Everyday symptoms could point to potential PTSD

When patients present with sleep problems or anxiety, physicians may want to consider the bigger picture. That can include post-traumatic stress disorder (PTSD).

Although PTSD is relatively rare in the population overall, it's present in a significant percentage of primary care visits, according to psychiatry researcher Paula P. Schnurr, PhD. "Perhaps between 20% and 30% of primary care patients have PTSD or have a history of PTSD, and the general population estimate for lifetime PTSD [prevalence] is 6%. Many primary care clinicians are addressing PTSD, whether or not they know it," she said.

To help clinicians screen for, diagnose, and treat PTSD and a related condition, acute stress disorder, the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense developed a clinical practice guideline that was released in 2023 and summarized in an article published by Annals of Internal Medicine on Feb. 27.

"The intended audience is anyone providing care," said Dr. Schnurr, the lead author on the guideline summary, who is the executive director of the National Center for PTSD in the Office of Mental Health and Suicide Prevention for the Veterans Health Administration (VHA) in Washington, D.C. "It applies broadly. … Even people who are not treating veterans or service members can use the guideline with confidence that the results will generalize to their patients."

Dr. Schnurr and Ilse Wiechers, MD, MPP, MHS, a coauthor of the guideline and the VHA Office of Mental Health and Suicide Prevention's deputy executive director, recently spoke to I.M. Matters about some of the guideline's key points.

Q: What's the difference between PTSD and acute stress disorder?

A: Dr. Schnurr: Acute stress disorder is a severe reaction that some people develop in the days and weeks following a traumatic experience. It's diagnosed within the first 30 days, and we don't diagnose PTSD until at least 30 days have elapsed. There are also more symptoms involved in PTSD. Most people have some of the symptoms of PTSD immediately or in the days and weeks after a traumatic event, so we don't make a diagnosis just on the basis of having some symptoms, because that's normal. But people with acute stress disorder not only have some symptoms, they are severe, and they are affecting their ability to function. In the case of PTSD, the symptoms are severe and affecting functioning and also persisting.

Q: The previous guideline on this topic was published in 2017. What are the biggest changes since then?

A: Dr. Schnurr: We now recommend a medication for treating nightmares, prazosin. We gave that a weak recommendation, but it is a recommendation to use it. The other is that in addition to psychotherapies and medications, we now suggest an alternative practice, mindfulness-based stress reduction, for the treatment of PTSD.

Q: The guideline made a strong recommendation for cognitive processing therapy, eye movement desensitization and reprocessing, and prolonged exposure as first-line PTSD treatments. What do primary care physicians need to know about these therapies, and should they be referring patients for them?

A: Dr. Schnurr: One quick and easy way to learn more about the therapies is to identify relevant sections in the guideline and follow through to links. I'd also like to recommend that people consider looking at the website for our National Center for PTSD, because we have a lot of information for clinicians, including primary care clinicians, to help them learn about how to talk about the therapies. We recognize that most primary care practices, even those with behavioral health clinicians, can't necessarily deliver 10 or 12 weekly sessions of psychotherapy. That's not how primary care practices typically are set up to work. We've got content to help clinicians learn more about the therapies and consider options for how they might help their patients access them.

If a physician has access to referrals for trauma-focused psychotherapy, we would encourage them to consider that, but at the heart of a guideline and how to use it is that it should be used as a tool to inform the clinical encounter. It's not a mandate to say that you should or should not do these things, necessarily, but it's meant to provide the best evidence for clinicians and for a clinician to share with a patient. If a patient wanted trauma-focused psychotherapy, we would recommend that primary care physicians try to find options, for example, in their referral networks, if they have that. There's also opportunities with telehealth and some clinicians offering trauma-focused psychotherapy now, across the country.

Q: Is there a particular point when medications should be used for PTSD, and can primary care physicians prescribe them?

A: Dr. Wiechers: We acknowledge that while the strength of the recommendations for psychotherapy is first line, the availability of those first-line treatments, especially for folks that are in a primary care setting, may be challenging. We also have guideline-recommended pharmacotherapies, which are common antidepressants, and primary care docs are pretty comfortable with prescribing for depression. The dosing would be similar to those for major depressive disorder or generalized anxiety disorder. I would encourage people that if you're dealing with challenges around access to psychotherapy, starting pharmacotherapy is a reasonable thing for a primary care doctor to do when they've made a diagnosis of PTSD and a patient is struggling and is open to the idea of starting a medication. It doesn't need to be one and then the other, or one and not the other. The two can go hand in hand and often go hand in hand.

Q: Would follow-up for these medications be the same for PTSD as for depression or for another indication?

A: Dr. Wiechers: By and large, it's a similar process in terms of what your titration schedule would be. Titrating up on, for example, sertraline for PTSD would be similar to the way you would titrate up to a therapeutic dose for major depressive disorder. From a primary care perspective, they would be thinking about similar follow-up scheduling as they would with a patient with major depressive disorder starting one of those medications.

Q: Are there any medications that a patient with PTSD or acute stress disorder shouldn't be prescribed, or any therapies that they should be counseled to stop taking?

A: Dr. Wiechers: There are two that I would like to in particular highlight. Number one is benzodiazepines. Very strong evidence, consistently now over many years, shows that benzodiazepines actually increase risk of harm for all patients with PTSD. The other thing I would caution people about is cannabis. Use of cannabis in patients with PTSD is also consistently shown in the scientific literature to cause more harm than good. Both of those are things that people commonly will think can help, if you ask the lay public, but both of those have significant risks for patients with PTSD. (Editor's note: For more on cannabis, see the story on hospital care in this issue.)

Q: Do you have any recommendations for talking to patients about stopping cannabis, in particular?

A: Dr. Wiechers: It can be a tough conversation. Here's one way I approach it. I say to patients, "Hey, look, you're here seeing me today because things aren't going well. You're using the cannabis, but things still are not great, so much so that you're here talking to me about what else you can do. Let's give this psychotherapy a try, let's give this medication a try, and in doing that, I'm going to ask you to try stopping the cannabis as well, because it's not working right now, so let's try something different." Try to engage them, essentially, in having a conversation about trying something different for a little bit.

The other framework when I'm talking to folks about trying to reduce cannabis use is harm reduction. If we can talk about scaling back usage, and if they can do that and the world doesn't end, we've had a trial and things are going well, so let's try a little bit more. Instead of smoking twice a day, can we smoke once a day, can we smoke every other day? Maybe we can smoke once a week, or just on the weekends. Maybe we go a month without and see how that goes. If you can engage them and move them a little bit each time you see them, rather than trying to go from all to none, the conversation is a lot easier.

Q: Are there any other take-home points from the guideline for primary care physicians?

A: Dr. Wiechers: I'd like to stress that primary care doctors and clinicians should be mindful of trauma and look for patients who have trauma histories that have impact on their current experience in life. There are a lot of symptoms of PTSD that are just seen as a symptom, whether it's problems with sleep or anxiety and some kind of hyperarousal, and people don't realize that's actually PTSD that they're dealing with. It's not insomnia singularly or generalized anxiety or panic, it's actually the part of a larger cluster of symptoms that would be diagnosed as PTSD. I'd encourage physicians to be mindful of screening and what the diagnosis looks like, and think to ask patients about trauma history.

Dr. Schnurr: Most of all, we want primary care physicians to understand that PTSD is a treatable disorder. It's not hopeless; it doesn't have to be chronic. That doesn't mean we have a silver bullet yet, but it does mean that there's something that primary care physicians can do. All of this conversation with the patients starts with finding out whether they have PTSD, so in primary care, screening and assessment are the first step that we recommend.

Q: What's the next step?

A: Dr. Schnurr: I mentioned earlier that the guideline is a tool to promote conversation and decision making, so the next step if you have a patient with PTSD is we recommend finding out their values and their preferences and, in shared decision making, giving them information about what's recommended and what's not recommended, and trying to arrive at a treatment strategy.

There's evidence, including a randomized controlled trial I was involved with that was published in 2015 in Psychiatric Services, that when patients learn more about the treatments for a condition—what works, what doesn't work, what's involved—they will prefer evidence-based treatments. That's why we emphasize knowing the evidence and sharing it with patients, talking with patients, so that you can collaboratively decide on the best course of action.