SAN FRANCISCO – For the most part, veterans get first-line pharmacotherapy for posttraumatic stress disorder, but Iraq and Afghanistan veterans are less likely than others to finish an adequate 90-day therapeutic trial, especially if they are also depressed, according to an analysis of Veterans Affairs pharmacy records presented at the American Psychiatric Association’s Institute on Psychiatric Services.
Younger, more recent veterans might be too busy with school, jobs, or young families to bother with refills or dose adjustments. They also might not be as aware of mental health issues as older veterans, or as good at navigating the health system, according to lead investigator Dr. Shaili Jain, a psychiatrist at the Palo Alto, Calif., Veterans Affairs (VA) Medical Center and a research fellow at the VA’s National Center for Posttraumatic Stress Disorder.
Whatever the case, the findings "suggest a more vulnerable subtype of veterans," she said. "If I have a vet coming back from Iraq or Afghanistan who has PTSD [posttraumatic stress disorder] and also is pretty depressed, that’s somebody I know I’ve got to watch out for. Maybe I’ll have them come back sooner for an appointment or make sure I am collaborating with" their other doctors to keep them from falling through the cracks. Establishing a strong therapeutic alliance is also essential.
The 482 VA patients in the study all had DSM-IV diagnoses of PTSD. Half served in Iraq or Afghanistan. Their average age was 40; 47% were women, and 69% were white.
"If I have a vet coming back from Iraq or Afghanistan who has PTSD and also is pretty depressed, that’s somebody I know I’ve got to watch out for."
Psychotropic drugs were prescribed to 377; of those, 73% got a first-line treatment, either a selective serotonin reuptake inhibitor (SSRI) or a serotonin norepinephrine reuptake inhibitor (SNRI). Just 61% stayed on the drug for 90 days or longer, judging from whether or not they refilled their prescriptions to cover the full 3 months.
In general, veterans were more likely to be started on an SSRI or SNRI if they were in psychotherapy (odds ratio, 2.51) or had concurrent depression (OR, 7.38).
Iraq and Afghanistan veterans were about half as likely as others to take the drug for 90 days (OR, 0.44); concurrent depression made that even less likely (OR, 0.29).
The results echo previous work finding the group less likely than other vets to use mental health services and more likely to quit a recommended course of psychotherapy early, Dr. Jain said.
To build the therapeutic alliance, "I always try to be cognizant of how important that first impression is. It’s really important to listen to their story" without interrupting or being distracted by a computer screen. It’s also important to tell "patients that we want to see them again and that we can make them better," Dr. Jain said.
Like other people, it is likely that veterans worry about drug side effects. When that’s the case, "I start off with some real basics – that these meds are not going to make you into a zombie. You’re not going to get hooked on them. You’re not going to have to check out of your life because you’re on these meds. Millions of people take them and lead perfectly full and active lives," Dr. Jain said.
Discussion of side effects comes after that point has been made.
Dr. Jain said she has no disclosures.