Spotting—and treating—PTSD in primary care

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Applied Evidence

Spotting—and treating—PTSD in primary care

J Fam Pract. 2010 February;59(2):75-80

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References

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FAST TRACK

Research supports the use of second-line medications to target specific PTSD symptoms.

Research also supports the use of second-line medications to target specific PTSD symptoms. Other classes of antidepressants, benzodiazepines and nonbenzodiazepine hypnotics, atypical antipsychotics, and mood-stabilizing agents are typically used in addition to SSRIs, and in combination with psychotherapy.²

Collaborative care is an ideal approach. In addition to being the setting in which chronic mental and physical health problems are often managed,^1,2 primary care is well suited for a collaborative approach to PTSD.^2,31 In a collaborative care model, the efforts of the primary care physician might be extended with the help of midlevel providers and periodic consultation with a mental health specialist. Collaborative care management of depression in primary care has been found to be superior to the usual care, and this model is promising for PTSD.^32-35

CASE. Maureen: It has now been 5 years since Maureen’s diagnosis: a moderately severe case of chronic PTSD. Since then, I have continued to see her regularly, and have been able to cut back on her pain medication, adjust her dosage of psychotropic medication, and convince her to enter psychotherapy. While Maureen still has multiple health problems, her functioning has improved and, for the first time, she has been able to undergo vital health screening, including Pap smears, mammography, and colonoscopy.

FAST TRACK

Symptoms of subclinical PTSD may wax and wane, and may be triggered by physical or psychological stress.

CASE. Dominic: After his PTSD diagnosis, it took Dominic nearly 18 months to return to baseline, with the help of frequent primary care visits, an SSRI, and CBT. He began feeling so much better that we stopped the medication after 2 years of treatment, and he didn’t return to the office for 2 or 3 years, other than for flu shots and other routine health needs. When the fire in the house down the street reactivated his PTSD symptoms, we restarted the SSRI and I met with him monthly for about 6 months to monitor his PTSD symptoms and provide support. By the end of 6 months, Dominic’s PTSD symptoms had largely resolved. Recognizing that PTSD can remain subclinical for a long time but that symptoms may wax and wane, we decided to keep him on antidepressant therapy indefinitely. Dominic is feeling well, and comes in for yearly follow-up.

CORRESPONDENCE
John R. Freedy, University Family Medicine, 9228 Medical Plaza Drive, Charleston, SC 29406; freedyjr@musc.edu