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For the Management of Posttraumatic Stress Disorder (PTSD) VA/DOD CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF POSTTRAUMATIC STRESS DISORDER AND ACUTE STRESS DISORDER Department of Veterans Affairs Department of Defense QUALIFYING STATEMENTS The Department of Veterans Affairs and the Department of Defense guidelines are based upon the best information available at the time of publication. They are designed to provide information and assist decision making. They are not intended to define a standard of care and should not be construed as one. Neither should they be interpreted as prescribing an exclusive course of management. This Clinical Practice Guideline is based on a systematic review of both clinical and epidemiological evidence. Developed by a panel of multidisciplinary experts, it provides a clear explanation of the logical relationships between various care options and health outcomes while rating both the quality of the evidence and the strength of the recommendation. Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Every healthcare professional making use of these guidelines is responsible for evaluating the appropriateness of applying them in the setting of any particular clinical situation. These guidelines are not intended to represent TRICARE policy. Further, inclusion of recommendations for specific testing and/or therapeutic interventions within these guidelines does not guarantee coverage of civilian sector care. Additional information on current TRICARE benefits may be found at www.tricare.mil or by contacting your regional TRICARE Managed Care Support Contractor. Version 3.0 – 2017 VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder Prepared by: The Management of Posttraumatic Stress Disorder Work Group With support from: The Office of Quality, Safety and Value, VA, Washington, DC & Office of Evidence Based Practice, U.S. Army Medical Command Version 3.0 – 2017 Based on evidence reviewed through March 2016 June 2017 Page 2 of 200 VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder Table of Contents I. Introduction ..................................................................................................................................... 5 II. Background...................................................................................................................................... 5 A. Definition of Traumatic Events ............................................................................................................ 5 B. Acute Stress Reaction and Diagnosis of Acute Stress Disorder ......................................................... 6 C. Diagnosis of Posttraumatic Stress Disorder ........................................................................................ 8 D. DSM-IV versus DSM-5: Clinical Practice Guideline Implications ...................................................... 11 E. Epidemiology and Impact .................................................................................................................. 13 III. About this Clinical Practice Guideline ............................................................................................. 16 A. Methods ............................................................................................................................................. 16 B. Summary of Patient Focus Group Methods and Findings ................................................................ 20 C. Conflicts of Interest ........................................................................................................................... 21 D. Scope of this Clinical Practice Guideline ........................................................................................... 21 E. Highlighted Features of this Clinical Practice Guideline ................................................................... 22 F. Patient-centered Care ....................................................................................................................... 22 G. Shared Decision Making .................................................................................................................... 23 H. Background on Co-occurring Conditions with Posttraumatic Stress Disorder ................................ 23 I. Implementation ................................................................................................................................. 24 IV. Guideline Work Group ................................................................................................................... 26 V. Algorithm ...................................................................................................................................... 27 Module A: Acute Stress Reaction/Disorder .............................................................................................. 28 Module B: Assessment and Diagnosis of Posttraumatic Stress Disorder ................................................ 30 Module C: Management of Posttraumatic Stress Disorder ..................................................................... 32 VI. Recommendations ......................................................................................................................... 33 A. General Clinical Management ........................................................................................................... 37 B. Diagnosis and Assessment of Posttraumatic Stress Disorder .......................................................... 39 C. Prevention of Posttraumatic Stress Disorder ................................................................................... 41 D. Treatment of Posttraumatic Stress Disorder .................................................................................... 44 E. Treatment of Posttraumatic Stress Disorder with Co-occurring Conditions ................................... 72 VII. Knowledge Gaps and Recommended Research .............................................................................. 76 A. Shared Decision Making and Collaborative Care .............................................................................. 76 B. Treatments for Acute Stress Disorder and Preventing Posttraumatic Stress Disorder .................. 76 June 2017 Page 3 of 200 VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder C. Treatments for Posttraumatic Stress Disorder ................................................................................. 76 D. Non-Pharmacologic Biological Treatments for Posttraumatic Stress Disorder ............................... 78 E. Technology-based Treatments for Posttraumatic Stress Disorder .................................................. 78 F. Treatments for Posttraumatic Stress Disorder with Comorbidities and Co-occurring Conditions. 78 Appendix A: Evidence Review Methodology ....................................................................................... 79 A. Developing the Scope and Key Questions ........................................................................................ 79 B. Conducting the Systematic Review ................................................................................................... 83 C. Convening the Face-to-face Meeting ................................................................................................ 87 D. Grading Recommendations ............................................................................................................... 88 E. Recommendation Categorization ..................................................................................................... 91 F. Drafting and Submitting the Final Clinical Practice Guideline.......................................................... 93 Appendix B: Patient Focus Group Methods and Findings .................................................................... 95 A. Methods ............................................................................................................................................. 95 B. Patient Focus Group Findings ............................................................................................................ 95 Appendix C: Pharmacotherapy Dosing Table ...................................................................................... 97 Appendix D: Evidence Table ............................................................................................................... 98 Appendix E: 2010 Recommendation Categorization Table ................................................................ 104 Appendix F: Participant List .............................................................................................................. 140 Appendix G: Literature Review Search Terms and Strategy ........................................................... 142 A. Topic-specific Search Terms ............................................................................................................ 142 B. Search Strategies ............................................................................................................................. 156 Appendix H: Abbreviation List .......................................................................................................... 183 References .........................................................................................................................................
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