Most Canadians will be exposed to at least one traumatic event in their lifetime. Nevertheless, as the lifetime prevalence of posttraumatic stress disorder (PTSD) is reported to be 9.2% in Canada, the majority of persons exposed to trauma do not develop PTSD but rather have a normal response to an abnormal situation.[1-3] Yet the significant impact of repetitive trauma exposure on Canada’s workforce clearly takes a toll. Rates of PTSD are greater in specific populations, such as first responders, than in the general population,[1] and compensable mental health injuries in BC are common. In 2019 and 2020, 641 and 555 injured workers, respectively, had claims accepted for PTSD by WorkSafeBC.

Implications for treating physicians

First-line treatment for PTSD is trauma-focused psychotherapy, which includes exposure-based and/or cognitive restructuring interventions such as prolonged exposure, cognitive processing therapy, eye movement desensitization and reprocessing, and trauma-focused cognitive-behavioral therapy (CBT).[3-6] Although these therapies differ in their methods and protocols, each uses a cognitive or behavioral technique to assist the affected individual in processing the index trauma and to mitigate its illness-inducing appraisal. These interventions are available through WorkSafeBC and are provided by contracted mental health care providers (psychologists, clinical counselors, and/or occupational therapists). These providers are located throughout the province to assist injured workers as close to their home community as possible. Services are currently provided in person or virtually, and online CBT educational programs are also available. Referrals can be made to comprehensive outpatient and residential interdisciplinary programs when indicated. Expedited referrals to specific WorkSafeBC-contracted psychiatrists are also available.

Pharmacotherapy can also be helpful, particularly in injured workers who do not wish to engage in psychotherapy, in those with more severe presentations, or to target specific symptoms. To date, selective serotonin reuptake inhibitors (fluoxetine, sertraline, and paroxetine have the strongest evidence) and venlafaxine are the recommended first-line interventions.[4,6] A host of other agents have been used as mono- or augmentation therapy when first-line pharmacotherapy is ineffective. The use of benzodiazepines merits particular comment. These are frequently prescribed for injured workers exposed to trauma, although most treatment guidelines either question their usefulness or recommend avoiding them altogether.[7] In addition to general concerns about dependency and adverse side effects, more specific concerns revolve around their potential role in reducing the efficacy of exposure interventions (although a 2017 review[7] has questioned the evidence for this finding) and increasing the severity of symptoms that can be present in patients with PTSD.[4,8] As long-term use raises increasing concerns of dependency and loss of efficacy, WorkSafeBC normally limits financial coverage of benzodiazepines to a maximum of 2 weeks postinjury.

Other selective comments regarding pharmacotherapy for PTSD are as follows:

Prazosin is frequently prescribed for PTSD-related nightmares with reported good effect, although one commonly used guideline suggests there is still insufficient evidence regarding its efficacy.[4]
Cannabis or cannabis derivatives are not currently recommended due to the lack of evidence-established efficacy as well as potential adverse effects.[4]

Treating physicians are encouraged to consult recent clinical practice guidelines[4-6] for further details and to follow the emerging literature related to cannabis and psychedelics for PTSD.[4,9,10] Ultimately, treatment decisions need to be made on a case-by-case basis.

Finally, treating physicians may also wish to discuss posttraumatic growth—positive personal growth and resiliency after exposure to adversity—to normalize the experience and prevent pathology.[11,12] This is not to minimize the significant impact of trauma exposure on workers who continue to provide invaluable service to our communities, particularly during recent global challenges.

For further assistance

Contact WorkSafeBC’s RACE line/app Monday to Friday 8 a.m. to 5 p.m., billable under accepted or pending claims (billing code 19930).
—Tanya Fairweather, MD, CCFP, FCFP
Medical Advisor II
—Harry Karlinsky, MD, MSc, FRCRP
Psychiatric Consultant, WorkSafeBC

This article is the opinion of WorkSafeBC and has not been peer reviewed by the BCMJ Editorial Board.

References

1. Carleton RN, Afifi TO, Turner S, et al. Exposures to potentially traumatic events among public safety personnel in Canada. Can J Behav Sci 2019;51:37-52.

2. Duckers M, Alisic E, Brewin C. A vulnerability paradox in the cross-national prevalence of post-traumatic stress disorder. Br J Psychiatry 2016;209:300-305.

3. Shalev A, Liberzon I, Marmar C. Post-traumatic stress disorder. N Engl J Med 2017;376:2459-2469.

4. Department of Veterans Affairs, Department of Defense. VA/DoD clinical practice guideline for the management of posttraumatic stress disorder and acute stress disorder. June 2017. Accessed 15 October 2021. www.healthquality.va.gov/guidelines/MH/ptsd/VADoDPTSDCPGFinal012418.pdf [11].

5. National Institute for Health and Care Excellence. Post-traumatic stress disorder. NICE Guideline. 5 December 2018. Accessed 15 October 2021. www.nice.org.uk/guidance/ng116 [12].

6. Phoenix Australia. Australian guidelines for the prevention and treatment of acute stress disorder, posttraumatic stress disorder and complex PTSD. Accessed 15 October 2021. www.phoenixaustralia.org/australian-guidelines-for-ptsd [13].

7. Starcevic V. No role for benzodiazepines in posttraumatic stress disorder? A surplus of certainty despite scarce evidence. Australas Psychiatry 2017;25:339-341.

8. Guina J, Rossetter SR, DeRhodes BJ, et al. Benzodiazepines for PTSD: A systematic review and meta-analysis. J Psychiatr Pract 2015;21:281-303.

9. Tupper, Wood E, Yensen R, Johnson MW. Psychedelic medicine: A re-emerging therapeutic paradigm. CMAJ 2015;187:1054-1059.

10. Krediet, Bostoen T, Breeksemaet J, et al. Reviewing the potential of psychedelics for the treatment of PTSD. Int J Neuropsychopharmacol 2020;23:385-400.

11. Brooks S, Amlôt R, Rubin GJ, Greenberget N. Psychological resilience and post-traumatic growth in disaster-exposed organisations: Overview of the literature. BMJ Mil Health 2020;166:52-56.

12. Finstad GL, Giorgi G, Lulli LG, et al. Resilience, coping strategies and posttraumatic growth in the workplace following COVID-19: A narrative review on the positive aspects of trauma. Int J Environ Res Public Health 2021;18:9453.