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Development of a Practice Tool for Primary Care Providers: Medication Management of Posttraumatic Stress Disorder in Veterans with Mild Traumatic Brain Injury

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Abstract

Posttraumatic stress disorder (PTSD) and comorbid mild traumatic brain injury (mTBI) are highly prevalent in veterans who served in Iraq [Operation Iraqi Freedom/Operation New Dawn] and Afghanistan [Operation Enduring Freedom]. Complicated psychotropic medications are used for treatment of PTSD and comorbid mTBI symptoms lead to polypharmacy related complications. Primary care providers (PCPs) working in Community Based Outpatient Clinics (CBOCs) are usually burdened with the responsibility of managing this complicated medication regimen or relevant side effects. The PCPs do not feel equipped to provide this complicated psychopharmacological management. Thus, there is a need for a comprehensive yet concise tool for the medication management of PTSD in veterans with comorbid mTBI. (1) To conduct focus groups of interdisciplinary team of experts and other stake holders to assess need, (2) To carefully review current VA/Department of Defense practice guideline to identify content, (3) To develop an evidence based, user friendly, and concise pocket guide for the PCP’s. Content was identified by review of current guidelines and available literature and was finalized after input from stakeholders, multidisciplinary team of experts, and review of qualitative data from focus groups/interviews of clinicians working in remote CBOCs. The pocket tool was formatted and designed by multimedia service. A pocket guide in the form of a bi-fold, 4″ × 5.5″ laminated card was developed. One thousand hard copies were distributed in the local VA medical center. This product is available online for download at the South-Central Mental Illness Research, Education, and Clinical Center website (https://www.mirecc.va.gov/VISN16/ptsd-and-mtbi-pocket-card.asp). This pocket card provides PCPs an easy to carry and user-friendly clinical decision-making tool to effectively treat veterans with PTSD and comorbid mTBI.

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Abbreviations

CBOCs:

Community based outpatient clinics

CBT:

Cognitive behavioral therapy

DSM-5:

Diagnosis and statistical manual of mental disorder, Fifth Edition

EBP:

Evidence based psychotherapy

FDA:

Food and Drug Administration

GABA:

Gamma-aminobutyric Acid

ICD-10:

International classification of diseases, 10th Edition

IOM:

Institute of Medicine

IR:

Immediate release

mTBI:

Mild traumatic brain injury

NIH:

National Institutes of Health

OIF:

Operation Iraqi Freedom

OEF:

Operations enduring freedom

OND:

Operation new dawn

PCS:

Post-concussion syndrome

PE:

Prolonged exposure

PCPs:

Primary care providers

PRC:

Polytrauma Rehabilitation Center

PTSD:

Posttraumatic stress disorder

SC MIRECC:

South Central Mental Illness Research, Education, and Clinical Center

SNRIs:

Serotonin-norepinephrine reuptake inhibitors

SR:

Sustained release

SSRI:

Selective Serotonin Reuptake Inhibitor

STVHCS:

South Texas Veterans Health Care System

TBI :

Traumatic brain injury

TCAs:

Tricyclic antidepressants

TFT:

Trauma-focused therapy

QTc:

Corrected QT interval

UTHSCSA:

University of Texas Health Science Center at San Antonio

VA:

Department of Veterans Affairs

VISN:

Veterans Integrated Service Network

VSSC:

VHA Support Service Center

XR :

Extended release

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Role of the Funding Source

The funding sources had no involvement in the product design, the collection, analysis and interpretation of data, the writing of this manuscript, or the decision to submit this manuscript for publication.

Ethical Approval

This is not a research study involving humans.

Disclaimer

The views expressed herein are solely those of the authors and do not reflect an endorsement by or the official policy or position of the South Texas Veterans Healthcare System, the University of Texas Health Science Center at San Antonio, the Department of Veterans Affairs, or the U.S. government. The information in the guide is designed to provide information to assist decision making. It is not intended to define a standard of care and should not be construed as one. Neither should it be interpreted as prescribing an exclusive course of management. Variations in practice will inevitably and appropriately occur when clinicians consider the needs of individual Veterans, available resources, and limitations unique to an institution or type of practice. Every healthcare professional making use of the guide is responsible for evaluating the appropriateness of applying them in the setting of any particular clinical situation.

Additional Contributions

We would like to thank the focus group attendees for their invaluable contribution. Dr. Baig’s salary is supported by the Department of Veterans Affairs. Holly McKenna provided administrative support.

Funding

This research was supported by South Central Mental Illness Research, Education, and Clinical Center (SC MIRECC) clinical educator grant program from the U.S. Department of Veterans Affairs.

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Author notes

  1. Muhammad R. Baig and Adeel Meraj contributed equally to this manuscript.

Authors and Affiliations

  1. Mental Health, South Texas Veterans Healthcare System, 116 A, 7400 Merton Minter Blvd, San Antonio, TX, USA

    Muhammad R. Baig MD & Adeel Meraj MD

  2. Polytrauma Rehabilitation Center, San Antonio, TX, USA

    Muhammad R. Baig MD & Rebecca N. Tapia MD

  3. Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA

    Muhammad R. Baig MD

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  1. Muhammad R. Baig MD
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Correspondence to Muhammad R. Baig MD.

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Baig, M.R., Meraj, A. & Tapia, R.N. Development of a Practice Tool for Primary Care Providers: Medication Management of Posttraumatic Stress Disorder in Veterans with Mild Traumatic Brain Injury. Psychiatr Q 91, 1465–1478 (2020). https://doi.org/10.1007/s11126-020-09767-w

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