On Monday, the Department of Veterans Affairs (VA) and Department of Defense (DoD) released an updated version of the VA/DoD Clinical Practice Guideline (CPG) for the Management of Posttraumatic Stress Disorder (PTSD) and Acute Stress Disorder (ASD). The new version incorporates research conducted since the last revision in 2010 and covers treatment for both PTSD and ASD. There are several new recommendations, so both seasoned and new mental health practitioners should take time to review it.
What’s in the updated PTSD CPG?
The CPG contains the latest recommendations based on evidence spanning prevention, screening, assessment, diagnosis, treatment, and clinical management. There are visual algorithms to use as quick references for acute stress reaction, assessment and diagnosis of ASD and PTSD, and management of ASD and PTSD. It’s important to note the CPG provides recommendations for the management of ASD and PTSD in adults only, not children or adolescents.
Here are some recommendations provided in the CPG.
The updated CPG provides more specificity regarding recommendations for and against medications for the treatment of PTSD. This information is summarized in multiple tables throughout the guideline, as well as in the VA/DoD PTSD CPG – Pocket Card and the VA/DoD PTSD CPG – Clinician Summary.
- The CPG provides a strong recommendation for the first line of treatment for PTSD: individual, manualized trauma-focused psychotherapy, over use of pharmacologic and non-pharmacologic interventions for primary treatment. Only if the patient prefers not to use this therapy or it is not available, then pharmacotherapy or other specified evidence-based individual non-trauma focused psychotherapy can be used (see CPG for details). However, in an effort to increase access to care, the CPG strongly recommends using those trauma-focused psychotherapies that have demonstrated efficacy using secure video teleconferencing (VTC).
- The CPG presents a strong recommendation for use of selective serotonin reuptake inhibitors (SSRIs) fluoxetine, paroxetine, or sertraline and serotonin norepinephrine reuptake inhibitor (SNRI) venlafaxine for patients diagnosed with PTSD who choose not to engage in or are unable to access trauma-focused psychotherapy.
- The CPG makes a strong recommendation against treating PTSD with divalproex, tiagabine, guanfacine, risperidone, benzodiazepines, ketamine, hydrocortisone, or D-cycloserine, as monotherapy due to the lack of strong evidence for their efficacy and/or known adverse effect profiles and associated risks.
- The CPG recommends against using atypical antipsychotics, benzodiazepines, and divalproex as augmentation therapy for the treatment of PTSD due to low quality evidence or the absence of studies and their association with known adverse effects.
- For nightmares associated with PTSD, there is insufficient evidence to recommend for or against the use of prazosin as mono- or augmentation therapy.
- There is insufficient evidence to recommend using any complementary and integrative health (CIH) practices including mindfulness, yoga, meditation, or acupuncture as the primary treatment for PTSD.
- The CPG strongly recommends against using cannabis to treat PTSD because of the lack of evidence for efficacy, known adverse effects, and associated risks.
These are just a few details from the guideline, but there’s so much more! As a provider, it’s important to get familiar with the PTSD CPG so you can deliver the latest evidence-based quality of care for our service members.
Clinical support tools and other PTSD information
Deployment Health Clinical Center (DHCC) collaborates with the DoD/VA Evidence Based Practice Work Group to develop clinical support tools to help make CPGs easier to use in daily practice. These tools are for providers, clinic leaders, line leaders, patients, and families to provide general information about PTSD, explain changes in PTSD treatments, and offer resources. The clinical support tools for PTSD are currently being updated to align with the new CPG so check back soon for updated tools and information!
In the meantime, check out DHCC’s PTSD section for general information on PTSD, related DoD policy guidance and resources, and Psychological Health by the Numbers reports for the latest surveillance data on PTSD and other mental health conditions in the military.
Dr. Alia Creason is a contracted licensed clinical psychologist on the evidence-based practice team at the Deployment Health Clinical Center. She has a doctorate in counseling and human systems and a master of public health in maternal and child health.
The views expressed in Clinician's Corner blogs are solely those of the author and do not necessarily reflect the opinion of the Deployment Health Clinical Center or Department of Defense.