analyzing the results of the survey questions, we first calculated the mean (Avg), standard deviation (SD), and confidence interval (CI) for each item. The CI is a statistically calculated range which tells you that there is a 95% chance that the mean score would fall within that range if the survey were repeated with a similar group of experts. The CIs for each treatment option are shown as horizontal bars. When the bars do not overlap, it indicates that there is a statistically significant difference between the mean scores of the two choices. Rating Categories. We designated a rating of first, second, or third line for each item, determined by the category into which the 95% CI of its mean score fell. In assigning a rating for each item, we followed a stringent rule to avoid chance upgrading and assigned the lowest rating into which the confidence interval fell. For example, if the bottom of the confidence interval even bordered on the next lower category, we considered the item to be in the lower group. The following graphic conventions are used to indicate the different rating categories. * Treatments of choice (items rated “9” by at least half the experts) First line (the entire CI had to fall at or above a score of 6.5 or greater) Second line (the CI had to fall between 3.5 and 6.49) Third line (a portion of the CI had to fall below 3.5) Numeric Values. Next to the chart we give a table of numeric values for the mean score (Avg) and standard deviation (SD) for each item, and the percentage of experts who rated the option treatment of choice (9), first line (7–9), second line (4–6), and third line (1–3). (Note: the percentage for treatment of choice [Tr of Chc] is also included in the total percentage for first line.) 7 Expert Consensus Guideline Series 20 Please rate the appropriateness of each of the following formats for psychotherapy sessions during the initial phase (first 3 months) of treatment for PTSD. Tr of 1st 2nd 3rd 95% CONFIDENCE INTERVALS Third Line Second Line First Line Avg(SD) Chc Line Line Line * Individual 81 98 0 2 Combination of individual and group therapy 6.7(1.7) 17 56 42 2 Combination of individual and family therapy 6.4(1.7) 10 50 42 8 Therapist-led PTSD group 6.0(1.9) 12 40 48 12 Family 5.3(1.9) 4 23 58 19 3.7(1.9) 2 % 8 % 38 % 54 % Self-help PTSD group 1 2 3 What the Ratings Mean First line treatments are options that the panel feels are usually appropriate as initial treatment for a given situation. Treatment of choice, when it appears, is an especially strong first line recommendation (having been rated as “9” by at least half the experts). In choosing between several first line recommendations, or deciding whether to use a first line treatment at all, clinicians should consider the overall clinical situation, including the patient’s prior response to treatment, side effects, general medical problems, and patient preferences. Second line treatments are reasonable choices for patients who cannot tolerate or do not respond to the first line choices. Alternatively, you might select a second line choice as your initial treatment if the first line options are deemed unsuitable for a particular patient (e.g., because of poor previous response, inability to follow psychotherapy instructions, inconvenient dosing regimen, particularly annoying side effects, a general medical contraindication, a potential drug-drug interaction, or if the experts don’t agree on a first line treatment). For some questions, second line ratings dominated, especially when the experts did not reach any consensus on first line options. In such cases, to differentiate within the pack, we label those items whose confidence intervals overlap with the first line category as “high second line.” Third line treatments are usually inappropriate or used only when preferred alternatives have not been effective. From Survey Results to Guidelines After the survey results were analyzed and ratings assigned, the next step was to turn these recommendations into userfriendly guidelines. For example, the results of Survey Question 20 presented above are shown on p. 50 and are used in Guideline 2C: Level of Care during the Initial Phase of Treatment (p. 13). The graphic for Survey Question 20 shows that the experts rated individual psychotherapy sessions as first line, since the bar for this option falls entirely within the first line category. In addition, because 81% of the experts rated individual sessions as 9, they are considered the treatment format of choice (indicated by the star in the bar). The bars for a combination of individual 8 8.7(1.2) 4 5 6 7 8 9 and group or family therapy straddle the first and second line categories, resulting in a “top tier” second line designation for these two options. Guideline 2C therefore recommends individual psychotherapy sessions as the format of choice for psychotherapy during the acute phase of treatment (first 3 months or until the patient is stabilized) and suggests that clinicians also consider a combination of individual and group or family therapy. Whenever the guideline gives more than one treatment in a rating category, we list them in the order of their mean scores. LIMITATIONS AND ADVANTAGES OF THE GUIDELINES These guidelines can be viewed as an expert consultation, to be weighed in conjunction with other information and in the context of each individual patient-physician relationship. The recommendations do not replace clinical judgment, which must be tailored to the particular needs of each clinical situation. We describe groups of patients and make suggestions intended to apply to the average patient in each group. However, individual patients will differ greatly in their treatment preferences and capacities, their history of response to previous treatments, their family history of treatment response, and their tolerance for different side effects. Therefore, the experts’ first line recommendations will certainly not be appropriate in all circumstances. We remind readers of several other limitations of these guidelines: 1. The guidelines are based on a synthesis of the opinions of a large group of experts. From question to question, some of the individual experts would differ with the consensus view. 2. We have relied on expert opinion precisely because we are asking crucial questions that are not yet well answered by the literature. One thing that the history of medicine teaches us is that expert opinion at any given time can be very wrong. Accumulating research will ultimately reveal better and clearer answers. Clinicians should therefore stay abreast of the literature for developments that would make at least some of our recommendations obsolete. We will continue to revise the guidelines periodically based on new research information and on reassessment of expert opinion to keep them up-to-date. J Clin Psychiatry 1999;60 (suppl 16) Treatment of Posttraumatic Stress Disorder 3. The guidelines are financially sponsored by the pharmaceutical industry, which could possibly introduce biases. Because of this, we have made every step in guideline development transparent, report all results, and take little or no editorial liberty. 4. These guidelines are comprehensive but not exhaustive; because of the nature of our method, we omit some interesting topics on which we did not query the expert panel. Despite these limitations, the Expert Consensus Guideline 5–9 Series represents a significant advance because of the guidelines’ specificity, ease of use, and the credibility that comes from achieving a very high response rate from a large sample of the leading experts in the field. SUGGESTED TOUR The best way to use these guidelines is first to read the Table of Contents to get an overview of how the document is organized. Next, read through the individual guidelines. Finally, you may find it fascinating to compare your opinions with those of the experts on each of the questions; we strongly recommend that you use the detailed survey results presented in the second half of this publication in this way. The guidelines are organized so that clinicians can quickly locate the experts’ treatment recommendations. The recommendations are presented in 11 easy-to-use tabular guidelines that are organized into four sections: I. II. III. IV. Diagnosis (pp. 10–11) Selecting Initial Treatment Strategies (pp. 12–23) What to Do After the Initial Trial (pp. 24–29) Other Treatment Issues (pp. 30–31) We also include a Primary Care Treatment Guide (pp. 32–33) that summarizes the key recommendations in an easy-to-use format for primary care practitioners. The guidelines are followed by a summary of the results of the treatment surveys (pp. 34–68). Finally, we include a patient-family educational handout (pp. 69–76) that can be reproduced for distribution to families and patients. We gratefully acknowledge the Anxiety Disorders Association of America for their help in developing these educational materials. The data supporting the recommendations given in the guidelines are referenced by means of numbered notes on the guideline pages. These notes refer to specific questions and answers in the two expert surveys that were used to develop the guideline recommendations. Let’s examine how a clinician might use the guidelines in selecting a treatment for a hypothetical patient who presents with J Clin Psychiatry 1999;60 (suppl 16) what appears to be acute PTSD. In the table of contents, the clinician locates Guideline 1: How to Recognize PTSD (p. 10) and uses the information there to assist in evaluating the patient and confirming the diagnosis of PTSD. The clinician can then go to Guideline 2: Selecting the Overall Treatment Strategy (p. 12), for information on the appropriateness of starting treatment with psychotherapy or medication or a combination of both, depending on the age of the patient and the severity and chronicity of symptoms. Information on selecting specific psychotherapy techniques and medications for different types of presentations are covered in Guideline 3: Selecting the Initial Psychotherapy (p. 14) and Guideline 4: Selecting the Initial Medication (p. 18). If the patient does not have an adequate response to the initial treatment strategy selected, the clinician can then refer to Section III. What to Do Next after the Initial Trial (p. 24). No set of guidelines can ever improve practice if read just once. These guidelines are meant to be used in an ongoing way, since each patient’s status and phase of illness will require different interventions at different times. Locate your patient’s problem or your question about treatment in the Table of Contents and compare your plan with the guideline recommendations. We believe the guideline recommendations will reinforce your best judgment when you are in familiar territory and help you with new suggestions when you are in a quandary. References 1. Foa EB, Keane TM, Friedman MJ. PTSD Treatment Guidelines. New York: Guilford (in press) 2. Frances A, Kahn D, Carpenter D, Frances C, Docherty J. A new method of developing expert consensus practice guidelines. Am J Man Care 1998;4:1023–1029 3. Kahn DA, Docherty JP, Carpenter D, Frances A. Consensus methods in practice guideline development: a review and description of a new method. Psychopharmacol Bull 1997;33:631–639 4. Brook RH, Chassin MR, Fink A, et al. A method for the detailed assessment of the appropriateness of medical technologies. International Journal of Technology Assessment in Health Care 1986;2:53– 63 5. Kahn DA, Carpenter D, Docherty JP, Frances A. The expert consensus guideline series: treatment of bipolar disorder. J Clin Psychiatry 1996;57(suppl 12A):1–88 6. McEvoy JP, Weiden PJ, Smith TE, Carpenter D, Kahn DA, Frances A. The expert consensus guideline series: treatment of schizophrenia. J Clin Psychiatry 1996;57(suppl 12B):1–58 7. March JS, Frances A, Carpenter D, Kahn DA. The expert consensus guideline series: treatment of obsessive-compulsive disorder. J Clin Psychiatry 1997;58(suppl 4):1–72 8. Alexopoulos GS, Silver JM, Kahn DA, Frances A, Carpenter D. The expert consensus guideline series: treatment of agitation in older persons with dementia. Postgraduate Medicine Special Report, April 1998:1–88 9. McEvoy JP, Scheifler PL, Frances A. The expert consensus guideline series: treatment of schizophrenia 1999. J Clin Psychiatry 1999;60(suppl 11):1–80 9 Expert Consensus Guideline Series I. DIAGNOSIS Guideline 1: How to Recognize PTSD 1A: The Types of Extreme Stressors That Cause PTSD Type of stressor Examples Serious accident Car, plane, boating, or industrial accident Natural disaster Tornado, hurricane, flood, or earthquake Criminal assault Being physically attacked, mugged, shot, stabbed, or held at gunpoint Military Serving in an active combat theater Sexual assault Rape or attempted rape Child sexual abuse Incest, rape, or sexual contact with an adult or much older child Child physical abuse or severe neglect Beatings, burning, restraints, starvation Hostage/imprisonment/torture Being kidnapped or taken hostage, terrorist attack, torture, incarceration as a prisoner of war or in a concentration camp, displacement as a refugee Witnessing or learning about traumatic events Witnessing a shooting or devastating accident, sudden unexpected death of a loved one 1B: The Impact of the Stressor The stressor must be extreme, not just severe The event involved actual or threatened death, serious injury, rape, or childhood sexual abuse. Would not include many frequently encountered stressors that are severe but not extreme (e.g., losing a job, divorce, failing in school, expected death of a loved one). The stressor causes powerful subjective responses The person experienced intense fear, helplessness, or horror. 1C: The Key Symptoms of PTSD Key symptoms Examples Reexperiencing the traumatic event x Intrusive, distressing recollections of the event x Flashbacks (feeling as if the event were recurring while awake) x Nightmares (the event or other frightening images recur frequently in dreams) x Exaggerated emotional and physical reactions to triggers that remind the person of the event Avoidance x Of activities, places, thoughts, feelings, or conversations related to the trauma Emotional numbing x Loss of interest x Feeling detached from others x Restricted emotions Increased arousal x Difficulty sleeping x Irritability or outbursts of anger x Difficulty concentrating x Hypervigilance x Exaggerated startle response 10 J Clin Psychiatry 1999;60 (suppl 16) Treatment of Posttraumatic Stress Disorder 1D: The Duration of Symptoms If the duration of symptoms is The diagnosis is Comments Less than 1 month Acute stress disorder (not PTSD) These are symptoms that occur in the immediate aftermath of the stressor and may be transient and self-limited. Although not yet diagnosable as PTSD, the presence of severe symptoms during this period is a risk factor for developing PTSD. 1–3 months Acute PTSD Active treatment during this acute phase of PTSD may help to reduce the otherwise high risk of developing chronic PTSD. 3 months or longer Chronic PTSD Long-term symptoms may need longer and more aggressive treatment and are likely to be associated with a higher incidence of cormorbid disorders. 1E: The Most Common Comorbid Disorders in a Patient with PTSD Because PTSD often co-occurs with the disorders listed below, it is useful to screen for them in any patient with PTSD and to take them into account in treatment planning. (See Guidelines 2B, 3B, and 4C for information about selecting treatments for PTSD when it is accompanied by complicating comorbidity.) Comorbid conditions x Substance abuse or dependence x Major depressive disorder x Panic disorder/agoraphobia x Generalized anxiety disorder x Obsessive-compulsive disorder x Social phobia x Bipolar disorder J Clin Psychiatry 1999;60 (suppl 16) 11 Expert Consensus Guideline Series II. SELECTING INITIAL TREATMENT STRATEGIES Guideline 2: Selecting the Overall Treatment Strategy 2A: Sequencing Treatments: Whether to Start with Psychotherapy, Medication, or a Combination of Both This guideline provides information on the sequencing of psychotherapy and medication in the treatment of PTSD. We asked the same questions of two separate groups: psychotherapy experts and medication experts. Both groups recommended psychotherapy as a first line treatment for PTSD, but the medication experts were much more likely to combine medication with psychotherapy from the start, especially for those patients with more severe or chronic problems. 1 2 Age Severity Acute PTSD In children and younger adolescents Milder Psychotherapy first Psychotherapy first More severe Psychotherapy first* or Combination of medication and psychotherapy* Psychotherapy first* or Combination of medication and psychotherapy* In older adolescents and adults Milder Psychotherapy first Psychotherapy first† or Combination of medication and psychotherapy† More severe Psychotherapy first* or Combination of medication and psychotherapy* Psychotherapy first* or Combination of medication and psychotherapy* Milder Psychotherapy first Psychotherapy first More severe Psychotherapy first* or Combination of medication and psychotherapy* Psychotherapy first* or Combination of medication and psychotherapy* In geriatric patients Chronic PTSD *On this question, the psychosocial experts preferred psychotherapy first, whereas the medication experts preferred combination treatment. †On this question, the medication experts rated both psychotherapy and combined treatment first line, while the psychosocial experts preferred psychotherapy first. 1 Question 1 12 2 Question 2 J Clin Psychiatry 1999;60 (suppl 16) Treatment of Posttraumatic Stress Disorder 2B: Sequencing Treatments When PTSD Presents with Psychiatric Comorbidity When a comorbid psychiatric disorder is present, the experts recommend treating PTSD with a combination of both psychotherapy and medication from the start. It is therefore vital that questions about comorbidity and substance use should be included in the evaluation of every patient with PTSD. Comorbid condition Depressive disorder Bipolar disorder Recommended strategy 3 Combine psychotherapy and medication from the start 3 Combine psychotherapy and medication from the start Other anxiety disorders (e.g., panic disorder, social phobia, obsessive-compulsive 3 disorder, generalized anxiety disorder) Substance abuse or dependence 3 Combine psychotherapy and medication from the start 4 Milder problems with substance abuse Provide treatment for both substance abuse and PTSD simultaneously More severe problems with substance abuse Treat substance abuse problems first or Provide treatment for both substance abuse and PTSD simultaneously Question 3 4 Question 4 2C: Level of Care During the Initial Phase of Treatment (First 3 Months or Until Stabilized) During the initial stage of treatment, the experts recommend that psychotherapy should generally be delivered weekly in individual sessions of about 60 minutes duration. Weekly medication visits are recommended for the first month, with visits every other week thereafter. Recommendations for treatment intensity during the maintenance phase are given in Guideline 8. (bold italics = treatment of choice) 5 Frequency of psychotherapy sessions 5 Duration of psychotherapy sessions Format of psychotherapy sessions 6 Frequency of medication visits 5 Recommended Also consider Weekly Twice a week 60 minutes* > 60 minutes* or 45 minutes Individual Combination of individual and group or family therapy Weekly for the first month and every 2 weeks thereafter Weekly for all 3 months Every 2 weeks for all 3 months *Longer sessions may be needed for exposure therapy to allow for habituation. 5 Questions 18–20 6 Question 41 J Clin Psychiatry 1999;60 (suppl 16) 13 Expert Consensus Guideline Series Guideline 3: Selecting the Initial Psychotherapy Brief Descriptions of the Most Recommended Psychotherapy Techniques* Anxiety management (stress inoculation training): teaching a set of skills that will help patients cope with stress: x Relaxation training: teaching patients to control fear and anxiety through the systematic relaxation of the major muscle groups. x Breathing retraining: teaching slow, abdominal breathing to help the patient relax and/or avoid hyperventilation with its unpleasant and often frightening physical sensations. x Positive thinking and self-talk: Teaching the person how to replace negative thoughts (e.g., “I’m going to lose control”) with positive thoughts (e.g., “I did it before and I can do it again”) when anticipating or confronting stressors. x Assertiveness training: teaching the person how to express wishes, opinions, and emotions appropriately and without alienating others. x Thought stopping: distraction techniques to overcome distressing thoughts by inwardly “shouting stop.” Cognitive therapy: helping to modify unrealistic assumptions, beliefs, and automatic thoughts that lead to disturbing emotions and impaired functioning. For example, trauma victims often have unrealistic guilt related to the trauma: a rape victim may blame herself for the rape; a war veteran may feel it was his fault that his best friend was killed. The goal of cognitive therapy is to teach patients to identify their own particular dysfunctional cognitions, weigh the evidence for and against them, and adopt more realistic thoughts that will generate more balanced emotions. Exposure therapy: helping the person to confront specific situations, people, objects, memories, or emotions that have become associated with the stressor and now evoke an unrealistically intense fear. This can be done in two ways: x Imaginal exposure: the repeated emotional recounting of the traumatic memories until they no longer evoke high levels of distress. x In vivo exposure: confrontation with situations that are now safe, but which the person avoids because they have become associated with the trauma and trigger strong fear (e.g., driving a car again after being involved in an accident; using elevators again after being assaulted in an elevator). Repeated exposures help the person realize that the feared situation is no longer dangerous and that the fear will dissipate if the person remains in the situation long enough rather than escaping it. Play therapy: therapy for children employing games to allow the introduction of topics that cannot be effectively addressed more directly and to facilitate the exposure to, and the reprocessing of, the traumatic memories. Psychoeducation: educating patients and their families about the symptoms of PTSD and the various treatments that are available for it. Reassurance is given that PTSD symptoms are normal and expectable shortly after a trauma and can be overcome with time and treatment. Also includes education about the symptoms and treatment of any comorbid disorders. *We also asked the experts about eye movement desensitization reprocessing (EMDR), hypnotherapy, and psychodynamic psychotherapy, but they did not rate these techniques highly for the treatment of PTSD. 14 J Clin Psychiatry 1999;60 (suppl 16) Treatment of Posttraumatic Stress Disorder 7 3A: Preferred Psychotherapy Techniques for Different Target Symptoms Three psychotherapy techniques—exposure therapy, cognitive therapy, and anxiety management—are considered to be the most useful in the treatment of PTSD. As shown in the table below, the experts make distinctions among the techniques depending on which specific type of symptom presentation is most prominent. Psychoeducation is recommended as a high second line option for all types of target symptoms, probably reflecting the experts’ belief that it is important in the treatment of every patient with PTSD, but is not by itself sufficient. Note also that the experts recommend considering play therapy for certain types of target symptoms in children. (bold italics = treatment of choice) 7 Most prominent symptom Recommended techniques Also consider Intrusive thoughts x Exposure therapy x x x x Flashbacks x Exposure therapy x Anxiety management x Cognitive therapy x Psychoeducation Trauma-related fears, panic, and avoidance x Exposure therapy x Cognitive therapy x Anxiety management x Psychoeducation x Play therapy for children Numbing/detachment from others/loss of interest x Cognitive therapy x Psychoeducation x Exposure therapy Irritability/angry outbursts x Cognitive therapy x Anxiety management x Psychoeducation x Exposure therapy Guilt/shame x Cognitive therapy x Psychoeducation x Play therapy for children General anxiety (hyperarousal, hypervigilance, startle) x Anxiety management x Exposure therapy x Cognitive therapy x Psychoeducation x Play therapy for children Sleep disturbance x Anxiety management x Exposure therapy x Cognitive therapy x Psychoeducation Difficulty concentrating x Anxiety management x Cognitive therapy x Psychoeducation Cognitive therapy Anxiety management Psychoeducation Play therapy for children Question 13 J Clin Psychiatry 1999;60 (suppl 16) 15 Expert Consensus Guideline Series 8 3B: Preferred Psychotherapy Techniques for PTSD with Comorbid Psychiatric Conditions The type of comorbidity accompanying PTSD affects the choice of the specific psychotherapy techniques. The experts are especially likely to recommend cognitive therapy in the treatment of PTSD when there is a comorbid mood or anxiety disorder or a cluster B personality disorder. Anxiety management is especially recommended when a comorbid anxiety disorder is present or there are substance abuse problems. Exposure therapy is also especially recommended when there is a comorbid anxiety disorder. (bold italics = treatment of choice) 8 Comorbid condition Recommended techniques Also consider Depressive disorder x Cognitive therapy x x x x Bipolar disorder x Cognitive therapy x Psychoeducation x Anxiety management Other anxiety disorder (e.g., panic disorder, social phobia, obsessive-compulsive disorder, generalized anxiety disorder) x Anxiety management x Cognitive therapy x Exposure therapy x Psychoeducation Substance abuse or dependence x Anxiety management x Cognitive therapy x Psychoeducation Severe cluster B personality disorder (e.g., borderline) with impulsivity x Cognitive therapy x Anxiety management x Psychoeducation Exposure therapy Psychoeducation Anxiety management Play therapy for children Question 14 9 3C: Selecting Psychotherapy Techniques Based on the Patient’s Age To some extent, the choice of psychotherapy varies depending on the patient’s age. Play therapy may be useful for children and younger adolescents. Exposure therapy is more strongly recommended for adults than for children or for geriatric patients. (bold = first line) Preferred techniques 9 For children and younger adolescents x x x x Play therapy Psychoeducation Anxiety management Cognitive therapy For adults and older adolescents x x x x Cognitive therapy Exposure therapy Anxiety management Psychoeducation For geriatric patients x x x x Cognitive therapy Anxiety management Psychoeducation Exposure therapy Question 16 16 J Clin Psychiatry 1999;60 (suppl 16) Treatment of Posttraumatic Stress Disorder 3D: Selecting Psychotherapy Techniques Based on Effectiveness, Safety, Acceptability, and Speed of Action The following table presents the experts’ recommendations for specific psychotherapy techniques based on the overall effectiveness, speed of action, usefulness for different stressors, safety, and acceptability of these techniques. As indicated in Guidelines 3A–3C, the selection of a specific psychotherapy technique will also depend on the type of presentation of PTSD, the type of accompanying comorbidity, and the patient’s age. The choice may vary with the stage of treatment, the strength of the therapeutic alliance, the therapist’s clinical judgment, and the patient’s preference and previous response to treatment. Recommended techniques Also consider x Exposure therapy x Cognitive therapy x Anxiety management Quickest acting techniques x Exposure therapy x Anxiety management x Cognitive therapy x Psychoeducation Techniques preferred across all the 12 different types of trauma x Cognitive therapy x Exposure therapy x Anxiety management x Psychoeducation x Anxiety management x Psychoeducation x Cognitive therapy x Play therapy for children x Exposure therapy x Psychoeducation x Cognitive therapy x Anxiety management x Play therapy for children 10 Most effective techniques 11 10 Safest techniques 10 Most acceptable techniques Further recommendation for combining psychotherapy techniques: The experts believe that the techniques that are effective for PTSD when used alone (anxiety management, cognitive therapy, exposure therapy, and psychoeducation) are also helpful when used in combination. They consider combinations especially appropriate for patients who have a complex presentation or who have had an inadequate response to treatment (see Guidelines 5A, 5B, 6A, and 6B). The choice of which and how many of the techniques to combine should be based on clinical judgment and patient preference. For children, the experts also consider it appropriate to combine play therapy with any of the previous four 13 techniques. 10 Question 15 11 Question 17 J Clin Psychiatry 1999;60 (suppl 16) 12 Question 25 13 Question 26 17 Expert Consensus Guideline Series Guideline 4: Selecting the Initial Medication 14 4A: Preferred Classes of Medications Based on Different Target Symptoms We asked the experts about their preferences for different classes of medication for different types of target symptoms. In nearly every case, the newer antidepressants, particularly the selective serotonin reuptake inhibitors (SSRIs), were favored regardless of the type of symptom that was prominent. Mood stabilizers may also be helpful for prominent irritability or anger. Benzodiazepines may sometimes be helpful in the short term, but must be used with caution because of the risk of substance abuse problems. 15 Most prominent symptom Recommended medications Also consider Intrusive thoughts x SSRIs* x Nefazodone x Venlafaxine x Tricyclic antidepressants Flashbacks x SSRIs x Nefazodone x Venlafaxine x Tricyclic antidepressants Trauma-related fears, panic, and avoidance x SSRIs x Nefazodone x Venlafaxine x Tricyclic antidepressants x Benzodiazepines (e.g., 16 clonazepam )† General anxiety (hyperarousal, hypervigilance, startle) x SSRIs x Nefazodone x Venlafaxine x x x x Numbing/detachment from others/loss of interest x SSRIs x Nefazodone x Venlafaxine x Tricyclic antidepressants Tricyclic antidepressants Benzodiazepines† Antiadrenergics Buspirone x x x x SSRIs Nefazodone Venlafaxine Tricyclic antidepressants x Trazodone x x x x Zolpidem Benadryl Tricyclic antidepressants Benzodiazepines† Irritability/angry outbursts x SSRIs x Nefazodone x Venlafaxine x Mood stabilizers (e.g., divalproex ) x Tricyclic antidepressants x Antiadrenergics Difficulty concentrating x SSRIs x Nefazodone x Venlafaxine x Tricyclic antidepressants Guilt/shame x SSRIs x Nefazodone x Venlafaxine x Tricyclic antidepressants Dissociative symptoms Sleep disturbance 17 18 *SSRIs = sertraline, paroxetine, fluoxetine, fluvoxamine, citalopram †The experts recommend using caution in prescribing benzodiazepines for patients with current substance abuse problems or a history 19 of substance abuse problems. 14 Question 27 18 15 Question 35 16 Question 37 17 Question 56 18 Question 36 19 Question 38 J Clin Psychiatry 1999;60 (suppl 16) Treatment of Posttraumatic Stress Disorder 20 4B: Preferred Classes of Medications Based on Different Types of Stressors We also asked about preferences for the different classes of medication in a variety of different types of stressful situation. Just as when we asked about choice of medications for different target symptoms, the newer antidepressants were favored regardless of the type of stressor. Other medications to consider are tricyclic antidepressants, mood stabilizers, and benzodiazepines. 21 Most prominent stressor Recommended medications Also consider Military combat x SSRIs x Nefazodone x Venlafaxine x Tricyclic antidepressants 22 x Mood stabilizers (e.g., divalproex ) Sexual trauma as an adult x SSRIs x Nefazodone x Venlafaxine x Tricyclic antidepressants x Benzodiazepines (e.g., 23 clonazepam )* Sexual or physical abuse in childhood x SSRIs x Nefazodone x Venlafaxine x Tricyclic antidepressants x Mood stabilizers Accidents x SSRIs x Nefazodone x Venlafaxine x Tricyclic antidepressants x Benzodiazepines* Natural disasters x SSRIs x Nefazodone x Venlafaxine x Tricyclic antidepressants x Benzodiazepines* Victim of violent crime or torture x SSRIs x Nefazodone x Venlafaxine x Tricyclic antidepressants x Mood stabilizers Other trauma (e.g., witnessing a traumatic event) x SSRIs x Nefazodone x Venlafaxine x Tricyclic antidepressants x Benzodiazepines* *The experts recommend using caution in prescribing benzodiazepines for patients with current substance abuse problems or a history 24 of substance abuse problems. 20 Question 28 21 Question 35 J Clin Psychiatry 1999;60 (suppl 16) 22 Question 36 23 Question 37 24 Question 38 19 Expert Consensus Guideline Series 25 4C: Preferred Medications for PTSD with Comorbid Psychiatric Conditions The newer antidepressants are also useful in treating patients whose PTSD is accompanied by comorbid psychiatric disorders, except mania. Mood stabilizers are recommended for patients whose PTSD is accompanied by bipolar disorder, whether they are in the manic or depressed phase of the illness. (bold italics = treatment of choice) 26 Comorbid condition Recommended medications Also consider Unipolar depressive disorder x x x x SSRIs Nefazodone Venlafaxine Tricyclic antidepressants Bipolar disorder, depressed phase x x x x SSRIs Nefazodone Venlafaxine 27 Mood stabilizers (e.g., divalproex ) Bipolar disorder, manic or hypomanic phase x Mood stabilizers x Atypical antipsychotics x Conventional antipsychotics Obsessive-compulsive disorder x SSRIs x Nefazodone x Venlafaxine x Tricyclic antidepressants Panic disorder x SSRIs x Nefazodone x Venlafaxine x Tricyclic antidepressants x Benzodiazepines (e.g., 28 clonazepam )* Social phobia x SSRIs x Nefazodone x Venlafaxine x Tricyclic antidepressants x Benzodiazepines* Generalized anxiety disorder x SSRIs x Nefazodone x Venlafaxine x Tricyclic antidepressants x Benzodiazepines* x Buspirone x Tricyclic antidepressants *The experts recommend using caution in prescribing benzodiazepines for patients with current substance abuse problems or a history 29 of substance abuse problems. 25 Question 29 20 26 Question 35 27 Question 36 28 Question 37 29 Question 38 J Clin Psychiatry 1999;60 (suppl 16) Treatment of Posttraumatic Stress Disorder 30 4D: Preferred Medications for PTSD with Comorbid General Medical Conditions The experts also recommend the newer antidepressants for the treatment of PTSD in patients who have a variety of different general medical conditions. The second line choices vary by type of disorder. 31 Comorbid condition Recommended medications Also consider Central nervous system damage or disorder (e.g., head trauma, epilepsy, stroke) x SSRIs x Nefazodone x Venlafaxine x Mood stabilizers (e.g., divalproex ) Chronic pain x x x x x Mood stabilizers Hypertension x SSRIs x Nefazodone x Venlafaxine x Antiadrenergics x Mood stabilizers x Benzodiazepines (e.g., 33 clonazepam )* x Tricyclic antidepressants Cardiac disease x SSRIs x Nefazodone x Venlafaxine x Benzodiazepines* x Mood stabilizers Thyroid abnormality x SSRIs x Nefazodone x Venlafaxine x Tricyclic antidepressants x Benzodiazepines* x Mood stabilizers Diabetes x SSRIs x Nefazodone x Venlafaxine x Tricyclic antidepressants x Mood stabilizers Respiratory disease (e.g., asthma, emphysema) x SSRIs x Nefazodone x Venlafaxine x Tricyclic antidepressants x Mood stabilizers Gastrointestinal disease (e.g., ulcer) x SSRIs x Nefazodone x Venlafaxine x Tricyclic antidepressants x Benzodiazepines* Liver disease x SSRIs x Nefazodone x Venlafaxine 32 SSRIs Nefazodone Venlafaxine Tricyclic antidepressants *The experts recommend using caution in prescribing benzodiazepines for patients with current substance abuse problems or a history 34 of substance abuse problems. 30 Question 30 31 Question 35 J Clin Psychiatry 1999;60 (suppl 16) 32 Question 36 33 Question 37 34 Question 38 21 Expert Consensus Guideline Series 35 4E: Selecting Medications for Women of Childbearing Age (bold italics = treatment of choice) If patient is Recommended medications Pregnant or breastfeeding x The experts prefer not to use medications in women who are pregnant or breastfeeding, but when necessary they would choose an SSRI. Woman of childbearing age x SSRIs x Nefazodone x Venlafaxine 35 Question 34 4F: Selecting Medications Based on Effectiveness, Safety, and Acceptability for Different Age Groups Factor Most effective Safest 36 37 Most acceptable 38 In children In adults/adolescents In geriatric patients x SSRIs x Nefazodone* x Venlafaxine x x x x SSRIs Nefazodone Venlafaxine Tricyclic antidepressants x SSRIs x Nefazodone x Venlafaxine x SSRIs x Nefazodone x Venlafaxine x x x x SSRIs Nefazodone Venlafaxine Buspirone x SSRIs x Nefazodone x Venlafaxine x SSRIs x Nefazodone x Venlafaxine x x x x x SSRIs Nefazodone Venlafaxine Benzodiazepines† Buspirone x SSRIs x Nefazodone x Venlafaxine 39 Further recommendation: In treating PTSD in older adults, the experts recommend the following strategies: x Taking a very careful history of all medications the person is taking x Monitoring carefully for interactions with other medications x Starting with a low dose of medication x Increasing medication dose slowly *italics = top second line options †The experts recommend using caution in prescribing benzodiazepines for patients with current substance abuse problems or a history 40 of substance abuse problems. 36 Questions 33 & 35 22 37 Questions 31& 35 38 Questions 32 & 35 39 Question 39 40 Question 38 J Clin Psychiatry 1999;60 (suppl 16) Treatment of Posttraumatic Stress Disorder 41 4G: Defining an Adequate Initial Medication Trial Before deciding that a patient has not responded to a medication, the clinician should be sure that the treatment trial has been adequate in dose and duration. Too often, patients have received numerous medications, but never in systematic adequate trials that enable the clinician to judge whether the medication would actually work if given appropriately. The experts recommend allowing slightly more time for patients who are showing a partial response compared to those with no response. For information on adequate doses, see Guideline 9. Length of time to wait before switching to or adding another medication No response Partial response Antidepressant 6 weeks 8 weeks Antipsychotic 3 weeks 4 weeks Benzodiazepine 2 weeks 3 weeks Buspirone 4 weeks 5 weeks Mood stabilizer 4 weeks 6 weeks Antiadrenergic 2 weeks 3 weeks 41 Question 40 J Clin Psychiatry 1999;60 (suppl 16) 23 Expert Consensus Guideline Series III. WHAT TO DO AFTER THE INITIAL TRIAL Definitions of Terms Remission/good response: > 75% reduction in symptoms and response maintained for at least 3 months Partial response: 25%–75% of symptoms remain No response: < 25% reduction in symptoms Persistently refractory: little or no response after multiple trials of medications and psychotherapy techniques Guideline 5: When the Patient Has Had No Response 5A. Selecting the Next Step We asked the experts to recommend the next step when patients with PTSD have had no response to the initial treatment. Their first line recommendations were the same for patients with acute and chronic PTSD as well as for patients who also have suicidal or aggressive tendencies. For patients receiving monotherapy (i.e., medication alone or psychotherapy alone), the experts offer two general treatment recommendations: 1. Add the type of treatment the patient has not yet received (i.e., add medication to psychotherapy or add psychotherapy to medication) and/or 2. Switch to a different psychotherapy technique or to a different medication. Both of these strategies may be helpful, either separately or in combination. Clinicians should use their clinical judgment, based on the specific situation, in deciding whether to add a new treatment, switch to a different treatment, or do both. Presentation No response to 42 psychotherapy alone No response to medication 43 alone No response to combined 44 psychotherapy and medication Acute and chronic PTSD Add medication and/or Switch to other psychotherapy technique(s) Add psychotherapy and/or Switch to another medication Switch to another medication and/or Switch to or add other psychotherapy technique(s) 42 Question 6 43 Question 8 44 Question 10 45 5B: Strategies for Further Psychotherapy For a patient who is not responding to one of the three preferred psychotherapy techniques, the experts recommend adding one or both of the other two techniques. Adequate psychoeducation should also always be provided. If current psychotherapy technique is Combine with Also consider Anxiety management x Cognitive therapy x Exposure therapy x Psychoeducation Cognitive therapy x Anxiety management x Exposure therapy x Psychoeducation Exposure therapy x Anxiety management x Cognitive therapy x Psychoeducation 45 Question 26 24 J Clin Psychiatry 1999;60 (suppl 16) Treatment of Posttraumatic Stress Disorder 5C: Choosing the Next Medication For the purpose of this survey, no response to medication was defined as < 25% reduction in symptoms. If there is no response to an adequate trial of the first medication, the experts usually recommend switching to a different type of medication. Fortunately, there is a wide array of medications to choose from. (bold = first line) If initial treatment was Switch to x x x x x x Venlafaxine Nefazodone Tricyclic antidepressant Monoamine oxidase inhibitor A different SSRI 47 Mood stabilizer (e.g., divalproex ) 48 x x x x x SSRI Venlafaxine Tricyclic antidepressant Monoamine oxidase inhibitor Mood stabilizer 49 x x x x x SSRI Tricyclic antidepressant Nefazodone Monoamine oxidase inhibitor Mood stabilizer A mood stabilizer given for explosive, 50 irritable, aggressive, or violent behavior x x x x x x Another mood stabilizer SSRI Atypical antipsychotic Venlafaxine Nefazodone Tricyclic antidepressant A mood stabilizer given for a patient with 51 PTSD and comorbid bipolar disorder x Continue mood stabilizer x Add an SSRI An atypical antipsychotic given for explosive, irritable, aggressive, 52 or violent behavior x Mood stabilizer x Antidepressant x Another atypical antipsychotic An atypical antipsychotic given for prominent flashbacks/dissociative symptoms/psychotic symptoms 53 associated with PTSD x x x x 46 An SSRI Nefazodone Venlafaxine 46 47 48 51 52 53 Question 45 Question 49 Question 36 Question 50 J Clin Psychiatry 1999;60 (suppl 16) Question 46 Question 51 Mood stabilizer Antidepressant Another atypical antipsychotic Conventional antipsychotic 49 Question 47 50 Question 48 25 Expert Consensus Guideline Series Guideline 6: When the Patient Has Only a Partial Response 6A: Selecting the Next Step Partial response was defined as 25%–75% of symptoms remaining. There is one major difference between the experts’ recommendations when there is a partial response as opposed to no response. When a patient is having a partial response to treatment, the experts are more likely to recommend continuing the current treatment and adding another medication and/or adding additional psychotherapy. (bold italics = treatment of choice) Presentation Partial response to 54 psychotherapy alone Partial response to 55 medication alone Partial response to combined 56 psychotherapy and medication Acute PTSD Add medication and/or Add or switch to other psychotherapy technique(s) Add psychotherapy Add or switch to another medication and/or Add or switch to other psychotherapy technique(s) Chronic PTSD Add medication and/or Add or switch to other psychotherapy technique(s) Add psychotherapy and/or Add another medication Add or switch to another medication or Raise the dose of the medication to a higher than usual level and/or Add or switch to other psychotherapy technique(s) PTSD with strong suicidal or aggressive tendencies Add medication and/or Add other psychotherapy technique(s) Add psychotherapy and/or Add another medication Add or switch to another medication or Raise the dose of the medication to a higher than usual level and/or Add or switch to other psychotherapy technique(s) 54 Question 5 26 55 Question 7 56 Question 9 J Clin Psychiatry 1999;60 (suppl 16) Treatment of Posttraumatic Stress Disorder 57 6B: Strategies for Further Psychotherapy Just as when there is no response (see Guideline 5B), if a patient is having a partial response to one of the three preferred psychotherapy techniques, the experts recommend adding one or both of the other two techniques. Adequate psychoeducation should also always be provided. If current psychotherapy technique is Combine with Also consider Anxiety management x Cognitive therapy x Exposure therapy x Psychoeducation Cognitive therapy x Anxiety management x Exposure therapy x Psychoeducation Exposure therapy x Anxiety management x Cognitive therapy x Psychoeducation 57 Question 26 6C: Selecting Adjunctive Medications When a patient is having a partial response to medication alone, the experts recommend adding another medication as an adjunct rather than switching to a different medication. In this table, we present the experts’ recommendations for adjunctive medications. The most highly recommended adjunctive medication in the treatment of PTSD is a mood stabilizer. For recommendations for choices of medications to switch to, see Guideline 5C. (bold = first line) If the initial treatment was The following medications are recommended as adjuncts x Mood stabilizer (e.g., divalproex ) x Tricyclic antidepressant 58 59 An SSRI 60 x Mood stabilizer 61 x Mood stabilizer Nefazodone Venlafaxine A mood stabilizer given for explosive, irritable, 62 aggressive, or violent behavior x x x x x x x SSRI Atypical antipsychotic Another mood stabilizer Trazodone Nefazodone Venlafaxine Tricyclic antidepressant A mood stabilizer given for a patient with PTSD and 63 comorbid bipolar disorder x x x x x x SSRI Nefazodone Venlafaxine Atypical antipsychotic Tricyclic antidepressant Another mood stabilizer An atypical antipsychotic given for explosive, 64 irritable, aggressive, or violent behavior x Mood stabilizer x Antidepressant An atypical antipsychotic given for prominent flashbacks/dissociative symptoms/psychotic 65 symptoms associated with PTSD x Mood stabilizer x Antidepressant x Clonazepam* *The experts recommend using caution in prescribing benzodiazepines for patients with current substance abuse problems or a history 66 of substance abuse problems. 58 59 65 66 Question 45 Question 51 Question 36 Question 38 J Clin Psychiatry 1999;60 (suppl 16) 60 Question 46 61 Question 47 62 Question 48 63 Question 49 64 Question 50 27 Expert Consensus Guideline Series Guideline 7: When the Patient Has Not Responded to Multiple Previous Treatments PTSD that has been persistently refractory to treatment is defined as a course of illness in which there has been little or no response after multiple adequate trials of medication and psychotherapy. It is important not to lose hope, even when patients have not responded to previous treatments. The first step is a careful assessment to reevaluate for possible causes of nonresponse (e.g., substance abuse problems, comorbid psychiatric conditions). The experts then recommend developing a comprehensive treatment plan using combinations of medications and psychotherapy techniques to be given in systematic, sequential trials to discover which customized treatment package will work best for the particular patient. Finding the right treatment for the individual patient requires clinical art and judgment, determination, persistence, and realistic optimism. (bold italics = treatment of choice) Recommended x Assess for substance abuse problems x Reevaluate for psychiatric comorbidity x Assess for the presence of a complicating neurological or other general medical condition x Assess for secondary gain x Reevaluate diagnosis of PTSD 67 Assessment strategies 68 Medication interventions Combine medications: Preferred combination: antidepressant + mood stabilizer Also consider Antidepressant + antipsychotic or Antidepressant + antipsychotic + mood stabilizer or Two antidepressants or Adjunctive benzodiazepine* or trazodone Psychosocial 69 interventions Combine psychotherapy techniques (see Guidelines 5B and 6B) and/or Add special rehabilitation programs (e.g., social skills training, vocational rehabilitation) and/or Add family therapy Indications for 70 hospitalization Risk of suicide Risk of harm to others *The experts recommend using caution in prescribing benzodiazepines for patients with current substance abuse problems or a history 71 of substance abuse problems. 67 Question 11 28 68 Questions11 & 52 69 Question 11 70 Question 54 71 Question 38 J Clin Psychiatry 1999;60 (suppl 16) Treatment of Posttraumatic Stress Disorder Guideline 8: When the Patient Has a Remission or Good Response: Strategies for the Maintenance Phase 8A. Psychotherapy Issues See Guideline 2C for level of care recommendations for the initial phase of treatment (first 3 months or until stabilized). This guideline presents the experts’ recommendations for the duration and the intensity of psychotherapy treatment during the maintenance phase after the patient has achieved a good response to treatment. How long to continue psychotherapy after 72 a good response x Acute PTSD: continue for up to 3 more months, with booster sessions every 2–4 weeks x Chronic PTSD: continue for up to 6 more months, with booster sessions every 2–4 weeks initially and then less frequently as needed after that, depending on the level of recovery Indications for continuing 73 booster sessions x x x x x x x x Current life stressors Poor social supports High suicide risk in the past History of violence Persistence of some symptoms Poor functioning when symptomatic Presence of comorbid Axis I disorder(s) Presence of comorbid Axis II disorder(s) 72 73 Questions 21 & 22 Question 23 8B. Medication Issues See Guideline 2C for level of care recommendations for the initial phase of treatment (first 3 months or until stabilized). This guideline presents the experts’ recommendations for the duration and the intensity of medication treatment during the maintenance phase after the patient has achieved a good response to treatment. Duration of treatment before considering tapering 74 medication 74 x Acute PTSD: 6–12 months x Chronic PTSD with excellent response: 12–24 months x Chronic PTSD with residual symptoms: usually at least 24 months and possibly longer, especially if the indications listed below are present Indications for continuing medication treatment for a 75 longer period x x x x x x x x x Frequency of medication 76 visits x Months 3–6: monthly x Months 6–12: every 1–2 months x After 12 months: every 3 months Recommended method of 77 tapering medication x To avoid discontinuation/withdrawal syndrome: Taper medication over 2 weeks–1 month, except for the benzodiazepines, which experts recommend tapering over 1 month or longer x To lessen the likelihood of relapse in a patient with risk factors for relapse: Taper medication over a longer period, 4–12 weeks, except for the benzodiazepines, for which experts recommend tapering for longer than 12 weeks Question 43 75 Question 44 J Clin Psychiatry 1999;60 (suppl 16) Current life stressors Poor social supports Persistence of some symptoms High suicide risk in the past History of violence Presence of comorbid Axis I disorder(s) Long duration of PTSD symptoms Poor functioning when symptomatic History of severe PTSD symptoms 76 Question 42 77 Questions 57 & 58 29 Expert Consensus Guideline Series IV. OTHER TREATMENT ISSUES Guideline 9: Medication Dosing 78 The following table summarizes the experts’ dosing recommendations. These are a rough guide, and it is advisable to consult the Physicians’ Desk Reference and other standard pharmacology texts for more information on recommended doses. Clinical judgment is necessary in selecting doses for the specific patient, especially for children, the elderly, those with comorbid medical conditions, and those receiving combinations of medications. Acute phase* Average target dose (mg/day) Adult starting dose (mg/day) Adult Child Older adult Highest target dose (mg/day)† citalopram (Celexa) 20 20–40 20 20 60 fluoxetine (Prozac) 10–20 20–50 10–20 20 80 50 100–250 50 100 300 paroxetine (Paxil) 10–20 20–50 20 20 50 sertraline (Zoloft) 25–50 50–150 50 75 200 nefazodone (Serzone) 100 300–500 200 250 600 venlafaxine (Effexor XR) 75 75–225 50 150 225 500 500–1500 750 750 2000 haloperidol (Haldol) 2 2–10 1.5 3 20 risperidone (Risperdal) 1 2–6 1.5 2.5 8 olanzapine (Zyprexa) 5 5–15 5 7.5 20 quetiapine (Seroquel) 50 100–400 —‡ 150 800 buspirone (BuSpar) 15 20–60 20 30 60 alprazolam (Xanax)§ 1 1–4 1 1.5 4 clonazepam (Klonopin)§ 1 1–4 1.5 1.5 4 Medication SSRIs fluvoxamine (Luvox) Other antidepressants Mood stabilizers divalproex (Depakote) Antipsychotics Anti-anxiety medications *Recommended maintenance doses were generally equivalent to acute phase doses. †Based on package insert. ‡The experts did not make any dosing recommendations for quetiapine in children. §The experts recommend using caution in prescribing benzodiazepines for patients with current substance abuse problems or a history 79 of substance abuse problems. 78 Question 55 30 79 Question 38 J Clin Psychiatry 1999;60 (suppl 16) Treatment of Posttraumatic Stress Disorder Guideline 10: Enhancing Compliance 80 Facilitating full patient cooperation with treatment is often the crucial factor in successful treatment. The following table presents the experts’ recommendations for improving the therapeutic relationship and enhancing the patient’s role in the treatment process. Type of Strategy Recommendation General x x x x Programmatic x Evaluate for and treat substance abuse problems x Ensure easy and prompt access to treatment For patients receiving medication x Select medications based on side effect tolerance x Start low and go slow to avoid side effects Psychoeducation Frequently review with patient the rationale for the treatment intervention Take patient preference into account in selecting treatments Involve a relative or significant other at an early stage 80 Questions 24 & 53 Guideline 11: Prevention of PTSD and Avoiding Chronicity 81 An ounce of prevention is often worth a pound of cure. Helping people deal effectively with their immediate reaction to an extreme stressor may well avoid PTSD altogether or at least shorten the duration of symptoms. The experts recommend providing education, normalization, guilt relief, and emotional catharsis for everyone who develops symptoms after an extreme stressor. If the symptoms last longer than 1 month, the experts recommend adding specific psychotherapy techniques and considering medication to avoid chronicity. (bold italics = treatment of choice) To prevent PTSD in patients with acute stress disorder To prevent chronic symptoms in patients with acute PTSD Recommended x x x x x x x x Also consider x Anxiety management techniques x Provide group crisis intervention x Cognitive therapy Provide psychoeducation Normalize the reaction to the event Relieve irrational guilt Facilitate emotional recalling and retelling of the event Provide psychoeducation Relieve irrational guilt Normalize the reaction to the event Facilitate emotional recalling and retelling of the event x Cognitive therapy x Exposure therapy x Anxiety management techniques x Start treatment with an antidepressant 81 Question 12 J Clin Psychiatry 1999;60 (suppl 16) 31 Expert Consensus Guideline Series V. PRIMARY CARE TREATMENT GUIDE FOR POSTTRAUMATIC STRESS DISORDER I. RECOGNITION The diagnosis of PTSD requires exposure to an extreme stressor and a characteristic set of symptoms that have lasted for at least 1 month. What is an extreme stressor? Examples include x Serious accident or natural disaster x Rape or criminal assault x Combat exposure x Child sexual or physical abuse or severe neglect x Hostage/imprisonment/torture/displacement as refugee x Witnessing a traumatic event x Sudden unexpected death of a loved one The person has the following three main types of symptoms: Re-experiencing of the traumatic event as indicated by x Intrusive distressing recollections of the event x Flashbacks (feeling as if the event were recurring while awake) II. EARLY INTERVENTION AND PREVENTION What to do immediately after exposure to an extreme stressor or trauma: x Help the patient understand that it is normal to be upset and have distressing symptoms shortly after a trauma. x Provide education about acute stress reactions and PTSD (you may want to give the patient a copy of the “Guide for Patients and Families” that begins on p. 69). x Encourage the patient to talk with family and friends about the trauma and experience the feelings associated with it. x Educate family and significant others about the importance of listening and being tolerant of the person’s emotional reactions. x Help the patient and family accept the need for repeated retelling of the event in order to facilitate recovery. x Provide emotional support. x Relieve irrational guilt. x Refer to peer support group or trauma counseling. x Consider short-term sleep medication for insomnia. x Nightmares (the event or other frightening images recur frequently in dreams) x Exaggerated emotional and physical reactions to triggers that remind the person of the event Avoidance and emotional numbing as indicated by x Extensive avoidance of activities, places, thoughts, feelings, or conversations related to the trauma x Loss of interest x Feeling detached from others x Restricted emotions Increased arousal as indicated by x Difficulty sleeping x Irritability or outbursts of anger x Difficulty concentrating x Hypervigilance x An exaggerated startle response Ask about possible trauma and resulting symptoms in patients who present with depression, anxiety, or substance abuse problems, since these often co-occur with PTSD. 32 III. TREATMENT SELECTION If symptoms have lasted for at least 1 month without significant improvement: 1. Offer or refer for psychological treatment 2. Also prescribe medication if: x Symptoms are severe and/or persistent. x Daily functioning is severely disrupted. x Patient has severe insomnia. x Patient has another psychiatric problem (e.g., depression, anxiety, suicidal thoughts). x Patient is experiencing a lot of stress. x Patient has already been receiving psychotherapy and is still having significant symptoms. J Clin Psychiatry 1999;60 (suppl 16) Treatment of Posttraumatic Stress Disorder IV. RECOMMENDED MEDICATIONS VI. RECOMMENDED MEDICATION DOSES FOR ADULTS (mg/day) Start with a selective serotonin reuptake inhibitor (SSRI) for at least an 8-week treatment trial. Evaluate response every 1–2 weeks and increase dose as needed. Medication After 8 weeks of SSRI trial: Starting Average Max sertraline (Zoloft) 25–50 50–150 200 x If no response, switch to nefazodone or venlafaxine. paroxetine (Paxil) 10–20 20–50 50 x If partial response, add a mood stabilizer such as divalproex. fluoxetine (Prozac) 10–20 20–50 60 fluvoxamine (Luvox) 50 100–250 300 If patient has other significant problems, consider: citalopram (Celexa) 20 20–40 60 nefazodone (Serzone) 100 300–500 600 venlafaxine (Effexor XR) 75 75–225 225 500 500–1500 2000 buspirone (BuSpar) 15 20–60 60 alprazolam (Xanax) 1 1–4 4 clonazepam (Klonopin) 1 1–4 4 x For severe insomnia, short-term treatment with trazodone. x For significant anxiety, short-term treatment with a benzodiazepine* or longer term treatment with buspirone. x For comorbid bipolar disorder, prominent irritability or anger, or aggressive behavior, adding a mood stabilizer. *Note: benzodiazepines should be avoided or used very cautiously in patients who have current substance abuse problems or a history of substance abuse problems. V. RECOMMENDED PSYCHOLOGICAL TREATMENTS x Anxiety management: relaxation training, breathing retraining, positive thinking and self-talk, assertiveness training, and thought stopping x Cognitive therapy: correcting irrational beliefs, especially unrealistic guilt about the trauma x Exposure therapy: desensitizing the anxiety caused by reminders of the trauma by progressive exposure to them SSRIs Other Antidepressants Mood Stabilizers divalproex (Depakote) Anti-anxiety Medications VII. WHEN TO REFER FOR SPECIALIZED PSYCHIATRIC CARE Primary care clinicians may decide to refer for specialized psychiatric care at any point, depending on how comfortable they are treating PTSD, the particular needs and preferences of the patient, and the availability of other services. However, referral for specialized care is often necessary in the following situations: x Patient has persistent impairing PTSD symptoms that have not responded to at least one systematic medication trial adequate in dose and duration. x Patient has suicidal thoughts/behavior. x Patient has had persistent problems with medication side effects. x Patient has other serious psychiatric problems (e.g., depression, anxiety) that are not improving with treatment. x Patient has substance abuse problems. x Patient is experiencing other life stressors and/or has limited social support. J Clin Psychiatry 1999;60 (suppl 16) 33 Expert Consensus Guideline Series Survey Questions Answered by All the Experts 1 It is important for clinicians and patients to decide how to sequence treatments. Please rate each method for starting the initial treatment(s) for acute PTSD (1–3 months posttrauma) for both a patient with milder PTSD and a patient with more severe PTSD (i.e., with severe agitation, impulsivity, violence, suicidal behavior, or significant functional impairment). Assume that the patient will be receiving the most appropriate type of psychotherapy or medication. Psychotherapy experts Medication experts Tr of 1st 2nd 3rd Tr of 1st 2nd 3rd Avg(SD) Rank Chc Line Line Line Avg(SD) Rank Chc Line Line Line In children and younger adolescents MILDER PTSD 73 98 2 0 8.2(1.2) Chc 50 94 4 2 3rd 0 8 35 56 5.2(2.0) 2nd 6 27 50 23 3rd 0 2 29 69 4.1(1.8) 2nd 0 13 45 43 7.8(1.4) 1st 45 83 17 0 6.5(2.4) 2nd 23 62 23 15 Combined psychotherapy and medication from the start 6.0(2.0) 2nd 13 48 41 11 7.8(1.2) 1st 36 85 15 0 Medication for PTSD first 4.8(1.9) 2nd 2 17 55 28 6.2(1.7) 2nd 6 47 43 11 Psychotherapy for PTSD first 8.8(0.5) Chc 80 100 0 0 7.9(1.5) 1st 44 87 9 4 Combined psychotherapy and medication from the start 4.4(2.1) 2nd 2 12 46 42 6.0(1.9) 2nd 11 38 55 8 Medication for PTSD first 3.4(1.8) 3rd 0 6 37 57 4.6(1.7) 2nd 2 15 57 28 Psychotherapy for PTSD first 7.8(1.3) 1st 42 84 16 0 6.0(2.2) 2nd 17 46 37 17 Combined psychotherapy and medication from the start 6.7(1.8) 2nd 22 61 33 6 8.1(1.2) 1st 48 88 12 0 5.1(1.9) 2nd 0 26 54 20 6.6(1.7) 2nd 15 52 44 4 Psychotherapy for PTSD first 8.5(1.0) Chc 69 96 4 0 7.8(1.4) 1st 40 85 13 2 Combined psychotherapy and medication from the start 4.9(2.2) 2nd 4 26 49 26 6.2(1.9) 2nd 8 46 44 10 Medication for PTSD first 3.6(2.0) 3rd 0 10 33 56 5.0(1.8) 2nd 0 27 51 22 Psychotherapy for PTSD first 8.6(0.9) Chc Combined psychotherapy and medication from the start 3.7(2.0) Medication for PTSD first 2.8(1.6) Psychotherapy for PTSD first MORE SEVERE PTSD In adults and older adolescents MILDER PTSD MORE SEVERE PTSD Medication for PTSD first In geriatric patients MILDER PTSD MORE SEVERE PTSD 34 Psychotherapy for PTSD first 7.6(1.3) 1st 33 78 22 0 6.0(2.3) 2nd 17 52 27 21 Combined psychotherapy and medication from the start 6.5(1.9) 2nd 22 50 43 7 7.8(1.6) 1st 46 85 13 2 Medication for PTSD first 5.0(1.8) 2nd 0 % 27 % 51 % 22 % 6.8(1.7) 2nd 17 % 60 % 38 % 2 % J Clin Psychiatry 1999;60 (suppl 16) PTSD Survey Questions Answered by All the Experts 2 Now please rate each method for starting the initial treatment(s) for chronic PTSD. Psychotherapy experts Medication experts Tr of 1st 2nd 3rd Tr of 1st 2nd 3rd Avg(SD) Rank Chc Line Line Line Avg(SD) Rank Chc Line Line Line In children and younger adolescents MILDER PTSD 70 96 4 0 7.8(1.5) 1st 43 84 14 2nd 2 26 33 41 6.7(2.0) 2nd 13 69 22 9 3rd 0 2 42 56 5.2(1.8) 2nd 2 27 53 20 7.9(1.4) 1st 46 87 13 0 6.7(2.0) 2nd 20 65 26 9 Combined psychotherapy and medication from the start 6.1(2.1) 2nd 18 44 44 11 8.3(1.0) Chc 51 93 7 0 Medication for PTSD first 4.6(2.0) 2nd 0 14 55 32 6.5(1.5) 2nd 7 53 40 7 Psychotherapy for PTSD first 8.5(0.9) Chc 73 96 4 0 7.3(1.8) 1st 33 73 23 4 Combined psychotherapy and medication from the start 5.2(2.3) 2nd 4 36 40 24 7.1(1.8) 1st 21 68 28 4 Medication for PTSD first 3.9(2.0) 3rd 0 6 53 41 5.6(1.8) 2nd 6 34 53 13 Psychotherapy for PTSD first 7.9(1.5) 1st 49 84 14 2 5.9(2.3) 2nd 12 50 29 21 Combined psychotherapy and medication from the start 6.8(2.0) 2nd 26 62 30 8 8.4(0.9) Chc 62 96 4 0 5.1(1.9) 2nd 2 20 58 22 6.7(1.4) 2nd 8 59 37 4 Psychotherapy for PTSD first 8.3(1.1) Chc 64 91 9 0 7.1(1.9) 1st 26 70 22 8 Combined psychotherapy and medication from the start 5.2(2.1) 2nd 0 31 47 22 6.8(2.0) 2nd 22 63 29 8 Medication for PTSD first 4.0(2.1) 3rd 0 6 53 40 5.8(2.0) 2nd 8 37 49 14 Psychotherapy for PTSD first 8.5(0.9) Chc Combined psychotherapy and medication from the start 4.5(2.3) Medication for PTSD first 3.4(1.8) Psychotherapy for PTSD first 2 MORE SEVERE PTSD In adults and older adolescents MILDER PTSD MORE SEVERE PTSD Medication for PTSD first In geriatric patients MILDER PTSD MORE SEVERE PTSD Psychotherapy for PTSD first 7.7(1.3) 1st 37 80 20 0 5.8(2.2) 2nd 9 50 31 19 Combined psychotherapy and medication from the start 6.6(2.1) 2nd 26 55 36 9 8.0(1.3) 1st 47 92 6 2 Medication for PTSD first 5.0(1.9) 2nd 2 % 22 % 57 % 22 % 6.8(1.6) 2nd 11 % 64 % 32 % 4 % J Clin Psychiatry 1999;60 (suppl 16) 35 Expert Consensus Guideline Series 3 Now please rate each method for starting the initial treatment(s) for PTSD when it is complicated by the following comorbid conditions. Assume that PTSD is the primary diagnosis. Note: results from psychotherapy and medication experts are combined. Tr of 1st 2nd 3rd Avg(SD) Chc Line Line Line 95% CONFIDENCE INTERVALS Third Line Second Line First Line PTSD + depressive disorder Combined psychotherapy and medication from the start 7.7(1.5) 39 81 15 3 Psychotherapy for PTSD first 6.5(2.2) 22 56 31 12 Medication for PTSD first 5.9(2.2) 10 47 35 17 PTSD + bipolar disorder Combined psychotherapy and medication from the start 7.7(1.8) 49 81 13 5 Medication for PTSD first 6.4(2.4) 27 58 28 13 Psychotherapy for PTSD first 4.8(2.6) 8 31 36 34 PTSD + other anxiety disorder (e.g., obsessivecompulsive disorder, social phobia, panic disorder, generalized anxiety disorder) Combined psychotherapy and medication from the start 7.1(2.1) 33 69 23 8 Psychotherapy for PTSD first 6.8(2.2) 30 63 27 10 Medication for PTSD first 5.7(2.3) 9 41 38 20 PTSD + severe cluster B personality disorder (e.g., borderline) with impulsivity Combined psychotherapy and medication from the start 6.9(2.2) 32 63 27 9 Psychotherapy for PTSD first 6.8(2.2) 28 63 24 13 5.4(2.3) 5 % 38 % 36 % 25 % Medication for PTSD first 1 4 2 3 4 5 6 7 8 9 Now please rate the appropriateness of the following treatment strategies for PTSD complicated by substance abuse problems. Note: results from psychotherapy and medication experts are combined. Tr of 1st 2nd 3rd Avg(SD) Chc Line Line Line 95% CONFIDENCE INTERVALS Third Line Second Line First Line Milder substance abuse Provide combined treatment for substance abuse and PTSD simultaneously 7.8(1.4) 42 82 17 1 Treat PTSD first 6.0(2.2) 12 46 38 15 Treat substance abuse problems first 5.9(2.0) 7 46 38 15 More severe substance abuse Treat substance abuse problems first 7.5(1.8) 38 79 18 3 Provide combined treatment for substance abuse and PTSD simultaneously 7.1(2.0) 38 68 26 7 4.2(1.9) 1 % 9 % 54 % 37 % Treat PTSD first 1 36 2 3 4 5 6 7 8 9 J Clin Psychiatry 1999;60 (suppl 16) PTSD Survey Questions Answered by All the Experts 5 A patient with PTSD has had an adequate trial of psychotherapy alone but has achieved only a partial response. Please rate the appropriateness of the following strategies as a next step. Assume that you will either provide the treatment or can make an appropriate referral for treatment. Psychotherapy experts Medication experts Tr of 1st 2nd 3rd Tr of 1st 2nd 3rd Avg(SD) Rank Chc Line Line Line Avg(SD) Rank Chc Line Line Line In acute PTSD Add other psychotherapy techniques 7.8(1.5) 1st 35 88 10 2 5.8(2.1) 2nd 4 50 37 13 Add medication 7.0(1.7) 1st 27 67 29 4 8.1(1.0) 1st 42 94 6 0 Switch to other psychotherapy techniques 6.8(1.8) 2nd 21 60 35 6 5.1(1.8) 2nd 2 17 63 19 Stop psychotherapy. Start medication 3.0(2.2) 3rd 2 8 20 73 3.6(2.1) 3rd 0 16 29 55 In chronic PTSD Add other psychotherapy techniques 7.6(1.5) 1st 33 85 13 2 5.7(2.0) 2nd 4 46 38 15 Add medication 7.4(1.7) 1st 33 75 21 4 8.4(0.9) Chc 56 98 2 0 Switch to other psychotherapy techniques 7.0(1.5) 1st 19 62 37 2 5.2(1.7) 2nd 2 15 65 19 Stop psychotherapy. Start medication 2.9(2.1) 3rd 2 8 23 69 3.9(2.2) 3rd 0 18 31 51 In PTSD with strong suicidal or aggressive tendencies Add medication 7.8(1.9) Chc 55 82 12 6 8.5(0.8) Chc 69 98 2 0 Add other psychotherapy techniques 7.7(1.7) 1st 37 84 12 4 5.5(2.5) 2nd 14 43 33 24 Switch to other psychotherapy techniques 6.7(2.0) 2nd 24 59 29 12 4.8(2.3) 2nd 6 22 49 29 Stop psychotherapy. Start medication 2.7(2.3) 3rd 4 % 8 % 16 % 76 % 3.4(2.3) 3rd 2 % 14 % 20 % 67 % 6 A patient with PTSD has had an adequate trial of psychotherapy alone but has had no response. Please rate the appropriateness of the following strategies as a next step. Assume that you will either provide the treatment or can make an appropriate referral for treatment. Psychotherapy experts Medication experts Tr of 1st 2nd 3rd Tr of 1st 2nd 3rd Avg(SD) Rank Chc Line Line Line Avg(SD) Rank Chc Line Line Line In acute PTSD Switch to other psychotherapy techniques 7.8(1.5) 1st 40 85 13 2 5.9(1.9) 2nd 6 46 40 13 Add medication 7.4(1.6) 1st 29 79 19 2 8.1(1.2) 1st 45 94 4 2 Add other psychotherapy techniques 6.8(2.0) 2nd 25 65 25 10 5.2(2.4) 2nd 4 33 42 25 Stop psychotherapy. Start medication 4.2(2.6) 3rd 8 19 40 40 5.1(2.3) 2nd 4 35 38 27 In chronic PTSD Switch to other psychotherapy techniques 7.7(1.7) 1st 39 78 20 2 5.6(2.1) 2nd 8 35 46 19 Add medication 7.7(1.4) 1st 35 85 12 4 8.2(1.1) Chc 53 94 4 2 Add other psychotherapy techniques 6.7(2.0) 2nd 24 62 26 12 4.9(2.3) 2nd 4 29 42 29 Stop psychotherapy. Start medication 4.0(2.6) 3rd 6 19 38 42 5.2(2.5) 2nd 6 38 29 33 In PTSD with strong suicidal or aggressive tendencies Add medication 7.9(1.8) Chc 57 90 6 4 8.5(1.1) Chc 70 94 4 2 Switch to other psychotherapy techniques 7.6(1.9) 1st 44 82 12 6 5.4(2.3) 2nd 4 40 37 23 Add other psychotherapy techniques 6.7(2.3) 2nd 29 61 22 16 4.9(2.6) 2nd 10 31 40 29 Stop psychotherapy. Start medication 3.9(2.9) 3rd 10 % 22 % 29 % 49 % 4.7(2.7) 2nd 6 % 33 % 27 % 40 % J Clin Psychiatry 1999;60 (suppl 16) 37 Expert Consensus Guideline Series 7 A patient with PTSD has had an adequate trial (i.e., duration and dose) of medication alone but has achieved only a partial response. Please rate the appropriateness of the following strategies as a next step. Assume that you will either provide the treatment or can make an appropriate referral for treatment. Psychotherapy experts Medication experts Tr of 1st 2nd 3rd Tr of 1st 2nd 3rd Avg(SD) Rank Chc Line Line Line Avg(SD) Rank Chc Line Line Line In acute PTSD Add psychotherapy 8.3(1.3) Chc 64 96 2 2 8.1(1.0) 1st 45 96 4 0 Switch medication. Start psychotherapy 5.7(2.5) 2nd 11 47 34 19 5.6(2.2) 2nd 4 35 47 18 Switch to another medication 5.3(1.9) 2nd 0 32 47 21 5.9(1.8) 2nd 6 42 48 10 Raise the dose of the medication to a higher than usual level 4.9(2.4) 2nd 9 29 38 33 5.9(2.2) 2nd 12 50 35 15 Add another medication 4.9(2.1) 2nd 2 26 43 30 6.5(1.8) 2nd 10 58 37 6 Stop medication. Start psychotherapy 4.7(2.7) 2nd 14 26 38 36 2.9(1.9) 3rd 0 10 19 71 Add psychotherapy 8.2(1.7) Chc 65 94 2 4 7.9(1.3) 1st 41 88 12 0 Switch medication. Start psychotherapy 5.9(2.6) 2nd 15 50 29 21 5.8(2.3) 2nd 4 47 31 22 In chronic PTSD Switch to another medication 5.6(1.8) 2nd 0 36 47 17 6.3(1.8) 2nd 8 54 38 8 Add another medication 5.3(2.0) 2nd 4 30 48 22 7.2(1.6) 1st 17 71 27 2 Raise the dose of the medication to a higher than usual level 5.2(2.3) 2nd 9 33 40 27 6.6(2.0) 2nd 17 65 25 10 Stop medication. Start psychotherapy 4.5(2.5) 2nd 8 22 36 42 2.6(1.7) 3rd 0 4 19 77 In PTSD with strong suicidal or aggressive tendencies Add psychotherapy 8.1(1.7) Chc 63 92 4 4 7.8(1.5) 1st 44 84 14 2 Switch medication. Start psychotherapy 6.0(2.7) 2nd 19 58 21 21 5.8(2.3) 2nd 10 39 43 18 47 40 13 6.2(1.9) 2nd 10 51 37 12 Switch to another medication 5.9(1.8) 2nd 2 Raise the dose of the medication to a higher than usual level 5.6(2.6) 2nd 13 47 27 27 6.7(2.0) 2nd 24 61 31 8 Add another medication 5.3(2.1) 2nd 4 39 39 22 7.4(1.3) 1st 18 78 22 0 3rd 6 % 3rd 0 % 6 % 10 % 85 % Stop medication. Start psychotherapy 38 3.8(2.5) 20 % 20 % 60 % 2.2(1.8) J Clin Psychiatry 1999;60 (suppl 16) PTSD Survey Questions Answered by All the Experts 8 A patient with PTSD has had an adequate trial (i.e., duration and dose) of medication alone but has achieved no response. Please rate the appropriateness of the following strategies as a next step. Assume that you will either provide the treatment or can make an appropriate referral for treatment. Psychotherapy experts Medication experts Tr of 1st 2nd 3rd Tr of 1st 2nd 3rd Avg(SD) Rank Chc Line Line Line Avg(SD) Rank Chc Line Line Line In acute PTSD Add psychotherapy 8.0(1.6) Chc 61 84 12 4 6.7(2.4) 2nd 27 63 21 15 Switch medication. Start psychotherapy 6.6(2.4) 2nd 22 67 20 12 7.2(1.8) 1st 21 77 17 6 Switch to another medication 6.1(2.2) 2nd 13 54 31 15 7.5(1.7) 1st 31 79 17 4 Stop medication. Start psychotherapy 6.0(2.7) 2nd 24 51 27 22 3.9(2.4) 3rd 2 19 27 54 Add another medication 4.2(2.4) 2nd 2 20 41 39 5.5(2.4) 2nd 13 38 33 29 Raise the dose of the medication to a higher than usual level 3.8(2.4) 3rd 2 16 36 49 4.2(2.5) 2nd 8 21 37 42 Add psychotherapy 7.8(1.7) Chc 57 82 14 4 6.6(2.4) 2nd 29 60 25 15 Switch medication. Start psychotherapy 6.6(2.4) 2nd 24 60 28 12 7.3(1.9) 1st 29 76 18 6 In chronic PTSD Switch to another medication 6.3(1.9) 2nd 13 54 35 11 7.6(1.6) 1st 29 85 12 4 Stop medication. Start psychotherapy 5.9(2.6) 2nd 20 49 27 24 3.7(2.2) 3rd 2 13 33 54 Add another medication 4.5(2.4) 2nd 4 22 42 36 5.9(2.5) 2nd 13 48 29 23 Raise the dose of the medication to a higher than usual level 3.9(2.5) 3rd 5 18 32 50 4.8(2.5) 2nd 10 31 37 33 In PTSD with strong suicidal or aggressive tendencies Add psychotherapy 7.9(1.7) Chc 56 85 12 4 6.7(2.4) 2nd 27 62 27 12 Switch medication. Start psychotherapy 6.8(2.4) 2nd 26 70 18 12 7.4(2.0) 1st 38 75 19 6 Switch to another medication 6.4(2.2) 2nd 19 57 28 15 7.4(1.7) 1st 31 75 21 4 Stop medication. Start psychotherapy 5.3(2.7) 2nd 16 37 35 29 3.0(2.4) 3rd 4 12 23 65 Add another medication 4.5(2.4) 2nd 4 22 40 38 6.3(2.5) 2nd 21 58 23 19 Raise the dose of the medication to a higher than usual level 3.9(2.6) 3rd 4 % 22 % 24 % 53 % 4.7(2.4) 2nd 8 % 29 % 40 % 31 % J Clin Psychiatry 1999;60 (suppl 16) 39 Expert Consensus Guideline Series 9 A patient with PTSD has had an adequate initial trial of a combination of the psychotherapy you thought would be most effective and an appropriate medication at an adequate dose, but has had only a partial response. Please rate the appropriateness of the following strategies as a next step. Assume that you will either provide the treatment or can make an appropriate referral for treatment. Psychotherapy experts Medication experts Tr of 1st 2nd 3rd Tr of 1st 2nd 3rd Avg(SD) Rank Chc Line Line Line Avg(SD) Rank Chc Line Line Line In acute PTSD Add another psychotherapy technique 7.1(2.1) Switch to another psychotherapy technique Switch to another medication 1st 29 77 15 8 5.8(2.0) 2nd 4 48 41 11 6.9(1.5) 2nd 19 65 33 2 5.7(1.7) 6.4(1.7) 2nd 8 56 35 8 6.8(1.5) 2nd 4 37 57 6 2nd 17 61 37 2 Raise the dose of the medication to a higher than usual level 5.4(2.3) 2nd 4 40 36 24 6.3(2.1) 2nd 15 52 37 11 Add another medication 5.3(2.0) 2nd 2 30 48 22 6.9(1.7) 2nd 19 63 33 4 Stop medication. Continue psychotherapy 4.0(2.3) 3rd 6 14 37 49 2.7(1.6) 3rd 0 2 26 72 Stop psychotherapy. Continue medication 2.8(1.8) 3rd 2 2 31 67 3.2(1.7) 3rd 0 6 30 65 In chronic PTSD Add another psychotherapy technique 7.1(2.0) 1st 29 75 17 8 5.6(2.0) 2nd 4 43 44 13 Switch to another psychotherapy technique 6.8(1.5) 2nd 15 62 38 0 5.8(1.7) 2nd 4 33 57 9 Switch to another medication 6.4(1.8) 2nd 9 60 30 11 6.8(1.4) 2nd 13 57 41 2 Add another medication 5.4(2.0) 2nd 7 27 56 18 7.3(1.5) 1st 20 78 19 4 Raise the dose of the medication to a higher than usual level 5.4(2.5) 2nd 9 38 40 22 6.8(1.8) 2nd 17 69 24 7 Stop medication. Continue psychotherapy 3.5(2.0) 3rd 2 4 43 53 2.5(1.6) 3rd 0 2 23 75 Stop psychotherapy. Continue medication 2.7(1.8) 3rd 2 2 27 71 3.2(1.7) 3rd 0 6 30 65 In PTSD with strong suicidal or aggressive tendencies Add another psychotherapy technique 7.1(2.1) 1st 33 71 21 8 5.6(2.2) 2nd 4 43 39 19 Switch to another psychotherapy technique 6.8(1.6) 2nd 20 55 43 2 5.7(1.9) 2nd 6 37 46 17 Switch to another medication 6.8(1.6) 2nd 10 73 21 6 7.0(1.5) 1st 19 64 32 4 Add another medication 5.9(2.0) 2nd 9 41 46 13 7.8(1.1) 1st 28 91 9 0 Raise the dose of the medication to a higher than usual level 5.8(2.5) 2nd 11 51 31 18 6.9(1.9) 2nd 17 70 20 9 Stop medication. Continue psychotherapy 3.1(1.9) 3rd 2 6 25 69 2.1(1.4) 3rd 0 2 13 85 Stop psychotherapy. Continue medication 2.6(1.8) 3rd 2 % 2 % 24 % 75 % 2.7(1.8) 3rd 0 % 6 % 22 % 72 % 40 J Clin Psychiatry 1999;60 (suppl 16) PTSD Survey Questions Answered by All the Experts 10 A patient with PTSD has had an adequate initial trial of a combination of the psychotherapy you thought would be most effective and an appropriate medication at an adequate dose, but has had no response. Please rate the appropriateness of the following strategies as a next step. Assume that you will either provide the treatment or can make an appropriate referral for treatment. Psychotherapy experts Medication experts Tr of 1st 2nd 3rd Tr of 1st 2nd 3rd Avg(SD) Rank Chc Line Line Line Avg(SD) Rank Chc Line Line Line In acute PTSD Switch to another psychotherapy technique 7.3(1.8) 1st 33 75 21 4 6.2(2.0) 2nd 11 55 32 13 Switch to another medication 6.8(2.1) 2nd 24 69 22 8 7.7(1.2) 1st 33 85 15 0 Add another psychotherapy technique 6.7(2.1) 2nd 21 62 31 8 5.3(2.3) 2nd 6 36 40 25 Add another medication 5.1(2.5) 2nd 9 28 41 30 6.0(2.2) 2nd 13 48 37 15 Raise the dose of the medication to a higher than usual level 4.3(2.5) 2nd 4 24 31 44 5.1(2.4) 2nd 10 27 42 31 Stop medication. Continue psychotherapy 4.0(2.4) 3rd 2 16 37 47 2.8(1.8) 3rd 0 4 23 74 Stop psychotherapy. Continue medication 2.7(1.7) 3rd 2 2 25 73 2.7(1.6) 3rd 0 2 21 77 In chronic PTSD Switch to another psychotherapy technique 7.2(1.9) 1st 31 71 24 6 6.1(2.1) 2nd 8 53 34 13 Switch to another medication 7.0(1.8) 1st 22 71 27 2 7.8(1.1) 1st 30 89 11 0 Add another psychotherapy technique 6.6(2.2) 2nd 24 63 25 12 5.4(2.3) 2nd 6 40 38 23 Add another medication 5.4(2.3) 2nd 11 28 48 24 6.4(2.1) 2nd 15 57 30 13 Raise the dose of the medication to a higher than usual level 4.6(2.5) 2nd 7 27 38 36 5.7(2.3) 2nd 9 38 42 21 Stop medication. Continue psychotherapy 3.7(2.1) 3rd 2 6 44 50 2.7(1.7) 3rd 0 2 21 77 Stop psychotherapy. Continue medication 2.7(1.8) 3rd 2 2 26 72 2.8(1.7) 3rd 0 2 25 74 In PTSD with strong suicidal or aggressive tendencies Switch to another medication 7.3(1.6) 1st 24 80 16 4 8.0(1.1) 1st 38 89 11 0 Switch to another psychotherapy technique 7.2(1.8) 1st 29 76 18 6 5.9(2.0) 2nd 4 49 34 17 Add another psychotherapy technique 6.7(2.1) 2nd 22 65 25 10 5.5(2.4) 2nd 9 40 34 26 Add another medication 5.8(2.3) 2nd 17 35 48 17 6.8(2.0) 2nd 19 65 25 10 Raise the dose of the medication to a higher than usual level 4.8(2.6) 2nd 9 33 29 38 5.7(2.6) 2nd 13 44 29 27 Stop medication. Continue psychotherapy 3.3(2.0) 3rd 2 4 35 60 2.1(1.5) 3rd 0 2 8 91 Stop psychotherapy. Continue medication 2.7(1.9) 3rd 2 % 2 % 27 % 71 % 2.6(1.8) 3rd 0 % 4 % 13 % 83 % J Clin Psychiatry 1999;60 (suppl 16) 41 Expert Consensus Guideline Series 11 Rate the appropriateness of the following interventions for a patient with chronic PTSD who has been persistently refractory to treatment. Assume that the patient has received an adequate course of a number of the usual psychotherapy and medication treatments either alone or in combination. Note: results from psychotherapy and medication experts are combined. Tr of 1st 2nd 3rd Avg(SD) Chc Line Line Line 95% CONFIDENCE INTERVALS Third Line Second Line First Line * * 8.1(1.4) 53 89 8 3 8.1(1.3) 50 92 6 2 Assess for the presence of a neurological or other general medical condition 7.7(1.5) 39 85 13 2 Assess for secondary gain 7.4(1.6) 30 78 18 4 Reevaluate diagnosis of PTSD 7.3(1.9) 37 73 20 7 Consider special rehabilitation programs (e.g., social skills training, vocational rehabilitation) 6.8(1.4) 10 66 32 2 Combination of multiple psychotherapy techniques 6.0(1.9) 11 41 48 11 Assess for substance abuse problems Reevaluate for psychiatric comorbidity Family therapy 6.0(1.6) 5 39 53 8 Combinations of multiple medications 6.0(1.9) 6 47 42 12 Multiple medications + multiple psychotherapy techniques 5.3(2.4) 10 31 44 25 Hospitalize the patient 4.8(1.9) 4 20 48 32 Electroconvulsive therapy 3.3(1.8) 1 % 8 % 30 % 62 % 1 42 2 3 4 5 6 7 8 9 J Clin Psychiatry 1999;60 (suppl 16) PTSD Survey Questions Answered by All the Experts 12 Please rate the appropriateness of the following prevention strategies during the first month after the trauma and in the period from 1 to 3 months after the trauma. Note: results from psychotherapy and medication experts are combined. Tr of 1st 2nd 3rd Avg(SD) Chc Line Line Line 95% CONFIDENCE INTERVALS Third Line Second Line First Line First month after trauma (to prevent PTSD in patients with acute stress disorder) Provide psychoeducation 8.1(1.5) 59 90 8 2 8.0(1.4) 50 86 13 1 Relieve irrational guilt 7.7(1.4) 39 81 18 1 Facilitate emotional recalling and retelling of the event 7.0(1.9) 31 66 30 4 Anxiety management techniques (stress inoculation training) 6.7(1.8) 21 62 32 6 * * Normalize the reaction to the event Provide group crisis intervention (e.g., incident debriefing) 6.3(2.2) 22 50 36 15 Cognitive therapy 6.1(1.8) 11 45 48 7 Provide short-term sleep medication 5.8(2.2) 12 41 44 16 Exposure therapy 5.4(2.2) 12 29 51 19 Start short-term treatment with a benzodiazepine 4.3(2.3) 3 21 42 37 Brief psychodynamic psychotherapy 4.2(2.3) 3 20 36 45 Start treatment with an antidepressant 4.1(2.2) 3 15 43 43 EMDR (eye movement desensitization reprocessing) 3.8(2.4) 5 18 26 56 Hypnotherapy 3.1(1.8) 2 3 33 64 Start short-term treatment with an antipsychotic 2.4(1.6) 1 2 20 78 7.9(1.5) 53 79 20 1 1–3 months after trauma (to prevent chronic symptoms in patients with acute PTSD) Provide psychoeducation * Relieve irrational guilt 7.9(1.2) 35 88 11 1 Normalize the reaction to the event 7.5(1.6) 40 72 25 3 Facilitate emotional recalling and retelling of the event 7.4(1.7) 31 81 13 6 Cognitive therapy 7.0(1.8) 23 71 25 4 Exposure therapy 6.9(2.0) 23 70 24 6 Anxiety management techniques (stress inoculation training) 6.9(1.6) 18 66 29 5 Start treatment with an antidepressant 6.1(2.2) 16 49 37 14 Provide short-term sleep medication 5.4(2.0) 6 27 54 19 Provide group crisis intervention (e.g., incident debriefing) 5.0(2.2) 5 29 39 32 Brief psychodynamic psychotherapy 5.0(2.3) 5 31 37 32 EMDR 4.4(2.6) 10 26 31 44 Start short-term treatment with a benzodiazepine 4.2(2.1) 1 12 50 39 Hypnotherapy 3.5(2.0) 2 7 35 57 3.0(1.8) 1 % 3 % 32 % 65 % Start short-term treatment with an antipsychotic 1 J Clin Psychiatry 1999;60 (suppl 16) 2 3 4 5 6 7 8 9 43 Expert Consensus Guideline Series Survey Questions Answered Only by Psychotherapy Experts 13 Rate the appropriateness of each of the different psychotherapy techniques for each PTSD symptom assuming that it is the most prominent target of treatment. Consider each technique independently. Tr of 1st 2nd 3rd Avg(SD) Chc Line Line Line 95% CONFIDENCE INTERVALS Third Line Second Line First Line Anxiety management techniques General anxiety (hyperarousal, hypervigilance, startle) 7.8(1.4) 42 85 13 2 Sleep disturbance 7.4(1.4) 29 76 22 2 Trauma-related fears, panic, and avoidance 7.2(1.8) 31 71 24 6 Irritability/angry outbursts 7.1(1.8) 24 73 20 6 Difficulty concentrating 7.0(1.5) 18 67 31 2 Flashbacks 6.4(1.9) 14 57 35 8 Intrusive thoughts 6.3(1.8) 10 55 35 10 Dissociative symptoms 6.0(1.8) 10 35 55 8 Numbing/detachment from others/loss of interest 5.3(2.0) 6 25 53 22 Guilt/shame 5.0(2.1) 4 27 43 27 Cognitive therapy * 8.4(1.1) 65 92 8 0 Irritability/angry outbursts 7.5(1.3) 27 82 18 0 Trauma-related fears, panic, and avoidance 7.5(1.1) 23 81 19 0 Numbing/detachment from others/loss of interest 7.0(1.6) 21 65 33 2 Guilt/shame Intrusive thoughts 6.9(1.6) 20 71 25 4 General anxiety (hyperarousal, hypervigilance, startle) 6.7(1.6) 13 65 29 6 Dissociative symptoms 6.5(1.8) 16 52 42 6 Flashbacks 6.4(1.9) 18 57 31 12 Difficulty concentrating 6.2(1.6) 8 41 51 8 Sleep disturbance 6.0(1.7) 6 43 47 10 7.9(1.7) 57 84 12 4 Exposure therapy Trauma-related fears, panic, and avoidance * * * 7.9(1.7) 53 82 12 6 7.9(1.6) 53 80 18 2 General anxiety (hyperarousal, hypervigilance, startle) 7.0(1.9) 29 67 25 8 Sleep disturbance 6.2(2.2) 22 46 38 16 Numbing/detachment from others/loss of interest 6.0(2.1) 8 45 35 20 Irritability/angry outbursts 6.0(2.2) 20 40 50 10 Difficulty concentrating 5.9(2.2) 18 42 44 14 Dissociative symptoms 5.6(2.3) 12 38 42 20 5.5(2.4) 16 % 38 % 38 % 24 % Flashbacks Intrusive thoughts Guilt/shame 1 44 2 3 4 5 6 7 8 9 J Clin Psychiatry 1999;60 (suppl 16) PTSD Survey Questions Answered Only by Psychotherapy Experts 13. Continued. Tr of 1st 2nd 3rd Avg(SD) Chc Line Line Line 95% CONFIDENCE INTERVALS Third Line Second Line First Line Play therapy for children General anxiety (hyperarousal, hypervigilance, startle) 6.2(2.4) Trauma-related fears, panic, and avoidance 6.2(2.5) 22 59 24 16 Guilt/shame 6.0(2.5) 19 57 27 16 Intrusive thoughts 6.0(2.5) 16 54 30 16 Irritability/angry outbursts 5.9(2.5) 14 51 35 14 19 58 25 17 Flashbacks 5.9(2.5) 14 54 30 16 Numbing/detachment from others/loss of interest 5.6(2.4) 11 43 38 19 Sleep disturbance 5.4(2.3) 8 39 44 17 Dissociative symptoms 5.4(2.6) 8 41 32 27 Difficulty concentrating 5.2(2.4) 8 35 43 22 Psychoeducation Trauma-related fears, panic, and avoidance 6.4(2.3) 26 52 38 10 General anxiety (hyperarousal, hypervigilance, startle) 6.4(2.2) 24 52 38 10 Irritability/angry outbursts 6.2(2.2) 22 51 35 14 Intrusive thoughts 6.2(2.3) 24 51 33 16 Flashbacks 6.2(2.4) 25 51 29 20 Guilt/shame 6.2(2.3) 20 51 31 18 Difficulty concentrating 6.1(2.3) 20 49 33 18 Numbing/detachment from others/loss of interest 6.1(2.3) 22 47 37 16 Dissociative symptoms 6.1(2.3) 22 43 41 16 6.0(2.5) 20 % 49 % 31 % 20 % Sleep disturbance 1 The mean ratings for these three techniques were below 5.5 2 3 4 EMDR Avg(SD) 5 6 7 8 9 Hypnotherapy Avg(SD) Psychodynamic psychotherapy Avg(SD) Intrusive thoughts 4.8(2.8) 3.7(2.3) 4.2(2.3) Flashbacks 4.7(2.7) 3.7(2.4) 3.9(2.2) Trauma-related fears, panic, and avoidance 4.5(2.7) 3.8(2.2) 4.2(2.3) General anxiety (hyperarousal, hypervigilance, startle) 4.3(2.6) 3.9(2.3) 4.1(2.2) Numbing/detachment from others/loss of interest 3.8(2.3) 3.5(2.1) 4.8(2.6) Dissociative symptoms 3.7(2.4) 4.1(2.5) 4.5(2.6) Sleep disturbance 3.7(2.6) 3.9(2.2) 3.9(2.3) Irritability/angry outbursts 3.7(2.7) 3.4(2.0) 4.5(2.5) Difficulty concentrating 3.8(2.4) 3.5(2.0) 4.0(2.4) Guilt/shame 4.0(2.7) 3.6(2.2) 5.4(2.8) J Clin Psychiatry 1999;60 (suppl 16) 45 Expert Consensus Guideline Series 14 How does the presence of a comorbid psychiatric disorder affect your choice of psychotherapy techniques in treating PTSD? Please rate the appropriateness of each of the following psychotherapy techniques for a patient whose PTSD is complicated by the following conditions. Assume that PTSD is the primary diagnosis. Consider each technique independently. Tr of 1st 2nd 3rd Avg(SD) Chc Line Line Line 95% CONFIDENCE INTERVALS Third Line Second Line First Line Anxiety management techniques Other anxiety disorder 7.9(1.4) 41 90 8 2 Substance abuse or dependence 7.1(1.9) 32 76 16 8 Severe cluster B personality disorder 6.9(2.0) 29 65 27 8 Bipolar disorder 6.6(1.7) 15 63 33 4 Depressive disorder 6.5(1.8) 16 60 34 6 8.3(1.1) 58 96 2 2 Other anxiety disorder 7.8(1.4) 37 90 8 2 Bipolar disorder 7.2(1.7) 24 76 18 6 Severe cluster B personality disorder 7.1(2.1) 41 69 22 8 Substance abuse or dependence 7.0(2.1) 31 73 20 8 Other anxiety disorder 7.2(2.0) 36 76 14 10 Depressive disorder 6.8(2.1) 20 65 18 16 Bipolar disorder 5.8(2.3) 13 48 31 21 Substance abuse or dependence 5.7(2.4) 16 44 32 24 Severe cluster B personality disorder 5.4(2.5) 17 38 31 31 Depressive disorder 6.0(2.8) 18 61 18 21 Other anxiety disorder 5.6(3.0) 20 51 20 29 Bipolar disorder 5.1(2.9) 10 43 23 33 Cognitive therapy * Depressive disorder Exposure therapy Play therapy for children Severe cluster B personality disorder 5.1(2.9) 7 45 24 31 Substance abuse or dependence 4.5(2.7) 9 28 34 38 Other anxiety disorder 6.9(2.1) 33 61 33 6 Substance abuse or dependence 6.8(2.3) 38 62 26 12 Depressive disorder 6.8(2.1) 29 59 35 6 Bipolar disorder 6.7(2.3) 30 60 32 9 6.5(2.4) 29 % 63 % 23 % 15 % Psychoeducation Severe cluster B personality disorder 1 The mean ratings for these three techniques were below 5.0 46 2 3 4 EMDR Avg(SD) 5 6 7 8 9 Hypnotherapy Avg(SD) Psychodynamic psychotherapy Avg(SD) Depressive disorder 3.8(2.6) 3.2(1.8) 4.8(2.7) Bipolar disorder 3.6(2.4) 2.8(1.6) 3.8(2.4) Other anxiety disorder 4.0(2.6) 3.5(2.1) 4.3(2.5) Substance abuse or dependence 3.6(2.6) 2.9(1.8) 3.9(2.6) Severe cluster B personality disorder 3.3(2.5) 2.9(2.0) 4.8(2.8) J Clin Psychiatry 1999;60 (suppl 16) PTSD Survey Questions Answered Only by Psychotherapy Experts 15 Please rate the overall effectiveness, safety, and acceptability of each of the following psychotherapy techniques for a patient with PTSD. Give your highest ratings to those techniques you consider most effective, safe, or acceptable. Tr of 1st 2nd 3rd Avg(SD) Chc Line Line Line 95% CONFIDENCE INTERVALS Third Line Second Line First Line Effectiveness (likely to decrease PTSD symptoms by 75% and improve general functioning) Imaginal exposure 7.9(1.2) 36 90 8 2 Cognitive therapy 7.3(1.4) 21 73 25 2 In vivo exposure 7.2(1.9) 29 73 18 8 Anxiety management techniques 6.6(1.2) 6 55 43 2 Psychoeducation 5.6(2.1) 12 37 47 16 Play therapy for children 5.3(2.1) 6 37 37 26 EMDR 4.9(2.5) 9 32 34 34 Psychodynamic psychotherapy 4.4(2.4) 6 24 37 39 Hypnotherapy 3.7(1.7) 2 4 47 49 8.3(0.9) 49 96 4 0 8.2(0.9) 51 94 6 0 Safety (unlikely to increase severity of symptoms, agitation, or suicidality) Anxiety management techniques * Psychoeducation Cognitive therapy 8.1(1.1) 48 92 8 0 Play therapy for children 7.0(1.6) 14 74 23 3 Imaginal exposure 6.3(1.5) 6 50 46 4 EMDR 6.3(1.9) 11 57 32 11 Psychodynamic psychotherapy 6.2(2.2) 14 51 35 14 In vivo exposure 6.0(2.0) 6 50 31 19 Hypnotherapy 4.3(1.9) 0 11 55 34 Acceptability (likely to promote engagement, responsiveness, and retention in treatment) Psychoeducation 7.8(1.6) 49 78 22 0 Cognitive therapy 7.7(1.3) 27 84 14 2 Anxiety management techniques 7.5(1.4) 29 76 22 2 Play therapy for children 7.0(1.9) 24 68 27 5 Imaginal exposure 5.9(1.8) 6 45 43 12 Psychodynamic psychotherapy 5.9(2.3) 16 45 37 18 EMDR 5.8(2.1) 9 45 36 19 In vivo exposure 5.4(2.1) 8 33 45 22 Hypnotherapy 4.4(1.6) 0 % 9 % 64 % 27 % 1 J Clin Psychiatry 1999;60 (suppl 16) 2 3 4 5 6 7 8 9 47 Expert Consensus Guideline Series 16 How does the age of the patient affect your choice of psychotherapy techniques in treating PTSD? Please rate the overall appropriateness of each of the following psychotherapy techniques for a patient with PTSD in each of the following age groups. Tr of 1st 2nd 3rd Avg(SD) Chc Line Line Line 95% CONFIDENCE INTERVALS Third Line Second Line First Line Children and younger adolescents Play therapy 7.1(2.1) 32 71 22 7 Psychoeducation 7.0(2.1) 37 65 28 7 Anxiety management techniques 6.9(1.6) 15 64 32 4 Cognitive therapy 6.2(1.9) 15 48 43 9 Imaginal exposure 5.8(2.2) 13 44 29 27 In vivo exposure 5.7(2.5) 20 48 25 27 Psychodynamic psychotherapy 3.8(2.6) 9 19 28 53 EMDR 3.6(2.7) 5 20 25 55 Hypnotherapy 3.2(1.9) 3 5 30 65 Cognitive therapy 7.9(1.6) 48 88 10 2 Imaginal exposure 7.8(1.9) 49 88 4 8 Anxiety management techniques 7.5(1.6) 32 82 14 4 Psychoeducation 7.4(2.1) 46 70 24 6 In vivo exposure 7.1(2.3) 43 72 15 13 EMDR 5.0(2.9) 13 40 22 38 Psychodynamic psychotherapy 4.9(2.6) 11 30 32 38 Hypnotherapy 3.8(2.2) 5 9 39 52 Cognitive therapy 7.9(1.5) 42 89 9 2 Anxiety management techniques 7.6(1.7) 36 82 13 4 Adults and older adolescents Geriatric patients Psychoeducation 7.5(2.1) 47 72 21 6 Imaginal exposure 6.9(2.2) 30 73 16 11 In vivo exposure 6.4(2.6) 31 55 29 17 Psychodynamic psychotherapy 4.8(2.5) 9 26 35 40 EMDR 4.7(2.8) 8 33 28 40 Hypnotherapy 3.7(2.1) 0 % 8 % 41 % 51 % 1 48 2 3 4 5 6 7 8 9 J Clin Psychiatry 1999;60 (suppl 16) PTSD Survey Questions Answered Only by Psychotherapy Experts 17 Which of the following psychotherapy techniques acts most quickly? Please give your highest ratings to those techniques you think have the fastest effect. Tr of 1st 2nd 3rd Avg(SD) Chc Line Line Line 95% CONFIDENCE INTERVALS Third Line Second Line First Line Imaginal exposure 7.3(1.7) 26 82 16 2 In vivo exposure 7.0(1.9) 25 71 25 4 Anxiety management techniques 6.7(1.3) 6 62 38 0 Cognitive therapy 6.6(1.4) 10 54 44 2 Psychoeducation 6.2(2.0) 15 46 46 8 EMDR 5.8(2.9) 26 53 16 30 Play therapy for children 4.8(2.5) 11 24 43 32 Hypnotherapy 4.1(2.4) 5 17 33 50 3.2(2.0) 0 % 6 % 33 % 60 % Psychodynamic psychotherapy 1 18 2 3 4 5 6 7 8 9 Frequency of visits: initial treatment phase. Please rate the appropriateness of the following frequencies of psychotherapy sessions during the initial phase (first 3 months) of treatment for PTSD. Tr of 1st 2nd 3rd Avg(SD) Chc Line Line Line 95% CONFIDENCE INTERVALS Third Line Second Line First Line Weekly throughout 7.9(1.5) 36 94 2 4 Twice a week 6.8(2.2) 29 61 31 8 Weekly for first month and every 2 weeks thereafter 5.7(1.8) 2 34 52 14 Every 2 weeks 4.0(1.9) 2 8 52 40 Monthly 2.2(1.6) 2 2 12 86 1.7(1.3) 2 % 2 % 2 % 96 % Every 2 months 1 19 2 3 4 5 6 7 8 9 Please rate the appropriateness of the following durations of psychotherapy sessions during the initial phase (first 3 months) of treatment for PTSD. Tr of 1st 2nd 3rd Avg(SD) Chc Line Line Line 95% CONFIDENCE INTERVALS Third Line Second Line First Line 60 minutes 7.5(1.8) 29 82 12 6 > 60 minutes 7.0(2.1) 31 69 23 8 45 minutes 6.1(2.3) 16 50 36 14 30 minutes 2.9(1.8) 2 4 23 73 1.8(1.3) 2 % 2 % 4 % 94 % 15 minutes 1 J Clin Psychiatry 1999;60 (suppl 16) 2 3 4 5 6 7 8 9 49 Expert Consensus Guideline Series 20 Please rate the appropriateness of each of the following formats for psychotherapy sessions during the initial phase (first 3 months) of treatment for PTSD. Tr of 1st 2nd 3rd Avg(SD) Chc Line Line Line 95% CONFIDENCE INTERVALS Third Line Second Line First Line * 8.7(1.2) 81 98 0 2 Combination of individual and group therapy 6.7(1.7) 17 56 42 2 Combination of individual and family therapy 6.4(1.7) 10 50 42 8 Therapist-led PTSD group 6.0(1.9) 12 40 48 12 Family 5.3(1.9) 4 23 58 19 3.7(1.9) 2 % 8 % 38 % 54 % Individual Self-help PTSD group 1 2 3 4 5 6 7 8 9 21 Frequency of visits: maintenance phase. What frequency of psychotherapy visits makes sense in the maintenance phase? Assume that a patient with PTSD has already had a good response after 3 months of treatment and continues to do well. Rate the appropriateness of the following frequencies of psychotherapy follow-up visits for each subsequent time period. 3–6 months 6–12 months After 12 months Tr of 1st 2nd 3rd Tr of 1st 2nd 3rd Tr of 1st 2nd 3rd Avg(SD) Rank Chc Line Line Line Avg(SD) Rank Chc Line Line Line Avg(SD) Rank Chc Line Line Line Once a week 4.6(2.7) 2nd 13 28 36 36 3.3(2.5) 3rd 6 12 27 61 2.4(2.2) 3rd 6 8 10 82 Every 2 weeks 5.8(2.3) 2nd 6 51 31 18 3.9(2.5) 3rd 2 27 18 55 2.6(2.1) 3rd 2 8 16 76 Once a month 6.5(2.2) 2nd 14 67 20 12 5.3(2.4) 2nd 8 37 39 24 3.3(2.3) 3rd 4 8 35 57 Every 2 months 5.2(1.8) 2nd 0 27 54 19 5.0(2.3) 2nd 6 22 53 24 3.7(2.5) 3rd 6 18 29 53 Every 3 months 4.3(2.3) 2nd 8 13 52 35 5.0(2.4) 2nd 4 33 39 29 3.9(2.5) 3rd 2 20 31 49 Every 6 months 3.6(2.2) 3rd 2 11 34 55 4.5(2.4) 2nd 4 27 39 35 4.7(2.7) 2nd 4 35 29 37 No more visits 3.4(2.7) 3rd 4 21 13 67 5.3(3.1) 2nd 22 44 18 38 6.4(3.0) 2nd 41 61 16 24 22 On average, how long would you continue the psychotherapy before trying to taper and discontinue it in each of the following situations? Acute PTSD, remission Chronic PTSD, remission Chronic PTSD, residual symptoms Tr of 1st 2nd 3rd Tr of 1st 2nd 3rd Tr of 1st 2nd 3rd Avg(SD) Rank Chc Line Line Line Avg(SD) Rank Chc Line Line Line Avg(SD) Rank Chc Line Line Line 3 months 90 4 6 6.8(2.5) 2nd 37 61 27 12 6.5(2.4) 2nd 27 63 24 14 5.9(2.2) 2nd 10 46 36 18 6.6(2.3) 2nd 16 73 8 18 6.7(2.1) 2nd 18 68 18 14 12 months 3.7(2.0) 3rd 2 6 46 48 5.5(2.3) 2nd 13 29 52 19 5.9(2.3) 2nd 16 45 39 16 24 months 2.4(1.6) 3rd 2 2 20 78 3.9(2.2) 3rd 4 13 38 49 4.3(2.3) 2nd 6 16 42 42 > 24 months 1.7(1.3) 3rd 2 2 0 98 2.9(2.1) 3rd 2 6 25 69 3.0(2.0) 3rd 2 6 30 64 6 months 50 7.9(1.9) Chc 54 J Clin Psychiatry 1999;60 (suppl 16) PTSD Survey Questions Answered Only by Psychotherapy Experts 23 Assume that a patient with PTSD is doing well in the maintenance phase (in remission for 6–12 months) and you are considering discontinuing psychotherapy, but are concerned about the possibility of relapse. Give your highest ratings to those factors that would support continuing psychotherapy for a longer time. Tr of 1st 2nd 3rd Avg(SD) Chc Line Line Line 95% CONFIDENCE INTERVALS Third Line Second Line First Line Current life stressors 7.2(1.9) 23 77 15 8 High suicide risk in the past 7.0(2.0) 25 67 25 8 Poor social supports 6.7(1.8) 10 63 27 10 Persistence of some symptoms 6.5(2.2) 25 58 33 10 Presence of Axis I comorbidity 6.3(2.0) 12 58 33 10 Past violence 6.2(2.1) 12 52 35 13 Poor functioning when symptomatic 6.1(2.1) 13 50 38 12 Presence of Axis II comorbidity 6.1(2.2) 12 42 48 10 History of severe PTSD symptoms 5.6(1.9) 6 27 61 12 5.6(2.2) 12 % 31 % 52 % 17 % Long duration of PTSD symptoms 1 24 2 3 4 5 6 7 8 9 Please rate the appropriateness of the following strategies for enhancing compliance with psychotherapy treatment. Tr of 1st 2nd 3rd Avg(SD) Chc Line Line Line 95% CONFIDENCE INTERVALS Third Line Second Line First Line * Psychoeducation 8.3(1.4) 63 92 6 2 Frequently review rationale for treatment with patient 7.8(1.6) 42 87 12 2 Ensure easy and prompt access to treatment 7.7(1.2) 29 87 12 2 Evaluate for and treat substance abuse problems 7.6(1.3) 33 85 13 2 Take patient preference into account in selecting treatments 7.6(1.5) 33 88 8 4 Involve a relative or significant other at an early stage 6.9(1.5) 19 58 42 0 Peer support group 6.3(1.6) 15 42 56 2 6.0(1.5) 10 % 25 % 69 % 6 % Family therapy 1 2 3 4 5 6 7 8 9 Because of space limitations, we could not present the complete results of the following questions. Results are available on request. 25 Does the type of stressful event affect your choice of psychotherapy techniques? Please rate the appropriateness of each of the following psychotherapy techniques for the treatment of PTSD that is associated with each of the following types of stressors. Cognitive therapy, exposure therapy, anxiety management, and psychoeducation received the highest ratings for all the different types of stressors. 26 How well do the different psychotherapy techniques go together at the outset of treatment and also for a patient who is not having an adequate response to a single psychotherapy technique? The four techniques preferred for use alone— anxiety management techniques, cognitive therapy, exposure therapy, and psychoeducation—are also recommended in combination with one another. J Clin Psychiatry 1999;60 (suppl 16) 51 Expert Consensus Guideline Series Survey Questions Answered Only by Medication Experts In questions 27–30, we asked about the appropriateness of the following classes of medications: newer antidepressants, traditional antidepressants, mood stabilizers, benzodiazepines, antiadrenergics, buspirone, and atypical and conventional antipsychotics. Due to space limitations, we report here only the situations for which the mean rating for a given class of medication was 5.0 or higher. Complete results are available on request. 27 Rate the appropriateness of the different classes of medication for each PTSD symptom assuming that it is the most prominent target of treatment. Tr of 1st 2nd 3rd Avg(SD) Chc Line Line Line 95% CONFIDENCE INTERVALS Third Line Second Line First Line Newer antidepressants (e.g., SSRIs, nefazodone, venlafaxine) Trauma-related fears, panic, and avoidance 8.1(1.2) 49 91 8 2 Intrusive thoughts 7.9(1.3) 46 89 11 0 Numbing/detachment from others/loss of interest 7.8(1.2) 39 87 13 0 General anxiety (hyperarousal, hypervigilance, startle) 7.7(1.4) 44 78 22 0 Difficulty concentrating 7.6(1.2) 30 83 17 0 Flashbacks 7.6(1.5) 39 81 17 2 Irritability/angry outbursts 7.4(1.5) 28 78 20 2 Guilt/Shame 7.3(2.0) 35 76 19 6 Sleep disturbance 7.1(1.7) 30 65 33 2 Dissociative symptoms 6.8(1.9) 25 62 33 6 Traditional antidepressants (e.g., tricyclics) Sleep disturbance 6.7(1.5) 13 50 46 4 Trauma-related fears, panic, and avoidance 6.4(1.5) 6 46 48 6 General anxiety (hyperarousal, hypervigilance, startle) 6.1(1.6) 2 46 44 9 Difficulty concentrating 6.1(1.4) 0 41 56 4 Numbing/detachment from others/loss of interest 6.1(1.7) 6 44 48 7 Irritability/angry outbursts 6.0(1.4) 4 28 67 6 Intrusive thoughts 6.0(1.8) 9 37 52 11 Flashbacks 5.9(1.7) 7 37 54 9 Guilt/Shame 5.9(1.8) 4 44 44 11 Dissociative symptoms 5.3(1.7) 4 27 58 15 Mood stabilizers (e.g., divalproex) Irritability/angry outbursts 6.4(1.9) 11 49 43 8 6.0(1.7) 4 43 46 11 Benzodiazepines Sleep disturbance General anxiety (hyperarousal, hypervigilance, startle) 5.8(1.7) 2 41 48 11 Trauma-related fears, panic, and avoidance 5.6(1.8) 2 35 52 13 Antiadrenergics (propranolol, clonidine) General anxiety (hyperarousal, hypervigilance, startle) 5.5(2.1) 8 38 43 19 Irritability/angry outbursts 5.1(2.1) 6 32 42 26 5.3(1.9) 2 % 30 % 54 % 17 % Buspirone General anxiety (hyperarousal, hypervigilance, startle) 1 52 2 3 4 5 6 7 8 9 J Clin Psychiatry 1999;60 (suppl 16) PTSD Survey Questions Answered Only by Medication Experts 28 Does the type of stressful event affect your choice of medications? Please rate the appropriateness of the different classes of medication for the treatment of PTSD that is associated with each of the following types of stressors. Tr of 1st 2nd 3rd Avg(SD) Chc Line Line Line 95% CONFIDENCE INTERVALS Third Line Second Line First Line Newer antidepressants (e.g., SSRIs, nefazodone, venlafaxine) Sexual trauma as an adult 8.0(1.2) 40 96 2 2 Victim of violent crime or torture 8.0(1.2) 42 96 2 2 Military combat 8.0(1.2) 40 94 4 2 Sexual or physical abuse in childhood 8.0(1.2) 40 96 2 2 Natural disasters 7.9(1.2) 34 94 4 2 Other trauma (e.g., being diagnosed with a lifethreatening illness, witnessing a traumatic event) 7.9(1.4) 38 94 4 2 Accidents 7.9(1.3) 36 94 4 2 Traditional antidepressants (e.g., tricyclics) Military combat 6.3(1.6) 8 44 54 2 Sexual trauma as an adult 6.2(1.5) 8 34 64 2 Victim of violent crime or torture 6.1(1.5) 4 38 58 4 Accidents 6.1(1.5) 6 38 58 4 Sexual or physical abuse in childhood 6.0(1.5) 6 34 64 2 Natural disasters 6.0(1.5) 4 36 60 4 Other trauma (e.g., being diagnosed with a lifethreatening illness, witnessing a traumatic event) 5.9(1.5) 4 36 58 6 Mood stabilizers (e.g., divalproex) Military combat 5.2(1.9) 2 27 55 18 Sexual or physical abuse in childhood 5.2(1.8) 0 24 55 20 Victim of violent crime or torture 5.0(1.7) 0 16 65 18 Accidents 5.2(1.9) 4 27 57 16 Natural disasters 5.2(1.9) 4 26 56 18 Sexual trauma as an adult 5.1(1.8) 2 22 59 18 5.0(1.9) 4 % 26 % 53 % 21 % Benzodiazepines Other trauma (e.g., being diagnosed with a lifethreatening illness, witnessing a traumatic event) 1 J Clin Psychiatry 1999;60 (suppl 16) 2 3 4 5 6 7 8 9 53 Expert Consensus Guideline Series 29 How does the presence of a comorbid psychiatric disorder affect your choice of medications in treating PTSD? Please rate the appropriateness of the different classes of medication for a patient whose PTSD is complicated by the following conditions. Assume that PTSD is the primary diagnosis. Tr of 1st 2nd 3rd Avg(SD) Chc Line Line Line 95% CONFIDENCE INTERVALS Third Line Second Line First Line Newer antidepressants (e.g., SSRIs, nefazodone, venlafaxine) Unipolar depressive disorder * * * * 8.7(0.5) 78 100 0 0 8.4(0.9) 60 96 4 0 8.3(1.1) 57 96 2 2 8.1(1.4) 54 85 13 2 Generalized anxiety disorder 7.5(1.6) 37 80 19 2 Bipolar disorder, depressed phase 7.5(1.6) 34 83 13 4 8.1(1.4) 52 91 6 4 Bipolar disorder, depressed phase 7.1(1.6) 22 69 28 4 Traditional antidepressants (e.g., tricyclics) Unipolar depressive disorder 7.1(1.3) 15 67 33 0 Panic disorder 6.6(1.6) 9 61 35 4 Generalized anxiety disorder 6.0(1.5) 4 39 56 6 Bipolar disorder, depressed phase 6.0(1.9) 9 40 49 11 Social phobia 5.9(1.7) 4 40 49 11 Obsessive-compulsive disorder 5.6(2.2) 4 44 37 19 Obsessive-compulsive disorder Panic disorder Social phobia Mood stabilizers (e.g., divalproex) Bipolar disorder, manic/hypomanic phase * Benzodiazepines Panic disorder 6.0(1.7) 4 43 49 8 Generalized anxiety disorder 5.9(1.7) 4 39 50 11 Social phobia 5.3(1.8) 2 32 53 15 Generalized anxiety disorder 5.8(2.0) 4 41 44 15 Atypical antipsychotics Bipolar disorder, manic/hypomanic phase 5.5(2.0) 2 39 39 22 5.2(2.2) 6 % 28 % 49 % 23 % Buspirone Conventional antipsychotics (e.g., haloperidol, thioridazine) Bipolar disorder, manic/hypomanic phase 1 54 2 3 4 5 6 7 8 9 J Clin Psychiatry 1999;60 (suppl 16) PTSD Survey Questions Answered Only by Medication Experts 30 How does the presence of a comorbid general medical condition affect your choice of medications in treating PTSD? Please rate the appropriateness of the different classes of medication for a patient whose PTSD is complicated by the following conditions. Tr of 1st 2nd 3rd Avg(SD) Chc Line Line Line 95% CONFIDENCE INTERVALS Third Line Second Line First Line Newer antidepressants (e.g., SSRIs, nefazodone, venlafaxine) Chronic pain 7.7(1.2) 30 85 15 0 Respiratory disease (e.g., asthma, emphysema) 7.6(1.4) 34 79 21 0 Cardiac disease 7.5(1.4) 28 81 19 0 Diabetes 7.5(1.5) 32 77 23 0 Thyroid abnormality 7.4(1.5) 32 72 28 0 Hypertension 7.3(1.4) 23 75 25 0 Central nervous system damage or disorder (e.g., head trauma, epilepsy, stroke) 7.3(1.3) 20 72 28 0 Gastrointestinal disease (e.g., ulcer) 7.0(1.8) 23 64 32 4 Liver disease 6.5(2.1) 23 57 36 8 Traditional antidepressants (e.g., tricyclics) Chronic pain 6.8(1.2) 6 63 37 0 Gastrointestinal disease (e.g., ulcer) 5.8(1.7) 6 35 56 10 Respiratory disease (e.g., asthma, emphysema) 5.6(1.6) 4 23 69 8 Thyroid abnormality 5.3(1.5) 2 23 67 10 Diabetes 5.3(1.5) 2 19 71 10 Hypertension 5.0(1.5) 0 13 71 15 Mood stabilizers (e.g., divalproex) Central nervous system damage or disorder (e.g., head trauma, epilepsy, stroke) 6.5(1.8) 8 62 30 8 Chronic pain 5.6(1.9) 2 43 43 14 Hypertension 5.2(1.8) 0 25 59 16 Diabetes 5.0(1.7) 0 23 60 17 Respiratory disease (e.g., asthma, emphysema) 5.0(1.6) 0 23 63 13 Cardiac disease 5.0(1.8) 0 23 58 19 Thyroid abnormality 5.0(1.8) 0 21 62 17 Antiadrenergics (E-blockers, clonidine) Hypertension 6.3(2.0) 6 57 30 13 Benzodiazepines Cardiac disease 5.3(1.9) 2 26 55 19 Thyroid abnormality 5.1(1.9) 2 25 54 21 Hypertension 5.1(1.7) 0 19 62 19 5.1(1.8) 0 % 21 % 62 % 17 % Gastrointestinal disease (e.g., ulcer) 1 J Clin Psychiatry 1999;60 (suppl 16) 2 3 4 5 6 7 8 9 55 Expert Consensus Guideline Series 31 Please rate the safety of each of the following classes of medication for treating a patient with PTSD (9 = least likely to cause serious problems or drug interactions). If you do not have experience with treating children and younger adolescents, please cross this column out. Tr of 1st 2nd 3rd Avg(SD) Chc Line Line Line 95% CONFIDENCE INTERVALS Third Line Second Line First Line In children and younger adolescents SSRIs 7.5(1.9) 33 86 10 5 Other newer antidepressants (e.g., nefazodone, venlafaxine) 6.8(1.5) 10 60 40 0 Buspirone 6.0(2.2) 14 52 29 19 Antiadrenergics (e.g., propranolol, clonidine) 6.0(1.9) 5 43 43 14 Mood stabilizers (e.g., divalproex) 5.4(1.5) 0 19 67 14 Atypical antipsychotics 4.9(1.9) 0 24 48 29 Traditional antidepressants (e.g., tricyclics) 4.8(1.4) 0 10 81 10 Benzodiazepines 4.6(1.8) 0 19 48 33 Conventional antipsychotics (e.g., haloperidol, thioridazine) 3.1(1.3) 0 0 43 57 SSRIs 7.5(1.7) 34 83 13 4 Other newer antidepressants (e.g., nefazodone, venlafaxine) 7.2(1.4) 19 75 23 2 Buspirone 7.0(1.8) 15 79 15 6 Benzodiazepines 6.0(1.9) 11 47 43 9 Antiadrenergics (e.g., propranolol, clonidine) 5.9(1.6) 4 38 57 6 Mood stabilizers (e.g., divalproex) 5.9(1.7) 2 38 55 8 Atypical antipsychotics 5.8(1.7) 2 42 48 10 Traditional antidepressants (e.g., tricyclics) 5.4(1.6) 4 21 70 9 Conventional antipsychotics (e.g., haloperidol, thioridazine) 4.2(1.7) 2 9 55 36 SSRIs 7.1(1.7) 21 71 27 2 Other newer antidepressants (e.g., nefazodone, venlafaxine) 6.6(1.7) 12 59 35 6 Buspirone 6.3(1.9) 12 50 42 8 Mood stabilizers (e.g., divalproex) 5.4(1.6) 0 33 52 15 Atypical antipsychotics 5.3(1.7) 0 27 61 12 Benzodiazepines 4.8(1.8) 2 17 56 27 Traditional antidepressants (e.g., tricyclics) 4.5(1.6) 0 10 67 23 Antiadrenergics (e.g., propranolol, clonidine) 4.2(1.7) 0 8 64 28 Conventional antipsychotics (e.g., haloperidol, thioridazine) 3.9(1.8) 0 % 6 % 50 % 44 % In adults/older adolescents In geriatric patients 1 56 2 3 4 5 6 7 8 9 J Clin Psychiatry 1999;60 (suppl 16) PTSD Survey Questions Answered Only by Medication Experts 32 Please rate the patient acceptability (tolerability and adherence) of each of the following classes of medication for treating a patient with PTSD. Tr of 1st 2nd 3rd Avg(SD) Chc Line Line Line 95% CONFIDENCE INTERVALS Third Line Second Line First Line In children and younger adolescents SSRIs 7.4(1.1) 18 77 23 0 Other newer antidepressants (e.g., nefazodone, venlafaxine) 6.8(1.1) 0 62 38 0 Buspirone 6.1(1.6) 0 43 52 5 Antiadrenergics (e.g., propranolol, clonidine) 5.9(2.0) 0 41 45 14 Benzodiazepines 5.4(1.9) 0 38 43 19 Mood stabilizers (e.g., divalproex) 5.2(1.5) 0 18 68 14 Atypical antipsychotics 4.8(1.8) 0 14 62 24 Traditional antidepressants (e.g., tricyclics) 4.5(1.6) 0 5 76 19 Conventional antipsychotics (e.g., haloperidol, thioridazine) 3.4(1.5) 0 5 41 55 SSRIs 7.7(1.0) 21 87 13 0 Other newer antidepressants (e.g., nefazodone, venlafaxine) 7.4(1.0) 15 83 17 0 Benzodiazepines 7.0(1.5) 11 72 26 2 Buspirone 6.5(1.7) 4 60 34 6 In adults/older adolescents Mood stabilizers (e.g., divalproex) 5.9(1.5) 2 36 58 6 Traditional antidepressants (e.g., tricyclics) 5.8(1.3) 4 21 75 4 Antiadrenergics (e.g., propranolol, clonidine) 5.7(1.9) 2 38 49 13 Atypical antipsychotics 5.5(1.6) 2 25 63 12 Conventional antipsychotics (e.g., haloperidol, thioridazine) 3.9(1.6) 0 4 47 49 SSRIs 7.2(1.2) 15 77 23 0 Other newer antidepressants (e.g., nefazodone, venlafaxine) 6.7(1.3) 8 61 39 0 Buspirone 6.2(1.6) 4 54 42 4 Benzodiazepines 5.9(1.6) 2 37 58 6 Mood stabilizers (e.g., divalproex) 5.5(1.5) 2 29 67 4 Atypical antipsychotics 5.3(1.7) 2 22 63 16 Traditional antidepressants (e.g., tricyclics) 4.9(1.4) 0 12 71 18 Antiadrenergics (e.g., propranolol, clonidine) 4.4(1.7) 0 10 58 33 Conventional antipsychotics (e.g., haloperidol, thioridazine) 3.8(1.7) 0 % 10 % 40 % 50 % In geriatric patients 1 J Clin Psychiatry 1999;60 (suppl 16) 2 3 4 5 6 7 8 9 57 Expert Consensus Guideline Series 33 Please rate the effectiveness of each of the following classes of medication for treating a patient with PTSD. Tr of 1st 2nd 3rd Avg(SD) Chc Line Line Line 95% CONFIDENCE INTERVALS Third Line Second Line First Line In children and younger adolescents 24 84 16 0 6.9(1.8) 9 70 26 4 SSRIs 7.7(1.1) Other newer antidepressants (e.g., nefazodone, venlafaxine) Traditional antidepressants (e.g., tricyclics) 5.5(2.0) 0 36 52 12 Antiadrenergics (e.g., propranolol, clonidine) 4.9(2.1) 4 20 48 32 Mood stabilizers (e.g., divalproex) 4.8(1.8) 0 21 50 29 Benzodiazepines 4.2(1.4) 0 8 56 36 Buspirone 4.0(1.7) 0 8 52 40 Atypical antipsychotics 3.8(1.7) 0 8 33 58 Conventional antipsychotics (e.g., haloperidol, thioridazine) 2.8(1.4) 0 0 25 75 SSRIs 8.1(1.0) 42 90 10 0 Other newer antidepressants (e.g., nefazodone, venlafaxine) 7.4(1.5) 22 75 24 2 Traditional antidepressants (e.g., tricyclics) 6.5(1.5) 8 46 52 2 Mood stabilizers (e.g., divalproex) 5.4(1.8) 2 27 58 15 Benzodiazepines 5.0(1.8) 4 23 50 27 Atypical antipsychotics 4.6(1.9) 2 20 43 37 In adults/older adolescents Antiadrenergics (e.g., propranolol, clonidine) 4.4(1.9) 2 12 56 33 Buspirone 4.4(2.0) 4 15 52 33 Conventional antipsychotics (e.g., haloperidol, thioridazine) 3.4(1.8) 0 4 38 58 SSRIs 7.7(1.1) 29 85 15 0 Other newer antidepressants (e.g., nefazodone, venlafaxine) 6.9(1.6) 12 68 30 2 Traditional antidepressants (e.g., tricyclics) 5.6(1.6) 2 31 60 10 Mood stabilizers (e.g., divalproex) 5.0(1.7) 2 21 58 21 Benzodiazepines 4.5(1.6) 0 12 60 29 Buspirone 4.4(1.9) 4 12 58 31 Atypical antipsychotics 4.3(1.8) 0 14 45 41 Antiadrenergics (e.g., propranolol, clonidine) 3.8(1.8) 0 10 42 48 3.2(1.6) 0 % 4 % 38 % 58 % In geriatric patients Conventional antipsychotics (e.g., haloperidol, thioridazine) 1 58 2 3 4 5 6 7 8 9 J Clin Psychiatry 1999;60 (suppl 16) PTSD Survey Questions Answered Only by Medication Experts 34 Which of the following classes of medication are you most comfortable using in women of childbearing age? Give higher ratings to the classes of medications you consider safest to use during each of the following phases. Tr of 1st 2nd 3rd Avg(SD) Chc Line Line Line 95% CONFIDENCE INTERVALS Third Line Second Line First Line Pregnant SSRIs 5.6(2.3) 12 42 36 22 Other newer antidepressants (e.g., nefazodone, venlafaxine) 4.6(2.1) 0 22 46 33 Traditional antidepressants (e.g., tricyclics) 4.4(2.2) 2 26 38 36 Buspirone 3.6(2.0) 2 10 38 52 Conventional antipsychotics (e.g., haloperidol, thioridazine) 3.5(1.9) 0 6 34 60 Benzodiazepines 3.3(1.7) 0 4 38 58 Antiadrenergics (e.g., propranolol, clonidine) 3.2(1.9) 0 6 35 59 Atypical antipsychotics 3.1(1.7) 0 2 27 71 Mood stabilizers (e.g., divalproex) 2.4(1.6) 0 2 14 84 SSRIs 5.3(2.5) 10 35 39 27 Other newer antidepressants (e.g., nefazodone, venlafaxine) 4.7(2.2) 0 20 52 28 Traditional antidepressants (e.g., tricyclics) 4.1(2.1) 0 17 46 38 Buspirone 3.5(2.0) 2 7 35 59 Antiadrenergics (e.g., propranolol, clonidine) 3.3(1.8) 0 4 40 56 Mood stabilizers (e.g., divalproex) 3.1(1.9) 0 6 34 60 Benzodiazepines 3.1(1.7) 0 2 33 65 Atypical antipsychotics 3.0(1.6) 0 2 34 64 Conventional antipsychotics (e.g., haloperidol, thioridazine) 2.7(1.6) 0 2 21 77 8.3(0.9) 50 98 2 0 Other newer antidepressants (e.g., nefazodone, venlafaxine) 7.9(0.9) 24 96 4 0 Traditional antidepressants (e.g., tricyclics) 6.7(1.3) 8 54 46 0 Buspirone 6.1(2.3) 12 60 25 15 Breastfeeding Not pregnant * SSRIs Benzodiazepines 6.1(2.1) 12 52 35 13 Mood stabilizers (e.g., divalproex) 6.0(1.8) 6 43 49 8 Atypical antipsychotics 5.5(2.1) 4 40 40 19 Antiadrenergics (e.g., propranolol, clonidine) 5.5(2.0) 4 37 40 23 Conventional antipsychotics (e.g., haloperidol, thioridazine) 4.5(2.2) 2 % 23 % 38 % 38 % 1 J Clin Psychiatry 1999;60 (suppl 16) 2 3 4 5 6 7 8 9 59 Expert Consensus Guideline Series 35 Assume that you have decided to use an antidepressant to treat a patient with PTSD. Please give your highest ratings to the antidepressants you believe have the best combination of effectiveness, safety, and tolerability. Tr of 1st 2nd 3rd Avg(SD) Chc Line Line Line 95% CONFIDENCE INTERVALS Third Line Second Line First Line Sertraline (Zoloft) 8.1(0.9) 42 96 4 0 Paroxetine (Paxil) 8.1(0.8) 35 98 2 0 Fluoxetine (Prozac) 7.8(1.1) 34 91 9 0 Fluvoxamine (Luvox) 7.3(1.2) 16 78 20 2 Citalopram (Celexa) 7.2(1.4) 22 76 24 0 Nefazodone (Serzone) 6.9(1.8) 20 66 32 2 Venlafaxine (Effexor) 6.7(1.2) 6 54 46 0 Tricyclic antidepressant 6.3(1.3) 6 45 55 0 Mirtazapine (Remeron) 5.9(1.2) 0 30 68 3 Monoamine oxidase inhibitor (Nardil, Parnate) 5.6(1.6) 2 29 62 10 5.0(1.7) 0 % 18 % 64 % 18 % Bupropion (Wellbutrin) 1 36 2 3 4 5 6 7 8 9 Assume that you have decided to use a mood stabilizer to treat a patient with PTSD. Please give your highest ratings to the mood stabilizers you believe have the best combination of effectiveness, safety, and tolerability. Tr of 1st 2nd 3rd Avg(SD) Chc Line Line Line 95% CONFIDENCE INTERVALS Third Line Second Line First Line Divalproex (Depakote) 7.0(1.9) 24 68 28 4 Gabapentin (Neurontin) 6.4(1.8) 14 50 47 3 Carbamazepine (Tegretol) 5.9(1.7) 2 46 44 10 Lamotrigine (Lamictal) 5.6(1.9) 9 34 54 11 Lithium 5.3(1.9) 6 31 50 19 5.1(1.8) 0 % 32 % 45 % 23 % Topiramate (Topamax) 1 2 3 4 5 6 7 8 9 37 Assume that you have decided to use an antianxiety medication to treat a patient with PTSD. Please give your highest ratings to the antianxiety medications you believe are most effective, best tolerated, and least likely to cause addiction and withdrawal symptoms. Tr of 1st 2nd 3rd Avg(SD) Chc Line Line Line 95% CONFIDENCE INTERVALS Third Line Second Line First Line History of substance abuse Buspirone (BuSpar) 6.9(2.0) 24 71 18 10 Clonazepam (Klonopin) 5.4(1.9) 10 27 63 10 Clorazepate (Tranxene) 4.2(1.7) 0 13 56 31 Oxazepam (Serax) 4.2(1.8) 2 11 55 34 Lorazepam (Ativan) 4.0(1.8) 2 8 52 40 Chlordiazepoxide (Librium) 3.8(1.5) 0 8 43 49 Diazepam (Valium) 3.6(1.8) 0 10 35 55 3.1(1.9) 2 % 8 % 22 % 69 % Alprazolam (Xanax) 1 60 2 3 4 5 6 7 8 9 J Clin Psychiatry 1999;60 (suppl 16) PTSD Survey Questions Answered Only by Medication Experts 37. continued Tr of 1st 2nd 3rd Avg(SD) Chc Line Line Line 95% CONFIDENCE INTERVALS Third Line Second Line First Line No history of substance abuse Clonazepam (Klonopin) 6.5(1.9) 18 51 43 6 Buspirone (BuSpar) 6.0(2.2) 12 47 41 12 Lorazepam (Ativan) 5.3(1.9) 6 30 54 16 Oxazepam (Serax) 5.1(1.8) 2 18 65 16 Clorazepate (Tranxene) 5.1(1.6) 0 17 72 11 Diazepam (Valium) 4.9(1.9) 4 22 55 24 Chlordiazepoxide (Librium) 4.8(1.6) 0 16 63 22 4.4(1.8) 0 % 12 % 51 % 37 % Alprazolam (Xanax) 1 38 2 3 4 5 6 7 8 9 Please rate the following possible contraindications to using benzodiazepines in a patient with PTSD. Give your highest ratings to the situations in which you would definitely not use a benzodiazepine. Tr of 1st 2nd 3rd Avg(SD) Chc Line Line Line 95% CONFIDENCE INTERVALS Third Line Second Line First Line * Previous misuse of benzodiazepines 7.6(2.3) 81 6 13 Recent substance abuse 7.5(2.0) 34 83 9 8 History of prior substance abuse 6.5(1.7) 11 60 34 6 Self-injurious behavior 5.5(1.7) 4 26 66 8 Aggressive behavior 5.3(1.5) 2 21 68 11 Comorbid personality disorders 5.2(1.5) 0 21 70 9 Family history of substance abuse 4.9(1.5) 0 11 66 23 4.7(2.0) 4 % 23 % 51 % 26 % History of chronic insomnia 1 39 53 2 3 4 5 6 7 8 9 Please rate the appropriateness of the following strategies in treating PTSD in older adults (65 years and older). Tr of 1st 2nd 3rd Avg(SD) Chc Line Line Line 95% CONFIDENCE INTERVALS Third Line Second Line First Line Take a very careful history of all medications the patient is taking, including over-the-counter drugs * 8.8(0.5) 81 100 0 0 8.6(0.7) 74 100 0 0 Start with a low dose of medication 8.0(1.2) 49 91 9 0 Increase medication dose slowly 8.0(1.2) 43 91 9 0 Avoid medication combinations 6.4(1.9) 15 55 34 11 5.3(2.4) 11 % 34 % 40 % 26 % Monitor carefully for interactions with other medications * If healthy, titrate and increase dose as you would for a younger patient 1 J Clin Psychiatry 1999;60 (suppl 16) 2 3 4 5 6 7 8 9 61 Expert Consensus Guideline Series 40 Length of adequate trial. Assume you are treating a patient with PTSD with a medication. If the patient is having an inadequate response to the first medication you have selected, how long would you wait in weeks before switching to or adding another medication? Partial response (weeks) Milder PTSD More severe PTSD Avg(SD) Avg(SD) No response (weeks) Milder PTSD More severe PTSD Avg(SD) Avg(SD) Newer antidepressant (e.g., SSRI, nefazodone, venlafaxine) 7.8(2.9) 7.1(2.9) 5.8(2.3) 5.0(2.5) Traditional antidepressant (e.g., tricyclics) 7.2(2.7) 6.6(2.8) 5.4(2.3) 4.9(2.4) Atypical antipsychotic 4.5(2.8) 3.7(2.3) 3.3(2.0) 2.9(1.7) Conventional antipsychotic (e.g., haloperidol, thioridazine) 4.1(2.6) 3.3(2.1) 3.3(2.2) 2.8(1.8) Mood stabilizer (e.g., divalproex) 5.8(2.7) 5.2(2.6) 4.4(2.3) 3.9(2.0) Buspirone 5.2(3.1) 4.7(2.6) 4.2(2.3) 3.8(1.9) Benzodiazepine 2.8(1.9) 2.6(2.0) 2.2(1.5) 2.1(1.6) Antiadrenergic (e.g., propranolol, clonidine) 3.0(1.8) 2.8(1.9) 2.3(1.5) 2.2(1.7) 41 Frequency of visits: initial treatment phase. Rate the appropriateness of the following frequencies of medication visits during the initial phase (first 3 months) of treatment for PTSD. Tr of 1st 2nd 3rd Avg(SD) Chc Line Line Line 95% CONFIDENCE INTERVALS Third Line Second Line First Line Weekly for 1st month and every 2 weeks thereafter 7.6(1.4) 35 Weekly throughout 6.2(2.0) 12 50 42 8 Every 2 weeks 6.1(1.5) 2 42 54 4 Twice a week 4.4(1.9) 2 14 51 35 Monthly 4.1(2.0) 2 13 40 46 2.3(1.6) 0 % 2 % 13 % 85 % Every 2 months 1 2 3 4 5 6 7 8 9 75 25 0 42 Frequency of visits: maintenance phase. What frequency of medication visits makes sense in the maintenance phase? Assume that a patient with PTSD has already had a good response after 3 months of treatment and continues to do well. Rate the appropriateness of the following frequencies of medication follow-up visits for each subsequent time period. 3–6 months 6–12 months After 12 months Tr of 1st 2nd 3rd Tr of 1st 2nd 3rd Tr of 1st 2nd 3rd Avg(SD) Rank Chc Line Line Line Avg(SD) Rank Chc Line Line Line Avg(SD) Rank Chc Line Line Line 3.5(2.2) 3rd 2 Every 2 weeks 4.9(2.3) 2nd 9 25 45 Once a month 7.6(1.5) 1st 38 81 19 Every 2 months 5.6(2.1) 2nd 4 45 Every 3 months 4.2(2.1) 2nd 0 17 Every 6 months 2.6(1.5) 3rd 0 2 No more visits 1.2(0.5) 3rd 0 0 Once a week 62 13 2.8(1.8) 3rd 0 30 3.8(2.2) 3rd 2 13 36 0 6.4(2.3) 2nd 26 58 30 34 21 6.8(1.8) 2nd 15 68 25 46 37 6.0(2.2) 2nd 13 49 36 23 75 3.7(1.7) 3rd 0 4 0 100 1.4(0.9) 3rd 0 0 26 60 8 2.2(1.5) 3rd 0 4 11 85 51 2.9(1.8) 3rd 0 4 26 70 11 5.2(2.3) 2nd 9 28 51 21 8 6.1(2.0) 2nd 8 53 36 11 15 7.0(1.9) 2nd 21 72 23 6 45 51 5.2(2.3) 2nd 8 34 40 26 4 96 2.2(2.2) 3rd 4 9 9 81 23 70 J Clin Psychiatry 1999;60 (suppl 16) PTSD Survey Questions Answered Only by Medication Experts 43 On average, how long would you continue a medication before trying to taper and discontinue it in each of the following situations? Acute PTSD, remission Chronic PTSD, remission Chronic PTSD, residual symptoms Tr of 1st 2nd 3rd Tr of 1st 2nd 3rd Tr of 1st 2nd 3rd Avg(SD) Rank Chc Line Line Line Avg(SD) Rank Chc Line Line Line Avg(SD) Rank Chc Line Line Line 3 months 4.0(2.3) 3rd 6 20 25 55 2.3(1.4) 3rd 0 2 10 88 2.5(1.8) 3rd 0 4 17 79 6 months 6.1(2.3) 2nd 16 45 41 14 4.0(2.2) 3rd 2 19 29 52 3.6(2.3) 3rd 0 21 21 58 12 months 7.0(1.8) 2nd 22 68 26 6 6.9(2.0) 2nd 25 62 30 8 5.9(2.5) 2nd 15 46 37 17 24 months 5.4(2.1) 2nd 2 35 43 22 6.7(1.8) 2nd 9 70 23 8 6.3(2.3) 2nd 8 62 25 13 > 24 months 4.0(2.3) 3rd 2 16 33 51 6.1(2.3) 2nd 17 46 38 15 6.3(2.7) 2nd 29 62 17 21 44 Assume that a patient with PTSD is doing well in the maintenance phase (in remission for 6–12 months) and you are considering discontinuing medication, but are concerned about the possibility of relapse. Give your highest ratings to those factors that would support continuing medication for a longer time. Tr of 1st 2nd 3rd Avg(SD) Chc Line Line Line 95% CONFIDENCE INTERVALS Third Line Second Line First Line Current life stressors 7.8(1.3) 36 87 11 2 Persistence of some symptoms 7.7(1.2) 30 87 13 0 High suicide risk in the past 7.6(1.4) 36 87 11 2 Presence of Axis I comorbidity 7.5(1.2) 25 87 13 0 Long duration of PTSD symptoms 7.5(1.6) 30 77 19 4 Poor functioning when symptomatic 7.3(1.4) 25 77 21 2 History of severe PTSD symptoms 7.3(1.4) 21 75 23 2 Past violence 7.2(1.5) 19 75 23 2 Poor social supports 7.1(1.5) 17 74 25 2 Presence of Axis II comorbidity 6.1(1.4) 2 % 43 % 51 % 6 % 1 2 3 4 5 6 7 8 9 45 After an adequate trial (dose and duration) of an SSRI, a patient with PTSD has had either a partial response or no response, and you believe a further medication intervention is warranted. Rate the appropriateness of the following medication strategies as your next choice. Partial response: Add No response: Switch to Tr of 1st 2nd 3rd Tr of 1st 2nd 3rd Avg(SD) Rank Chc Line Line Line Avg(SD) Rank Chc Line Line Line A different SSRI 2.2(1.5) 3rd 0 2 18 80 5.7(2.4) 2nd 12 42 31 27 Atypical antipsychotic 4.2(2.1) 2nd 0 20 41 39 3.5(1.7) 3rd 0 4 38 58 Benzodiazepine 4.9(2.0) 2nd 0 29 48 23 3.4(1.7) 3rd 0 4 38 58 Buspirone (BuSpar) 4.9(2.1) 2nd 2 25 49 25 3.8(1.8) 3rd 0 8 51 41 Monoamine oxidase inhibitor 1.6(1.3) 3rd 0 2 6 92 5.8(2.1) 2nd 8 47 37 16 Mood stabilizer 5.8(2.2) 2nd 10 46 37 17 5.3(1.9) 2nd 2 32 48 20 Nefazodone (Serzone) 3.9(2.4) 3rd 2 16 29 55 6.7(1.6) 2nd 14 61 35 4 Tricyclic antidepressant 5.1(2.2) 2nd 0 37 37 27 6.7(1.5) 2nd 15 50 48 2 Venlafaxine (Effexor) 3.4(2.1) 3rd 2 % 4 % 40 % 56 % 6.8(1.6) 2nd 18 % 64 % 30 % 6 % J Clin Psychiatry 1999;60 (suppl 16) 63 Expert Consensus Guideline Series 46 After an adequate trial (dose and duration) of nefazodone, a patient with PTSD has had either a partial response or no response, and you believe a further medication intervention is warranted. Partial response: Add No response: Switch to Tr of 1st 2nd 3rd Tr of 1st 2nd 3rd Avg(SD) Rank Chc Line Line Line Avg(SD) Rank Chc Line Line Line 47 Atypical antipsychotic 4.2(2.0) 2nd 0 16 47 37 3.3(1.8) 3rd 0 4 32 64 Benzodiazepine 4.6(2.2) 2nd 0 24 46 30 3.7(1.8) 3rd 0 4 44 52 Buspirone (BuSpar) 4.6(2.2) 2nd 4 22 47 31 4.0(1.8) 3rd 0 8 53 39 Monoamine oxidase inhibitor 1.6(1.0) 3rd 0 0 4 96 6.1(1.8) 2nd 8 46 46 8 Mood stabilizer 5.5(2.1) 2nd 6 40 42 18 5.4(1.8) 2nd 0 31 47 22 SSRI 4.2(2.7) 3rd 10 29 20 51 7.9(1.5) 1st 44 90 8 2 Tricyclic antidepressant 4.0(2.1) 3rd 0 13 40 47 6.6(1.2) 2nd 6 44 54 2 Venlafaxine (Effexor) 3.6(2.2) 3rd 0 % 13 % 33 % 54 % 6.8(1.6) 2nd 21 % 56 % 40 % 4 % After an adequate trial (dose and duration) of venlafaxine, a patient with PTSD has had either a partial response or no response, and you believe a further medication intervention is warranted. Partial response: Add No response: Switch to Tr of 1st 2nd 3rd Tr of 1st 2nd 3rd Avg(SD) Rank Chc Line Line Line Avg(SD) Rank Chc Line Line Line Atypical antipsychotic 4.4(2.1) 2nd 0 21 45 34 3.6(2.0) 3rd 0 8 33 59 Benzodiazepine 4.8(2.0) 2nd 2 23 56 21 3.7(2.1) 3rd 2 10 41 49 Buspirone (BuSpar) 4.5(2.4) 2nd 6 26 38 36 3.8(2.0) 3rd 2 6 55 38 Monoamine oxidase inhibitor 1.4(0.8) 3rd 0 0 2 98 5.9(2.1) 2nd 6 51 33 16 Mood stabilizer 5.5(2.3) 2nd 10 44 35 21 5.7(1.9) 2nd 2 40 44 17 Nefazodone (Serzone) 3.8(2.3) 3rd 2 9 42 49 6.4(1.9) 2nd 10 54 35 10 SSRI 3.6(2.5) 3rd 0 21 21 57 7.4(2.0) 1st 35 82 12 6 Tricyclic antidepressant 3.8(2.1) 3rd 2 % 9 % 38 % 53 % 6.4(1.3) 2nd 4 % 47 % 51 % 2 % 48 A patient with PTSD characterized by explosive, irritable, aggressive, or violent behavior has had either a partial response or no response to an adequate trial (dose and duration) of a mood stabilizer, and you believe a further medication intervention is warranted. Partial response: Add No response: Switch to Tr of 1st 2nd 3rd Tr of 1st 2nd 3rd Avg(SD) Rank Chc Line Line Line Avg(SD) Rank Chc Line Line Line 64 Another mood stabilizer 5.4(2.3) 2nd 6 38 36 26 6.9(1.8) 2nd 24 58 40 2 Atypical antipsychotic 6.2(1.8) 2nd 4 46 46 8 6.4(1.8) 2nd 10 51 39 10 Benzodiazepine 3.9(2.1) 3rd 2 12 41 47 3.3(2.0) 3rd 0 8 37 55 Buspirone (BuSpar) 4.4(2.3) 2nd 4 22 41 37 3.5(2.1) 3rd 2 8 40 52 Monoamine oxidase inhibitor 3.3(2.0) 3rd 0 6 33 60 4.2(2.0) 2nd 2 16 40 44 Nefazodone (Serzone) 5.1(2.3) 2nd 6 30 43 28 5.6(1.8) 2nd 2 34 52 14 SSRI 6.6(2.2) 2nd 24 61 29 10 6.7(1.9) 2nd 16 72 20 8 Trazodone (Desyrel) 5.3(1.8) 2nd 2 29 58 13 4.6(1.7) 2nd 0 17 59 24 Tricyclic antidepressant 5.0(1.9) 2nd 0 24 57 18 5.2(1.6) 2nd 2 16 69 14 Venlafaxine (Effexor) 5.1(2.0) 2nd 2 % 33 % 48 % 20 % 5.6(1.8) 2nd 4 % 36 % 53 % 11 % J Clin Psychiatry 1999;60 (suppl 16) PTSD Survey Questions Answered Only by Medication Experts 49 A patient with PTSD and comorbid bipolar disorder has received an adequate trial (dose and duration) of a mood stabilizer. The bipolar disorder is adequately controlled, but there has been either a partial response or no response in the PTSD symptoms, and you believe a further medication intervention is warranted. Partial response: Add No response: Add Tr of 1st 2nd 3rd Tr of 1st 2nd 3rd Avg(SD) Rank Chc Line Line Line Avg(SD) Rank Chc Line Line Line Another mood stabilizer 5.0(2.3) 2nd 2 26 45 30 4.8(2.2) 2nd 4 23 44 33 Atypical antipsychotic 5.2(2.1) 2nd 2 29 46 25 5.1(2.1) 2nd 0 37 35 29 Benzodiazepine 4.5(1.7) 2nd 0 10 63 27 4.3(1.9) 2nd 0 10 57 33 Buspirone (BuSpar) 4.1(2.1) 3rd 0 13 45 43 4.2(2.0) 2nd 0 13 46 42 Monoamine oxidase inhibitor 3.8(2.1) 3rd 0 12 35 53 4.4(2.3) 2nd 2 26 34 40 Nefazodone (Serzone) 5.6(2.0) 2nd 6 41 47 12 5.8(2.1) 2nd 4 50 36 14 SSRI 7.0(1.9) 2nd 20 76 18 6 7.2(1.8) 1st 26 76 20 4 Trazodone (Desyrel) 4.7(1.7) 2nd 2 11 64 25 5.0(1.6) 2nd 2 18 68 14 Tricyclic antidepressant 5.0(1.7) 2nd 2 16 63 20 5.4(1.7) 2nd 2 24 59 16 Venlafaxine (Effexor) 5.5(1.9) 2nd 4 % 36 % 47 % 17 % 5.8(1.8) 2nd 4 % 42 % 46 % 13 % 50 A patient with PTSD characterized by explosive, irritable, aggressive, or violent behavior has had either a partial response or no response to an adequate trial (dose and duration) of an atypical antipsychotic, and you believe a further medication intervention is warranted. Partial response: Add No response: Switch to Tr of 1st 2nd 3rd Tr of 1st 2nd 3rd Avg(SD) Rank Chc Line Line Line Avg(SD) Rank Chc Line Line Line Another atypical antipsychotic 2.7(1.9) 3rd 0 6 18 76 5.2(2.5) 2nd 12 38 38 24 Antiadrenergic 4.9(1.9) 2nd 2 18 57 24 4.2(2.1) 2nd 4 12 50 38 Antidepressant 6.5(1.9) 2nd 10 60 30 10 6.1(2.1) 2nd 12 47 39 14 Benzodiazepine 4.1(2.0) 2nd 0 10 48 42 3.2(2.0) 3rd 0 4 44 52 Buspirone (BuSpar) 4.3(2.0) 2nd 0 10 54 35 3.5(2.2) 3rd 2 10 31 58 Conventional antipsychotic 3.1(2.1) 3rd 0 12 18 70 4.6(2.3) 2nd 0 22 44 34 Mood stabilizer 7.3(1.5) 1st 28 % 72 % 24 % 4 % 7.4(1.4) 1st 32 % 68 % 32 % 0 % 51 A patient with prominent flashbacks, dissociative symptoms, and/or psychotic symptoms associated with PTSD has had either a partial response or no response to an adequate trial (dose and duration) of an atypical antipsychotic, and you believe a further medication intervention is warranted. Partial response: Add No response: Switch to Tr of 1st 2nd 3rd Tr of 1st 2nd 3rd Avg(SD) Rank Chc Line Line Line Avg(SD) Rank Chc Line Line Line 2 10 25 65 5.7(2.6) 2nd 2nd 2 15 50 35 3.6(2.0) Another atypical antipsychotic 3.2(2.2) 3rd Antiadrenergic 4.3(1.9) 17 48 29 23 3rd 2 6 44 50 Antidepressant 6.4(1.8) 2nd 14 63 31 6 5.8(2.2) 2nd 15 42 42 17 Clonazepam (Klonopin) 5.1(1.7) 2nd 0 21 60 19 4.4(2.0) 2nd 0 12 55 33 Buspirone (BuSpar) 4.0(1.9) 3rd 0 15 38 47 3.2(1.8) 3rd 0 4 29 67 Conventional antipsychotic 3.3(2.3) 3rd 4 15 19 67 5.4(2.4) 2nd 6 42 33 25 2nd 18 % 2nd 16 % 43 % 45 % 12 % Mood stabilizer J Clin Psychiatry 1999;60 (suppl 16) 6.6(1.9) 61 % 33 % 6 % 6.1(2.2) 65 Expert Consensus Guideline Series 52 Understanding that there are different clinical profiles that influence the choice of medication combinations for a patient with chronic PTSD who has been persistently refractory to treatment, give your highest ratings to the combinations that are most commonly used in your practice for such patients. Tr of 1st 2nd 3rd Avg(SD) Chc Line Line Line 95% CONFIDENCE INTERVALS Third Line Second Line First Line Antidepressant + mood stabilizer 7.1(1.6) 27 69 29 2 Antidepressant + antipsychotic 6.2(1.6) 8 48 46 6 Mood stabilizer + antidepressant + antipsychotic 5.8(2.1) 8 40 44 15 Medication(s) of choice + adjunctive benzodiazepine 5.5(2.1) 4 36 47 17 Medication(s) of choice + adjunctive trazodone 5.4(2.1) 6 33 49 18 Two antidepressants 5.2(2.1) 6 30 53 17 Medication(s) of choice + adjunctive clonidine 4.7(2.0) 2 20 53 27 Antipsychotic + mood stabilizer 4.7(1.7) 2 15 63 21 Medication(s) of choice + adjunctive buspirone 4.6(2.1) 0 22 51 27 Two mood stabilizers 4.1(1.8) 0 13 46 40 Two antipsychotics 2.7(1.4) 0 % 0 % 29 % 71 % 1 53 2 3 4 5 6 7 8 9 Please rate the appropriateness of the following strategies for enhancing compliance with medication treatment. Tr of 1st 2nd 3rd Avg(SD) Chc Line Line Line 95% CONFIDENCE INTERVALS Third Line Second Line First Line Take patient preference into account when selecting treatments 8.1(1.0) 43 94 6 0 Psychoeducation 8.0(1.3) 46 87 13 0 Evaluate for and treat substance abuse problems 7.8(1.2) 41 85 15 0 Frequently review rationale for treatment with patient 7.8(1.0) 30 91 9 0 Ensure easy and prompt access to treatment 7.6(1.1) 30 85 15 0 Select medications based on side effect tolerance 7.4(1.2) 19 80 20 0 Involve a relative or significant other at an early stage 7.3(1.2) 19 78 22 0 Start low and go slow to avoid side effects 7.3(1.3) 19 80 20 0 Peer support group 6.6(1.5) 11 57 41 2 Select a medication that requires only once daily administration 6.4(1.5) 11 52 43 6 6.0(1.4) 4 % 31 % 65 % 4 % Family therapy 1 66 2 3 4 5 6 7 8 9 J Clin Psychiatry 1999;60 (suppl 16) PTSD Survey Questions Answered Only by Medication Experts 54 Rate the appropriateness of the following indications for hospitalizing a patient with PTSD. Tr of 1st 2nd 3rd Avg(SD) Chc Line Line Line 95% CONFIDENCE INTERVALS Third Line Second Line First Line * * 8.8(0.6) 85 98 2 0 8.7(0.7) 80 98 2 0 Risk of accidental injury 6.7(1.6) 17 55 42 4 Decompensation due to noncompliance as outpatient 6.5(1.2) 2 56 44 0 To implement higher risk medication combinations 6.2(1.7) 6 48 44 7 Acute dissociative symptoms 6.2(1.2) 4 33 67 0 Persistently refractory to outpatient treatment 6.2(1.4) 2 48 50 2 Comorbid medical illness 5.9(1.6) 4 37 54 9 Comorbid substance abuse 5.9(1.5) 6 34 58 8 Comorbid psychiatric illness 5.7(1.4) 0 22 70 7 Lack of sufficient external support from family and treatment system 5.6(1.5) 2 30 63 7 4.7(1.7) 0 % 11 % 69 % 20 % Risk of suicide Risk of harm to others Need for medication adjustment 1 J Clin Psychiatry 1999;60 (suppl 16) 2 3 4 5 6 7 8 9 67 Expert Consensus Guideline Series 55 Appropriate Dose. Please write in the dose range (total mg per 24 hours) you recommend for each of the following medications to ensure an adequate trial in a patient with PTSD during both acute and maintenance treatment. If you do not have experience with treating children, please cross out the column for child doses. Adult starting dose (mg/day) Average target dose for acute treatment Children/ Adults/ Geriatric younger older patients adolescents adolescents (mg/day) (mg/day) (mg/day) Highest Average potential adult maintenance final dose dose (mg/day) (mg/day) Avg(SD) Avg(SD) Avg(SD) Avg(SD) Avg(SD) Avg(SD) citalopram (Celexa) 17.0(4.6) 18.0(8.4) 34.1(13.4) 25.4(10.6) 62.1 (11.0) 33.0(9.7) fluoxetine (Prozac) 15.8(5.0) 15.0 (7.1) 32.1(15.3) 21.0(10.6) 77.5 (19.6) 31.8(11.4) 46.6(18.1) 61.9 (52.3) 153.8(74.5) 114.9(63.9) 287.1(87.5) 163.4(63.6) SSRIs fluvoxamine (Luvox) paroxetine (Paxil) 15.3(5.1) 16.7(7.1) 30.8(11.3) 21.7(10.4) 60.4 (16.0) 31.8(10.4) sertraline (Zoloft) 42.0(14.3) 58.0(31.6) 117.5(48.8) 81.7(42.4) 224.6 (60.0) 119.0(41.8) Other antidepressants nefazodone (Serzone) 106.7(54.2) 200.0(111.8) 353.4(142.8) 247.0(121.6) 595.5(116.0) 387.8(97.3) venlafaxine (Effexor) 71.0(90.9) 52.1(25.5) 170.5(89.8) 132.6(95.3) 318.3 (87.6) 182.3(81.4) Mood stabilizers divalproex (Depakote) 459.9(227.1) 679.2 (955.0) 1169.2(613.8) 784.6(511.0) Antipsychotics haloperidol (Haldol) 2.2(2.2) 1.6(1.4) 5.5(3.8) 2.9(2.1) 2094.4 (1142.9) 1271.9(507.7) 19.8(17.7) 4.9(3.3) risperidone (Risperdal) 1.4(0.7) 1.5(1.3) 3.8(1.8) 2.6(1.7) 8.3(3.6) 3.9(1.4) olanzapine (Zyprexa) 5.2(2.0) 4.3(1.9) 11.5(5.4) 7.3(4.1) 23.1 (9.1) 10.3(3.1) quetiapine (Seroquel) 44.1(25.0) 295.3(181.9) 169.1(123.9) 526.5(243.7) 248.5(149.3) — Anti-anxiety medications alprazolam (Xanax) 0.9(0.5) 1.0 (0.9) 2.4(1.4) 1.5(1.0) 6.0 (2.8) 2.4(1.0) buspirone (BuSpar) 16.2(6.5) 20.0 (10.7) 37.3(17.6) 27.1(13.6) 67.5 (25.7) 38.3(14.1) clonazepam (Klonopin) 1.0(0.7) 1.3(1.9) 2.7(1.9) 1.7(1.7) 6.3(4.1) 3.0(3.2) Because of space limitations, we could not present the complete results of the following questions. Results are available on request. 56 Give your highest ratings to the sedative hypnotics you believe are most effective and best tolerated for sleep disturbances in PTSD. Results available on request. Trazodone was rated first line both with and without a history of substance abuse. Zolpidem and benadryl were higher second line. For patients without a history of substance abuse, benzodiazepines were also rated higher second line. For patients with a history of substance abuse, benzodiazepines were rated third line. 57 You have decided to discontinue long-term treatment with one of the following medications. Rate the appropriateness of each of the following discontinuation schedules for preventing discontinuation/withdrawal syndrome. Assume the patient was receiving an average dose of the medication for the treatment of PTSD. Results available on request. To avoid discontinuation/withdrawal syndrome, the experts recommend tapering medication over 2 weeks–1 month, except for the benzodiazepines, for which the experts recommend tapering over 1 month or longer. 58 You have decided to discontinue long-term treatment with one of the following medications, but the patient has risk factors for relapse. Rate the appropriateness of each of the following discontinuation schedules for preventing relapse. Assume the patient was receiving an average dose of the medication for the treatment of PTSD. Results available on request. To lessen the likelihood of relapse in a patient with risk factors for relapse, the experts recommend tapering medication over 4– 12 weeks, except for the benzodiazepines, for which the experts recommend tapering for longer than 12 weeks. 68 J Clin Psychiatry 1999;60 (suppl 16) Treatment of Posttraumatic Stress Disorder Expert Consensus Treatment Guidelines For Posttraumatic Stress Disorder: A Guide For Patients and Families I f you or someone you care about has been diagnosed with posttraumatic stress disorder (PTSD), you may feel that your problem is rare and that you have to face it alone. This is not the case. There are many people in a similar situation, and lots of help is available. As many as 70% of adults in the United States have experienced at least one major trauma in their lives, and many of them have suffered from the emotional reactions that are called PTSD. It is estimated that 5% of the population currently have PTSD, and that 8% have had PTSD at some point in their lives. Women are twice as likely to have PTSD as men. Fortunately, very effective treatments for PTSD are now available to help you or your loved one overcome this problem and get back to a normal life. This guide is designed to answer the most commonly asked questions about PTSD based on answers to a recent survey of 100 experts. A person with PTSD has three main types of symptoms: Re-experiencing of the traumatic event as indicated by x Intrusive distressing recollections of the event x Flashbacks (feeling as if the event were recurring while awake) x Nightmares (the event or other frightening images recur frequently in dreams) x Exaggerated emotional and physical reactions to triggers that remind the person of the event Avoidance and emotional numbing as indicated by x Extensive avoidance of activities, places, thoughts, feelings, or conversations related to the trauma x Loss of interest x Feeling detached from others x Restricted emotions WHAT IS POSTTRAUMATIC STRESS DISORDER? The diagnosis of PTSD requires exposure to an extreme stressor and a characteristic set of symptoms that have lasted for at least 1 month. What is an extreme stressor? Examples include x Serious accident or natural disaster x Rape or criminal assault x Combat exposure x Child sexual or physical abuse or severe neglect x Hostage/imprisonment/torture/displacement as refugee x Witnessing a traumatic event x Sudden unexpected death of a loved one Other kinds of severe (but not extreme) stress can be very upsetting but generally do not cause PTSD (such as losing a job, divorce, failing in school, the expected death of an elderly parent). This Guide was prepared by Edna B. Foa, Ph.D., Jonathan R. T. Davidson, M.D., Allen Frances, M.D., and Ruth Ross, M.A. The guide includes recommendations contained in the Expert Consensus Treatment Guidelines for Posttraumatic Stress Disorder. The Editors gratefully acknowledge the Anxiety Disorders Association of America (ADAA) for their generous help and permission to adapt their written materials. Abbott Laboratories, Bristol-Myers Squibb, Eli Lilly, Janssen Pharmaceutica, Pfizer Inc, and Solvay Pharmaceuticals provided unrestricted educational grants in support of this project. J Clin Psychiatry 1999;60 (suppl 16) Increased arousal as indicated by x Difficulty sleeping x Irritability or outbursts of anger x Difficulty concentrating x Hypervigilance x An exaggerated startle response What other problems are associated with PTSD? The three types of symptoms of PTSD described above are the most typical reactions to traumas. However, there are other problems that are also common. Many of these will improve when the PTSD symptoms are successfully treated, but some may require additional treatment on their own. Panic attacks Individuals who have experienced a trauma may have panic attacks when exposed to something that reminds them of the trauma (e.g., encountering a man who looks like the rapist; riding in a car again after having had a bad accident, hearing a storm blow up after being in a destructive hurricane). A panic attack involves intense feelings of fear or discomfort that are accompanied by physical or psychological symptoms. Physical symptoms include pounding or racing heart, sweating, trembling or shaking, a feeling of shortness of breath or choking, chest pain, nausea, dizziness, chills, hot flushes, numbness, or tingling. The person may also experience psychological symptoms such as feeling unreal or detached or fearing that he is going crazy, dying, or is having a heart attack. 69 Expert Consensus Guideline Series Severe avoidant behavior Avoidance of reminders of the trauma is one of the characteristic symptoms of PTSD. However, sometimes the avoidance begins to extend far beyond reminders of the original trauma to all sorts of situations in everyday life. This can become so severe that the person becomes virtually housebound or is able to go out only if accompanied by someone else. Depression Many people become depressed after experiencing a trauma and no longer take interest or pleasure in things they used to enjoy before. They may also develop unjustified feelings of guilt and self-blame and feel that the experience was their fault, even when this is clearly not true. For example, a rape victim may blame herself for having walked in the parking lot alone early in the evening; a victim of industrial disaster may blame himself for not having noticed an imperceptible noise in the engine that preceded the explosion. Suicidal thoughts and feelings Sometimes the depression can become so severe that people feel that life is no longer worth living. Studies show that as many as 50% of rape victims report suicidal thoughts. If you or your loved one is having suicidal thoughts following a traumatic event, it is very important to consult a professional right away and get the help you need to overcome this. Substance abuse People with PTSD may turn to alcohol or drugs to try to deaden their pain. They may also misuse prescription or overthe-counter drugs. Although this may seem to be an understandable reaction, inappropriate substance use greatly aggravates the person’s symptoms and makes successful treatment much more difficult. Alcohol and drugs can provide only temporary relief and, in the long run, make a bad situation much worse. Facing the problem without alcohol or drugs will help you get over it sooner and with fewer problems. Feelings of alienation and isolation People with PTSD need increased social support, but they often feel very alone and isolated by their experience and find it very difficult to reach out to others for help. They find it especially hard to believe that other people will be able to understand what they have gone through. PTSD symptoms may also make it difficult to function socially. For example, someone who has been assaulted by a stranger may develop a fear of all strangers. Marital and family misunderstandings are also common after a severe trauma. Feelings of mistrust and betrayal After going through a terrible experience, you may lose faith in other people and feel that you have been betrayed or cheated by the world, by fate, or by God. However, getting 70 better requires reaching out and taking the chance that other people will understand. A good alliance with your therapist and/or spiritual counselor can go a long way towards helping you reconnect. Anger and irritability Anger and irritability are common reactions among trauma survivors. Of course, anytime we have been treated wrongly, and especially when we have been assaulted, anger is a natural and justified reaction. However, extreme anger can interfere with recovery and make it hard for a person to get along with others at home, at work, and in treatment. Severe impairment in daily functioning Some people with PTSD have very severe problems functioning both socially and at work or school for a long period of time after the trauma. For example, an assault victim may refuse to leave the house alone after dark, thus severely curtailing social and leisure activities. A person may lose his ability to concentrate and be unable to fulfill his obligations at work. A rape victim may become too fearful to stay alone and have to move back into her parents’ home after 10 years of independent living. Prompt treatment is crucial because it helps prevent these problems from ever developing. Strange beliefs and perceptions Occasionally, someone who has undergone a severe trauma may temporarily develop strange ideas or perceptions (e.g., believing that that they can communicate with or actually see a dead parent). Although these symptoms are scary and resemble delusions and hallucinations, they are usually temporary and often go away on their own. What is the usual course after exposure to an extreme stressor? How long psychological disturbances last after a trauma can vary greatly. Some people have few or no long-lasting effects, whereas others may continue to have problems for months or even years after the trauma and will not get better unless treated by a professional. The range of possible responses to a trauma are described below in order of severity. Only a mild and brief response to a stressor Although some people may have no problems at all after a terrible experience, it is more common to have at least some symptoms after a trauma. Often these go away quickly without any treatment. Acute stress disorder Acute stress disorder is diagnosed when symptoms last for less than 1 month, but are more severe than what most people have. This is too brief to be considered PTSD but increases the risk of later developing PTSD. J Clin Psychiatry 1999;60 (suppl 16) Treatment of Posttraumatic Stress Disorder Acute PTSD When the symptoms last for longer than 1 month and are seriously interfering with the person’s ability to function, the diagnosis is changed to PTSD. If symptoms have lasted only 1–3 months, this is called acute PTSD. Anyone who continues to have severe symptoms for longer than a month after a trauma should consult a health professional. Chronic PTSD If symptoms continue for longer than 3 months, this is called chronic PTSD. Once PTSD becomes established, it is less likely to improve without treatment and you should definitely get help right away. Delayed PTSD Although the symptoms of PTSD usually begin immediately after (or within a few weeks of) the trauma, they sometimes appear only several months or even years later. This is more likely to happen on the anniversary of the traumatic event or if another trauma is experienced, especially if it reminds the person of the original event. Why do some people recover from a trauma while others don’t? We do not know exactly why one person may have little difficulty after a trauma, while someone else may suffer for years afterwards. However, the following factors appear to make it more likely that the person will develop PTSD: x the more severe the trauma x the longer it lasted x the closer the person was to it x the more dangerous it seemed x the more times the person has been traumatized x the trauma was inflicted by other people (e.g., rape) x the person gets negative reactions from friends and relatives For example, if you actually see someone being shot or are shot at yourself, it is more likely that you will get PTSD than if you just heard the shots and found out about the murder afterward. A rape victim whose life was in danger is more likely to develop chronic PTSD than a rape victim who did not believe she was likely to be killed. People are much more likely to get PTSD after being raped or tortured than after being in an earthquake or hurricane. The boyfriend of a rape victim might blame her for not being careful enough, or friends may refuse to listen sympathetically to the victim, instead strongly urging her to “forget about it and get on with life.” Guilt and intense anger may also interfere with recovery. Failing to process the traumatic event by sharing it with significant others can make it difficult to get over its effects. Finally, substance use makes it more likely that people will have a hard time dealing with the aftermath of a trauma. J Clin Psychiatry 1999;60 (suppl 16) THE TREATMENT OF PTSD Two types of treatment are helpful for PTSD: psychotherapy and medication. Some people recover from PTSD with psychotherapy alone, while others need a combination of psychotherapy and medication, and some need only medication. You and your doctor will discuss what is best for you. Psychotherapy alone may be best for you if x Your symptoms are milder x You are pregnant or breastfeeding x You prefer not to take medication x You have a medical condition that medication might interfere with Medication is often needed if x Your symptoms are severe or have lasted a long time x You have another psychiatric problem (e.g., depression or anxiety) that is making it harder for you to recover from PTSD x You are thinking about suicide x You are experiencing a lot of stress in your life x You are having a very hard time functioning x You have been receiving psychotherapy alone and are still having many disturbing PTSD symptoms PSYCHOTHERAPY The experts on PTSD believe that three types of psychotherapy are especially effective in treating it—anxiety management, cognitive therapy, exposure therapy. Play therapy may be useful in the treatment of children with PTSD. Anxiety management In anxiety management, the therapist will teach you the following skills to help you cope better with the symptoms of PTSD: x Relaxation training: you learn to control fear and anxiety by systematically relaxing your major muscle groups. x Breathing retraining: you learn slow, abdominal breathing to relax and/or avoid hyperventilation with its unpleasant and often frightening physical sensations (e.g., palpitations, dizziness, tingling). x Positive thinking and self-talk: you learn to replace negative thoughts (e.g., “I’m going to lose control”) with positive thoughts (e.g., “I did it before and I can do it again”) when facing reminders of a stressor. x Assertiveness training: you learn how to express your wishes, opinions, and emotions without alienating others. x Thought stopping: you learn how to use distraction to overcome distressing thoughts (inwardly “shouting stop”). 71 Expert Consensus Guideline Series Cognitive therapy The therapist helps you change the irrational beliefs that may be disturbing your emotions and making it hard for you to function. For example, trauma victims often feel unrealistically guilty as if they had brought about the trauma: a crime victim may blame himself for not being more careful, or a war veteran may feel it was his fault that his best friend was killed. The goal of cognitive therapy is to teach you how to identify your own particular upsetting thoughts, weigh the evidence for and against them, and then to adopt more realistic thoughts that can help you achieve more balanced emotions. Exposure therapy In exposure therapy, the therapist helps you confront specific situations, people, objects, memories, or emotions that remind you of the trauma and now evoke an unrealistically intense fear in your everyday life. This can be done in two ways: x Exposure in the imagination: the therapist asks you to repeatedly retell the traumatic memories until they no longer evoke high levels of distress. x Exposure in reality: the therapist helps you to confront the situations in your life that are now safe but which you want to avoid because they trigger strong fear (e.g., driving a car again after being involved in an accident, using elevators after being assaulted in an elevator, going back home after being robbed there). Your fear will gradually begin to dissipate if you force yourself to remain in the situation rather than trying to escape it. Repeated exposures will help you to realize that the feared situation is no longer dangerous and that you can handle it. Play therapy Play therapy is used to treat children with PTSD. The therapist uses games to introduce topics that cannot be dealt with more directly. This can help children confront and reprocess traumatic memories. Education and supportive counseling The experts consider it very important for people with PTSD (and their families) to learn about the symptoms of PTSD and the various treatments that are available for it. Even if you have had PTSD symptoms for a long time, the first step in finally getting control of them is to understand the problem and what can be done to help it. Other types of psychotherapy A number of other types of psychotherapy (eye movement desensitization reprocessing [EMDR], hypnotherapy, and psychodynamic psychotherapy) have been used in the treatment of PTSD and may sometimes be helpful for some people. However, the group of experts we surveyed did not rate 72 the effectiveness of these treatments nearly as highly as those that were described in detail above. MEDICATION TREATMENT A number of different types of medication can be used to treat PTSD. SSRI antidepressants The experts consider the selective serotonin reuptake inhibitor (SSRI) antidepressant medications to be the best first choice for treating the symptoms of PTSD. There are currently five SSRIs available in the United States: x Zoloft (sertraline) x Paxil (paroxetine) x Prozac (fluoxetine) x Luvox (fluvoxamine) x Celexa (citalopram) Other newer antidepressants The experts also thought highly of two other newer antidepressants and one of these would be the next choice if the SSRI antidepressant did not work or caused side effects that required a switch to a different class of medication: x Serzone (nefazodone) x Effexor (venlafazine) Your doctor may sometimes recommend other types of medication, particularly if you have not responded to treatment with one of the newer antidepressants listed above. Tricyclic antidepressants The tricyclic antidepressants (e.g., imipramine, amitriptyline [Elavil]) are helpful in PTSD. However, they are not generally first-choice drugs because they have more side effects than the newer antidepressants. Mood stabilizers The experts recommend adding a mood stabilizer, such as divalproex (Depakote), to the antidepressant if the person is having only a partial response. Mood stabilizers are the usual treatment for bipolar disorder (manic-depressive illness) and they are recommended for treating people who have both bipolar disorder and PTSD. They are also used especially for certain types of PTSD symptoms (such as prominent irritability or anger). Anti-anxiety medications Benzodiazepines are a type of medication used to reduce anxiety, usually only on a short-term or intermittent basis. They include x Valium (diazepam) x Xanax (alprazolam) x Klonopin (clonazepam) x Ativan (lorazepam) J Clin Psychiatry 1999;60 (suppl 16) Treatment of Posttraumatic Stress Disorder Your doctor should not prescribe a benzodiazepine for you if you have current problems with substance abuse or a history of such problems, because of the risk of developing dependence on them. BuSpar (buspirone) is another medication that is used to treat anxiety on a more long-term basis, since it takes several weeks to start working. It has the great advantage of not being addictive. Sequencing and combining medications Most of the time, one of the SSRIs will be the firstchoice medication. If this does not help, your doctor may then suggest a different type of drug, probably nefazodone or venlafaxine. As a third choice, you may be given one of the older tricyclic antidepressants. Your doctor may also try combining another kind of medication, particularly a mood stabilizer, with the antidepressant if your PTSD symptoms have responded only partially to treatment with a single medication. The doctor might also try adding an antianxiety drug, such as BuSpar or a benzodiazepine, to the antidepressant. How long is medication usually needed? For acute PTSD (when your symptoms have lasted less than 3 months), most experts recommend continuing your medication for 6–12 months. For chronic PTSD (when your symptoms have lasted longer than 3 months), it is recommended that you continue to take your medication for at least 12–24 months and perhaps even longer if you are still having significant symptoms. What are the side effects of the medications used to treat PTSD? Any medication can have side effects, especially early in the course of taking it. If you stay on the medication, you will usually get used to it and the side effects will often go away by themselves. Sometimes the dose may need to be lowered to achieve this. Be sure to tell your doctor about any side effects you are having so that your medication dosage can be adjusted to help the problem. Don’t stop your medication on your own. The newer antidepressants can cause nausea and bowel symptoms, weight loss or gain, impaired sexual functioning, sleep disturbances, and increased nervousness. In addition to the side effects listed above, the older antidepressants are more likely to cause dry mouth, constipation, dizziness, sleepiness, and altered heart rate. Benzodiazepines can cause sedation, tiredness, forgetfulness, unsteadiness, impaired attention and reactions in driving, and physical dependence. Selecting medication for relapses If you start to have troublesome PTSD symptoms again after stopping medication, your doctor will probably suggest restarting the medicine that helped you before. If you start to relapse while you are still taking medication, then the doctor J Clin Psychiatry 1999;60 (suppl 16) will probably try switching you to the next medication in the sequence described above (see “Sequencing and combining medications”) or he might try adding another medication to the one you are taking. TREATMENT OF ASSOCIATED PROBLEMS Sometimes people with PTSD develop depressive symptoms that are severe enough to require additional treatment. It is especially important to seek treatment if you are having suicidal thoughts or feelings. Your doctor may recommend psychotherapy or medication treatment or a combination of both, depending on how severe your depression is. Two kinds of psychotherapy, cognitive-behavioral therapy and interpersonal therapy, may be especially helpful for depression. You doctor may also prescribe an antidepressant medication if you are not already taking one. Sometimes people with PTSD have other anxiety symptoms, such as panic disorder, that may require additional treatment. Your doctor may recommend that you be taught special anxiety management techniques and/or may prescribe a medication to reduce your symptoms. It is fortunate that the antidepressant medications that have been found to be most effective for treating PTSD are also the ones used to treat anxiety or depression. This means that your doctor can often treat your PTSD symptoms and any associated anxiety or depression you have with just one medication. It also means that if you do have a lot of anxiety or depression, you are much more likely to need an antidepressant medication. People with PTSD frequently turn to drugs or alcohol for comfort. However, substance abuse only makes it harder to recover from PTSD, since it is necessary to face the memories of the trauma in order to get over it. If you are having substance use problems that are interfering with your recovery, your doctor may recommend that you enroll in a special treatment program for substance problems. WHY DO MANY PEOPLE NOT RECEIVE APPROPRIATE TREATMENT FOR PTSD? People with PTSD often do not seek professional help. This may be because they do not realize that they have a problem or that the problem can be treated. There is also a natural tendency to avoid dealing with the unpleasant feelings associated with the trauma. The very symptoms of PTSD—withdrawal, feelings of guilt or mistrust—may make it difficult for some people to seek help and get treatment. Fortunately, our knowledge of PTSD has grown greatly over the last 10 years and the disorder has received extensive research and media attention. This has increased the chances that people will recognize their PTSD symptoms and seek treatment for them. There are many effective treatment approaches that can be used and chances of improvement with treatment are very good. 73 Expert Consensus Guideline Series ARE THERE WAYS TO PREVENT PTSD? People have a natural tendency to avoid inflicting pain on themselves and it certainly is painful to stay in touch with traumatic memories. However, if you try to push the memories of the trauma away, PTSD symptoms are likely to become more severe and last longer. It is therefore important to face the memories, feel the emotions, and try to work through them. It can also be very helpful to reach out to other people who can provide support and share your feelings about what happened. It is common and natural to feel guilty after a trauma, but it is also irrational and not helpful. Revealing your sense of guilt to other people you trust can help you see that what happened was not your fault. Try to get back to doing the things you’ve always done as soon as possible. important things you can do is to give the message: “You are not to blame—and you are not alone.” It is also important to have realistic expectations while the person is recovering and not to expect too much or too little from the person. Encourage your loved one to join a PTSD support group. Participating in a group with others who have experienced extreme trauma can help people to understand that they are not alone and to learn how to cope with their symptoms and work towards their own recovery. Learn about the disorder If you have a family member or friend with PTSD, learn all you can about the illness and its treatment. This will help you understand behavior that might otherwise seem frustrating or difficult to deal with. A number of educational books are listed at the end of this guide. WHAT CAN I DO TO HELP MY RECOVERY? There are a number of things you can to do to help yourself recover from PTSD: x Learn about your disorder x Talk about the problem to others x Expose yourself to situations that remind you of the trauma x Seek treatment x If medication is prescribed, be sure to take it in the recommended doses and report any side effects you have x Avoid alcohol or illicit drugs x Don’t quit your treatment and don’t give up hope x Join a support group WHAT CAN FAMILIES AND FRIENDS DO TO HELP? Provide emotional support and be a good listener It can be very painful for friends and family members to watch a loved one suffer after a severe trauma. Unfortunately, common sense reactions are often counterproductive and may make the person feel even more isolated and hopeless. Undoubtedly, you will be tempted time and again to encourage the person to stop reliving and simply forget about the trauma and get on with life. Unfortunately, this seemingly reasonable advice is usually not helpful in this situation and is likely to make things worse. In the long run, the person’s chances of recovery and regaining a good quality of life are enhanced when he or she is encouraged to share the pain and memories associated with the traumatic experience. The person may need to talk about the traumatic events over and over again, and one of the best things family members and friends can do is to be patient and sympathetic listeners. Being able to share the feelings and pain can help the person feel less alone. Friends and family members can provide important emotional support and can also try to help the person let go of any unrealistic guilt they feel about what they have been through. One of the most 74 Encourage the person to stick with treatment During treatment, the therapist may try to help your loved one get in touch with feelings about the trauma. This can be very difficult and there may be a temporary increase in symptoms and distress. Emotional support from family and friends can be especially helpful during this period. Sometimes you can help the person perform the exposure tasks that are part of the therapy (e.g., driving a car after a serious accident, revisiting the street where a mugging occurred). It can be hard for your loved one to stick with treatment, especially when the therapist is asking him to face emotionally frightening and upsetting memories. Your encouragement and support can make a big difference if your loved one is tempted to quit treatment. Consider family counseling If a member of your family is having PTSD symptoms that are seriously interfering with the functioning of your family, you may want to ask the therapist about family counseling. Such counseling can improve communications and help return the family to normal. FINAL THOUGHTS No matter how long you have been suffering from PTSD, something can be done to help you get over it and dramatically improve your life. It is important to accept that the treatment will also ask something of you—you may need to revisit painful experiences you would rather avoid, and you may need to take medication that might have some side effects. But if you commit yourself to the treatment and stick with it, there is a good chance that you will soon begin to feel better and regain your quality of life. PTSD is painful—but fortunately it is a treatable condition, and you can get better. J Clin Psychiatry 1999;60 (suppl 16) Treatment of Posttraumatic Stress Disorder ORGANIZATIONS YOU SHOULD KNOW ABOUT Anxiety Disorders Association of American (ADAA) maintains a national network of 165 self-help support groups, has a catalogue bookstore of educational materials for consumers and professionals, and publishes a list of therapists to help people locate specialists where they live. Contact them at 11900 Parklawn Drive, Suite 100 Rockville, MD 20852-2624 301-231-9350 Website: www.adaa.org The following organizations can also provide information and support. National Organization for Victim Assistance (NOVA) 1757 Park Road, NW Washington, DC 20010 202-232-6682 Website: www.try-nova.org National Victim Center 2111 Wilson Boulevard, Suite 300 Arlington, VA 22201 800-394-2255 Website: www.nvc.org Trauma Survivors Anonymous 2022 Fifteenth Avenue Columbus, VA 31901 706-649-6500 International Society for Traumatic Stress Studies (ISTSS) 60 Revere Drive, Suite 500 Northbrook, IL 60062 847-480-9028 Website: www.istss.org National Depressive and Manic-Depressive Association (NDMDA) 730 N. Franklin St., Suite 501 Chicago IL, 60610-3526 800-82-NDMDA (800-826-3632) Website: www.ndmda.org National Mental Health Association (NMHA) National Mental Health Information Center 1021 Prince Street Alexandria, VA 22314-2971 800-969-6642 Website: www.nmha.org J Clin Psychiatry 1999;60 (suppl 16) The National Mental Health Consumer Self Help Clearinghouse 1211 Chestnut St., 11th Floor Philadelphia, PA 19107 800-688-4226 website: www.mentalhelp.net FOR MORE INFORMATION The following materials provide more information on PTSD. Unless otherwise indicated, they are available from ADAA. To order or to obtain a complete ADAA publications list, call 301-231-9350. Allen JG. Coping with Trauma: A Guide to Self Understanding. American Psychiatric Press, 1995 Brooks B, Siegel PM. The Scared Child: Helping Kids Overcome Traumatic Events. John Wiley, 1996 (to order, call 732-469-4400) Coffey R. Unspeakable Truths and Happy Endings: Human Cruelty and the New Trauma Therapy. Sidran Press, 1998 Davidson JRT, Foa EB, eds. Posttraumatic Stress Disorder: DSM-IV and Beyond. American Psychiatric Press, 1993 (to order, call 800-368-5777) Finney LD. Clear Your Past: Change Your Future. New Harbinger, 1997 Foa EB, Rothbaum BO. Treating the Trauma of Rape: Cognitive-Behavioral Therapy for PTSD. Guilford, 1998 (to order, call 800-365-7006) Frances AF, First MB. Your Mental Health, Scribner, 1999 (available at bookstores) Gorman J. The Essential Guide to Psychiatric Drugs. St. Martin’s, 1995 Herman JL. Trauma and Recovery. Basic Books, 1997 (to order, call 800-386-5656) Matsakis A. Trust after Trauma: A Guide to Relationships for Survivors and Those Who Love Them. New Harbinger, 1998 Porterfield KM. Straight Talk about Post-traumatic Stress Disorder: Coping with the Aftermath of Trauma. Facts on File, 1996 (to order, call 800-322-8755) Rothbaum B, Foa E. Reclaiming Your Life after Rape. Psychological Corporation, 1999 (to order, call 800-211-8378) To request more copies of this handout, please contact ADAA at 301-231-9350. You can also download the text of this handout on the Internet at: www.psychguides.com 75 Expert Consensus Guideline Series R R HOW CAN I TELL IF I HAVE PTSD?* Problems concentrating? Yes No PTSD is a serious, yet treatable, medical disorder. It is not a sign of personal weakness. If you think you may have PTSD, answer the following questions and show this checklist to your health care professional. R R Feeling “on guard”? Yes No R R Yes or No? An exaggerated startle response? Yes No R R Have you experienced or witnessed a life-threatening Yes No event that caused intense fear, helplessness, or horror? R R Do your symptoms interfere with your daily life? Yes No Do you re-experience the event in at least one of the following ways? R R Have your symptoms lasted at least 1 month? Yes No R R Repeated, distressing memories and/or Yes No dreams? Having more than one illness at the same time can make it more difficult to diagnose and treat the different conditions. Illnesses that sometimes complicate PTSD include depression and substance abuse. To see if you have other problems that may need treatment, please complete the following questions. R R Acting or feeling as if the event were hapYes No pening again (flashbacks or a sense of reliving it)? R R Intense physical and/or emotional distress Yes No when you are exposed to things that remind you of the event? Do you avoid reminders of the event and feel numb, compared to the way you felt before, in three or more of the following ways? R R Have you experienced changes in sleeping or eating Yes No habits? More days than not, do you feel R R Sad or depressed? Yes No R R Avoiding thoughts, feelings, or conversaYes No tion about it? R R Uninterested in life? Yes No R R Avoiding activities, places, or people who Yes No remind you of it? R R Worthless or guilty? Yes No R R Being unable to remember important parts Yes No of it? During the last year, has the use of alcohol or drugs R R Losing interest in significant activities in Yes No your life? R R R R R R Resulted in your failure to fulfill responsiYes No bilities related to work, school, or family? Yes No Placed you in a dangerous situation, such as Yes No driving a car under the influence? R R Feeling that your range of emotions is Yes No restricted? R R R R R R Feeling detached from other people? Feeling as if your future has shrunk (for Yes No example, you don’t expect to have a career, marriage, children, or a normal life span)? Gotten you arrested? Yes No Continued despite causing problems for you Yes No and/or your loved ones? Are you troubled by two or more of the following? R R Problems sleeping? Yes No R R Yes No 76 Irritability or outbursts of anger? * Symptoms listed here are based on criteria for posttraumatic stress disorder, major depressive disorder, and substance use disorders in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric Association; 1994. Checklist reprinted by permission of the Anxiety Disorders Association of America. J Clin Psychiatry 1999;60 (suppl 16) Other Published Expert Consensus Guidelines McEvoy JP, Scheifler PL, Frances A. The Expert Consensus Guideline Series: Treatment of Schizophrenia 1999. J Clin Psychiatry 1999;60(suppl 11). Alexopoulos GS, Silver JM, Kahn DA, Frances A, Carpenter D. The Expert Consensus Guideline Series: Treatment of Agitation in Older Persons with Dementia. Postgraduate Medicine Special Report April 1998. March JS, Frances A, Carpenter D, Kahn DA. The Expert Consensus Guideline Series: Treatment of Obsessive-Compulsive Disorder. J Clin Psychiatry 1997;58(suppl 4). McEvoy JP, Weiden PJ, Smith TE, Carpenter D, Kahn DA, Frances A. The Expert Consensus Guideline Series: Treatment of Schizophrenia. J Clin Psychiatry 1996;57(suppl 12B). Kahn DA, Carpenter D, Docherty JP, Frances A. The Expert Consensus Guideline Series: Treatment of Bipolar Disorder. J Clin Psychiatry 1996;57(suppl 12A). Expert Consensus Guidelines are in preparation for: Psychiatric and Behavioral Problems in Mental Retardation Attention-Deficit/Hyperactivity Disorder Bipolar Disorder 1999 Treatment of Depression in Women Guidelines can be downloaded from our web site: www.psychguides.com