Changing prescribing practices?

Changing prescribing practices?

by Sareen -

As many of my colleagues have mentioned, I was surprised to read the article (Raskind et. al, 2018) and find that the results showed no benefit from prazosin vs placebo in helping with nightmares. From years of experience working at a VA, it was a given that prazosin helped with PTSD related nightmares. I felt surprisingly defensive at the results. I found myself questioning the results, rereading the article to look for how the study was not valid or generalizable. One notable point was that it was not representative of acute PTSD-- that the population was fairly stable. The authors noted that prescribers may have prescribed prazosin for their more acute patients and so the responders could be the more acute patients. And of course, the exclusion criteria really limits the generalizability of this study: no other comorbid psychiatric diagnoses, no SI/HI, no substance use. In addition, the group consisted of mostly men, and military related PTSD as a diagnosis. I really appreciated our journal club discussion, and how we went through the article to really address any potential biases, omissions, or other potential red flags. Coming out of the journal club, I was reflecting on whether this would alter my prescribing practice and change how prazosin may be a go to drug for PTSD related nightmares. At this point, without further studies, I don’t think it will. Most patients I will see will likely not fit this demographic, so this may not apply. Even among a Veteran population, most patients seeking MH care for nightmares may also not fit into this population. It will, however, add some hesitation and skepticism on my part, which I believe I will need to be cautious of when advocating and explaining this medication to a patient when offering them hope for relief. 

Something that I have been continue to think about, though, is my initial reaction to the results, and the skepticism I had. I thought about how for me personally, if I don’t agree with the results, I look harder to find ways that the study is invalid or not generalizable. If I do agree with the results, I may be less likely to comb through each part with a fine-tooth comb. All the more reason to get better practice at reading articles with a more critical eye all of the time, so that it becomes my baseline for how to read a research article. Thanks for a good discussion, all.

 

Raskind, M. A., Peskind, E. R., Chow, B., Harris, C., Davis-Karim, A., Homes, K. L., . . . Huang, G. D. (2018). Trial of prazosin for post-traumatic stress disorder in military veterans. The New England Journal of Medicine, 378(6): 507-517.

Re: Changing prescribing practices?

by Laura Compton -

Sareen,

I really appreciate you sharing your process of self-reflection - not only in regards to your clinical practice, but in your gut response to information that conflicted with your strongly-held belief. That kind of reflection and self-critique is key for being a strong provider (and modeling it helps the rest of us)! I'm fascinated by cognitive biases and how we meaningfully address them, especially when they impact patient outcomes. Confirmation bias may lead us to ignore or suppress evidence that conflicts with our belief and can lead us to be overconfident in our treatment plan, even when it may not be the best for our client (Croskerry, 2003).

As far as impact, I agree with you - I don't know that this study will have a significant impact on my clinical practice because prazosin still has the strongest evidence for treating PTSD-related nightmares, and it's a relatively low-risk medication that is generally well-tolerated, so it's worth trying most of the time. But the article has made me re-evaluate the strength of prazosin's evidence, and I will adjust my patient teaching to reflect more modest expectations of efficacy. Also, knowing that prazosin isn't effective for many clients with PTSD will inspire me to keep checking the literature for new treatment options! 


References

Croskerry, P. (2003). The importance of cognitive errors in diagnosis and strategies to minimize them. Academic Medicine, 78(8), 775-780. Retrieved from https://insights-ovid-com.ucsf.idm.oclc.org/pubmed?pmid=12915363

Re: Changing prescribing practices?

by Julia -

Sareen, 

Thank you for your post. I'm interested to hear your take on all of this given that you have much experience working at the VA. 

You do a good job of highlighting some of the flaws of this study, particularly the exclusion of acute cases or co-morbid conditions. I agree with you that these make the study results less generalizable. I also feel that while this study would not alter my approach regarding use of Prazosin, it may slightly change the way that I talk about Prazosin with clients when it comes to setting expectations. 

I also appreciate your honesty regarding your reaction to the results. I too find that when a study's results go against what I believe I try to find weaknesses or reasons to discredit it. Likewise, when an article supports my practices I am probably too quick to deem it valid. You do a thoughtful job of exploring this tendency and reminding us about the importance of reading all articles critically, regardless of our pre-existing biases. 

Re: Changing prescribing practices?

by Diane Kim -

Hi Sareen and Julia,

I appreciated reading both of your perspectives on the issue of subjectivity of the reader (and prescriber's) lens. It is important to honestly and openly acknowledge the fact that many of us have own biases around certain medications or treatment regimens, for so many reasons. Perhaps we have had personal experiences with medications (either positive or negative), that may impact the way in which we present a particular medication to a patient. Additionally, it is not uncommon for someone to have a pre-established narrative around something and to look for things (when reading an article, for example) that may further support that narrative. In this case, as Sareen mentioned, our own pre-set biases around a certain medication may affect how we use literature to support that bias (or not). I agree with Sareen that reading more and more articles and practicing how to appraise them critically will be crucial in cultivating our capacity to be objective readers.