An interactive, online treatment algorithm provides a decision tree complete with graded supporting evidence and special clinical considerations for patients with posttraumatic stress disorder.
The new tool is a product of the International Psychopharmacology Algorithm Project, said Jonathan Davidson, M.D., chairman of the IPAP PTSD algorithm faculty. Last year, the group launched its online, interactive algorithm for diagnosing and treating schizophrenia. Both are free to registered users at www.ipap.com
“We hope the PTSD algorithm will be used both in the United States and internationally as a readily available” guide, Dr. Davidson said. “It presents clinicians with the types of problems they are likely to encounter with these patients and helps them identify where to start treatment and where to go next if treatment fails or if the patient is only partially responsive. It also lays out the evidence for those decisions.”
The algorithm is intended for use by mental health clinicians and primary care physicians who might be the first to suspect and diagnose PTSD in their patients. “It's very much aimed at people who are going to encounter these patients in general practice, and that includes all primary care physicians,” said Dr. Davidson, professor of psychiatry and behavioral science at Duke University, Durham, N.C.
The document exists online, so it has the fluidity to respond quickly to any research or new drug options that could alter treatment protocol, he added. As cochair of the committee that examined PTSD criteria for DSM-IV, Dr. Davidson appreciates that kind of flexibility. “You don't have to wait 2 years for a committee's suggestions to go through the bureaucracy.”
The algorithm begins with the initial decision after a diagnosis of PTSD—whether to offer psychosocial therapy, pharmacotherapy, or both. Psychosocial factors, such as the presence of suicidality, psychoses, nightmares, sleep disorder, and compliance, affect that decision.
It then explores initial medication choices along with appropriate dosages, calling for a minimum 4- to 6-week trial of a selective serotonin reuptake inhibitor or a selective norepinephrine reuptake inhibitor, or a tricyclic antidepressant if those choices are unavailable.
The algorithm really proves its usefulness after this node, he said, as it considers those patients who fail to respond or have only a partial response. “The question then is where to go. What do you do if, for example, the patients have continued nightmares?” Choices include increasing the dose or adding additional medications. If after several medication adjustments, there is still not adequate repose, the algorithm suggests reevaluating for another disorder and adding psychosocial therapy, as appropriate.
A click on any node in the algorithm takes the reader to notes containing literature references and grading the level of evidence upon which the decision node is based. Since it's also intended for use outside the U.S., all pharmacotherapy suggestions include alternative drugs that may be more available in other countries.
The algorithm is being translated into Spanish, Chinese, Japanese, and Thai. In fact, Dr. Davidson and coauthor Kathryn Connor, M.D., are preparing to visit Thailand to help train 100 physicians to recognize and treat PTSD, with the algorithm playing an important part.
Areas of Thailand that were hit by the tsunami are experiencing high rates of PTSD, Dr. Davidson said. “In the United States, the prevalence is about 6%, and that has stayed relatively stable for years. The prevalence is obviously tied up with prevalence of trauma in a community and whether there is support for the survivors and preservation of the community, both of which are important determinants.”
The PTSD algorithm was supported by grants from the Dean Foundation, a not-for-profit entity. The Dean Foundation accepts funds from pharmaceutical companies, including AstraZeneca, Bristol-Myers Squibb, Eli Lilly, Janssen, Johnson & Johnson, Novartis, Pfizer, Forest, GlaxoSmithKline, UCB Pharma, and Wyeth-Ayerst.