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Women veterans with posttraumatic stress disorder (PTSD) have historically received more psychiatric medications relative to males. Even with increased rates of PTSD and greater numbers of comorbidities, these differences do not account for the gender differences observed in prescribing. 
The most recent (2017) clinical practice guideline from the Department of Veterans Affairs and Department of Defense (VA/DoD) for the treatment of PTSD (The Management of Posttraumatic Stress Disorder Work Group, 2017) specifically recommends or suggests seven antidepressants for the treatment of PTSD. Perhaps more importantly, the guideline specifically recommends against the use of benzodiazepines, atypical antipsychotics, and select anticonvulsant medications for PTSD treatment. Despite this recommendation, these medications are often still prescribed to patients with a PTSD diagnosis.
What Steps Has the VA taken to Address this Issue?
Over the last decade and following publications that highlighted the continued prescribing of guideline discordant medications to PTSD patients (Bernardy et al., 2013; Lund et al., 2012; Hawkins et al., 2012), the VA established various initiatives aimed at prescribing clinicians to improve medication safety.  These included the Psychotropic Drug Safety Initiative, the Opioid Safety Initiative, national academic detailing initiatives, and the VIONE (Vital, Important, Optional, Not Indicated, and Every medication has a reason) project. Reductions in polypharmacy, benzodiazepines, opioids, and antipsychotic prescribing in the VA are likely the result of these efforts (Hadlandsmyth et al., 2021, Bernardy et al., 2022, Lin et al., 2019).  However, gender differences that were previously noted in the VA in 2013 (Bernardy et al., 2013) still exist.  It appears that the efforts to improve prescribing practices have often overlooked the intersection between PTSD and gender, during a decade where the number of women veterans receiving care in the VA has almost doubled. 
Why is it Important to Examine Gender Differences in Prescribing to PTSD Patients?
Women, in general and those with PTSD, have higher rates of depressive and anxiety disorders compared to men (McLean et al., 2011; Walter et al., 2022). Additionally, PTSD symptom clusters such as re-experiencing and anxious arousal appear more prominently in women (Charak et al., 2014) and might contribute to increased prescribing of the guideline-discordant medications to address symptoms such as insomnia and anxiety. Research has also noted that women with PTSD have a changed sensitivity to GABA-A receptor active substances which suggests that medications such as sleeping pills would be less useful for women (Moller et al., 2016). Finally, a discussion of specific medications during pregnancy and lactation is an essential part of shared decision-making in women of reproductive age. Counseling, however, is not always offered when medications are prescribed (Schwarz et al., 2013). 
Do Gender Differences in Prescribing among Veterans with PTSD still Exist?
By specifically examining longitudinal prescribing practices for PTSD in the VA over the last 10 years (2010-2019), we found that women veterans were more likely to receive all psychotropic medications of interest across all classes relative to men. More importantly, the most substantial differences were observed for medications that are recommended against prescribing for PTSD by the VA/DoD clinical practice guideline. 
Guideline recommended antidepressants decreased modestly for both women and men over the past decade.  Women, however, were particularly more likely to receive antidepressants recommended against relative to men.  Like earlier work (Bernardy et al., 2013), women veterans were again more likely to receive benzodiazepine prescriptions, and this is not accounted for by other factors such as demographics and comorbidities.  Women were also more likely than men to receive anticonvulsant medications which are guideline discordant for PTSD, in the absence of a comorbid psychiatric disorder.  It may be the case that these prescribing patterns reflect symptom-driven prescribing in the absence of a formal diagnosis. We are left once again looking for potential hypotheses to explain these gender differences.  
Implications of this Work
The VA has made a great deal of progress in addressing medication safety among veterans with PTSD, but this research suggests that there is still future work to be done.  Our timeline ended in 2019 but new research suggests that women have disproportionately been impacted by stress during the pandemic (Lowe et al., 2021) and that there has been increased benzodiazepine prescriptions to women during this period of time (Milani et al., 2021). The VA now has an opportunity through its medication safety initiatives to better address the care of its growing number of women veterans through provider and patient education. These programs can also serve as a model for healthcare facilities outside the VA where increased benzodiazepine prescriptions to women have also been observed (Olfson et al., 2015). The growing concerns about benzodiazepine use calls for careful consideration when prescribing them to women, and should help create a change in prescriptive practices in and out of the VA.

Target Article 

Hadlandsmyth, K.,  Bernardy, N. C., &  Lund, B. C. (2022).  Gender differences in medication prescribing patterns for veterans with posttraumatic stress disorder: A 10-year follow-up study. Journal of Traumatic Stress,  00,  1– 12. https://doi.org/10.1002/jts.22861 

Discussion Questions

  • Why might women with PTSD receive more psychotropic medications than men?
  • Are there other comorbid disorders that might explain these prescribing differences?
  • How can community healthcare systems use information about VA safe prescribing initiatives to improve their practices?

About the Authors

Nancy C. Bernardy, PhD, is a clinical research psychologist, previously associated with the Executive Division of the National Center for PTSD in White River Junction, Vermont and the Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.  Her research has been supported by the Office of Rural Health of the Department of Veterans Affairs. Her research focuses on increasing evidence-based treatments for PTSD.
Katherine Hadlandsmyth, PhD is a clinical health psychologist at the Center for Access & Delivery Research and Evaluation at the Iowa City VA Health Care System, and with the Department of Anesthesia at the University of Iowa’s Carver College of Medicine. Her research interests include tailoring health interventions to women Veterans. 
Brian C. Lund, PharmD, MS is a pharmacist and epidemiologist and Core Investigator with the Veterans Rural Health Resource Center and the Center for Access & Delivery Research and Evaluation at the Iowa City VA Health Care System. His research focuses on pharmacoepidemiology and drug safety with an emphasis on mental health.

References Cited

Bernardy, N.C., Lund, B.C., Alexander, B., Jenkyn, A.B., Schnurr, P.P., & Friedman, M.J. (2013). Gender differences in prescribing among veterans diagnosed with posttraumatic stress disorder. Journal of General Internal Medicine, 28 Supplement 2, S542-548. https:doi.org/10/1007/s11606-012-2260-9.
Bernardy, N.C., Friedman, M., & Lund, B. (2022). Deimplementation of benzodiazepine prescribing in posttraumatic stress disorder in the Veterans Health Administration. Journal of Clinical Psychiatry, 83(3). https:doi.org/10.4088/JCCP.21m14128.
Charak, R., Armour, C., Elklit, A., Angmo, D., Elhai, J.D., & Koot, H.M. (2014). Factor structure of PTSD, and relation with gender in trauma survivors from India. European Journal of Psychotraumatology, 5, 25547. https://doi.org/10.3402/ejpt.v5.25547
Hadlandsmyth, K., Bernardy, N.C., & Lund, B. (2021). Central nervous system polytherapy among veterans with posttraumatic stress disorder: changes across a decade. General Hospital Psychiatry, 74, 46-50. https:doi.org/10.1016/j.genhospps7cu.2021.12.002.
Hawkins, E.J., Malte, C.A., Imel, Z.E., Saxon, A., & Kivlahan, D.R. (2012). Prevalence and trends of benzodiazepine use among Veterans Affairs patients with posttraumatic stress disorder, 2003-2010. Drug and Alcohol Dependence, 124(1), 154-161. https://doi.org/10.1016/j.drugalcdep.2012.01.003.
Lowe, S.R., Hennein, R., Feingold, J.H., Peccoralo, L.A., Ripp, J.A., Mazure, C.M., & Pietrzak, R.H. (2022). Are women less psychologically resilience than men? Background stressors underlying gender differences in reports of stress-related psychological sequelae. Journal of Clinical Psychiatry, 83(1). https:/doi.org/10.4088/JCP.21br14098.
Lin, L.A., Peltzman, T., McCarthy, J.F., Oliva, E.M., Trafton, J.A. & Bohnert, A.S. (2019). Changing trends in opioid overdose deaths and prescription opioid receipt among veterans. American Journal of Preventive Medicine. 57(1), 106-110. https://doi.org/10.1016/j.amepre.2019.01.016.
Lund, B.J., Bernardy, N.C., Alexander, B., & Friedman, M.J. (2012). Declining benzodiazepine use in veterans with posttraumatic stress disorder. Journal of Clinical Psychiatry, 73(3), 292-296. https:doi.org/10.4088/JCP.10m06775.
McLean, C.P., Asnaani, A., Litz, B.T., & Hofmann, S.G. (2011). Gender differences in anxiety disorders: prevalence, course of illness, comorbidity and burden of illness. Journal of Psychiatric Research, 45(8), 102701935. https://doi.org/10.1016/j.jpsychires.2011.03.006.
Milani, S.A, Raji, M.A., Chen, L., & Kuo, Y-F., (2021). Trends in the use of benzodiazepines, z-hypnotics, and serotonergic drugs among US women and men before and during the COVID-19 pandemic. JAMA Network Open, 4(10):e2131012, doi:10.1001.jamanetworkopen.2021.31012. 
Moller, A.T., Backstrom, T., Nyberg, S., Sondergaard, H.P., & Helstrom, L. (2016). Women with PTSD have a changed sensitivity to GABA-A receptor active substances. Psychopharmacology, 233(11), 2025-2033. https://doi.org.10.1007/s00213-014-3776-y.
Olfson, M., King, M., & Schoenbaum, M. (2015). Benzodiazepine use in the United States. JAMA psychiatry, 72(2), 136-142. https://doi?10.1001/jamapsychiatry.2014.1763.
Schwarz, E.B., Mattocks, K., Brandt, C., Borrero, S., Zephyrin, L.C., Bathulapalli, H., & Haskell, S. (2013). Counseling of female veterans about risks of medication-induced birth defects, Journal of General Internal Medicine. 28(2), 598-603. https://doi.org/10.1007/s11606-012-2240-0
The Management of Posttraumatic Stress Disorder Work Group. VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder (2017). Retrieved June 8 from https://www.healthquality.va.gov/guidelines/mh/ptsd/
Walter, K.H., Levine, J.A., Madra, N.J., Beltran, J.L., Glassman, L.H., & Thomsen, C.J. (2022). Gender differences in disorders cormorbid with posttraumatic stress disorder among US. Sailors and Marines. Journal of Traumatic Stress.  https://doi.org/10.1002/jts.22807.