PTSD trends among veterans: Reuptake inhibitors most prescribed, psychotherapy preferred

Selective serotonin and serotonin-norepinephrine reuptake inhibitors were the most-prescribed medications among veterans who received treatment for PTSD.

However, the percentage of patients receiving medication for PTSD declined between 2009 and 2018 despite a doubling in the number of veterans diagnosed with PTSD in Veterans Health Administration (VHA) care.

“Selecting effective pharmacotherapy for PTSD is a complex decision-making process, characterized by consideration of numerous medications to best manage diverse symptom presentations while balancing against potential side effects,” Nicholas Holder, PhD, a mental illness research, education and clinical center advanced research postdoctoral fellow at the San Francisco Veterans Affairs Health Care System, and colleagues wrote.

Holder and colleagues examined prescription practice trends for veterans with PTSD using data from the VHA. They used ICD-9 and ICD-10 codes to determine PTSD diagnoses, identifying 1,353,416 patients in VHA care who were not diagnosed with bipolar or psychotic spectrum disorder. The researchers assessed data starting at diagnosis and followed patients during the years they were active in VHA care. They also examined outpatient prescription records from 2009 to 2018 for commonly prescribed medications for PTSD, including selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors (SNRIs), benzodiazepine prescriptions or second line/adjunctive medications (atypical antipsychotics [AAPs], mirtazapine, prazosin, trazodone, tricyclic antidepressants and nonbenzodiazepine hypnotics) for PTSD.

In 2009, 499,143 veterans in VHA care were diagnosed with PTSD. By 2018, diagnoses increased to 1,073,183. Despite this growth, the number of patients who received at least one of the examined mediations for PTSD decreased by 9% to 58% overall in 2018. Prescriptions of SSRIs changed the most during the time period analyzed, decreasing by 12.3% from 46.7% in 2009 to 34.4% in 2018. Prescriptions for AAP, non-benzodiazepine hypnotics and benzodiazepines also decreased, as did the number of patients receiving psychotherapy, by 19%. However, prescriptions for SNRIs increased by 2.3% during the study period. Factors such as gender, race, ethnicity and service area had no substantial impact on prescription trends.

According to Holder and colleagues, the decrease in medication prescriptions is partially explained by patients preferring psychotherapy to pharmacotherapy for PTSD treatment. Access to psychotherapy interventions for PTSD has increased substantially in the VHA in recent years, they wrote.

“Future research should continue to evaluate longitudinal trends in PTSD treatment practices and may benefit from evaluating pharmacotherapy and psychotherapy trends concurrently,” Holder and colleagues noted.