Practice recommendations from consensus conference: Research implications

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Practice Recommendations for the Treatment of
Veterans with Comorbid PTSD, mild TBI, and Pain
Results from the June 2009 Consensus Conference
and Research Implications
Matthew J. Friedman, MD, Ph.D. Executive
Director, National Center for PTSD White River
Junction, VT Nancy C. Bernardy, Ph.D. National
Center for PTSD White River Junction, VT

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Outline

• Background and Development of Consensus
  Conference
• Recommendations of Conference
• Research Implications

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Dilemma VA Clinicians Now Face

• No treatment trials comorbidity
• Only current guidance separate VA Clinical
  Practice Guidelines
• (www.healthquality.va.gov)
• Management of Post-traumatic Stress
• Management of Concussion/mild Traumatic Brain
  Injury
• VHA Pain Management Directive 2009
• Clinicians need information to guide clinical
  practice

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Recognition of the Problem

• Prompted the Special Committee on PTSD in FY08
  report
• to recommend a Consensus Conference be held
• Undersecretary for Health concurred. Dr. Katz
  charged
• NCPTSD in FY09 to develop multidisciplinary
  workgroup
• Objective To make treatment recommendations
  within the
• context of current VA programs and processes

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Survey of PTSD/PNS Clinicians

• Needs assessment of 40 clinicians
• Findings point to need for
• Educational materials for patients, family and
  providers
• Guidance on best practices for assessment and
  treatment, including comorbidites requiring
  specialized treatment such as pain, insomnia and
  substance abuse
• Coordination of services between
  providers/departments
• Research to build the evidence base for practice

Sayer et al, In press, JRRD
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Conference Participants June 1 and 2, 2009 -
Washington, D.C.

• Participants
• Mental Health (8)
• Rehabilitation (8)
• DoD and DCoE (4)
• Pain (2)
• Neurology (2)
• Primary Care (2)
• Pharmacy (2)
• Research (2)
• National Non-VA expert (1)
• Moderator - Dr. David Oslin

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Approach of Conference

• First day - Round table discussion of 3 primary
  strategic aspects patients, systems and
  outcomes in the following areas
• Assessment What are the best approaches?
• Treatment planning What are challenges?
• Treatment Are modifications necessary?
• Second day Development of practice
  recommendations

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Minneapolis VA Evidence Synthesis Program Review

• Literature review to develop evidence base
• and identify best practices for patients with
• comorbidity
• Prevalence? 28 studies included 3 military
  with comorbid prevalence between 5-7 among those
  with TBI, prevalence of PTSD was 33-39
• Assessments of mild TBI and PTSD and effective
  treatments? 0 studies met criteria
• Recommendations Need standard definitions and
  measurement accuracy of mTBI and PTSD and
  randomized trials to evaluate therapies

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Materials reviewed for Conference

• Results of Systematic Review
• VA/DoD Clinical Guidelines (www.healthquality.va.g
  ov)
• PTSD
• Revised Concussion/mTBI
• Pain
• Compilation of 24 research articles
• Pilot data from 2 PTSD clinics
• Summary of 2008 International DoD/DVBIC TBI
  Conference

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Relevance of Clinical Practice Guidelines

• How useful are current separate clinical practice
  guidelines for treating comorbid PTSD, mTBI and
  pain?
• How well can a Veteran with the comorbidity
  benefit from evidence-based therapies?
• Are treatment modifications needed?

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Emergent Themes of Conference
Access to treatment Menu of models of care Best
practices identified
Diagnosis Provider education Patient/family
education
Access
Education
Systems
Coordinate care Provider incentives Use of
resources
Assessment/ Treatment
Comprehensive treatment plans Follow clinical
guidelines Measure/monitor Concurrent,
collaborative treatments
Cross-cutting in that they were Important for
our key questions
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Educational Issues

• Differentiate history of injury, the exposure
  vs. current symptoms
• Active communication between providers not just
  CPRS notes
• Increased resource knowledge
• Pain programs
• Post-deployment clinics
• PRC / PNS / OEF/OIF
• MIRECC expertise
• Location and co-location

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Educational Issues

• Need for provider education
• Availability and assessment for assisted
  technologies and treatments
• Resource web links and knowledge of accessing
  information
• System of care and materials
• Need for patient/family education
• Educate patient and family throughout process
  (diagnosis - recovery)
• Demystify illness and process
• Promote recovery expectations

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Access / Process of Care

• Develop knowledge about entry pathways
• No wrong door to treatment
• Develop menu of different models of care at
  different type of locations
• Best Practice model vs. CBOC vs. Vet Centers
  with core elements identified
• Strike a proper balance between specialty and
  primary care
• Stress importance of supportive employment and
  educational programs

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Assessment / Treatment

• Comprehensive assessment to differentiate
  symptoms vs. diagnoses
• Prioritize to accommodate patients
  goals/preferences and include family
• Evidence-based treatments follow the existing
  CPG or manual guidelines or prescribed to ensure
  adequate dose
• Encourage concurrent, collaborative treatments

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Assessment / Treatment

• Treatment plans that
• Define and coordinate all treatment sources
• Deliver a recovery message on prognosis
• Include discharge planning exit strategies
• Step-down levels of care use post-deployment
  clinics to provide continuity
• What to do if the patient is not progressing
• Measure and monitor
• Reinforce need to stop meds when they do not work
• Assess effectiveness of treatment delivered

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Assessment / Treatment

• Key domains may require attention for treatment
  adjustments
• Partial responders compliance of treatment
• Memory, attention, executive functioning
• Hearing loss, pain, balance, sleep
• Polypharmacy
• Substance use / abuse
• Develop risk-benefit profile about medications
• Med A may benefit mTBI symptoms but not help
  PTSD symptoms

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System Issues

• Support providers providing interdisciplinary,
  coordinated care
• Incentives to providers at facilities to
  collaboratively manage and review cases
• Support providers to use non-formulary
  medications (using guidelines)
• Use consultation resources
• PRC / PNS are regional facilities
• Involve MIRECCs, NCPTSD, Centers of Excellence

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Next Steps

• Develop clear action plans for priorities with
  timelines
• Collect patient data with comorbidity to examine
  pertinent variables
• Identify potentially best practice settings
• Develop provider incentives for collaborative
  treatment
• Review Rural Health impacts
• Include family members
• Create resource library
• Develop research priorities

Art Psychiatric Times
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Research Implications

• Four emerging themes from conference education,
  access to care, assessment/treatment and systems
  were important for consideration of issues
  involving assessment, treatment planning and
  treatment
• Education Research Implications
• For Patients, What is the impact of
• Positive expectancy on outcomes/recovery
• Use of terminology of concussion vs. brain
  injury
• Motivational interviewing techniques
• Family involvement in treatment

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Research Implications

• Education Research Implications
• For Providers, What is the impact of
• Increased access to and knowledge of
• existing resources (pain programs,
• PRC/PNS/OEF/OIF programs, NCPTSD)
• Information about availability of assisted
  technologies (hand-held devices) for
  assessment/treatment
• Increased knowledge of the system of care
• A document that combines the key points of the 3
  existing clinical practice guidelines for ease of
  use by clinicians

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Research Implications

• Access/Process of Care Research Implications
• Identify potentially best practice models
• Need to test different treatment models in
  different settings
• Compare collaborative models with treatment as
  usual
• Test impact of supportive employment and
• vocational or educational programs
• - Determine needs for rural health settings

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Research Implications

• Assessment Research Implications
• Are there tools clinicians should add to their
  assessment for symptoms?
• Are there identifiable medical symptoms (hearing
  loss) that would inform assessment?
• What questions should clinicians add for
  determining quality of life functioning?
• Does an interdisciplinary, coordinated approach
  to assessment promote recovery?

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Research Implications

• Treatment Research Implications
• How do current clinical practice guidelines
  perform?
• Do other comorbidities (SUD, depression,
  insomnia) affect treatment choice/outcomes?
• Do we need to modify cognitive behavioral
  treatments?
• Are there other cognitive retraining/CBT
  approaches (skills training) that will compliment
  CPT and PE?
• Are there effective medications that compliment
  CBT?
• Do we need to develop other outcome measures
  besides the usual suspects (pain, pre/post,
  subjective ratings of improvement)?
• Does the addition of behavioral pain management
  promote recovery?

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Research Implications

• Systems Implications
• Does assignment to a single primary provider
  improve care?
• Can we administratively support providers who
  give interdisciplinary care?
• Does increased use of consultation resources
  promote recovery?
• Are telehealth treatments effective in these
  complex patients with comorbidities?

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• Conclusions
• Conference was a first step research is now
  needed to build evidence base
• For now, use the 3 clinical practice guidelines
• Keep focus on comorbidities
• Include family members in treatment and Veterans
  goals
• Improved communication between collaborative
  providers is needed
• Recommendations need to be disseminated to the
  field

Art psychiatric Annals