Schnurr Paula P, Hamblen Jessica L, Wolf Jonathan, Coller Rachael, Collie Claire, Fuller Matthew A, Holtzheimer Paul E, Kelly Ursula, Lang Ariel J, McGraw Kate, Morganstein Joshua C, Norman Sonya B, Papke Katie, Petrakis Ismene, Riggs David, Sall James A, Shiner Brian, Wiechers Ilse, Kelber Marija S
National Center for PTSD, White River Junction, Vermont, and Geisel School of Medicine at Dartmouth, Hanover, New Hampshire (P.P.S., J.L.H., P.E.H.).
Defense Health Agency, Falls Church, Virginia (J.W.).
Ann Intern Med. 2024 Mar;177(3):363-374. doi: 10.7326/M23-2757. Epub 2024 Feb 27.
The U.S. Department of Veterans Affairs (VA) and Department of Defense (DoD) worked together to revise the 2017 VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder. This article summarizes the 2023 clinical practice guideline (CPG) and its development process, focusing on assessments and treatments for which evidence was sufficient to support a recommendation for or against.
Subject experts from both departments developed 12 key questions and reviewed the published literature after a systematic search using the PICOTS (population, intervention, comparator, outcomes, timing of outcomes measurement, and setting) method. The evidence was then evaluated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method. Recommendations were made after consensus was reached; they were based on quality and strength of evidence and informed by other factors, including feasibility and patient perspectives. Once the draft was peer reviewed by an external group of experts and their inputs were incorporated, the final document was completed.
The revised CPG includes 34 recommendations in the following 5 topic areas: assessment and diagnosis, prevention, treatment, treatment of nightmares, and treatment of posttraumatic stress disorder (PTSD) with co-occurring conditions. Six recommendations on PTSD treatment were rated as strong. The CPG recommends use of specific manualized psychotherapies over pharmacotherapy; prolonged exposure, cognitive processing therapy, or eye movement desensitization and reprocessing psychotherapy; paroxetine, sertraline, or venlafaxine; and secure video teleconferencing to deliver recommended psychotherapy when that therapy has been validated for use with video teleconferencing or when other options are unavailable. The CPG also recommends against use of benzodiazepines, cannabis, or cannabis-derived products. Providers are encouraged to use this guideline to support evidence-based, patient-centered care and shared decision making to optimize individuals' health outcomes and quality of life.
美国退伍军人事务部（VA）和国防部（DoD）共同努力修订了2017年VA/DoD创伤后应激障碍和急性应激障碍管理临床实践指南。本文总结了2023年临床实践指南（CPG）及其制定过程，重点关注有足够证据支持赞成或反对建议的评估和治疗方法。
来自两个部门的主题专家提出了12个关键问题，并在使用PICOTS（人群、干预措施、对照、结局、结局测量时间和环境）方法进行系统检索后，对已发表的文献进行了审查。然后使用GRADE（推荐评估、制定和评价分级）方法对证据进行评估。在达成共识后提出建议；这些建议基于证据的质量和强度，并参考了其他因素，包括可行性和患者观点。一旦草案经过外部专家小组的同行评审并纳入他们的意见，最终文件就完成了。
修订后的CPG在以下5个主题领域包括34条建议：评估与诊断、预防、治疗、噩梦治疗以及共病情况下的创伤后应激障碍（PTSD）治疗。关于PTSD治疗的6条建议被评为强烈推荐。CPG建议使用特定的手册化心理治疗而非药物治疗；延长暴露疗法、认知加工疗法或眼动脱敏再处理心理治疗；帕罗西汀、舍曲林或文拉法辛；以及在推荐的心理治疗已被验证可用于视频远程会议或没有其他选择时，使用安全的视频远程会议来提供推荐的心理治疗。CPG还建议不要使用苯二氮卓类药物、大麻或大麻衍生产品。鼓励医疗服务提供者使用本指南来支持基于证据的、以患者为中心的护理以及共同决策，以优化个体的健康结局和生活质量。
