Psychiatric Annals

FROM THE GUEST EDITORS 

This Issue: Posttraumatic Stress Disorder

Jonathan Davidson, MD; Kenneth O. Jobson, MD

Abstract

The treatment of posttraumatic stress disorder (PTSD) can be approached from a psychological and psychopharmacologic point of view. The treatment decisions may rest on the expertise of the treating professional, the patient's preference, and the presence of comorbid psychiatric illness. The algorithm detailed in this issue of Psychiatric Annals has as its focus the psychopharmacologic treatment of PTSD. Unfortunately, little evidence exists on the effectiveness of combining psychological and medication treatment.

The impetus for the development for the PTSD treatment algorithm described in this issue came with the comportment of three factors. First was the increased need for expertise in the treatment of PTSD after the 9/11 tragedy, the Southeast Asia tsunami, and increases in combat-related PTSD. In addition, Dr. Davidson increasingly was being asked to consult on an international basis regarding PTSD treatment. Finally, the experience of the International Psychopharmacology Algorithm Project (IPAP) and Collegium Internationale Neuropsychopharmacologicum with the World Health Organization (WHO) led to IPAP's recognition of the emphasis the WHO has on post-disaster medical care.

We have been fortunate to have as faculty not only a distinguished group of international experts for the treatment of PTSD but also psychiatrists that had served as chairman of national PTSD committees, such as Dr. Kim in Japan and Dr. Zohar in Israel. Dr. Friedman brought his experience as a member of the American Psychiatric Association PTSD guideline committee, the Departments of Defense and Veterans Affairs PTSD committee, and the International Society for Traumatic Stress Studies guideline committee.

Dr. Davidson and all participating project faculty lead off the issue by providing the entire algorithm, which is organized in the form of nodes to describe the diagnostic task, choice of initial treatment, definition of response, length of treatment, and when to consider change. The management of nonresponse or partial response is discussed in detail, along with observations on augmentation, dose increase, or switch as possible treatment strategies. The clinician is then given suggestions as to treatment selection based on the prevailing symptomatology, to include insomnia or nightmares, psychosis, bipolar features, depression, or anxiety. The group identified eight important general principles that often need to be taken into account. A listing of the levels of evidence is given, along with the complete flow diagram.

Drs. Connor and Stein discuss the importance of taking into account clinical scenarios that are not uncommonly seen in the PTSD population. These include suicidality, other Axis I comorbidities, sleep disturbances, psychosis, substance abuse or dependence, nonadherence to treatment, ongoing trauma, cultural issues, litigation around the trauma, and the place of psychosocial treatment. As an addendum, Drs. Zachary Stowe and Jeffrey Newport of Emory University address issues related to women of childbearing potential.

Next, we provide a comprehensive description of a new program being introduced into the Veterans Affairs system. This process, referred to as knowledge management (KM), seeks to bridge the gap between clinical practice and the evidence base. As part of the VA Comprehensive Mental Health Strategic Plan, KM will be introduced to enable staff to be continuously informed of new best practice information. As described by the authors, Drs. Ruzek, Friedman, and Murray, PTSD was the disorder chosen for piloting this initiative. This most promising approach will no doubt be watched with interest as it develops in the VA system and can be expected to have more widespread dissemination.

Finally, Drs. Jobson and Hartley present a brief overview of some of the major extant guidelines and algorithms for PTSD and describe how the algorithms differ. Among the unusual aspects of this algorithm are the broad range of comorbidity considered and the need to take into account…

The treatment of posttraumatic stress disorder (PTSD) can be approached from a psychological and psychopharmacologic point of view. The treatment decisions may rest on the expertise of the treating professional, the patient's preference, and the presence of comorbid psychiatric illness. The algorithm detailed in this issue of Psychiatric Annals has as its focus the psychopharmacologic treatment of PTSD. Unfortunately, little evidence exists on the effectiveness of combining psychological and medication treatment.

The impetus for the development for the PTSD treatment algorithm described in this issue came with the comportment of three factors. First was the increased need for expertise in the treatment of PTSD after the 9/11 tragedy, the Southeast Asia tsunami, and increases in combat-related PTSD. In addition, Dr. Davidson increasingly was being asked to consult on an international basis regarding PTSD treatment. Finally, the experience of the International Psychopharmacology Algorithm Project (IPAP) and Collegium Internationale Neuropsychopharmacologicum with the World Health Organization (WHO) led to IPAP's recognition of the emphasis the WHO has on post-disaster medical care.

We have been fortunate to have as faculty not only a distinguished group of international experts for the treatment of PTSD but also psychiatrists that had served as chairman of national PTSD committees, such as Dr. Kim in Japan and Dr. Zohar in Israel. Dr. Friedman brought his experience as a member of the American Psychiatric Association PTSD guideline committee, the Departments of Defense and Veterans Affairs PTSD committee, and the International Society for Traumatic Stress Studies guideline committee.

In This Issue

Dr. Davidson and all participating project faculty lead off the issue by providing the entire algorithm, which is organized in the form of nodes to describe the diagnostic task, choice of initial treatment, definition of response, length of treatment, and when to consider change. The management of nonresponse or partial response is discussed in detail, along with observations on augmentation, dose increase, or switch as possible treatment strategies. The clinician is then given suggestions as to treatment selection based on the prevailing symptomatology, to include insomnia or nightmares, psychosis, bipolar features, depression, or anxiety. The group identified eight important general principles that often need to be taken into account. A listing of the levels of evidence is given, along with the complete flow diagram.

Drs. Connor and Stein discuss the importance of taking into account clinical scenarios that are not uncommonly seen in the PTSD population. These include suicidality, other Axis I comorbidities, sleep disturbances, psychosis, substance abuse or dependence, nonadherence to treatment, ongoing trauma, cultural issues, litigation around the trauma, and the place of psychosocial treatment. As an addendum, Drs. Zachary Stowe and Jeffrey Newport of Emory University address issues related to women of childbearing potential.

Next, we provide a comprehensive description of a new program being introduced into the Veterans Affairs system. This process, referred to as knowledge management (KM), seeks to bridge the gap between clinical practice and the evidence base. As part of the VA Comprehensive Mental Health Strategic Plan, KM will be introduced to enable staff to be continuously informed of new best practice information. As described by the authors, Drs. Ruzek, Friedman, and Murray, PTSD was the disorder chosen for piloting this initiative. This most promising approach will no doubt be watched with interest as it develops in the VA system and can be expected to have more widespread dissemination.

Finally, Drs. Jobson and Hartley present a brief overview of some of the major extant guidelines and algorithms for PTSD and describe how the algorithms differ. Among the unusual aspects of this algorithm are the broad range of comorbidity considered and the need to take into account a variety of other clinical situations. The article reviews briefly the history of the IPAP, describing previous activities, conferences and its interface with fields of data modeling, information science, and nascent efforts to keep algorithms current.

About the Guest Editors

Jonathan Davidson, MD, is professor, Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, where he is also director of the Anxiety and Traumatic Stress Program. He earned his medical degree at University College and University College Hospital Medical School in London, England. In addition to board certification in psychiatry in the United States, he is a fellow of the American Psychiatric Association, the Royal College of Psychiatrists (UK), and the American College of Neuropsychopharmacology.

Dr. Davidson has served as chairman of the National Institute of Mental Health's Treatment Assessment Review Committee and on the board of directors of the Anxiety Disorders Association of America. He was co-chair of the American Psychiatric Association's DSM-IV Work Group for PTSD.

Dr. Davidson has authored numerous books, book chapters, and articles for professionals and consumers on posttraumatic stress disorder, social phobia, herbal medicine, and anxiety. He is actively involved in research in complementary and alternative treatments and received professional training in homeopathic medicine in the United Kingdom.

Kenneth O. Jobson, MD, is founder and chairman of the board for the International Psycho-pharmacology Algorithm Project, a not-for-profit corporation with the purpose of developing and improving algorithms and protocols, the evidence on which they are based, and their utility. He is on the clinical faculty at the University of Tennessee, Department of Psychiatry, and is president of Psychiatry and Psychopharmacology Services, PC, in Knoxville, TN.

He received his medical degree from Emory University Medical School, Atlanta, GA, and was in general practice in Orange County, FL, for 6 years following his service as a flight surgeon in the United States armed forces. He completed his psychiatric residency at the University of North Carolina, Chapel Hill, NC, where he was in charge of the UNC psychopharmacology clinic. After completion of his psychiatry residency, he and Haroutune Dekirmenjian established the National Psychopharmacology Laboratory in Knoxville, the first national laboratory to offer blood levels of antidepressants and neuroleptics.

Dr. Jobson is a member of Collegium Internationale Neuropsychopharmacologicum, the Society of Biologic Psychiatry, the American Psychiatric Association, and the American Medical Association. With Drs. Jan Fawcett and Dan Stein, he edited the Textbook of Treatment Algorithms in Psychopharmacology.

Authors

10.3928/00485713-20051101-02

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