Trends in Medication Prescribing in Patients With PTSD From 2009 to 2018: A National Veterans Administration Study

Nicholas Holder, PhD; Anne Woods, MS; Thomas C. Neylan, MD; Shira Maguen, PhD; Karen H. Seal, MD, MPH; Nancy Bernardy, PhD; Ilse Wiechers, MD; Annie Ryder, BA; Ana-Marie Urbieta, MSW; Beth E. Cohen, MD, MAS

J Clin Psychiatry 2021;82(3):20m13522

ABSTRACT

Objective: To evaluate longitudinal prescription practice trends for patients diagnosed with posttraumatic stress disorder (PTSD) using a national cohort of veterans who engaged in Veterans Health Administration (VHA) care from 2009 to 2018.

Methods: Using ICD-9 and ICD-10 codes to determine diagnoses, 1,353,416 patients diagnosed with PTSD in VHA care were retrospectively identified who were not diagnosed with bipolar or psychotic spectrum disorder. Veterans were included in the analytic sample starting in the year of their first PTSD diagnosis for each year that they were active in VHA care. Outpatient prescription records were examined from 2009 to 2018 for medications that are commonly used as recommended (selective serotonin reuptake inhibitors [SSRIs], serotonin-norepinephrine reuptake inhibitors [SNRIs]) or second-line/adjunctive (atypical antipsychotics [AAPs], mirtazapine, prazosin, trazodone, tricyclic antidepressants, and non-benzodiazepine hypnotics) medications for PTSD. Benzodiazepine prescriptions were also examined.

Results: From 2009 to 2018, the percentage of patients active in VHA care who received at least one of the examined recommended or second-line/adjunctive medications for PTSD in a calendar year declined by 9.0% (absolute change). The largest absolute change in rates of prescribing for medication classes over the last decade were observed among SSRIs (−12.3%) and SNRIs (+6.4%). AAP use decreased 5.4% from 2009 to 2018, with most of this change (−4.3%) occurring from 2009 to 2013.

Conclusions: Consistent with clinical practice guidelines, SSRIs/SNRIs were the most common prescriptions for patients in the current study. Reductions in the percentage of patients receiving PTSD medications may reflect concerns regarding effectiveness, adverse side effects, increases in access to evidence-based psychotherapy for PTSD, and/or symptom improvement such that medication was no longer needed.

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