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KEY CONCEPTS
Trauma-focused cognitive behavioral therapy (CBT) and eye movement desensitization and reprocessing are the most effective nonpharmacologic methods to reduce symptoms of posttraumatic stress disorder (PTSD).
The selective serotonin reuptake inhibitors (SSRIs) and venlafaxine at moderate to high dose are considered first-line treatments for PTSD.
An adequate trial of SSRIs in PTSD is 8 to 12 weeks.
Patients with PTSD who respond to pharmacotherapy should continue treatment for at least 12 months.
CBT with behavioral techniques (eg, exposure and response prevention [ERP]) is the most common initial nonpharmacologic treatment of choice in obsessive-compulsive disorder (OCD).
Moderate-to-high dose SSRIs are the medication of choice for the treatment of OCD.
Clomipramine, a tricyclic antidepressant (TCA) with strong serotonin (5-HT) reuptake inhibition, is a second-line treatment option for OCD.
An adequate antidepressant trial for OCD treatment is 8 to 12 weeks.
Augmentation of SSRI treatment of OCD with low-to-moderate doses of antipsychotics may be helpful.
Medication taper can be considered after 1 to 2 years of treatment in patients with OCD.
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Patient Care Process for Posttraumatic Stress Disorder and Obsessive-Compulsive Disorder
Collect
Patient characteristics (eg, age, sex, pregnancy status)
Patient medical history (personal and family, include first-degree relatives’ response to medication)
Social history (eg, tobacco use/ethanol use/substance use/sexual activity)
Current medications including OTC use, herbal products, dietary supplements, and prior psychiatric medication use
Patient health preferences, beliefs, and treatment goals
Objective data
Blood pressure (BP), heart rate (HR), respiratory rate (RR), height, weight
Lipid panel and A1c or fasting blood sugar if starting antipsychotic therapy
Electrocardiogram (ECG) if starting a tricyclic antidepressant (TCA) in a patient with cardiovascular disease, patient <18 or >40 years of page, or with other risk factors for QT prolongation (eg, electrolyte abnormalities, concomitant medications with the potential to prolong the QT)
Validated rating scale score (eg, Clinician Administered PTSD Scale [CAPS] or Yale-Brown Obsessive-Compulsive Scale [Y-BOCS])
Results of any pharmacogenomics testing
Assess
Target symptoms (eg, intrusion, avoidance, reactivity, mood/cognition for PTSD and obsessions and/or compulsions for OCD) using CAPS, Y-BOCS, or other rating scale assessments
Functional impairment/quality of life
Sleep hygiene
Psychotic symptoms
Engagement in psychotherapy
Medication adherence
Ability/willingness to utilize and pay for pharmacotherapy or engage in psychotherapy
Ability/willingness to return to clinic for continued regular symptom assessment
Need to alter treatment plans due to results of pharmacogenomics testing
Plan*
Pharmacotherapy regimen including specific medication, dose, route, frequency, onset of action, and duration (see Fig. 91-1, Tables 91-1 through 91-4)
Monitoring parameters including efficacy (eg, rating scale score, sleep, other symptoms such as irritability, functional impairment, symptom diary) and safety (eg, suicidal ideation, adverse effects including insomnia, worsening anxiety or depression, gastrointestinal distress, sexual dysfunction, agitation); frequency and timing of follow-up
Patient education (eg, purpose of treatment, lifestyle modification, onset of action, treatment duration, drug-specific information, medication administration technique; see Fig. 91-1 and Tables 91-2, 91-3, and 91-5)
Self-monitoring ...