Use of Prazosin for Pediatric PTSD-Associated Nightmares and Sleep Disturbances: A Retrospective Chart Review

Trauma Exposure in Migrant Children: Impact on Sleep and Acute Treatment Interventions

Trauma exposure significantly impacts sleep in children. Nightmares are common. Evidence-based therapies are superior to medications but may not always be available in acute settings. No FDA-approved medications exist for the treatment of trauma-related sleep disturbances in youth. The evidence-base for the use of medications is largely based on case reports, retrospective chart reviews, clinical opinion, and adult studies. This evidence is reviewed for a number of medications, including prazosin, trazodone, alpha-2 agonists, quetiapine, and others.

Afraid and Awake: The Interaction Between Trauma and Sleep in Children and Adolescents

Traumatic experiences and sleep disturbances are both common in children and adolescents. Because of the reciprocal relationship between sleep complaints and trauma, a mental health evaluation should include not only an assessment of posttraumatic stress disorder and other trauma symptoms but also a specific evaluation of sleep-related complaints. Similarly, if a history of both trauma and sleep complaints is identified, an effective trauma-informed intervention, whether psychological, psychopharmacologic, or a combination of the two, should directly address sleep issues.

Patient journey of civilian adults diagnosed with posttraumatic stress disorder-A chart review study

OBJECTIVE

To assess the journey of individuals from experiencing a traumatic event through onset of symptoms, diagnosis, and treatment of posttraumatic stress disorder (PTSD).

METHODS

Patient- and psychiatrist-level data was collected (02/2022-05/2022) from psychiatrists who treated ≥1 civilian adult diagnosed with PTSD. Eligible charts covered civilian adults diagnosed with PTSD (2016-2020), receiving ≥1 PTSD-related treatment (selective serotonin reuptake inhibitors [SSRIs], serotonin-norepinephrine reuptake inhibitors [SNRIs], atypical antipsychotics [AAs]), and having ≥1 medical visit in the last 12 months. Collected information included clinical and treatment characteristics surrounding the PTSD diagnosis.

RESULTS

A total of 273 psychiatrists contributed data on 687 patients with PTSD (average age 36.1; 60.4% female). On average, the traumatic event and symptom onset occurred 8.7 years and 6.5 years prior to PTSD diagnosis, respectively. In the 6 months before diagnosis, 88.9% of patients had received a PTSD-related treatment. At time of diagnosis, 87.8% of patients had intrusion symptoms and 78.9% had alterations in cognition/mood; 41.2% had depressive disorder and 38.7% had anxiety. Diagnosis prompted treatment changes for 79.3% of patients, receiving treatment within 1.9 months on average, often with a first-line SSRI as either monotherapy (52.8%) or combination (24.9%). At the end of the 24-month study period, 34.4% of patients achieved psychiatrist-recorded remission. A total of 23.0% of psychiatrists expressed dissatisfaction with approved PTSD treatments, with 88.3% at least somewhat likely to prescribe AAs despite lack of FDA approval.

CONCLUSION

PTSD presents heterogeneously, with an extensive journey from trauma to diagnosis with low remission rates and limited treatment options.

Improving adolescent sleep in long-term Juvenile correctional settings: case examples with clinical, research, and policy implications

Poor sleep during adolescence is a public health concern that may be especially important to address among youth in juvenile correctional facilities, who tend to experience greater mental health challenges, substance use disorders, and traumatic stress exposure. However, evidence for addressing sleep in correctional settings is limited. Using de-identified composite clinical cases, this paper describes challenges and opportunities for addressing sleep disorders (i.e. insomnia) and promoting sleep health (i.e. improving duration, regularity, and behaviors) among adolescents in long-term juvenile correctional facilities. These clinical cases highlight common presenting problems and underscore the need for integrated sleep and mental health interventions as well as adaptations to enhance feasibility and efficacy of behavioral sleep treatment and sleep health promotion in juvenile correctional contexts. We conclude by summarizing clinical, research, and policy implications for addressing adolescent sleep problems and promoting sleep health and well-being in these contexts.

Behavioral and pharmacological interventions for the prevention and treatment of psychiatric disorders with children exposed to maltreatment

There is a well-established relation between exposure to child maltreatment and the onset and course of multiple, comorbid psychiatric disorders. Given the heterogeneous clinical presentations at the time services are initiated, interventions for children exposed to maltreatment need to be highly effective to curtail the lifelong burden and public health costs attributable to psychiatric disorders. The current review describes the most effective, well-researched, and widely-used behavioral and pharmacological interventions for preventing and treating a range of psychiatric disorders common in children exposed to maltreatment. Detailed descriptions of each intervention, including their target population, indicated age range, hypothesized mechanisms of action, and effectiveness demonstrated through randomized controlled trials research, are presented. Current limitations of these interventions are noted to guide specific directions for future research aiming to optimize both treatment effectiveness and efficiency with children and families exposed to maltreatment. Strategic and programmatic future research can continue the substantial progress that has been made in the prevention and treatment of psychiatric disorders for children exposed to maltreatment.

Evaluation of low dose prazosin for PTSD-associated nightmares in children and adolescents

Introduction

Knowledge about fundamental sleep disorders and dysregulation that occurs in children with PTSD is limited. Prazosin is an alpha-1 receptor antagonist often used off label for the treatment of PTSD-associated nightmares in adults; however, evaluation of its use in pediatrics and adolescents is limited. The primary objective of this study was to assess the impact of prazosin on nightmares associated with PTSD in this population. Secondary objectives included assessing side effects, changes in blood pressure, and 30-day readmission rates.

Methods

This was a retrospective, single-center chart review of inpatients diagnosed with PTSD nightmares from January 1, 2017, to July 31, 2019. Patients 4 to 18 years old with a PTSD diagnosis, experiencing nightmares, and initiating any dose of prazosin were assessed to determine efficacy and tolerance.

Results

Forty-two patients were evaluated to determine symptom improvement after initiation of prazosin for PTSD nightmares in children and adolescents. Of the 42 patients, 24 (57.1%) reported improvement in nightmares (average dose 1.05 mg). For secondary results, 38 (90.5%) patients continued prazosin at discharge, and 2 (5%) were readmitted within 30 days for reasons other than PTSD-associated nightmares. Thirty-four (81%) reported having no adverse effects to prazosin. There was no significant difference in systolic (P = .1883) or diastolic (P = .2777) blood pressure preinitiation and postinitiation of prazosin.

Discussion

Despite the limitations of this retrospective study, the data suggests that prazosin may be associated with an improvement in nightmares in children and adolescents with PTSD. Adverse events were rarely reported, and there was no significant change in blood pressure with initiation of prazosin.

Afraid and Awake: The Interaction Between Trauma and Sleep in Children and Adolescents

Traumatic experiences and sleep disturbances are both common in children and adolescents. Because of the reciprocal relationship between sleep complaints and trauma, a mental health evaluation should include not only an assessment of posttraumatic stress disorder and other trauma symptoms but also a specific evaluation of sleep-related complaints. Similarly, if a history of both trauma and sleep complaints is identified, an effective trauma-informed intervention, whether psychological, psychopharmacologic, or a combination of the two, should directly address sleep issues.

Doxazosin for the treatment of nightmare disorder: A diary-based case study

The α₁-adrenergic antagonist prazosin has showed good effect against posttraumatic stress disorder–related nightmares in several randomized controlled trials. The α₁-adrenergic antagonist doxazosin, which has a longer half-live than prazosin, has received far less attention in the treatment of such nightmares. Here, we report a case of a patient suffering from severe nightmares following an erroneous medical administration of adrenaline (causing severe physiological hyper-activation) who was treated with doxazosin. Over a period of 280 days, the patient kept a nightmare diary and took 0, 4, or 8 mg doxazosin. The analyses showed that 8 mg doxazosin (55.2% nightmare-free nights) worked better (odds ratio = 28.2; 95% confidence interval = 3.7–213.9) compared to nights without doxazosin (4.3% nightmare-free nights). Except dizziness, which was not regarded as particularly bothersome by the patient, doxazosin was well tolerated. It is concluded that doxazosin may be indicated as a pharmacological treatment for patients suffering from posttraumatic stress disorder–related nightmares.

A mechanistic model for individualised treatment of anxiety disorders based on predictive neural biomarkers

Increased amygdala responsiveness is the hallmark of fear and a characteristic across patients with anxiety disorders. The amygdala is embedded in a complex regulatory circuit. Multiple different mechanisms may elevate amygdala responsiveness and lead to the occurrence of an anxiety disorder. While top-down control by the prefrontal cortex (PFC) downregulates amygdala responses, the locus coeruleus (LC) drives up amygdala activation via noradrenergic projections. This indicates that the same fearful phenotype may result from different neural mechanisms. We propose a mechanistic model that defines three different neural biomarkers causing amygdala hyper-responsiveness in patients with anxiety disorders: (a) inherent amygdala hypersensitivity, (b) low prefrontal control and (c) high LC drive. First-line treatment for anxiety disorders is exposure-based cognitive behavioural therapy, which strengthens PFC recruitment during emotion regulation and thus targets low-prefrontal control. A treatment response rate around 50% (Loerinc et al., 2015, Clinical Psychological Reviews, 42, 72-82) might indicate heterogeneity of underlying neurobiological mechanisms among patients, presumably leading to high variation in treatment benefit. Transforming insights from cognitive neuroscience into applicable clinical heuristics to categorise patients based on their underlying biomarker may support individualised treatment selection in psychiatry. We review literature on the three anxiety-related mechanisms and present a mechanistic model that may serve as a rational for pathology-based diagnostic and biomarker-guided treatment selection in psychiatry.

Children Exposed to Maltreatment: Assessment and the Role of Psychotropic Medication

Pediatricians regularly care for children who have experienced child maltreatment. Child maltreatment is a risk factor for a broad range of mental health problems. Issues specific to child maltreatment make addressing emotional and behavioral challenges among maltreated children difficult. This clinical report focuses on 2 key issues necessary for the care of maltreated children and adolescents in pediatric settings: trauma-informed assessments and the role of pharmacotherapy in maltreated children and adolescents. Specific to assessment, current or past involvement of the child in the child welfare system can hinder obtaining necessary information or access to appropriate treatments. Furthermore, trauma-informed assessments can help identify the need for specific interventions. Finally, it is important to take both child welfare system and trauma-informed assessment approaches into account when considering the use of psychotropic agents because there are critical diagnostic and systemic issues that affect the prescribing and discontinuing of psychiatric medications among children with a history of child maltreatment.

Use of Prazosin for Pediatric Post-Traumatic Stress Disorder With Nightmares and/or Sleep Disorder: Case Series of 18 Patients Prospectively Assessed

OBJECTIVES

Few studies have investigated pharmacologic treatment for pediatric post-traumatic stress disorder (PTSD). Prazosin, an alpha-1 adrenergic receptor antagonist, has been studied and demonstrated to be efficacious in an adult population for PTSD related sleep disturbances; however, in the pediatric population, data is limited to case reports and retrospective case series. This study prospectively assessed the safety and effects of Prazosin on PTSD symptoms in a pediatric sample.

METHODS

Since 2016, 18 patients with PSTD under the age of 15 admitted in a child and adolescent psychiatric unit were challenged with prazosin as part of a treatment protocol. PTSD symptoms and adverse effects were collected weekly and prospectively assessed each month with validated clinical scales. All data were retrospectively analyzed. This treatment protocol and the evaluation of clinical data were approved by our Ethical committee for research on preexisting data at the University Teaching Hospital of Rouen.

RESULTS

Among the 18 patients (10 girls and 8 boys), 13 (72%) had experienced sexual abuse and 5 (28%) family violence. After 1 month of treatment with a mean prazosin dose of 2.16 ( ± 0.6) mg/day, the CGI-S score significantly decreased from 5.3 ( ± 0.9) to 2.9 ( ± 0.7) (improvement of 43%). The mean total UCLA-PTSD-RI score significantly decreased 11.4 points ( ± 5.4) during the first week and 37.9 ( ± 16) during the first month, leading to an improvement of 20% and 67%, respectively. The improvement was significant irrespective of trauma exposure or sex. No adverse effects were reported except for one patient (hypotension).

CONCLUSION

Consistent with prior case reports and retrospective reviews, our retrospective analysis of data prospectively and systematically assessed among 18 patients suggests that prazosin is well-tolerated and associated with improvement in symptoms for pediatric PTSD.

Management of mental health conditions in refugee youth: An overview for the psychiatric-mental health nurse practitioner

TOPIC

In 2017, there were a total of 70 million forcibly displaced individuals or refugees, worldwide. Unfortunately, over 50% of refugees are under the age of 18 years. Refugee youth are at-risk for a variety of mental health conditions.

PURPOSE

The purpose of this report is to provide psychiatric-mental health nurse practitioners (PMHNPs) with an understanding of unique cultural implications in refugee youth, risk factors towards the development of psychiatric illness, and means to identify those at-risk for sequelae or those meeting diagnostic criteria. Also presented are foundational treatment and management implications to ensure the provision of culturally sensitive and efficacious care to this unique population.

SOURCES USED

Utilizing PubMed, CINAHL, and PsycINFO, a literature review was conducted to identify relevant publications pertaining to mental health issues in refugee youth spanning from 2013 to present. Reference lists of identified articles were also searched.

CONCLUSIONS

A variety of risk and protective factors are discussed, spanning from premigration, during flight, and postsettling periods. PMHNPs must be proficient in screening and diagnosis of mental health conditions in refugee youth and implementation of pharmacological and psychotherapeutic interventions. PMHNPs must also be well versed in community-based resources that can be utilized to promote optimal outcomes.

British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders: An update

This British Association for Psychopharmacology guideline replaces the original version published in 2010, and contains updated information and recommendations. A consensus meeting was held in London in October 2017 attended by recognised experts and advocates in the field. They were asked to provide a review of the literature and identification of the standard of evidence in their area, with an emphasis on meta-analyses, systematic reviews and randomised controlled trials where available, plus updates on current clinical practice. Each presentation was followed by discussion, aiming to reach consensus where the evidence and/or clinical experience was considered adequate, or otherwise to flag the area as a direction for future research. A draft of the proceedings was circulated to all speakers for comments, which were incorporated into the final statement.

Locus coeruleus toggles reciprocal prefrontal firing to reinstate fear

Fear relapse represents a significant problem for individuals suffering from stress- and trauma-related disorders such as posttraumatic stress disorder. Here, we show that locus coeruleus norepinephrine activation produces fear relapse in rats. In addition, locus coeruleus activation inverts neuronal firing properties of the prelimbic and infralimbic cortices to drive this fear relapse. Elevated noradrenergic tone and subsequent changes in prefrontal firing properties represent a therapeutic target for combating fear relapse.

The medial prefrontal cortex (mPFC) plays an essential role in regulating emotion, including inhibiting fear when danger has passed. The extinction of fear, however, is labile and a number of factors, including stress, cause extinguished fear to relapse. Here we show that fear relapse in rats limits single-unit activity among infralimbic (IL) neurons, which are critical for inhibiting fear responses, and facilitates activity in prelimbic (PL) neurons involved in fear expression. Pharmacogenetic activation of noradrenergic neurons in the locus coeruleus mimics this shift in reciprocal IL–PL spike firing, increases the expression of conditioned freezing behavior, and causes relapse of extinguished fear. Noradrenergic modulation of mPFC firing represents a mechanism for relapse and a potential target for therapeutic interventions to reduce pathological fear.

Management of Post-Traumatic Nightmares: a Review of Pharmacologic and Nonpharmacologic Treatments Since 2013

PURPOSE OF REVIEW

Post-traumatic nightmares (PTN) are a common and enduring problem for individuals with post-traumatic stress disorder (PTSD) and other clinical presentations. PTN cause significant distress, are associated with large costs, and are an independent risk factor for suicide. Pharmacological and non-pharmacological treatment options for PTN exist. A previous review in this journal demonstrated that Prazosin, an alpha blocker, was a preferred pharmacological treatment for PTN and imagery rescripting therapy (IRT) was a preferred non-pharmacological treatment. Since that time, new and important research findings create the need for an updated review.

RECENT FINDINGS

Based on the results of a recent study in the New England Journal of Medicine, Prazosin has been downgraded by both the American Academy of Sleep Medicine (AASM) and the Veterans Health Administration/Department of Defense (VA/DoD) for PTN. In Canada, Nabilone, a synthetic cannabinoid, appears to be promising. Few recent studies have been published on non-pharmacological interventions for PTN; however, recent data is available with regard to using IRT on an inpatient setting, with German combat veterans, and through the use of virtual technology. Recent evidence supports the use of exposure, relaxation, and rescripting therapy (ERRT) with children and individuals with comorbid bipolar disorder and PTN. Prazosin is no longer considered a first-line pharmacological intervention for PTN by AASM and VA/DoD. However, in the absence of a suitable alternative, it will likely remain the preferred option of prescribers. IRT and ERRT remain preferred non-pharmacological treatments of PTN. Combining cognitive behavior therapy for insomnia (CBT-I) with IRT or ERRT may lead to improved outcomes.

Persistent Stress-Induced Neuroplastic Changes in the Locus Coeruleus/Norepinephrine System

Neural plasticity plays a critical role in mediating short- and long-term brain responses to environmental stimuli. A major effector of plasticity throughout many regions of the brain is stress. Activation of the locus coeruleus (LC) is a critical step in mediating the neuroendocrine and behavioral limbs of the stress response. During stressor exposure, activation of the hypothalamic-pituitary-adrenal axis promotes release of corticotropin-releasing factor in LC, where its signaling promotes a number of physiological and cellular changes. While the acute effects of stress on LC physiology have been described, its long-term effects are less clear. This review will describe how stress changes LC neuronal physiology, function, and morphology from a genetic, cellular, and neuronal circuitry/transmission perspective. Specifically, we describe morphological changes of LC neurons in response to stressful stimuli and signal transduction pathways underlying them. Also, we will review changes in excitatory glutamatergic synaptic transmission in LC neurons and possible stress-induced modifications of AMPA receptors. This review will also address stress-related behavioral adaptations and specific noradrenergic receptors responsible for them. Finally, we summarize the results of several human studies which suggest a link between stress, altered LC function, and pathogenesis of posttraumatic stress disorder.

Noradrenergic Modulation of Fear Conditioning and Extinction

The locus coeruleus norepinephrine (LC-NE) system plays a broad role in learning and memory. Here we begin with an overview of the LC-NE system. We then consider how both direct and indirect manipulations of the LC-NE system affect cued and contextual aversive learning and memory. We propose that NE dynamically modulates Pavlovian conditioning and extinction, either promoting or impairing learning aversive processes under different levels of behavioral arousal. We suggest that under high levels of stress (e.g., during/soon after fear conditioning) the locus coeruleus (LC) promotes cued fear learning by enhancing amygdala function while simultaneously blunting prefrontal function. Under low levels of arousal, the LC promotes PFC function to promote downstream inhibition of the amygdala and foster the extinction of cued fear. Thus, LC-NE action on the medial prefrontal cortex (mPFC) might be described by an inverted-U function such that it can either enhance or hinder learning depending on arousal states. In addition, LC-NE seems to be particularly important for the acquisition, consolidation and extinction of contextual fear memories. This may be due to dense adrenoceptor expression in the hippocampus (HPC) which encodes contextual information, and the ability of NE to regulate long-term potentiation (LTP). Moreover, recent work reveals that the diversity of LC-NE functions in aversive learning and memory are mediated by functionally heterogeneous populations of LC neurons that are defined by their projection targets. Hence, LC-NE function in learning and memory is determined by projection-specific neuromodulation that accompanies various states of behavioral arousal.