Practice Recommendations for the Treatment of Veterans with Comorbid PTSD, mild TBI, and Pain:

1. 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

2. Outline • Background and Development of Consensus Conference • Recommendations of Conference • Research Implications

3. 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

4. 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

5. 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

6. 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 Conference Participants – June 1 and 2, 2009 - Washington, D.C.

7. 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

8. 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

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

10. 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?

11. 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

12. 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

13. 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

14. 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

15. Assessment / Treatment • Comprehensive assessment to differentiate symptoms vs. diagnoses • Prioritize to accommodate patient’s 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

16. 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

17. 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

18. 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 MIRECC’s, NCPTSD, Centers of Excellence

19. 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

20. 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

21. 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

22. 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

23. 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?

24. 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?

25. 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?

26. 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 Veteran’s goals • Improved communication between collaborative providers is needed • Recommendations need to be disseminated to the field Art: psychiatric Annals