People with anxiety or PTSD following a traumatic brain injury are more likely to be prescribed medication than attend psychotherapy

A team of researchers explored treatment patterns among people diagnosed with anxiety or PTSD following a traumatic brain injury. The findings, published in the Journal of Neuropsychiatry and Clinical Neurosciences, revealed that these individuals are more likely to be prescribed psychotropic medication than to receive psychotherapy — which may be a cause for concern.

A traumatic brain injury (TBI) is a sudden injury to the brain that results in neural damage. This brain damage can manifest in symptoms of mental health disorders like anxiety and depression. But such mental health issues frequently go unnoticed, despite their poor effect on TBI recovery.

Research into anxiety disorders and PTSD following a TBI has been particularly limited, and there are few evidence-based recommendations for treating these populations. Accordingly, Marks and her colleagues sought to investigate the treatment patterns of people diagnosed with either of these disorders following a TBI. Specifically, the study authors assessed the use of psychotropic medication and psychotherapy.

“Anxiety and PTSD following TBI are common sequelae that impede recovery, but evidence-based treatment guidelines are lacking. As a clinician, I am interested in identifying treatment gaps to enhance access to care,” said study author Madeline R. Marks, an assistant professor at the University of Maryland School of Medicine.

The researchers obtained deidentified insurance claims data from the OptumLabs Data Warehouse (OLDW). The data set included longitudinal health information pertaining to a diverse set of enrollees across the United States. For their study, the researchers focused on enrollees who were above 18 years old and had been diagnosed with a traumatic brain injury sometime between January 2009 and June 2012. The authors further restricted the sample to people who were enrolled with medical and pharmacy benefits for at least one year prior to the TBI and two years after — leaving a sample of 207,354 individuals.

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Within this sample, the researchers identified enrollees who had been diagnosed with an anxiety disorder (42,475) or PTSD (1,232). With the help of an expert panel, they then analyzed the data and identified receipt of psychotherapy, as well as any prescriptions for medications used to treat anxiety and PTSD.

In line with U.S. trends, use of medication was much more common than psychotherapy. For the group with an anxiety disorder diagnosis, 76.2% received pharmacological treatment at least once post-TBI, but only 19.1% received psychotherapy treatment at least once post-TBI. For the group with a PTSD diagnosis, 75.2% received pharmacological treatment post-TBI, while only 36% received psychotherapy following TBI.

Among both groups, antidepressants were the most commonly prescribed class of psychotropic drugs. Interestingly, the anxiety disorder group was more likely to be prescribed antidepressants (51%) than the PTSD group (39.3%), although the two groups exhibited similar rates of depression.

The next most commonly prescribed drug class for the anxiety group was intermediate-acting benzodiazepines (19.1%). The authors say this is cause for concern since these drugs are no longer viewed as first-line treatments for anxiety and are even strongly discouraged in patients post-TBI due to concerns over side effects and addictive properties.

Participants with PTSD consulted psychotherapy at twice the rate of those with an anxiety disorder. But this number was nonetheless low, with the PTSD group still being more likely to receive medication than psychotherapy. This is also of concern, the researchers say, since psychotherapy is regarded as a first-line treatment for both PTSD and anxiety disorders and one that does not carry the risk of unfavorable medication interactions.

“Treatment patterns for anxiety and PTSD that we observed post-TBI do not align well with current recommendations,” Marks told PsyPost. “For example, psychotherapy is considered first-line treatment for PTSD, yet our results suggested that among individuals with TBI, pharmacotherapy is more often utilized. Similarly, benzodiazepines were commonly prescribed to individuals diagnosed with anxiety post-TBI despite concerns about cognitive and motor side effects and addictive properties.”

The study authors say that certain characteristics might explain differences in treatment patterns between the two groups. Participants with anxiety disorders after TBI were more likely to be older and female, while those with PTSD after TBI were more likely to be younger and male. Those with PTSD post-TBI were also more likely to have a substance use disorder. “Thus, emerging from these data are questions about how certain characteristics relate to diagnosis and subsequent treatment decisions,” Marks and her colleagues write. “This question is prompted by the observation that receipt of medication differs by diagnosis, despite the significant overlap in indications.”

A limitation of the study was that the researchers did not exclude enrollees who had been diagnosed with an anxiety disorder or PTSD prior to TBI. It is therefore not possible to draw conclusions specific to new-onset anxiety and PTSD.

“In all research based on administrative claims data, there are limitations related to documentation of diagnoses, as well as whether or not the medications were taken as prescribed,” Marks said. “Future studies should examine treatment patterns based on race, gender, and age.”

“Results from our study raised the importance of access to mental health care and evidence-based treatments for anxiety and PTSD post-TBI,” she added. “Improving treatment can start by training our healthcare providers in trauma-informed care, which can help providers recognize and initiate conversations about mental health. Second, we should seek to build stronger referral networks between medical locations treating TBI patients and mental health practitioners.”

The study, “Treatment Patterns of Anxiety and Posttraumatic Stress Disorder Following Traumatic Brain Injury”, was authored by Madeline R. Marks, Moira C. Dux, Vani Rao, and Jennifer S. Albrecht.