The guideline reviews the rationale for use and possible side effects for 5 medications that have been shown to be effective for the treatment of AUD: naltrexone, acamprosate, disulfiram, gapapentin, and topiramate. These treatments are meant as part of an interdisciplinary approach to the treatment of substance abuse, not as a substitute.

Naltrexone is an opioid antagonist. It is found to be more helpful in people who are still drinking versus people who are already abstaining from alcohol. It works to extinguish drinking by removing the positive reinforcement effects to alcohol on the brain. Studies have shown that it can help prevent the development of severe alcohol use disorder. It does not necessarily help on its own to achieve abstinence from alcohol, but even reduction of heavy drinking can reduce some of the major negative effects of alcohol use, including medical and occupational effects. Studies have shown that it is effective in reducing and preventing relapses into heavy drinking. It can be particularly helpful in people who have high cravings for alcohol. A typical dose of oral naltrexone is 25 mg bid. A once-monthly, extended-release injectable formulation (Vivitrol) is available as well and is typically dosed at 380 mg qmonth. Common side effects include diarrhea and abdominal cramping. There is an FDA black box warning about the potential for liver damage, but further research has shown that this is a rare side effect and occurred only in patients who were given a higher-than-recommended dose. Still, some physicians elect to check baseline LFTs and monitor them periodically. It is important to avoid using opiate medications while taking naltrexone.

Acamprosate is approved by the FDA for treatment for alcohol dependence with other supportive therapies. Studies have shown it to be helpful in both reduced consumption of as well as maintaining abstinence from alcohol. Its mechanism of action is still under study. Common side effects include diarrhea, headaches, insomnia and impotence. Less common but more serious side effects include irregular heart rate and effects on blood pressure. Acamprosate is cleared renally so it should be avoided in patients with significant renal impairment.

Disulfiram works by producing an acute sensitivity to alcohol consumption by inhibiting acetaldehyde dehydrogenase. With disulfiram on board, 5-10 minutes after alcohol consumption, the patient will experience “hangover” symptoms for the next 30 minutes-several hours. These symptoms include flushing of the skin, accelerated heart rate, shortness of breath, nausea, vomiting, headache and mental confusion. Typically the regimen is initiated by prescribing 500mg qday x 1-2weeks then the maintenance dose is 125-500mg qday until the patient has fully abstained from alcohol. There is no tolerance to disulfiram – the longer it is taken, the stronger its effects. The main drawback is that the patient has to be motivated to take the medication consistently. The medication does not decrease craving for alcohol, so it is important that it be used in conjunction with supportive therapy and motivational interviewing. Common side effects include headache and metallic taste in mouth. It should not be taken within 12 hours of drinking alcohol and its effects can last for up to 2 weeks.

Naltrexone and acamprosate have the best evidence backing their use in treating AUD. Disulfiram can be helpful if a patient is seeking abstinence and is motivated. Topiramate and gabapentin can be considered as treatment options once naltrexone and/or acamprosate have been tried first. More studies need to be conducted to assess their effectiveness in AUD, but generally the concern is that there is a higher risk of problematic side effects with these two medications compared to naltrexone and acamprosate. Patients taking topiramate are at an increased risk of cognitive dysfunction, dizziness and loss of appetite, whereas patients taking gabapentin may experience fatigue, insomnia, and headache.

The full practice guideline is included here as a reference for those who are interested in more detailed information.

https://psychiatryonline.org/doi/pdf/10.1176/appi.books.9781615371969

Pharmacological treatment is an important part of the interdisciplinary approach to effectively treating AUD and reducing its negative outcomes.

Adequate Trial Length: These medications can take 4-6 weeks to see the full positive effect once reaching a therapeutic dose. It is important to discuss this with patients prior to starting the medication so they have a realistic expectation about how long it may take to feel relief from their symptoms. And it is important for the prescriber to wait the full 4 weeks at a therapeutic dose prior to changing the medication. Of course the dose can be optimized based on the patients’ response in the meantime.

“Starting Low and Going Slow”: Particularly when treating anxiety disorders and drug naïve patients, it is important to “start low and go slow” to avoid problematic side effects. This is particularly true when prescribing these medications to children and adolescents as well as older patients. Slow titration has been shown to decrease the risks for increased anxiety, increased agitation and akathisia (internal restlessness) in patients being treated with SSRIs. For example when using fluoxetine in these situations, the prescriber might consider starting at 10 mg per day for one week prior to increasing to 20 mg per day, and then waiting at 20 mg for one month to assess response.

Higher Therapeutic Dose for Anxiety Disorders: While it is important to “start low and go slow” when treating anxiety disorders, many anxious patients require a higher dose for full efficacy. Using the same example of fluoxetine, while a dose range of 20-40 mg per day is adequate for treating depression, doses in the 40-80 mg range are often needed to treat anxiety disorders effectively, particularly obsessive-compulsive disorder. In these cases, it can take 3-4 months to get to a full therapeutic dose and to see full relief from symptoms.

Discontinuation Syndrome: The SSRIs, particularly the ones with shorter half-lives like paroxetine, fluvoxamine, and sertraline, can have a discontinuation syndrome if they are stopped abruptly. While the discontinuation syndrome is not dangerous or life threatening, it can be very uncomfortable for patients. Symptoms include: gastrointestinal upset, sleep disturbance, flu-like symptoms and an electrical shock sensation. The best way to avoid it is to taper SSRIs that have a shorter half-life. Fluoxetine on the other hand does not necessarily require a taper because it has a very long half-life.

Serotonin Syndrome: Serotonin syndrome is a potentially life threatening drug reaction that occurs when the body is exposed to too much serotonin. It most commonly occurs when two medications that increase serotonin in the central nervous system are taken together. Aside from the SSRIs, other medications that can increase serotonin in the brain include the triptans (used for migraines), certain pain medications (including Tramadol and Demerol), the MAOIs, and dextromethorphan (cough medication). Drugs of abuse like LSD and ecstasy have also been associated with serotonin syndrome. The symptoms of serotonin syndrome include: agitation, restlessness, diarrhea, nausea, vomiting, increased heart rate, increased blood pressure, increased body temperature, hallucinations, loss of coordination, overactive reflexes, myoclonus, and tremor. It is important to discuss this risk with patients, especially if they are taking more than one medication that can increase serotonin levels, so that they can seek immediate medical attention if they exhibit these symptoms.

FDA Black Box Warning: In 2004, the FDA issued a black box warning for all antidepressants and mood stabilizer medications based on research that showed an increased rate of spontaneous reporting of suicidal thoughts in adolescents and young adults treated with SSRIs. The FDA is currently re-evaluating the black box warning but for now it is important to discuss it with young patients who are being treated with these medications. It is important to keep in mind that the rate of the side effect did not increase by much, from 2/1000 patients to 4/1000 patients. In addition while there was in increase in the rate of reporting suicidal thoughts there was not an increase in actual suicidal gestures, suicide attempts or completed suicides. Some hypotheses about why the increase in reporting is seen includes: patients who are being treated with medications have more contact with mental health and medical providers and therefore may be more comfortable disclosing their suicidal thoughts; patients may experience improvements in their energy levels prior to improvements in their mood; the suicidal thoughts might be related to the increase in activation seen in young patients with SSRI treatment; and that spontaneous reporting of already present suicidal thoughts is a sign that the patient’s depression is improving. It is also important to remind patients and their families that these medications overall decrease the rate of suicide. Therefore they are an important part of treatment, with close monitoring, which includes phone or in person contact within 1-2 weeks after starting medication or increasing the dose.

It is our hope that this discussion about the nuances of using the SSRIs and other antidepressant medications helps for more effective usage of these important medication treatments in the primary care setting. Please feel free to call PC2 for specific questions related to specific patients.

For purposes of this article, crisis moments refer to those points in time when individuals lose physical and rational control of their behavior. Almost always, there are warning signs a person’s behavior is moving toward a crisis.

EMOTIONAL SIGNS: Crying, Yelling, No Talking at All, Arguing, Inappropriate Laughter, Fear, Confusion

BEHAVIORAL SIGNS: Rocking/Swaying, Rapid Breaths, Shaking Extremities, Pressured Speech, Tenseness in Body, Loud or Quiet, Clenched Fists, Poor Eye Contact, Pacing, Skittish Behaviors

The following tips can aid in early interventions and increase the likelihood of staff de-escalating an incident before it becomes dangerous.

1. Respect All Individuals’ Personal Space
   Personal space is the area around us that we consider an extension of ourselves. Anxiety rises when personal space is invaded. Heightened anxiety makes it more likely a person will act out in a more serious way.
   To avoid such a response, maintain at least an arm’s-length distance from a person whose behavior is escalating. In this way, you will also reduce danger to yourself by maintaining a margin of safety that allows you time to react.
   If you must touch an anxious person to provide medical care, explain what you are about to do before you begin. If the person objects, decide if: 1) the procedure can wait; 2) someone else might be better suited to provide the care; or 3) the procedure must be done at this very moment. This third alternative should be a last resort, chosen only due to acute medical necessity.
2. Be Aware of Your Own Body Position and Feelings
   In addition to maintaining adequate space between you and an anxious person, avoid direct, eye-to-eye, toe-to-toe positions, as they might be interpreted as challenging. Positions perceived as challenging can evoke a “fight or flight” response from the other person, and neither of those reactions is likely to be helpful. Standing at an angle to the person and off to the side is much less likely to escalate an agitated person’s behavior. Be aware of your own feelings (e.g., fear, anger, etc.) and consider asking for assistance from other staff if you feel the need.
3. 3. Be Empathic to Others’ Feelings
   Try not to judge or discount the feelings of others. Pay attention to them, and don’t be afraid of silence. Your calm, supportive presence is often more important than what could be conveyed with any words you might say.
4. Keep Nonverbal Cues Nonthreatening
   As a person begins to lose control of rational thought, the person becomes more tuned into your body language. Nonverbal communication — including gestures, facial expressions, movements and tone of voice — becomes paramount in conveying a calm, respectful attitude.
5. Ignore Challenging Questions
   When a person challenges your authority or an organizational policy; try to redirect the individual’s attention to the issue at hand. In general, it’s better to ignore the challenge and restate your request.
6. Set and Enforce Reasonable Limits
   If patients or family members become belligerent, defensive or disruptive, and calmly establish limits and directives clearly and concisely. When setting limits, offer simple, clear choices and consequences to the acting-out individual. Be sure the consequences are reasonable and enforceable. Be clear and firm, but avoid displaying anger, fear or hostility.
7. 7. Permit Verbal Venting When Possible
   It is often the safest and best alternative to let the person shout, removing others from the area when feasible. As a person is venting, there will be peaks and valleys in the outburst. If you cannot allow the person to continue venting, state the directives and reasonable limits during the “valleys” in the venting process.
8. 8. Identify Real Reason for the Behavior
   Even in the midst of an angry tirade, there is useful information to be gained about what a person is thinking and feeling. Anxious patients and family members can be highly critical of hospital staff for reasons that are much more related to the fear and helplessness they are experiencing than to the ways staff members are performing their duties. Try to listen for the feelings behind the facts. Restate the message you think you have received in order to determine if you correctly understood the person’s intent.
9. Stay Composed, Avoid Overreacting
   It’s hard not to take things personally. It is essential to do your best to remain calm and professional — at least on the outside. Your composed, rational response can go a long way toward influencing the person’s behavior in a positive way.
10. Use Physical Techniques Only as a Last Resort
    Physical restraint should be used only when people’s behaviors are dangerous to themselves or others. Physical intervention itself always carries some risk of injury to staff or to the person being restrained. Such interventions should be used, therefore, only when it is more dangerous NOT to intervene and by competent staff members who are trained.

These are some basic steps we hope all staff members can use to improve their interventions in potential crisis situations. The points above are not intended to replace training, but rather to provide an overview of some of the techniques and strategies that can be effective.

Resources: https://www.crisisprevention.com/Blog/June2011/Responding-to-Abusive-Patient-Behavior-Part-2

Consistent with a biopsychosocial model of illness, individuals with chronic pain often report that the pain interferes with their ability to engage in occupational and recreational activities. Their inability to engage in these activities can contribute to increased isolation, feelings of worthlessness and hopelessness, sleep disturbance, and depressed mood. It is estimated that ¼ of patients with chronic pain meet criteria for major depression. In addition, conditions such as anxiety, substance abuse and personality disorders occur at a greater rate in individuals who have a chronic pain condition than individuals who do not.

Depression and pain strongly reinforce each other. Therefore it is important to treat both concurrently in order to have the greatest chance for success.  Both antidepressants and anticonvulsants can be used for treating chronic pain. The types of pain that are most responsive to these medications are neuropathic syndromes, such as diabetic neuropathy, trigeminal neuropathy, and post-herpetic neuralgia.  Chronic headaches, migraines, fibromyalgia, arthritis pain, and chronic low back pain may also be treated successfully with these medications.  Combined use may be appropriate for some patients.

In terms of antidepressant medications, tricyclic antidepressants and serotonin norepinephrine reuptake inhibitors (SNRIs) have been found to be particularly helpful. The SSRIs have not been found to be particularly helpful on their own for pain specifically but definitely are helpful for the co-morbid depression frequently seen in patients with chronic pain. Alternatively, a combination of SSRI and low dose tricyclic medication can be helpful more specifically for the pain symptoms of a chronic pain syndrome which include sleep disturbance as a significant symptom.

In terms of anticonvulsant medications, carbamazepine, depakote, lamotrigine and gabapentin have the most evidence for being helpful for chronic pain syndromes. Lamotrigine and gabapentin have fewer drug interactions and don’t require blood monitoring, making them easier to use in general.

One of the most effective psychological approaches for pain management is based on a cognitive-behavioral therapy (CBT) approach. Its aim is to change maladaptive thoughts and behaviors that serve to maintain and exacerbate the experience of pain, to introduce relaxation training, and to promote increased activity and functioning. Alternative pain treatments like physical therapy and acupuncture/acupressure can also be considered.

In summary, when treating a patient with chronic pain, it is important to assess how the pain is affecting their quality of life and try to concurrently treat their chronic pain, their emotional discomfort and their overall functional capacity whenever possible.

•  Fatigue/low energy
•  Trouble initiating or maintaining sleep
•  Hypersomnia
•  Significant change in appetite, leading to change to weight
• Poor concentration
• Depressed mood

When someone presents with new onset depressive symptoms, it is important to obtain a thorough history, conduct a review of systems to determine if there are abnormal findings in other body systems, obtain a family history, and perform a physical exam. These can point the provider in the right direction in terms of a differential diagnosis. Medical conditions that can mimic symptoms of depression include:

• Hypothyroidism
• B12 deficiency
• Iron deficiency anemia
• Autoimmune disorders – fibromyalgia, lupus
• Sleep apnea
• Seasonal allergies
• Medication side effect – ex: pain medication, beta blockers, Accutane, Chantix

If there is a concern for a medical condition leading to depressive symptoms, consider appropriate lab tests and imaging studies to confirm or rule out the diagnosis. To be clear, not everyone who presents with depressive symptoms needs to have other medical conditions ruled out, just in situations when it makes sense clinically.

Case Study:
9 year old female who presents with fatigue and low energy and trouble with concentration x 2 months. She reports she does not understand why she feels so tired because she sleeps 7-8 hours per night. The daytime fatigue is causing her to feel sad some days because it is affecting her energy level with her 1 year old and at work. She does not have a history of depression. Medically she is healthy except she experienced significant blood loss during her delivery.

Next Steps?
Given that she does not have a history of depression, it is important to rule out other medical causes for her symptoms. Basic labs are ordered and show low Hb/Hct. Additional studies ordered to assess for iron-deficiency anemia and confirm the diagnosis. She is started on iron supplementation and encouraged to eat more iron- rich foods in her diet and sees improvement in her symptoms over the next 3 months.
It is hopeful that this discussion and case example give clearer guidelines on when to consider a medical workup for a patient presenting with classically depressive symptoms. One take home point is that it is important to conduct a brief review of systems even in a patient presenting with depressive symptoms as her chief complaint.

Call: Provider Consultations 858-880-6405 Email: BHCS.provider@vistahill.org Webpage: www.pc2education.org

It is important to thoroughly assess for other causes for the hallucinations before considering a psychotic disorder because primary psychotic disorders are very rare in children. It is important to conduct a thorough clinical history and physical exam, and to consider basic labs and/or brain imaging if there are other signs of a medical or neurological process. Medical causes for hallucinations include: seizures, brain tumors (particularly in the visual association areas, temporal lobes and area around the optic nerve and retina), thyroid disease, electrolyte imbalances and adrenal disorders.

Medications that can commonly cause hallucinations include steroids, anticholinergics, and stimulants. It is important to consider the possibility of illegal drug use, including marijuana, even in very young children, who may have either taken the drug on purpose or ingested it accidentally. Visual, olfactory and gustatory hallucinations in children may suggest a medication or substance-related cause. It is important to rule out hypnagogic hallucinations, which occur immediately before falling asleep and hypnopompic hallucinations, which occur during the transition from sleep to wakefulness, both of which are normal phenomena.

True hallucinations in children are more likely to be a part of a non-psychotic psychiatric disorder than a primary psychotic disorder. Hallucinations can occur in children with non-psychotic psychiatric disorders, like depression, anxiety, and disruptive disorders. Hallucinations are not uncommon in depression in children but may suggest a higher risk for developing bipolar disorder. It is common for grieving children to hear “voices” from recently deceased loved ones. It’s important to remember that children who have experienced trauma can experience hallucinations as part of the trauma reaction. Hallucinations are common in children with developmental delays, including autism spectrum disorder. Children with language disorders may talk about “voices” because they cannot describe their own thoughts. In these situations, it can be helpful to ask a child if s/he is experiencing the voice inside of outside his/her head.

After ruling out the above, one can consider a primary psychotic disorder. It is important to assess for other psychotic symptoms (like disorganized speech, bizarre behavior, delusions, paranoia) as well as negative symptoms of psychosis (apathy, amotivation, and decline in functioning) before assuming a primary psychotic disorder, because a diagnosis of a primary psychotic disorder should not be made based on hallucinations alone.

In conclusion, while the report of hallucinations in children is worrisome, it is unlikely that it represents a psychotic disorder. It is important to conduct a thorough history to determine the underlying cause of the reported symptom.

The Abnormal Involuntary Movement Scale is a standardized tool for assessing for EPS side effects in patients. Here is a link with instructions on how to conduct the assessment (typically takes 10 minutes), how to score it and a pdf of the scale.

https://pc2education.files.wordpress.com/2012/05/aims-abnormal-involuntary-movement-scale-screening-tool.pdf

One useful way to distinguish the types of EPS is to remember them in the time frame that they usually present:

Propranolol (Inderal) is a beta-blocker that can be helpful for akathisia with a typical dose range of 10-40 mg bid-tid. It should be dosed bid-tid for best effect. Side effects include hypotension, dizziness, and sedation. It can also be useful as an adjunctive medication for anxiety.

Benztropine (Cogentin) is an anti-cholinergic medication that can be helpful for neuroleptic-induced parkinsonism. It should be dosed bid because it has a short half-life. Starting dose is 0.5 mg bid and can increased as needed and tolerated to 2 mg bid. Side effects to monitor for include: confusion, sedation, constipation, dry mouth, urinary retention, and blurred vision. For this reason, benztropine should be avoided with low potency neuroleptic medications, to avoid additive anti-cholinergic side effects. Another commonly used anti-cholinergic medication is trihexyphenidyl (Artane), with a typical range of 5-15 mg dosed TID. Anticholinergic medications are not typically helpful for akathisia.

Amantadine is a dopamine agonist that can be used to treat neuroleptic-induced parkinsonism. Starting dose is 100mg bid with a max of 400mg/day. It is generally well tolerated and is associated with less memory impairment than anti-cholinergic medications. Primary side effects include: nausea, dry mouth, dizziness, and tremor.

IM diphenhydramine (Benadryl) can be used to treat acute dystonia. Oral diphenhydramine 25-100 mg can be helpful for neuroleptic-induced parkinsonism. Primary side effects include sleepiness, dry mouth and decreased motor coordination. It is available over the counter.

Tardive dyskinesia (TD) can be tricky. Initially it can improve if the dose of the neuroleptic medication is increased but overall it worsens with increases in dose. If the medication is discontinued, 1/3 of patients get better, 1/3 have no real change, and 1/3 get temporarily worse. The best option is to discontinue the medication and change to a lower potency, newer antipsychotic medication. Risk factors for TD include being female, older, smoking and being African American. Approximately 15% of patients taking long-term high potency neuroleptics will develop TD.

The FDA recently approved a medication for the treatment of TD, which up until now there was no treatment for. Valbenazine (Ingrezza) is a highly selective vesicular monoamine transporter 2 inhibitor. It is dosed as 80mg once per day. Side effects include sleepiness and OT prolongation. It is therefore important to monitor an EKG on patients taking valbenazine. It allows patients to potentially continue on a medication at a dose that is helpful for their psychotic symptoms without having to change medication or reduce the dose to treat their side effects.

The goal of this brief overview is to provide some baseline information on monitoring for, differentiating, and treating EPS side effects for medications that might be used in the primary care setting.

Decreased appetite:
If your patient’s appetite decreases after taking ADHD medicine, advise the parent to give the morning dose after breakfast so that the youth will eat better in the morning. Also advise them to serve a large dinner in the evening when the medication is beginning to wear off. Have them keep healthy, high-calorie, protein snacks on hand for whenever a child asks for food, even if it is before bedtime. Discuss with parents that it is more important to monitor the child’s weight than his day-to-day appetite. Advise them to let you know if the child’s poor appetite lasts for a long period, and consider reducing the dose or stopping the drug on weekends or summer breaks to allow appetite and food intake to return to normal.

Stomach pain or upset:
Advise parents not to give the medication on an empty stomach. Taking the medication with or immediately after food can be helpful for this side effect.

Sleep problems:
Parents should set up a regular bedtime routine that includes calming activities, such as bathing or reading.  Makes sure that a long-acting stimulant is only given in the mornings, typically no later than 10am, and an afternoon dose of a short-acting stimulant should typically not be given later than 3pm. If the sleep disturbance persists, the provider could consider switching from a long-acting to a shorter-acting form or reducing the dose or stopping an afternoon dose.

Daytime drowsiness:
If a child is taking atomoxetine (Strattera) or guanfacine (Tenex/Intuniv) or clonidine (Catapres/Kapvay) and experiences daytime sleepiness, consider giving the medication at bedtime instead of in the morning.  The provider could also consider lowering the dose or dividing the dose and giving it twice a day. 

Rebounding effects:
When an ADHD medication wears off in the afternoon or evening, some children have a period of more ADHD symptoms or irritability and moodiness.  This is more common with the stimulant medications than the non-stimulant medications. To prevent this “rebounding” consider using a longer-lasting medication or prescribing a small dose of fast-acting stimulant later in the day.

Mood Changes:
Make sure the parents are keeping an eye out for changes in the child’s mood and anxiety.  Stimulant medications can negatively affect mood symptoms and anxiety. If that does occur, consider using a non-stimulant medication instead to address the ADHD symptoms.

Finally, it is often advisable to schedule medication initiation or dosage changes to occur on weekends when parents can better monitor for side effect emergence

It is our hope that this practical primer on addressing the common side effects for ADHD medications is helpful to address problems that may arise in the primary care office. And remember providers can contact is at SmartCare for real-time consultation on particular cases.

Most people who experience a traumatic event, however, do not develop PTSD, so it is important to be aware of the risk factors for someone to develop PTSD after a traumatizing event. There is a genetic susceptibility to developing PTSD. PTSD shares genetic variance with other anxiety disorders like panic disorder and generalized anxiety disorder. PTSD also shares genetic variance with substance abuse disorders. People who experience an interpersonal assault are more likely to develop PTSD compared to people who experience a non-assault based trauma. PTSD is commonly seen in patients with military experience but can also be seen as a result of sexual assault, physical abuse, and domestic violence, in children and adults. PTSD is more commonly seen in situations where someone is exposed to a repeated trauma rather than a single trauma.

People with smaller hippocampi (the part of the limbic system that plays a role in both memory and inhibitory control) are more likely to develop PTSD after a traumatic event.  The hippocampus is an area of the brain with high numbers of gluco-corticoid receptors, glucocorticoids being part of the physiologic response to stress.  In PTSD, there is an over-activation of the Hypothalamic-Pituitary-Adrenal (HPA) axis which results in an increase in the fight or flight response. This contributes to the symptoms that are seen in PTSD, including hyper-vigilance, avoidance of triggers, nightmares, intrusive flashbacks, experiencing distress with reminders of the trauma, sleep disturbance, irritability, anger outbursts, and exaggerated startle response. Children experiencing PTSD will display it in their play and might also exhibit aggression, regression in their development and hyperactivity and impulsivity.

Patients with PTSD are at higher risk for suicidal ideation and suicide. They are at higher risk for other mental health concerns like other anxiety disorders and major depression. They are at higher risk for substance abuse problems, in large part in an effort to “self-medicate”.

The mainstay of treatment for PTSD is therapy (individual and group) and medication if needed. Trauma focused CBT is an evidence-based therapy practice used for PTSD. Additionally some patients find EMDR (eye movement desensitization and reprocessing) helpful for their symptoms. The SSRIs and other antidepressants can be useful for the depressive and anxiety symptoms of PTSD. Additionally medications like Prazosin can be used adjunctively for nightmares and sleep disturbance. Benzodiazepines are not particularly helpful for PTSD and therefore are not generally a recommended treatment.

It is our hope that this primer on PTSD is helpful for primary care providers to be able to screen for PTSD appropriately and refer for a more thorough assessment as needed.