Abstract

Department of Veterans Affairs (VA) has an overall commitment to providing evidence-based treatment in a context in which the clinician and patient together explore the symptoms and diagnosis, the goals of the patient, the array of possible interventions that may be helpful, and the patient's preference among interventions that can be recommended based on the available evidence. VA develops Clinical Practice Guidelines (CPGs) in conjunction with the Department of Defense (DOD) on a wide array of healthcare issues, including several mental health diagnoses and problems. This process is exemplary--it is fully interdisciplinary as well as interdepartmental across VA and DOD, input from stakeholders is invited in the process, and the process has a clearly defined methodology for identifying all evidence that should be reviewed in developing the CPG and for evaluating the level of evidence found in all relevant literature. resulting CPGs are thoughtful, data-driven documents that guide assessment and disease management and, when possible, prevention of disorders. Thus, VA, in full collaboration with DOD, has been a leader in organizing important documents to guide clinical decision-making. It is important to note that guiding clinical decision making is exactly what is meant. As noted on the Web site (http://www.healthquality.va.gov/ index.asp) that describes the CPG process, The use of guidelines must always be in the context of a health care provider's clinical judgment in the care of a particular patient. For that reason, the guidelines may be viewed as an educational tool to provide information and assist decision making. In addition, and increasingly in VA, it is not just the provider's judgment but also the preferences of the patient that must be used in making final treatment planning decisions. revised VA/DOD Clinical Practice Guideline for Management of Post-Traumatic Stress was published in 2010, as an update from the original 2004 CPG for Post-traumatic Stress disorder (PTSD); it can be accessed at http://www.healthquality.va.gov/ptsd/ptsd full.pdf [1]. It is an excellent exemplar of the principles outlined here. It reviewed evidence on diagnosis, treatment, and early intervention to prevent PTSD that was published between January 2002 and August 2009. It also drew heavily on other literature reviews and guidelines related to PTSD, including the guidelines developed by the International Society for Traumatic Stress Studies (ISTSS) [2] and a thorough review of PTSD treatment conducted by the Institute of Medicine [3]. In particular, the VA/DOD Working Group adopted several recommendations that mirror those of the ISTSS guideline. In addition to providing guidance on assessment and treatment of PTSD, the 2010 CPG also provides extensive review and guidelines related to acute stress reaction. full specific components of the CPG begin with a review of acute stress reaction/disorder (Algorithm A), covering assessment, treatment (early intervention, specifically), re-assessment, and follow-up, to detect possible development of an acute stress reaction into PTSD. next module covers management of PTSD, progressing from assessment to triage management of the patient, to planning and implementing treatment, to re-assessment. final module provides additional information on the specific treatments with the strongest evidence base for acute stress reaction and PTSD. This section again presents possible early interventions, this time with specific documentation of which interventions have the strongest evidence base and which are not recommended because of possible negative effects. Similar information for PTSD treatment is provided, broken down into the specific evidence regarding psychotherapy, pharmacotherapy, adjunctive services, somatic treatment, and complementary and alternative medicine approaches. Finally, this module also covers treatment for some prominent symptoms of PTSD that may be a focus of treatment, either independently or as part of an overall treatment plan. …

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