According to a study(ps.psychiatryonline.org) (abstract) in the February issue of the journal Psychiatric Services, mental health professionals in the Veterans Health Administration (VHA) system frequently treat U.S. veterans suffering from posttraumatic stress disorder (PTSD) with medications that are inconsistent with evidence-based guidelines.
The authors of the study -- all of whom work for the U.S. Department of Veterans Affairs (VA) in Iowa or at the VA's National Center for PTSD in Vermont -- also said that when they compared the prescribing patterns of VHA mental health and primary care clinicians, mental health professionals were much more likely to prescribe psychiatric medications currently not supported by a clinical practice guideline(www.healthquality.va.gov) jointly developed by the VA and the U.S. Department of Defense (DoD).
"Our primary objective was to identify the prescribing frequencies for three classes of medications rated in the VA-DoD PTSD guideline and the proportions attributable to various provider types," the authors wrote. "Our primary finding suggests that non-guideline-recommended treatments are frequently prescribed by mental health clinicians for veterans with PTSD. This finding … suggests that prescribing by mental health care specialists contributes considerably to the misalignment between guideline-based care and actual practice."
According to the study's primary analysis, VHA mental health clinicians accounted for a majority of prescribing across all three medication classes examined:
- 70.0 percent of selective serotonin reuptake inhibitors/serotonin-norepinephrine reuptake inhibitors,
- 79.7 percent of second-generation antipsychotics and
- 68.8 percent of benzodiazepines.
Moreover, when data showed prescribing frequencies for second-generation antipsychotics and benzodiazepines decreased slightly from 2006 to 2009, the authors attributed the change to primary care clinicians.
"The data suggest that the prescribing frequencies for these medications declined because a lower proportion of the prescribing was done by mental health providers, whereas the proportion done by primary care providers increased slightly," the authors wrote.
However, family physician Jeffrey Sonis, M.D., M.P.H., associate professor in the departments of social medicine and family medicine at the University of North Carolina at Chapel Hill, told AAFP News Now he had concerns about how the study's authors reached their conclusions.
"The data reported in the article are the proportion of prescriptions, in each medication class, prescribed by mental health providers and primary care providers for patients with PTSD," Sonis said. "They are not the 'prescribing frequencies' (i.e., rates of prescribing) of different medication classes by mental health providers and primary care providers for patients with PTSD."
Sonis noted that to be able to calculate prescribing frequencies, researchers need to know the number of visits for PTSD (or number of patients with PTSD) for mental health providers and primary care providers.
"In the absence of data on the number of visits for PTSD to each group, you truly can't draw any conclusion about the absolute or relative prescribing frequencies by mental health providers and primary care providers," he said.
Family physician Robert Rich Jr., M.D., of Bladenboro, N.C., chair of the AAFP Commission on Health of the Public and Science's Opioid Abuse and Pain Management Workgroup and one of 14 regional medical directors for Medicaid in the state, said that although he has observed some of the same prescribing patterns the study authors described in their research in the private community, he is not sure that this is a "red alert" issue.
"One of the things that I look at is our use of medications, and we have observed an alarming increase in the use of atypical psychotics … by our mental health providers in the treatment of depression in the private community," he said. "But if you look at the FDA literature about these medications, you don't see a lot that were technically approved as add-on medications, whereas a couple of the newer ones have done just that and have FDA approval for that purpose.
"It's not so much that (these doctors) are doing anything that's dangerous; it's just that there have not been a lot of studies to evaluate the effectiveness of some of the newer versus the older medications."