It would appear that I owe Dr. Suzana Gratia Hupp, the Associate Commissioner for Veterans Services to the Texas Health and Human Services Commission an apology. Or, at least an acknowledgment that she was ahead of me in the approval of a treatment known as EMDR for PTSD in Veterans.
Specifically, new Clinical Practice Guidelines (CPG) shared between VA and DoD, say:
For patients with PTSD, we recommend individual, manualized traumafocused psychotherapies that have a primary component of exposure and/or cognitive restructuring to include Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), Eye Movement Desensitization and Reprocessing (EMDR), specific cognitive behavioral therapies for PTSD, Brief Eclectic Psychotherapy (BEP), Narrative Exposure Therapy (NET), and written narrative exposure.
Some good news here is that the VA and DoD are working closer than ever. If a soldier starts with EMDR (or CPT, or another therapy) at their place of duty before discharge, they should be able to continue it at their local VA. Also, the CPG are aimed at making as many of these treatments as possible remotely, using telemental health. That’s great news for rural veterans or anyone not near a VA hospital.
Dr. Hupp – you were on point. Agree or disagree – I do appreciate the effort of you and your entire office to support the great Texas military, veterans, and families.
This press release highlights the update, first since 2010, and links to the guidelines themselves, which you can download at https://www.healthquality.va.gov/guidelines/MH/ptsd/VADoDPTSDCPGFinal.pdf
As highlighted by the VA:
- The CPG provides a strong recommendation for the first line of treatment for PTSD: individual, manualized trauma-focused psychotherapy, over use of pharmacologic and non-pharmacologic interventions for primary treatment. Only if the patient prefers not to use this therapy or it is not available, then pharmacotherapy or other specified evidence-based individual non-trauma focused psychotherapy can be used (see CPG for details). However, in an effort to increase access to care, the CPG strongly recommends using those trauma-focused psychotherapies that have demonstrated efficacy using secure video teleconferencing (VTC).
- The CPG presents a strong recommendation for use of selective serotonin reuptake inhibitors (SSRIs) fluoxetine, paroxetine, or sertraline and serotonin norepinephrine reuptake inhibitor (SNRI) venlafaxine for patients diagnosed with PTSD who choose not to engage in or are unable to access trauma-focused psychotherapy.
- The CPG makes a strong recommendation against treating PTSD with divalproex, tiagabine, guanfacine, risperidone, benzodiazepines, ketamine, hydrocortisone, or D-cycloserine, as monotherapy due to the lack of strong evidence for their efficacy and/or known adverse effect profiles and associated risks.
- The CPG recommends against using atypical antipsychotics, benzodiazepines, and divalproex as augmentation therapy for the treatment of PTSD due to low quality evidence or the absence of studies and their association with known adverse effects.
- For nightmares associated with PTSD, there is insufficient evidence to recommend for or against the use of prazosin as mono- or augmentation therapy.
- There is insufficient evidence to recommend using any complementary and integrative health (CIH) practices including mindfulness, yoga, meditation, or acupuncture as the primary treatment for PTSD.
- The CPG strongly recommends against using cannabis to treat PTSD because of the lack of evidence for efficacy, known adverse effects, and associated risks.
These are just a few details from the guideline, but there’s so much more! As a provider, it’s important to get familiar with the PTSD CPG so you can deliver the latest evidence-based quality of care for our service members.