Pharmacotherapy of post-traumatic stress disorder: a family practitioner’s guide to management of the disease (original) (raw)
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Prescribing Patterns for Patients With Posttraumatic Stress Disorder
Psychiatric Services, 2003
U nderstanding of the diagnosis and treatment of posttraumatic stress disorder (PTSD) has recently matured to the point that it has been possible to derive treatment guidelines from research evidence. Guidelines developed by the International Society for Traumatic Stress Studies (ISTSS) (1) and derived from surveys of expert clinicians and researchers (2) recommend medication and specific cognitive-behavioral therapies as first-line treatments. The recommendation that selective serotonin reuptake inhibitors (SSRIs) be used as first-line medication treatment is supported by large multicenter randomized controlled trials (3-6) that led to the approval of sertraline and paroxetine for PTSD by the U.S. Food and Drug Administration (FDA). Smaller randomized controlled trials had previously supported the efficacy of the traditional categories of antidepressant medications-tricyclics and monoamine oxidase inhibitors (MAOIs)-for the treatment of PTSD (7,8). These agents are not recommended as first-line options in PTSD guidelines (1,2), principally because of their side effect profiles and because of safety concerns. Rather, these and other medications are recommended as second-line strategies-treatments that can be substituted for or added to first-line interventions when the initial clinical response is inadequate or when tolerability is an issue. Second-line medication interventions for PTSD, apart from traditional antidepressants, include novel antidepressants other than the SSRIs-for example, nefazodone, bupropion, and mirtazepine-and mood stabilizers. Support for the use of these agents is not considered as compelling as that for the first-line agents, because evidence of efficacy typically falls short of the standard of randomized controlled trials (1). The one published randomized controlled trial of benzodiazepines for the treatment of PTSD did not support efficacy (9). Adverse consequences of benzodiazepine treatment among patients with PTSD have been reported (10), and their use for PTSD is not recommended by the ISTSS guidelines (1). The newer an
Drug and Alcohol Dependence, 2012
Background: Although the Veterans Affairs and Department of Defense (VA/DoD) clinical guidelines for management of posttraumatic stress disorder (PTSD) recommend against routine benzodiazepine use, little is known about the trends and clinical and prescription profiles of benzodiazepine use since these guidelines were released in 2004. Methods: This retrospective study included 64,872 patients with a PTSD diagnosis received from care at facilities in VA Northwest Veterans Integrated Service Network (VISN 20) during 2003-2010. Annual prevalence of any use was defined as any prescription for benzodiazepines, and long-term use was defined as >90 days' supply, in a year. Gender-specific logistic regressions were fit to estimate any and long-term benzodiazepine use, test for linear trends over 8-years and explore factors associated with trends. Results: The trend of age-adjusted benzodiazepine use over 8-years rose significantly from 25.0 to 26.8% among men and 31.2 to 38.8% among women. Long-term use in men and women increased from 15.4 to 16.4% and 18.0 to 22.7%, respectively. Comorbid psychiatric and alcohol use disorders (AUD) were associated with a greater increase in long-term use of benzodiazepines. In 2010, 61% of benzodiazepine users received >90 days' supply. Among those prescribed benzodiazepines long-term, 11% had AUD and 47% were also prescribed opioids long-term. Conclusion: Despite VA/DoD clinical guidelines recommending against routine use of benzodiazepines for PTSD, the adjusted prevalence of long-term use increased among men and women with PTSD in VISN 20. Widespread concomitant use of benzodiazepines and opioids suggests risk management systems and research on the efficacy and safety of these medications are needed.
Gender Differences in Prescribing Among Veterans Diagnosed with Posttraumatic Stress Disorder
Journal of General Internal Medicine, 2013
Objective: The Department of Veterans Affairs (VA) and Department of Defense (DoD) issued a revised posttraumatic stress disorder (PTSD) Clinical Practice Guideline (CPG) in 2010 with specific pharmacotherapy recommendations for evidence-based quality care. The authors examined prescribing frequencies over an 11 year period prior to the release of the new guideline to determine gender differences in pharmacotherapy treatment in veterans with PTSD.
Pharmacoepidemiology and Drug Safety, 2014
Purpose Second generation antipsychotics (SGAs) are widely used for post-traumatic stress disorder (PTSD), although without strong evidence base. With substantial numbers of veterans returning from Iraq/Afghanistan conflicts with PTSD, it is important to characterize the extent of SGA use and identify associated factors. Methods We determined time trends and patient characteristics associated with the use of SGAs in veterans with PTSD, without comorbid schizophrenia or bipolar disorders, using the Department of Veterans Affairs national administrative data 2003-2010. Results Among 732 085 veterans with PTSD, 27.6% received an intentional trial of an SGA in 2003-2010. The annual number treated with SGAs almost doubled (45 268 to 84 197, p < 0.001), while prescribing rates decreased (28.6% to 21.5%, p < 0.001). In multivariate analyses, African Americans (odds ratio (OR) = 1.07, 95%confidence interval (CI) = 1.06-1.09) and Hispanics (OR = 1.13, 95%CI = 1.10-1.17) were more likely to receive SGAs than Whites. Strongest clinical associations were with prior diagnosis of depression (OR = 1.96; 95%CI = 1.94-1.99), substance use disorders (OR = 1.86; 95%CI = 1.84-1.88), and other anxiety disorders (OR = 1.27; 95%CI = 1.26-1.29) (all p -< 0.0001) as well as cardiovascular risk factors. Veterans previously deployed to Iraq/Afghanistan had lower likelihood of SGA receipt. Substantial regional differences were demonstrated (South > Northeast; Midwest and West < Northeast; p < 0.0001); regional administrative units (veterans integrated service networks) contributed minimally to regional differences. Conclusions Post-traumatic stress disorder population growth is driving substantial increases in SGA use. Decreasing rates of the Department of Veterans Affairs prescribing may be due to integrated system-wide mechanisms (e.g., national practice guidelines), although regional variations remain prominent. These analyses provide foundational steps for identifying modifiable provider-level and organizationlevel determinants of SGA prescription in this growing population. Published 2013. This article is a U.S. Government work and is in the public domain in the USA. key words-antipsychotics; post-traumatic stress disorder; diffusion of innovations; pharmacoepidemiology
Psychiatric Annals, 2003
Since each us has previously published reviews of medication treat ment for adults and children with posttraumatic stress disorder (PTSD),[1-3 ] we approach the subject somewhat differently in this arti cle. We ask and answer 11 questions that we believe encompass major con cerns of prescribing psychiatrists about medication treatment for adults or children with PTSD. We hope that this presentation provides a syn thesis of research literature in a form that directly addresses common clinical decisions. When Do You Use Medication for PTSD? There is no simple rule that determines the choice of medication use in PTSD. Rather, medication should be considered an option among several potential therapeu tic interventions including cognitive behavioral thera py, psycho-education, supportive therapy, and family therapy. Decisions to use medications are appropriately tailored to individual patient needs and influenced by patient concerns and preferences.
Pharmacologic alternatives to antidepressants in posttraumatic stress disorder: A systematic review
Progress in Neuro-Psychopharmacology and Biological Psychiatry, 2009
The selective serotonin reuptake inhibitors (SSRIs) are considered the first-line pharmacological treatment for PTSD. However, even when treated with this class of drugs, response rates rarely exceed 60% and less than 20-30% of the patients achieve full remission. The aim of this study was to address this limitation by systematically reviewing the options left for the treatment of PTSD when patients do not respond satisfactorily to or tolerate SSRIs. A systematic review covering all original articles, letters and brief reports published in any language until October 2008 was conducted through searches in the ISI/Web of Science, PubMed and PILOTS databases. The search terms included the pharmacological class of each agent or its generic name plus "PTSD" or "stress disorder" in the title, in the abstract or as a keyword. Sixty-three articles were selected, covering the following categories: antipsychotics, anticonvulsants, adrenergic-inhibiting agents, opioid antagonists, benzodiazepines and other agents. None of the identified agents reached the level A of scientific evidence, 5 reached level B, 7 level C and 13 level D. The non-antidepressant agent with the strongest scientific evidence supporting its use in PTSD is risperidone, which can be envisaged as an effective add-on therapy when patients did not fully benefit from previous treatment with SSRIs. Prazosin, an adrenergic-inhibiting agent, is a promising alternative for cases of PTSD where nightmares and insomnia are prominent symptoms. So far, there is no consistent empirical support for using benzodiazepines in the prevention or in the treatment of PTSD, although these drugs could alleviate some associated non-specific symptoms, such as insomnia or anxiety. Further controlled clinical trials and meta-analysis are needed to guide clinicians in their search of effective pharmacological alternatives to antidepressants in PTSD.
Behavioral Sciences, 2014
Evidence-based psychotherapies (EBP) for Posttraumatic Stress Disorder are not utilized to their full extent within the Department of Veterans Affairs (VA). VA provides care to many persons with PTSD and has been in the forefront of clinical practice guidelines and EBP training and dissemination. Yet VA continues to find EBP implementation difficult. Veterans with PTSD often initially present to prescribing OPEN ACCESS Behav. Sci. 2014, 4 411 clinicians, who then help make care decisions. It is therefore critical that these clinicians correctly screen and triage appropriate mental health care. The purpose of this study was to assess VA prescribing clinicians' knowledge, perceptions, and referral behaviors related to EBPs for PTSD and to identify facilitators and barriers to implementing EBPs within VA. We conducted qualitative interviews with 26 VA prescribing clinicians. Limited access to EBPs was the most commonly noted barrier. The clinicians we interviewed also held specific beliefs and behaviors that may delay or deter EBPs. Strategies to improve utilization also emerged. Findings suggest the need for increased access to EBPs, training to optimize the role of prescribing clinicians in helping Veterans with PTSD make appropriate care decisions, and specific organizational changes to facilitate access and effective referral systems for EBPs.
Pharmacotherapy in post-traumatic stress disorder: evidence from randomized controlled trials
Current opinion in investigational drugs (London, England : 2000), 2009
This review discusses evidence-based pharmacotherapies for post-traumatic stress disorder (PTSD). The epidemiology of PTSD and its phenomenological characteristics are summarized. Focus is placed on the major classes of drugs for which at least a minimum of evidence-based outcome data are available from randomized controlled trials (RCTs). Drugs for the total symptom constellation of the disorder, specific PTSD symptoms, such as nightmares, and prevention of PTSD development post-trauma, are discussed. Where appropriate, RCT methodological problems that limit the conclusions drawn are discussed. In addition, recommendations for research to fill critical gaps in the knowledge of PTSD treatment are offered.
BJPsych open, 2016
The pharmacological treatment of post-traumatic stress disorder (PTSD) is extremely challenging, as no specific agent has been developed exclusively to treat this disorder. Thus, there are growing concerns among the public, providers and consumers associated with its use as the efficacy of some agents is still in question. We applied a dimensional and symptom cluster-based approach to better understand how the heterogeneous phenotypic presentation of PTSD may relate to the initiation of pharmacotherapy for PTSD initial episode. US veterans who served in the conflicts in Iraq and Afghanistan and received an initial PTSD diagnosis at the US Veterans Health Administration between 2008 and 2011 were included in this study. Veterans were followed for 365 days from initial PTSD diagnosis to identify initiation for antidepressants, anxiolytics/sedatives/hypnotics, antipsychotics and prazosin. Multivariable analyses were used to assess the relationship between the severity of unique PTSD sy...