Barbara Boughton

November 07, 2011

November 7, 2011 (San Francisco, California) — There is no doubt that posttraumatic stress disorder (PTSD) brings with it a great deal of mental suffering. However, the problem of how to best treat veterans with PTSD has long been a challenging one, and this quandary seems to be holding true for veterans of the United States' most recent engagements in Iraq and Afghanistan, according to researchers here at the American Psychiatric Association 2011 Institute on Psychiatric Services (APA-IPS).

Researchers from the National Center for PTSD in Menlo Park, California, found that 327 of 482 veterans who responded to a mailed survey, or 73%, received first-line pharmacotherapy for PTSD: either a selective serotonin reuptake inhibitor (SSRI) or a serotonin-norepinephrine reuptake inhibitor (SNRI).

However, veterans of the current conflicts in Iraq and Afghanistan were significantly less likely to complete a 90-day therapeutic trial of their antidepressants than veterans of earlier conflicts (multivariate odds ratio, .44; P < .01).

"SSRIs and SNRIs are first-line medications for the treatment of PTSD, but patients have to stay on them long enough to obtain a sufficient response," lead author Shali Jain, MD, told Medscape Medical News.

Dr. Jain noted that the researchers were especially interested in assessing treatment of PTSD in veterans of the current conflicts in Iraq and Afghanistan, so they intentionally oversampled these patients. Fifty percent of more than 1600 patients invited to participate were veterans of Operation Iraqi Freedom and Operation Enduring Freedom.

When investigators looked further at patient characteristics of veterans from the current conflicts, they found that those with a concurrent diagnosis of depression were significantly less likely receive a therapeutic trial of an SNRI or SSRI for 90 days (odds ratio, .29; confidence interval, 0.09 - 0.94; P < .05).

"It's not news that veterans of the current Iraq and Afghanistan wars are less likely to utilize mental healthcare than other veterans, but it does point out the importance of targeting antidepressant treatment to these younger veterans who may not be as sensitized to psychiatric treatment as older veterans," Dr. Jain said.

That may be easier said than done.

"Veterans with PTSD are often highly ambivalent about psychiatric treatment because they don't believe at first that their psychiatric condition is real," commented Charles Marmar, MD, Littauer professor of psychiatry and chair of the Department of Psychiatry at the New York University Langone Medical Center. Dr. Marmar formerly held positions as associate chief of staff for mental health and director of the PTSD research program at the Veterans Affairs (VA) Medical Center in San Francisco.

"At the VA we would turn cartwheels to get vets into treatments. We tried motivational interviewing, tried destigmatizing treatment by calling PTSD combat stress, and building our programs into primary care clinics," Dr. Marmar told Medscape Medical News.

At the San Francisco VA, considered one of the most innovative mental health programs for veterans from Iraq and Afghanistan, counseling was also offered via telephone and the Internet, Dr. Marmar added.

"The hope we have is that veterans will engage in treatment before they bottom out, before they become progressively more depressed, use more alcohol and marijuana, and ruin their health over time," he said.

Dr. Jain and Dr. Marmar have disclosed no relevant financial relationships.

American Psychiatric Association 2011 Institute on Psychiatric Services (APA-IPS): Abstract 3-25. Presented October 28, 2011.

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