Most veterans with posttraumatic stress disorder (PTSD) are prescribed
psychotropic medications, but the percentage decreases as they get older,
according to Department of Veterans Affairs' researchers.
Their study included 274,297 veterans in the VA health system diagnosed
with PTSD. About 80 percent of them received prescriptions for a psychiatric
drug in 2004, the year covered by the study. Of those, 89 percent got
prescriptions for antidepressants, 61 percent for
anxiolytics/sedatives-hypnotics, and 34 percent for antipsychotics. Similar
prescription percentages applied to veterans older than age 45 (n=244,947)
within the larger cohort, wrote Somaia Mohamed, M.D., an associate clinical
professor of psychiatry at the Yale School of Medicine, and Robert Rosenheck,
M.D., a professor of psychiatry and public health at Yale. Rosenheck is
director and Mohamed is associate director of the VA Northeast Program
Evaluation Center in West Haven,
Their research appeared in the October American Journal of Geriatric
Mohamed and Rosenheck used national administrative databases from the VA as
their source. The pharmacy data became available to health services
researchers at the VA only in recent years. The study measured only
prescription data, not outcomes.
Prescribing rates were lower for patients seen in primary care (52 percent
overall) compared with those seen in specialty mental health clinics (84
percent). Patients seen in mental health clinics may be sicker and have more
comorbidities than those seen in primary care settings, possibly accounting
for the higher number of prescriptions.
Prescribing rates dropped as the ages of the veterans increased (see
table). For instance, compared with 45- to 54-year-olds, those aged 75 to 84
were 46 percent less likely to receive a psychotropic prescription. There
might be several explanations for this effect, said Mohamed and Rosenheck. For
one thing, increasing medical comorbidities that appear with age may lead
physicians to be more cautious about prescribing another drug to an elderly
patient already using several medications.
Intensity of PTSD symptoms may also recede with age, according to previous
research cited by Mohamed and Rosenheck.
"Older veterans may [also] be reluctant to take medications because
they experience mental illness as more stigmatizing than younger
veterans," the researchers noted, referring to World War II and Korean
The strongest predictor for prescription of antidepressants,
anxiolytics/sedatives-hypnotics, or antipsychotics was a diagnosis of an
indicated illness for which these medications have been approved. However,
choice of treatment is often based on symptoms rather than diagnoses, said
Mohamed and Rosenheck in an interview.
"Many people who get antipsychotics don't have these
disorders," said Rosenheck. "That's not surprising in itself, but
in this study we have documented the magnitude of the practice."
Off-label use is rational, said Rosenheck, but there is little systematic
research on such use.
"The FDA has left it up to industry, but industry funds studies for
expanding indications for use," he said. "More research on drugs
assessing their value in treating symptoms, whether or not they arise as part
of a diagnosis, might provide a better evidence base for use of these
An abstract of "Pharmacotherapy for Older Veterans Diagnosed
With Posttraumatic Stress Disorder in Veterans Administration" is posted
A related abstract is posted at<www.psychiatrist.com/abstracts/abstracts.asp?abstract=200806/060811.htm>.▪