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Schnurr PP, Hamblen JL, Wolf J, Coller R, Collie C, Fuller MA, Holtzheimer PE, Kelly U, Lang AJ, McGraw K, Morganstein JC, Norman SB, Papke K, Petrakis I, Riggs D, Sall JA, Shiner B, Wiechers I, Kelber MS. The Management of Posttraumatic Stress Disorder and Acute Stress Disorder: Synopsis of the 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline. Ann Intern Med 2024; 177:363-374. [PMID: 38408360 DOI: 10.7326/m23-2757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024] Open
Abstract
DESCRIPTION The U.S. Department of Veterans Affairs (VA) and Department of Defense (DoD) worked together to revise the 2017 VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder. This article summarizes the 2023 clinical practice guideline (CPG) and its development process, focusing on assessments and treatments for which evidence was sufficient to support a recommendation for or against. METHODS Subject experts from both departments developed 12 key questions and reviewed the published literature after a systematic search using the PICOTS (population, intervention, comparator, outcomes, timing of outcomes measurement, and setting) method. The evidence was then evaluated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method. Recommendations were made after consensus was reached; they were based on quality and strength of evidence and informed by other factors, including feasibility and patient perspectives. Once the draft was peer reviewed by an external group of experts and their inputs were incorporated, the final document was completed. RECOMMENDATIONS The revised CPG includes 34 recommendations in the following 5 topic areas: assessment and diagnosis, prevention, treatment, treatment of nightmares, and treatment of posttraumatic stress disorder (PTSD) with co-occurring conditions. Six recommendations on PTSD treatment were rated as strong. The CPG recommends use of specific manualized psychotherapies over pharmacotherapy; prolonged exposure, cognitive processing therapy, or eye movement desensitization and reprocessing psychotherapy; paroxetine, sertraline, or venlafaxine; and secure video teleconferencing to deliver recommended psychotherapy when that therapy has been validated for use with video teleconferencing or when other options are unavailable. The CPG also recommends against use of benzodiazepines, cannabis, or cannabis-derived products. Providers are encouraged to use this guideline to support evidence-based, patient-centered care and shared decision making to optimize individuals' health outcomes and quality of life.
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Affiliation(s)
- Paula P Schnurr
- National Center for PTSD, White River Junction, Vermont, and Geisel School of Medicine at Dartmouth, Hanover, New Hampshire (P.P.S., J.L.H., P.E.H.)
| | - Jessica L Hamblen
- National Center for PTSD, White River Junction, Vermont, and Geisel School of Medicine at Dartmouth, Hanover, New Hampshire (P.P.S., J.L.H., P.E.H.)
| | - Jonathan Wolf
- Defense Health Agency, Falls Church, Virginia (J.W.)
| | - Rachael Coller
- Naval Medical Center San Diego, San Diego, California (R.C.)
| | - Claire Collie
- Office of Mental Health and Suicide Prevention, Veterans Health Administration, Washington, DC (C.C.)
| | - Matthew A Fuller
- Veterans Health Administration Pharmacy Benefits Management Service and Case Western Reserve University School of Medicine, Cleveland, Ohio (M.A.F.)
| | - Paul E Holtzheimer
- National Center for PTSD, White River Junction, Vermont, and Geisel School of Medicine at Dartmouth, Hanover, New Hampshire (P.P.S., J.L.H., P.E.H.)
| | - Ursula Kelly
- Joseph Maxwell Cleland Atlanta VA Medical Center and Emory University Nell Hodgson Woodruff School of Nursing, Atlanta, Georgia (U.K.)
| | - Ariel J Lang
- Center of Excellence for Stress and Mental Health at VA San Diego Healthcare System and University of California, San Diego, San Diego, California (A.J.L.)
| | - Kate McGraw
- Psychological Health Center of Excellence, Defense Health Agency, Falls Church, Virginia (K.M., M.S.K.)
| | - Joshua C Morganstein
- Uniformed Services University of the Health Sciences, Center for the Study of Traumatic Stress, Bethesda, Maryland (J.C.M.)
| | - Sonya B Norman
- National Center for PTSD, White River Junction, Vermont, and University of California, San Diego, San Diego, California (S.B.N.)
| | - Katie Papke
- National Social Work Program Office, Veterans Health Administration, Washington, DC (K.P.)
| | - Ismene Petrakis
- National Center for PTSD, West Haven, and Yale University School of Medicine, New Haven, Connecticut (I.P.)
| | - David Riggs
- Uniformed Services University of the Health Sciences, Center for Deployment Psychology, Bethesda, Maryland (D.R.)
| | - James A Sall
- Evidence Based Practice, Quality and Patient Safety, Veterans Health Administration, Washington, DC (J.A.S.)
| | - Brian Shiner
- White River Junction VA Medical Center, White River Junction, Vermont, and Geisel School of Medicine at Dartmouth, Hanover, New Hampshire (B.S.)
| | - Ilse Wiechers
- Office of Mental Health and Suicide Prevention, Veterans Health Administration, Washington, DC; Yale University School of Medicine, New Haven, Connecticut; and University of California, San Francisco, School of Medicine, San Francisco, California (I.W.)
| | - Marija S Kelber
- Psychological Health Center of Excellence, Defense Health Agency, Falls Church, Virginia (K.M., M.S.K.)
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Norred MA, Zuschlag ZD, Hamner MB. A Neuroanatomic and Pathophysiologic Framework for Novel Pharmacological Approaches to the Treatment of Post-traumatic Stress Disorder. Drugs 2024; 84:149-164. [PMID: 38413493 DOI: 10.1007/s40265-023-01983-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2023] [Indexed: 02/29/2024]
Abstract
Post-traumatic stress disorder (PTSD) is a debilitating disorder inflicting high degrees of symptomatic and socioeconomic burdens. The development of PTSD results from a cascade of events with contributions from multiple processes and the underlying pathophysiology is complex, involving neurotransmitters, neurocircuitry, and neuroanatomical pathways. Presently, only two medications are US FDA-approved for the treatment of PTSD, both selective serotonin reuptake inhibitors (SSRIs). However, the complex underlying pathophysiology suggests a number of alternative pathways and mechanisms that may be targets for potential drug development. Indeed, investigations and drug development are proceeding in a number of these alternative, non-serotonergic pathways in an effort to improve the management of PTSD. In this manuscript, the authors introduce novel and emerging treatments for PTSD, including drugs in various stages of development and clinical testing (BI 1358894, BNC-210, PRAX-114, JZP-150, LU AG06466, NYV-783, PH-94B, SRX246, TNX-102), established agents and known compounds being investigated for their utility in PTSD (brexpiprazole, cannabidiol, doxasoin, ganaxolone, intranasal neuropeptide Y, intranasal oxytocin, tianeptine oxalate, verucerfont), and emerging psychedelic interventions (ketamine, MDMA-assisted psychotherapy, psilocybin-assisted psychotherapy), with an aim to examine and integrate these agents into the underlying pathophysiological frameworks of trauma-related disorders.
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Affiliation(s)
- Michael A Norred
- Mental Health and Behavioral Sciences Service, James A. Haley Veterans Hospital, Tampa, FL, USA
- Department of Psychiatry and Behavioral Neurosciences, University of South Florida, Tampa, FL, USA
| | - Zachary D Zuschlag
- Mental Health and Behavioral Sciences Service, James A. Haley Veterans Hospital, Tampa, FL, USA
- Department of Psychiatry and Behavioral Neurosciences, University of South Florida, Tampa, FL, USA
| | - Mark B Hamner
- Behavioral Health Service, Ralph H. Johnson VA Medical Center, 109 Bee Street, Charleston, SC, 29401, USA.
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA.
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Munayco Maldonado GM, Schwartz TL. Differentiating the third generation of antipsychotics: a focus on lumateperone's similarities and differences. Int Clin Psychopharmacol 2024; 39:4-16. [PMID: 37781859 DOI: 10.1097/yic.0000000000000510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
The development of atypical antipsychotics has evolved to include newer pharmacodynamic properties. Lumateperone, aripiprazole, brexpiprazole, and cariprazine are all dopamine-2 receptor partial agonists with varying receptor affinities. This review aims to compare the clinical and pharmacodynamic differences among these four atypical antipsychotics, all of which are unique when compared to first- and second-generation antipsychotics. For consideration is further delineating these agents as being third-generation antipsychotics. PubMed searches were conducted to compile preclinical and clinical studies derived from animal models and human subjects. Information gathered included pharmacological mechanisms, clinical efficacy, future-oriented clinical approaches, and adverse effects. Efficacy for the shared indications of these drugs seems comparable. Differences among these drugs lie more in their adverse effect profiles. For example, lumateperone was found to have the lowest rate of weight gain while brexpiprazole was found to have the highest rate of weight gain associated with increased appetite. Aripiprazole had the lowest rates of extrapyramidal symptoms not including akathisia while cariprazine had the highest. All four agents reviewed have a variety of receptor affinities, which likely generates a variety of different adverse effects. This suggests that in any given patient, clinicians may see differential clinical effects.
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Affiliation(s)
| | - Thomas L Schwartz
- SUNY Distinguished Teaching Professor and Chair of Psychiatry, Norton College of Medicine at SUNY Upstate Medical University
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Zhang ZX, Liu RB, Zhang J, Xian-Yu CY, Liu JL, Li XZ, Zhang YQ, Zhang C. Clinical outcomes of recommended active pharmacotherapy agents from NICE guideline for post-traumatic stress disorder: Network meta-analysis. Prog Neuropsychopharmacol Biol Psychiatry 2023; 125:110754. [PMID: 36934999 DOI: 10.1016/j.pnpbp.2023.110754] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 03/14/2023] [Accepted: 03/16/2023] [Indexed: 03/21/2023]
Abstract
BACKGROUND Post-traumatic stress disorder (PTSD) is a mental disorder that can emerge after an individual experiences a traumatic event such as physical abuse, sexual/relationship violence, combat exposure, witnessing death, or serious injury. This study aimed to identify the most suitable drugs for the management of PTSD based on a network meta-analysis (NMA). METHODS Six databases (Ovid Medline, EMBase, CENTRAL, PsycINFO, Ovid Health and Psychosocial Instruments, and Web of Science) were searched from inception to September 6, 2022. RESULTS Thirty articles with a total of 5170 participants were included. Compared with placebo, active drugs including olanzapine (SMD = -0.66, 95% CI: -1.19 to -0.13), risperidone (SMD = -0.23, 95% CI: -0.42 to -0.03), quetiapine (SMD = -0.49, 95% CI: -0.93 to -0.04), venlafaxine (SMD = -0.29, 95% CI: -0.42 to -0.16), sertraline (SMD = -0.23, 95% CI: -0.34 to -0.11), paroxetine (SMD = -0.48, 95% CI: -0.60 to -0.36) and fluoxetine (SMD = -0.27, 95% CI: -0.42 to -0.12), significantly reduced the total clinician-administered PTSD scale score. CONCLUSION The results of this study support the use of paroxetine, venlafaxine, and quetiapine as first-line treatment for PTSD. In addition, quetiapine is recommended for patients with PTSD affected by symptoms of hyperarousal and re-experience disorder. Clinicians should prescribe medications based on the severity of PTSD symptoms and other conditions to develop the best treatment strategy for this patient population.
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Affiliation(s)
- Zhi-Xin Zhang
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, Hubei, China
| | - Run-Ben Liu
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, Hubei, China
| | - Jin Zhang
- Department of Information Resources, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, Hubei, China
| | - Chen-Yang Xian-Yu
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, Hubei, China
| | - Jia-Ling Liu
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, Hubei, China
| | - Xiao-Zheng Li
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, Hubei, China
| | - Yu-Qiang Zhang
- Division of Medical Affairs, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, Hubei, China..
| | - Chao Zhang
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, Hubei, China.
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Bajor LA, Balsara C, Osser DN. An evidence-based approach to psychopharmacology for posttraumatic stress disorder (PTSD) - 2022 update. Psychiatry Res 2022; 317:114840. [PMID: 36162349 DOI: 10.1016/j.psychres.2022.114840] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 09/05/2022] [Accepted: 09/07/2022] [Indexed: 01/04/2023]
Abstract
Algorithms for posttraumatic stress disorder were published by this team in 1999 and 2011. Developments since then warrant revision. New studies and review articles from January 2011 to November 2021 were identified via PubMed and analyzed for evidence supporting changes. Following consideration of variations required by special patient populations, treatment of sleep impairments remains as the first recommended step. Nightmares and non-nightmare disturbed awakenings are best addressed with the anti-adrenergic agent prazosin, with doxazosin and clonidine as alternatives. First choices for difficulty initiating sleep include hydroxyzine and trazodone. If significant non-sleep PTSD symptoms remain, an SSRI should be tried, followed by a second SSRI or venlafaxine as a third step. Second generation antipsychotics can be considered, particularly for SSRI augmentation when PTSD-associated psychotic symptoms are present, with the caveat that positive evidence is limited and side effects are considerable. Anti-adrenergic agents can also be considered for general PTSD symptoms if not already tried, though evidence for daytime use lags that available for sleep. Regarding other pharmacological and procedural options, e.g., transcranial magnetic stimulation, cannabinoids, ketamine, psychedelics, and stellate ganglion block, evidence does not yet support firm inclusion in the algorithm. An interactive version of this work can be found at www.psychopharm.mobi.
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Affiliation(s)
- Laura A Bajor
- James A. Haley VA Hospital, Tampa, FL, United States; University of South Florida Morsani School of Medicine, Tampa, FL, United States; VA Boston Healthcare System and Harvard South Shore Psychiatry Residency Training Program, Brockton, MA, United States.
| | - Charmi Balsara
- HCA Healthcare East Florida Division GME/HCA FL Aventura Hospital, United States
| | - David N Osser
- VA Boston Healthcare System and Harvard South Shore Psychiatry Residency Training Program, Brockton, MA, United States
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Gasparyan A, Navarro D, Navarrete F, Manzanares J. Pharmacological strategies for post-traumatic stress disorder (PTSD): From animal to clinical studies. Neuropharmacology 2022; 218:109211. [PMID: 35973598 DOI: 10.1016/j.neuropharm.2022.109211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 07/26/2022] [Accepted: 08/03/2022] [Indexed: 01/27/2023]
Abstract
Post-traumatic stress disorder (PTSD) is a disabling psychiatric condition with a critical familiar, personal, and social impact. Patients diagnosed with PTSD show various symptoms, including anxiety, depression, psychotic episodes, and sleep disturbances, complicating their therapeutic management. Only sertraline and paroxetine, two selective serotonin reuptake inhibitors, are approved by different international agencies to treat PTSD. In addition, these drugs are generally combined with psychotherapy to achieve positive results. However, these pharmacological strategies present limited efficacy. Nearly half of the PTSD patients do not experience remission of symptoms, possibly due to the high prevalence of psychiatric comorbidities. Therefore, in clinical practice, other off-label medications are common, even though the effectiveness of these drugs needs to be further investigated. In this line, antipsychotics, antiepileptics, adrenergic blockers, benzodiazepines, and other emerging pharmacological agents have aroused interest as potential therapeutic tools to improve some specific symptoms of PTSD. Thus, this review is focused on the most widely used drugs for the pharmacological treatment of PTSD with a translational approach, including clinical and preclinical studies, to emphasize the need to develop safer and more effective medications.
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Affiliation(s)
- Ani Gasparyan
- Instituto de Neurociencias, Universidad Miguel Hernández-CSIC, Avda. de Ramón y Cajal s/n, San Juan de Alicante, 03550, Alicante, Spain; Redes de Investigación Cooperativa Orientada a Resultados en Salud (RICORS), Red de Investigación en Atención Primaria de Adicciones (RIAPAd), Instituto de Salud Carlos III, MICINN and FEDER, Madrid, Spain; Departamento de Medicina Clínica, Universidad Miguel Hernández, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
| | - Daniela Navarro
- Instituto de Neurociencias, Universidad Miguel Hernández-CSIC, Avda. de Ramón y Cajal s/n, San Juan de Alicante, 03550, Alicante, Spain; Redes de Investigación Cooperativa Orientada a Resultados en Salud (RICORS), Red de Investigación en Atención Primaria de Adicciones (RIAPAd), Instituto de Salud Carlos III, MICINN and FEDER, Madrid, Spain; Departamento de Medicina Clínica, Universidad Miguel Hernández, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
| | - Francisco Navarrete
- Instituto de Neurociencias, Universidad Miguel Hernández-CSIC, Avda. de Ramón y Cajal s/n, San Juan de Alicante, 03550, Alicante, Spain; Redes de Investigación Cooperativa Orientada a Resultados en Salud (RICORS), Red de Investigación en Atención Primaria de Adicciones (RIAPAd), Instituto de Salud Carlos III, MICINN and FEDER, Madrid, Spain; Departamento de Medicina Clínica, Universidad Miguel Hernández, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
| | - Jorge Manzanares
- Instituto de Neurociencias, Universidad Miguel Hernández-CSIC, Avda. de Ramón y Cajal s/n, San Juan de Alicante, 03550, Alicante, Spain; Redes de Investigación Cooperativa Orientada a Resultados en Salud (RICORS), Red de Investigación en Atención Primaria de Adicciones (RIAPAd), Instituto de Salud Carlos III, MICINN and FEDER, Madrid, Spain; Departamento de Medicina Clínica, Universidad Miguel Hernández, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain.
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Yan JZ, Liu JL, Li XZ, Zhang ZX, Liu RB, Zhang C, Gong QQ. Effectiveness, Acceptability and Safety of Pharmaceutical Management for Combat-Related PTSD in Adults Based on Systematic Review of Twenty-Two Randomized Controlled Trials. Front Pharmacol 2022; 12:805354. [PMID: 35115944 PMCID: PMC8804358 DOI: 10.3389/fphar.2021.805354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 12/20/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: This study assessed the efficacy, acceptability, and safety of pharmaceutical management for combat-related post-traumatic stress disorder (PTSD) to provide a clinical decision-making basis for clinicians.Method: A comprehensive search was conducted using Ovid MEDLINE, Ovid EMBASE, Cochrane Library, Scopus, ScienceDirect, and Web of Science for randomized controlled trails (RCTs), which reported pharmaceutical management and placobo for adults with combat-related PTSD, that were published until April 21, 2021. The effectiveness, acceptability, and adverse events (AEs), were designed as interested outcomes. The change in total symptoms of combat-related PTSD according to the clinician rating scale was defined as primary outcome, and the others were defined as secondary outcomes.Results: Twenty-two RCTs with 1,221 patients were involved. Compared with placebo, overall active comparators had statistical differences for all outcomes, including the change in total symptoms of combat-related PTSD [SMD = −0.36, 95%CI (−0.62,−0.09)], depression [SMD = −0.28, 95%CI (−0.45,−0.10)], anxiety [SMD = −0.44, 95%CI (−0.64,−0.23)], re-experience [SMD = −0.33, 95%CI (−0.52,−0.13)], avoidance [SMD = −0.24, 95%CI (−0.43,−0.05)], and hyper-arousal [SMD = −0.26, 95%CI (−0.48,−0.03)]. Compared with the placebo, in terms of acceptability, overall active comparators did not significantly decrease all-cause discontinuance rates [RR = 0.97, 95%CI (0.78,1.20)], and the significance decreased due to AEs [RR = 2.42, 95%CI (1.41,4.13)]. Nevertheless, overall there was no statistically significant difference for overall AEs, including somnolence, sedation, dizziness, paresthesia, anxiety, blurred vision, generalized anxiety disorder, and sleep disturbance. All funnel plots were symmetrical and no publication bias was found.Conclusion: Active drugs, especially amitriptyline, imipramine, and quetiapine, had a positive effect on the improvement of combat-related PTSD symptoms. Despite there being no significant increase in the AEs of the active drugs, the fact that the discontinuation rates of these drugs, including risperidone, imipramine, and topiramate, were increased deserves attention. Furthermore, as active drugs were effective across ethnic groups and battlefields, active drug regimens were revealed to be more appropriate for treating people with symptoms of extreme severe PTSD (≥80) or PTSD that is at least 8 weeks old. In addition, current evidence was from adults under 60 years of age and male combat-related PTSD. Whether this evidence can be extended to other populations of combat-related PTSD needs to be confirmed by subsequent high-quality, large-sample studies.
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Affiliation(s)
- Jin-Zhu Yan
- Department of Obstetrics, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Jia-Ling Liu
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Xiao-Zheng Li
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Zhi-Xin Zhang
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Run-Ben Liu
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Chao Zhang
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
- *Correspondence: Chao Zhang, ; Qin-Qin Gong,
| | - Qin-Qin Gong
- Department of Obstetrics, Taihe Hospital, Hubei University of Medicine, Shiyan, China
- Center of Women’s Health Sciences, Taihe Hospital, Hubei University of Medicine, Shiyan, China
- *Correspondence: Chao Zhang, ; Qin-Qin Gong,
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Hoskins MD, Bridges J, Sinnerton R, Nakamura A, Underwood JFG, Slater A, Lee MRD, Clarke L, Lewis C, Roberts NP, Bisson JI. Pharmacological therapy for post-traumatic stress disorder: a systematic review and meta-analysis of monotherapy, augmentation and head-to-head approaches. Eur J Psychotraumatol 2021; 12:1802920. [PMID: 34992738 PMCID: PMC8725683 DOI: 10.1080/20008198.2020.1802920] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 07/16/2020] [Indexed: 12/13/2022] Open
Abstract
Background: Pharmacological approaches are widely used for post-traumatic stress disorder (PTSD) despite uncertainty over efficacy. Objectives: To determine the efficacy of all pharmacological approaches, including monotherapy, augmentation and head-to-head approaches (drug versus drug, drug versus psychotherapy), in reducing PTSD symptom severity. Method: A systematic review and meta-analysis of randomised controlled trials were undertaken; 115 studies were included. Results: Selective serotonin reuptake inhibitors (SSRIs) were found to be statistically superior to placebo in reduction of PTSD symptoms but the effect size was small (standardised mean difference -0.28, 95% CI -0.39 to -0.17). For individual monotherapy agents compared to placebo in two or more studies, we found small statistically significant evidence for the antidepressants fluoxetine, paroxetine, sertraline, venlafaxine and the antipsychotic quetiapine. For pharmacological augmentation, we found small statistically significant evidence for prazosin and risperidone. Conclusions: Some medications have a small positive effect on reducing PTSD symptom severity and can be considered as potential monotherapy treatments; these include fluoxetine, paroxetine, sertraline, venlafaxine and quetiapine. Two medications, prazosin and risperidone, also have a small positive effect when used to augment pharmacological monotherapy. There was no evidence of superiority for one intervention over another in the small number of head-to-head comparison studies.
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Affiliation(s)
- Mathew D. Hoskins
- Division of Psychological Medicine and Clinical Neuroscience, Cardiff University, Cardiff, UK
| | - Jack Bridges
- Division of Psychological Medicine and Clinical Neuroscience, Cardiff University, Cardiff, UK
| | - Robert Sinnerton
- Division of Psychological Medicine and Clinical Neuroscience, Cardiff University, Cardiff, UK
| | - Anna Nakamura
- Division of Psychological Medicine and Clinical Neuroscience, Cardiff University, Cardiff, UK
| | - Jack F. G. Underwood
- Division of Psychological Medicine and Clinical Neuroscience, Cardiff University, Cardiff, UK
| | - Alan Slater
- Division of Psychological Medicine and Clinical Neuroscience, Cardiff University, Cardiff, UK
| | - Matthew R. D. Lee
- Division of Psychological Medicine and Clinical Neuroscience, Cardiff University, Cardiff, UK
| | - Liam Clarke
- Division of Psychological Medicine and Clinical Neuroscience, Cardiff University, Cardiff, UK
| | - Catrin Lewis
- Division of Psychological Medicine and Clinical Neuroscience, Cardiff University, Cardiff, UK
| | - Neil P. Roberts
- Division of Psychological Medicine and Clinical Neuroscience, Cardiff University, Cardiff, UK
| | - Jonathan I. Bisson
- Division of Psychological Medicine and Clinical Neuroscience, Cardiff University, Cardiff, UK
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Zhao YF, Huang ZD, Gu HY, Guo GL, Yuan RX, Zhang C. Key Clinical Interest Outcomes of Pharmaceutical Administration for Veterans With Post-Traumatic Stress Disorder Based on Pooled Evidences of 36 Randomised Controlled Trials With 2,331 Adults. Front Pharmacol 2021; 11:602447. [PMID: 33390990 PMCID: PMC7773915 DOI: 10.3389/fphar.2020.602447] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 11/26/2020] [Indexed: 02/01/2023] Open
Abstract
Background: The effects of drug treatment on veterans, who have a high risk of post-traumatic stress disorder (PTSD), are not clear, and the guidelines are different from the recommendations of the recent meta-analysis. Our goal was to find the efficacy and frequencies of complications of drugs that can treat PTSD in veterans. Method: We searched Ovid MEDLINE, Ovid Embase, The Cochrane Library and Web of Science until January 1, 2020. The outcomes were designed as the change of PTSD total scale, subsymptom score, response rate, frequencies of complications outcomes, and acceptability. Results: We included a total of 36 randomised controlled trials with a total of 2,331 adults. In terms of overall effect, drug treatment is more effective than placebo in change in total PTSD symptoms scale (SMD = -0.24, 95% CI [-0.42, -0.06]) and response (RR = 1.66, 95% CI [1.01, 2.72]). However, in terms of frequencies of complications, drugs generally had a higher withdrawal rate (RR = 1.02, 95% CI [0.86, 1.20]) and a higher frequencies of complications (RR = 1.72, 95% CI [1.20, 2.47]) than placebo. Risperidone showed a good curative effect in change in total PTSD symptoms scale (SMD = -0.22, 95% CI [-0.43, 0.00]) and acceptability (RR = 1.31, 95% CI [0.82, 2.59]). The drugs acting on 5-HT receptors, our results showed that symptoms of hyper-arousal (SMD = -0.54, 95% CI [-0.86, -0.21]), symptoms of re-experiencing (SMD = -0.62, 95% CI [-0.86, -0.39]) and symptoms of avoidance (SMD = -0.53, 95% CI [- 0.77,-0.3]), The drugs acting on dopamine receptors, our results showed that symptoms of re-experiencing (SMD = -0.35, 95% CI [-0.55, -0.16]) and the drugs acting on α2 receptor has a significant effect on reducing total PTSD symptoms scale (SMD = -0.34, 95% CI [-0.62, -0.06]). Conclusion: Drug therapy can effectively treat PTSD, but its frequencies of complications should be considered. Different from the guidelines for adult PTSD, this study supports atypical antipsychotics, selective serotonin reuptake inhibitors and receptors that act on 5-HT and dopamine for the treatment of PTSD in veterans. Based on evidence among these drugs, the risperidone is the most effective for veterans, otherwise, sertraline is used as an alternative.
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Affiliation(s)
- Yi-Fan Zhao
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | | | - Hui-Yun Gu
- Department of Spine and Orthopedic Oncology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Guang-Ling Guo
- Center of Women's Health Sciences, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Rui-Xia Yuan
- Clinical Big Data Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Chao Zhang
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
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10
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Huang ZD, Zhao YF, Li S, Gu HY, Lin LL, Yang ZY, Niu YM, Zhang C, Luo J. Comparative Efficacy and Acceptability of Pharmaceutical Management for Adults With Post-Traumatic Stress Disorder: A Systematic Review and Meta-Analysis. Front Pharmacol 2020; 11:559. [PMID: 32457605 PMCID: PMC7225303 DOI: 10.3389/fphar.2020.00559] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 04/14/2020] [Indexed: 12/29/2022] Open
Abstract
The current clinical guidelines on post-traumatic stress disorder (PTSD) recommend selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) of drugs. However, there is uncertainty about the efficacy of other drugs and selecting which treatments work best for which patients. This meta-analysis evaluated efficacy and acceptability of pharmaceutical management for adults with PTSD. Randomized-controlled trials, which reported active comparators and placebo-controlled trials of pharmaceutical management for adults with PTSD, from the Ovid Medline, EMBase, CENTRAL, PsycINFO, Ovid Health and Psychosocial Instruments, and ISIWeb of Science, were searched until June 21, 2019. In terms of efficacy, all active drugs demonstrated superior effect than placebo (SMD = -0.33; 95% CI, -0.43 to -0.23). The medications were superior to placebo in reducing the symptom of re-experiencing, avoidance, hyperarousal, depression, and anxiety. For acceptability, medicine interventions for PTSD showed no increase in all-cause discontinuation compared with placebo. Nevertheless, in terms of safety, medicine interventions indicated a higher risk of adverse effect compared with placebo (RR = 1.47, 95% CI: 1.24 to 1.75). Compared with placebo, the SSRIs and atypical antipsychotics drugs had significant efficacy whether in patients with severe or extremely severe PTSD status. However, only atypical antipsychotics (SMD = -0.29, 95% CI: -0.48 to -0.10) showed superior efficacy than placebo in veterans. Medication management could be effective in intervention of PTSD, which demonstrated a sufficient improvement in the core symptoms. This meta-analysis supports the status of SSRIs and SNRIs as recommended pharmacotherapy. However, patients with different clinical characteristics of PTSD should consider individualized drug management.
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Affiliation(s)
| | | | | | | | | | | | - Yu-Ming Niu
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Chao Zhang
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Jie Luo
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
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11
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Goldberg JF. Personalized Pharmacotherapy for Bipolar Disorder: How to Tailor Findings From Randomized Trials to Individual Patient-Level Outcomes. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2019; 17:206-217. [PMID: 32047366 PMCID: PMC6999206 DOI: 10.1176/appi.focus.20190005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The quest for "personalized medicine" in psychiatry has focused mainly on pursuing potential biomarkers such as pharmacogenetic predictors of drug response. However, the collective randomized trial database across phases of bipolar disorder allows one to identify clinical characteristics that inform the likelihood of desired treatment outcomes. In turn, those characteristics, termed moderators and mediators of drug response, enable those who administer treatment to construct clinical profiles that can help them tailor pharmacotherapies to the features of a given patient rather than simply to an overall diagnosis. Bipolar disorder typically involves more heterogeneous than uniform clinical presentations, partly because of its highly prevalent psychiatric and medical comorbid conditions. Further clinical diversity arises from characteristics such as bipolar I versus II disorder subtype, rapid cycling, mixed versus pure affective episodes, psychosis, anxiety, chronicity, cognitive dysfunction, and suicidality, among other distinguishing features. By coupling such profiles with an awareness of the psychotropic breadth of spectrum held by particular medications, clinicians can devise strategic combination therapy regimens, capitalizing on synergies and using drugs that exert multiple relevant effects, addressing comorbid conditions, incorporating medications that could offset adverse effects of other agents, and avoiding or deprescribing medication options that lack known evidence to target symptoms within the clinical profile of a given patient.
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Affiliation(s)
- Joseph F Goldberg
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York City
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12
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Naß J, Efferth T. Pharmacogenetics and Pharmacotherapy of Military Personnel Suffering from Post-traumatic Stress Disorder. Curr Neuropharmacol 2018; 15:831-860. [PMID: 27834145 PMCID: PMC5652029 DOI: 10.2174/1570159x15666161111113514] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 09/23/2016] [Accepted: 11/08/2016] [Indexed: 12/26/2022] Open
Abstract
Background: Posttraumatic stress disorder (PTSD) is a severe problem among soldiers with combating experience difficult to treat. The pathogenesis is still not fully understood at the psychological level. Therefore, genetic research became a focus of interest. The identification of single nucleotide polymorphisms (SNPs) may help to predict, which persons are at high risk to develop PTSD as a starting point to develop novel targeted drugs for treatment. Methods: We conducted a systematic review on SNPs in genes related to PTSD pathology and development of targeted pharmacological treatment options based on PubMed database searches. We focused on clinical trials with military personnel. Results: SNPs in 22 human genes have been linked to PTSD. These genes encode proteins acting as neurotransmitters and receptors, downstream signal transducers and metabolizing enzymes. Pharmacological inhibitors may serve as drug candidates for PTSD treatment, e.g. β2 adrenoreceptor antagonists, dopamine antagonists, partial dopamine D2 receptor agonists, dopamine β hydroxylase inhibitors, fatty acid amid hydrolase antagonists, glucocorticoid receptor agonists, tropomyosin receptor kinase B agonists, selective serotonin reuptake inhibitors, catechol-O-methyltransferase inhibitors, gamma-amino butyric acid receptor agonists, glutamate receptor inhibitors, monoaminoxidase B inhibitors, N-methyl-d-aspartate receptor antagonists. Conclusion: The combination of genetic and pharmacological research may lead to novel target-based drug developments with improved specificity and efficacy to treat PTSD. Specific SNPs may be identified as reliable biomarkers to assess individual disease risk. Focusing on soldiers suffering from PTSD will not only help to improve treatment options for this specific group, but for all PTSD patients and the general population.
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Affiliation(s)
- Janine Naß
- Department of Pharmaceutical Biology, Institute of Pharmacy and Biochemistry, Johannes Gutenberg University, Staudinger Weg 5, 55128 Mainz. Germany
| | - Thomas Efferth
- Department of Pharmaceutical Biology, Institute of Pharmacy and Biochemistry, Johannes Gutenberg University, Staudinger Weg 5, 55128 Mainz. Germany
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13
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Varma A, Moore MB, Miller CWT, Himelhoch S. Topiramate as Monotherapy or Adjunctive Treatment for Posttraumatic Stress Disorder: A Meta-Analysis. J Trauma Stress 2018; 31:125-133. [PMID: 29388709 DOI: 10.1002/jts.22251] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Revised: 06/27/2017] [Accepted: 08/10/2017] [Indexed: 11/10/2022]
Abstract
Posttraumatic stress disorder (PTSD) is a chronic and debilitating condition for which clinicians sometimes turn to anticonvulsants as a treatment for symptoms. This study was a systematic review and meta-analysis of randomized controlled trials (RCT) that have assessed the efficacy of topiramate as monotherapy or adjunctive therapy, compared to placebo, for the treatment of PTSD in adults. Prescribers may be reluctant to turn to topiramate, given the commonly reported side effects of impaired cognition, sedation, fatigue, and headache. We searched PubMed, PsycInfo, and Cochrane Central databases for relevant trials. Five studies were identified as RCTs and thus met inclusion criteria; one additional nonpublished study was identified via phone contact with its authors. Of these six studies, one was excluded from the statistical meta-analysis due to its high dropout rate (16 of 40 participants). One of these studies was excluded from a stratified analysis of symptom types because this subscale data were unavailable. For overall symptomatology, topiramate showed a medium, but not significant effect, standardized mean difference (SMD) = 0.55, p = .082. Topiramate showed a small and significant reduction of hyperarousal symptoms, SMD = 0.35, 95% CI [0.029, 0.689], p = .033. Topiramate did not significantly reduce reexperiencing symptoms, SMD = 0.29, 95% CI [-0.019, 0.597], p = .067, or avoidance symptoms, SMD = 0.20, 95% CI [-0.105, 0.509], p = .198. Results did not differ significantly between veteran and nonveteran subjects, or between topiramate as monotherapy and adjunctive therapy. Further studies on topiramate will clarify its role in PTSD treatment.
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Affiliation(s)
- Archana Varma
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Michael B Moore
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Christopher W T Miller
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Seth Himelhoch
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland, USA
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14
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Luan S, Wan H, Zhang L, Zhao H. Efficacy, acceptability, and safety of adjunctive aripiprazole in treatment-resistant depression: a meta-analysis of randomized controlled trials. Neuropsychiatr Dis Treat 2018; 14:467-477. [PMID: 29445284 PMCID: PMC5810518 DOI: 10.2147/ndt.s156619] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Treatment-resistant depression (TRD) is common and potentially life-threatening in adults, and the benefits and risks of adjunctive aripiprazole in these patients remain controversial. Therefore, we conducted a meta-analysis of randomized controlled trials (RCTs) to assess the efficacy, acceptability, safety, and quality of life of adjunctive aripiprazole in patients with TRD. METHODS RCTs published in PubMed, Web of Science, and Embase were systematically reviewed to evaluate the efficacy and safety profiles of TRD patients who were treated with adjunctive aripiprazole. The main outcome measures included response rate, remission rate, changes from baseline in Montgomery-Asberg Depression Rating Scale (MADRS), Clinical Global Impression-severity (CGI-S), Clinical Global Impression-improvement (CGI-I), 17-Item Hamilton Rating Scale for Depression (HAM-D17), Sheehan Disability scale (SDS), and Inventory of Depressive Symptomatology Self-Report Scale (IDS-SR), discontinuation due to adverse events, and adverse events. Risk ratio (RR) or weight mean difference with 95% confidence intervals (CIs) were pooled using a fixed-effects or random-effects model according to the heterogeneity among studies. RESULTS A total of 8 RCTs involving 2,260 patients were included in this meta-analysis. Adjunctive aripiprazole was associated with a significantly higher remission rate (RR =1.64, 95% CI: 1.42 to 1.89; P<0.001) and response rate (RR =1.45, 95% CI: 1.13 to 1.87; P=0.004) than other treatments. Moreover, adjunctive aripiprazole had greater changes in MADRS score, CGI-S score, CGI-I score, HAM-D17 score, SDS score, and IDS-SR score. There were more patients treated with adjunctive aripiprazole who discontinued their treatments due to adverse events. The incidence of adverse events was significantly higher in the adjunctive aripiprazole group than in other treatment groups. CONCLUSION The adjunctive aripiprazole showed benefits in improving the response rate, remission rate, and the quality of life in patients with TRD. However, clinicians should interpret these findings with caution due to the evidence of potential treatment-related side effects.
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Affiliation(s)
- Shuxin Luan
- Department of Physiology, College of Basic Medical Sciences, Jilin University, Changchun, China.,Department of Mental Health, The First Hospital of Jilin University, Changchun, China
| | - Hongquan Wan
- Department of Mental Health, The First Hospital of Jilin University, Changchun, China
| | - Lei Zhang
- Department of Radiology, The First Hospital of Jilin University, Changchun, China
| | - Hua Zhao
- Department of Physiology, College of Basic Medical Sciences, Jilin University, Changchun, China.,Neuroscience Research Center, The First Hospital of Jilin University, Changchun, China
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15
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Cohen H, Zohar J, Kaplan Z, Arnt J. Adjunctive treatment with brexpiprazole and escitalopram reduces behavioral stress responses and increase hypothalamic NPY immunoreactivity in a rat model of PTSD-like symptoms. Eur Neuropsychopharmacol 2018; 28:63-74. [PMID: 29224968 DOI: 10.1016/j.euroneuro.2017.11.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Revised: 10/19/2017] [Accepted: 11/23/2017] [Indexed: 10/18/2022]
Abstract
The study explored effects of brexpiprazole (partial D2/5-HT1A agonist, 5-HT2A and α1B/2C-adrenoceptor antagonist) in rats exposed to predator scent stress (PSS), a proposed model of PTSD-like phenotype. Brexpiprazole (3.0mg/kg, PO), escitalopram (5.0mg/kg, IP) and their combination were administered twice daily for 14 days, starting 14 days after exposure to PSS or sham-PSS, shortly after a situational stress reminder. One day after last treatment behavioral responsivity was assessed. Brexpiprazole+escitalopram-treated rats spent more time in open arms, entered open arms more often and exhibited a lower anxiety index in the elevated plus maze than vehicle-treated, PSS-exposed rats. Adjunct brexpiprazole+escitalopram treatment reduced startle amplitude, compared with vehicle-treated, PSS-exposed rats. Treatment with either drug alone did not attenuate anxiety-like behaviors following PSS exposure. Use of cut-off behavioral criteria confirmed that adjunct treatment shifted prevalence of PSS-exposed rats from extreme towards minimal behavioral responders. One day following behavioral tests, brains were prepared for immunohistochemical analysis of number of BDNF-positive cells and of NPY-positive cells/fibers. PSS exposure decreased BDNF levels in hippocampus, but this was not affected by drug treatments. PSS exposure decreased number of NPY positive cells/fibers in paraventricular and arcuate nuclei of hypothalamus. Adjunct treatment with brexpiprazole+escitalopram increased NPY in PSS- and sham-exposed rats. Treatment with brexpiprazole alone had no effects, while treatment with escitalopram alone increased NPY in the arcuate nucleus of PSS-exposed rats. In conclusion, treatment with brexpiprazole+escitalopram may be an effective intervention for the attenuation of PTSD-like stress responses, which in part may be mediated by activating NPY function.
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Affiliation(s)
- Hagit Cohen
- Anxiety and Stress Research Unit, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Joseph Zohar
- The Chaim Sheba Medical Center, Sackler Medical School, Tel-Aviv University, Tel Hashomer, Israel
| | - Zeev Kaplan
- Anxiety and Stress Research Unit, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Jørn Arnt
- Synaptic Transmission, H. Lundbeck A/S, Ottiliavej 9, DK-2500 Valby, Denmark; Sunred Pharma Consulting ApS, Svend Gonges Vej 11A, DK-2680 Solrod Strand, Denmark.
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16
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17
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Starke JA, Stein DJ. Management of Treatment-Resistant Posttraumatic Stress Disorder. ACTA ACUST UNITED AC 2017. [DOI: 10.1007/s40501-017-0130-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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18
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Brancu M, Wagner HR, Morey RA, Beckham JC, Calhoun PS, Tupler LA, Marx CE, Taber KH, Hurley RA, Rowland J, McDonald SD, Hoerle JM, Moore SD, Kudler HS, Weiner RD, Fairbank JA. The Post-Deployment Mental Health (PDMH) study and repository: A multi-site study of US Afghanistan and Iraq era veterans. Int J Methods Psychiatr Res 2017; 26:e1570. [PMID: 28656593 PMCID: PMC6492939 DOI: 10.1002/mpr.1570] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 03/21/2017] [Accepted: 04/10/2017] [Indexed: 12/15/2022] Open
Abstract
The United States (US) Department of Veterans Affairs (VA) Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC) Post-Deployment Mental Health (PDMH) multi-site study examines post-deployment mental health in US military Afghanistan/Iraq-era veterans. The study includes the comprehensive behavioral health characterization of over 3600 study participants and the genetic, metabolomic, neurocognitive, and neuroimaging data for many of the participants. The study design also incorporates an infrastructure for a data repository to re-contact participants for follow-up studies. The overwhelming majority (94%) of participants consented to be re-contacted for future studies, and our recently completed feasibility study indicates that 73-83% of these participants could be reached successfully for enrollment into longitudinal follow-up investigations. Longitudinal concurrent cohort follow-up studies will be conducted (5-10+ years post-baseline) to examine predictors of illness chronicity, resilience, recovery, functional outcome, and other variables, and will include neuroimaging, genetic/epigenetic, serum biomarker, and neurocognitive studies, among others. To date, the PDMH study has generated more than 35 publications from the baseline data and the repository has been leveraged in over 20 publications from follow-up studies drawing from this cohort. Limitations that may affect data collection for a longitudinal follow-up study are also presented.
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Affiliation(s)
- Mira Brancu
- Durham VA Medical CenterDurhamNorth CarolinaUSA
- Department of Psychiatry and Behavioral SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
| | - H. Ryan Wagner
- Durham VA Medical CenterDurhamNorth CarolinaUSA
- Department of Psychiatry and Behavioral SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Rajendra A. Morey
- Durham VA Medical CenterDurhamNorth CarolinaUSA
- Department of Psychiatry and Behavioral SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Jean C. Beckham
- Durham VA Medical CenterDurhamNorth CarolinaUSA
- Department of Psychiatry and Behavioral SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Patrick S. Calhoun
- Durham VA Medical CenterDurhamNorth CarolinaUSA
- Department of Psychiatry and Behavioral SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Larry A. Tupler
- Durham VA Medical CenterDurhamNorth CarolinaUSA
- Department of Psychiatry and Behavioral SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Christine E. Marx
- Durham VA Medical CenterDurhamNorth CarolinaUSA
- Department of Psychiatry and Behavioral SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Katherine H. Taber
- W.G. Hefner VA Medical CenterSalisburyNorth CarolinaUSA
- Division of Biomedical SciencesEdward Via College of Osteopathic MedicineBlacksburgVirginiaUSA
- Department of Physical Medicine and RehabilitationBaylor College of MedicineHoustonTexasUSA
| | - Robin A. Hurley
- W.G. Hefner VA Medical CenterSalisburyNorth CarolinaUSA
- Department of Psychiatry and Behavioral SciencesBaylor College of MedicineHoustonTexasUSA
- Departments of Psychiatry and Behavioral MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
- Department of RadiologyWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Jared Rowland
- W.G. Hefner VA Medical CenterSalisburyNorth CarolinaUSA
- Departments of Psychiatry and Behavioral MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
- Department of Neurobiology and AnatomyWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Scott D. McDonald
- Hunter Holmes McGuire VA Medical CenterRichmondVirginiaUSA
- Departments of Psychology and Physical Medicine and RehabilitationVirginia Commonwealth UniversityRichmondVirginiaUSA
| | | | - Scott D. Moore
- Durham VA Medical CenterDurhamNorth CarolinaUSA
- Department of Psychiatry and Behavioral SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Harold S. Kudler
- Mental Health ServicesUS Department of Veterans AffairsWashingtonDistrict of ColumbiaUSA
| | - Richard D. Weiner
- Department of Psychiatry and Behavioral SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
| | | | - John A. Fairbank
- Durham VA Medical CenterDurhamNorth CarolinaUSA
- Department of Psychiatry and Behavioral SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
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Yabuki Y, Takahata I, Matsuo K, Owada Y, Fukunaga K. Ramelteon Improves Post-traumatic Stress Disorder-Like Behaviors Exhibited by Fatty Acid-Binding Protein 3 Null Mice. Mol Neurobiol 2017; 55:3577-3591. [PMID: 28516430 DOI: 10.1007/s12035-017-0587-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 04/28/2017] [Indexed: 12/14/2022]
Abstract
We previously reported that fatty acid-binding protein 3 (FABP3) knockout (Fabp3 -/-) mice exhibit abnormal dopamine-related behaviors such as enhanced dopamine D2 receptor antagonist-induced catalepsy behaviors. Here, we report that Fabp3 null mice exhibit cognitive deficits, hyperlocomotion and impaired fear extinction, and thus show post-traumatic stress disorder (PTSD)-like behaviors. Notably, chronic administration of ramelteon (1.0 mg/kg, p.o.), a melatonin receptor agonist, improved all PTSD-like behaviors tested in Fabp3 -/- mice. Relevant to mechanisms underlying impaired fear extinction, we observed significantly reduced levels of Ca2+/calmodulin-dependent protein kinase II (CaMKII) autophosphorylation without changes in ERK phosphorylation in the anterior cingulate cortex (ACC). Inversely, CaMKII autophosphorylation increased in the basolateral amygdala (BLA) but remained relatively unchanged in hippocampus of Fabp3 -/- mice. Likewise, the number of c-Fos-positive neurons in BLA significantly increased after exposure to contextual fear conditions but remained unchanged in the central nucleus of the amygdala (CeA). Importantly, chronic ramelteon administration (1.0 mg/kg, p.o.) restored abnormal c-Fos expression and CaMKII autophosphorylation in the ACC and BLA of Fabp3 -/- mice. Finally, the melatonin receptor antagonist luzindole (2.5 mg/kg, i.p.) blocked ramelteon-dependent improvements. Taken together, Fabp3 -/- mice show PTSD-like behaviors, and ramelteon is a likely attractive candidate for PTSD therapy.
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Affiliation(s)
- Yasushi Yabuki
- Department of Pharmacology, Graduate School of Pharmaceutical Sciences, Tohoku University, Aramaki-Aoba Aoba-ku, Sendai, 980-8578, Japan
| | - Ibuki Takahata
- Department of Pharmacology, Graduate School of Pharmaceutical Sciences, Tohoku University, Aramaki-Aoba Aoba-ku, Sendai, 980-8578, Japan
| | - Kazuya Matsuo
- Department of Pharmacology, Graduate School of Pharmaceutical Sciences, Tohoku University, Aramaki-Aoba Aoba-ku, Sendai, 980-8578, Japan
| | - Yuji Owada
- Department of Organ Anatomy, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Kohji Fukunaga
- Department of Pharmacology, Graduate School of Pharmaceutical Sciences, Tohoku University, Aramaki-Aoba Aoba-ku, Sendai, 980-8578, Japan.
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20
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Volchan E, Rocha-Rego V, Bastos AF, Oliveira JM, Franklin C, Gleiser S, Berger W, Souza GGL, Oliveira L, David IA, Erthal FS, Pereira MG, Figueira I. Immobility reactions under threat: A contribution to human defensive cascade and PTSD. Neurosci Biobehav Rev 2017; 76:29-38. [PMID: 28131873 DOI: 10.1016/j.neubiorev.2017.01.025] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 01/18/2017] [Accepted: 01/21/2017] [Indexed: 01/03/2023]
Abstract
Violence exacts a burden on public health. Gun violence is a major trigger for motor defensive reactions in humans and post-traumatic stress disorder (PTSD) is its main psychiatric sequela. However, studies of the human defensive cascade, especially the motor reactions, are at an early stage. This review focuses on studies that employ stabilometry, a methodology that assesses whole body motor reactions, to address defensive behaviors to violence-related threats. Special attention is given to three reactions: "attentive immobility", "immobility under attack" and "tonic immobility", with emphasis on the latter - a peritraumatic reaction which has been strongly associated with the severity of PTSD. These reactions are characterized by reduced body sway and bradycardia, except tonic immobility that presents robust tachycardia. The advances made by investigations into the immobility reactions of the human defensive cascade contribute to helping to bridge the gap between human and non-human species. Furthermore, progresses in basic research to objectively monitor motor defensive reactions under threat can help to develop a dimensional, trans-diagnostic approach to PTSD.
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Affiliation(s)
- E Volchan
- Instituto de Biofisica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Brazil.
| | - V Rocha-Rego
- Instituto de Biofisica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Brazil; Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro, Brazil
| | - A F Bastos
- Instituto de Biofisica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Brazil
| | - J M Oliveira
- Instituto de Biofisica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Brazil; Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro, Brazil
| | - C Franklin
- Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro, Brazil
| | - S Gleiser
- Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro, Brazil
| | - W Berger
- Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro, Brazil
| | - G G L Souza
- Instituto de Ciências Exatas e Biológicas, Universidade Federal de Ouro Preto, Brazil
| | - L Oliveira
- Instituto Biomédico, Universidade Federal Fluminense, Brazil
| | - I A David
- Instituto Biomédico, Universidade Federal Fluminense, Brazil
| | - F S Erthal
- Instituto de Biofisica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Brazil
| | - M G Pereira
- Instituto Biomédico, Universidade Federal Fluminense, Brazil
| | - I Figueira
- Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro, Brazil
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Thomas E, Stein DJ. Novel pharmacological treatment strategies for posttraumatic stress disorder. Expert Rev Clin Pharmacol 2016; 10:167-177. [PMID: 27835034 DOI: 10.1080/17512433.2017.1260001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION A wide range of medications have been studied for posttraumatic stress disorder (PTSD) and a number are registered for this indication. Nevertheless, current pharmacotherapies are only partially effective in some patients, and are minimally effective in others. Thus novel treatment avenues need to be explored. Areas covered: In considering novel pharmacological agents for the treatment of PTSD, this paper takes a translational approach. We outline how advances in our understanding of the underlying neurobiology of PTSD may inform the identification of potential new treatment targets, including glutamatergic, noradrenergic and opioid pathways. Expert commentary: Continued investigation of the neural substrates and signalling pathways involved in responses to trauma may inform the development of novel treatment targets for future drug development for PTSD. However, the translation of preclinical findings to clinical practice is likely to be complex and gradual.
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Affiliation(s)
- Eileen Thomas
- a Division of Consultation Liaison, Department of Psychiatry and Mental Health , University of Cape Town , Cape Town , South Africa
| | - Dan J Stein
- b US/UCT MRC Unit on Anxiety and Stress Disorders, Department of Psychiatry and Mental Health , University of Cape Town , Cape Town , South Africa
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Treatment-refractory posttraumatic stress disorder (TRPTSD): a review and framework for the future. Prog Neuropsychopharmacol Biol Psychiatry 2016; 70:170-218. [PMID: 26854815 DOI: 10.1016/j.pnpbp.2016.01.015] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 01/29/2016] [Accepted: 01/29/2016] [Indexed: 01/04/2023]
Abstract
Post-traumatic stress disorder (PTSD) is a serious psychiatric consequence of trauma that occurs in a proportion of individuals exposed to life-threatening events. Trauma-focused psychotherapy is often recommended as first choice for those who do not recover spontaneously. But many individuals require medications. In the US, only paroxetine (PRX) and sertraline (SRT) are FDA approved for PTSD. But response and remission rates with these medications are low, so numerous other pharmacologic interventions have been tried. To date, there has not been a systematic review of the data on what are the best next-step pharmacologic strategies for individuals who fail standard treatments. To that end, we review 168 published trials of medications other than PRX or SRT and provide a detailed analysis of the 88/168 studies that describe alternative pharmacologic interventions in patients refractory to other treatment. We also review clinical factors relevant to treatment-refractory PTSD; the neurobiology of extinction, as well as evidence-based psychotherapy and neuromodulation strategies for this condition.
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Lee DJ, Schnitzlein CW, Wolf JP, Vythilingam M, Rasmusson AM, Hoge CW. PSYCHOTHERAPY VERSUS PHARMACOTHERAPY FOR POSTTRAUMATIC STRESS DISORDER: SYSTEMIC REVIEW AND META-ANALYSES TO DETERMINE FIRST-LINE TREATMENTS. Depress Anxiety 2016; 33:792-806. [PMID: 27126398 DOI: 10.1002/da.22511] [Citation(s) in RCA: 223] [Impact Index Per Article: 27.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Revised: 03/21/2016] [Accepted: 03/26/2016] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Current clinical practice guidelines (CPGs) for posttraumatic stress disorder (PTSD) offer contradictory recommendations regarding use of medications or psychotherapy as first-line treatment. Direct head-to-head comparisons are lacking. METHODS Systemic review of Medline, EMBASE, PILOTS, Cochrane Central Register of Controlled Trials, PsycINFO, and Global Health Library was conducted without language restrictions. Randomized clinical trials ≥8 weeks in duration using structured clinical interview-based outcome measures, active-control conditions (e.g. supportive psychotherapy), and intent-to-treat analysis were selected for analyses. Independent review, data abstraction, and bias assessment were performed using standardized processes. Study outcomes were grouped around conventional follow-up time periods (3, 6, and 9 months). Combined effect sizes were computed using meta-analyses for medication versus control, medication pre-/posttreatment, psychotherapy versus control, and psychotherapy pre-/posttreatment. RESULTS Effect sizes for trauma-focused psychotherapies (TFPs) versus active control conditions were greater than medications versus placebo and other psychotherapies versus active controls. TFPs resulted in greater sustained benefit over time than medications. Sertraline, venlafaxine, and nefazodone outperformed other medications, although potential for methodological biases were high. Improvement following paroxetine and fluoxetine treatment was small. Venlafaxine and stress inoculation training (SIT) demonstrated large initial effects that decreased over time. Bupropion, citalopram, divalproex, mirtazapine, tiagabine, and topiramate failed to differentiate from placebo. Aripiprazole, divalproex, guanfacine, and olanzapine failed to differentiate from placebo when combined with an antidepressant. CONCLUSIONS Study findings support use of TFPs over nontrauma-focused psychotherapy or medication as first-line interventions. Second-line interventions include SIT, and potentially sertraline or venlafaxine, rather than entire classes of medication, such as SSRIs. Future revisions of CPGs should prioritize studies that utilize active controls over waitlist or treatment-as-usual conditions. Direct head-to-head trials of TFPs versus sertraline or venlafaxine are needed.
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Affiliation(s)
- Daniel J Lee
- Office of Evidence Based Practice, JBSA Fort Sam Houston, San Antonio, Texas. ,
- Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland. ,
| | - Carla W Schnitzlein
- Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland
- Department of Behavioral Health, Bayne-Jones Army Community Hospital, Fort Polk, Louisiana
| | - Jonathan P Wolf
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Meena Vythilingam
- Headquarters U.S. Marine Corps, Health Services, Arlington, Virginia
| | - Ann M Rasmusson
- Women's Health Science Division, National Center for PTSD, VA Boston Healthcare System, Boston University School of Medicine, Boston, Massachusetts
- Department of Veterans Affairs, Boston University School of Medicine, Boston, Massachusetts
- Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts
| | - Charles W Hoge
- Center for Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland
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Traumatic stress causes distinctive effects on fear circuit catecholamines and the fear extinction profile in a rodent model of posttraumatic stress disorder. Eur Neuropsychopharmacol 2016; 26:1484-1495. [PMID: 27492886 DOI: 10.1016/j.euroneuro.2016.06.004] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Revised: 05/14/2016] [Accepted: 06/10/2016] [Indexed: 01/08/2023]
Abstract
Central catecholamines regulate fear memory across the medial prefrontal cortex (mPFC), amygdala (AMYG), and hippocampus (HPC). However, inadequate evidence exists to address the relationships among these fear circuit areas in terms of the fear symptoms of posttraumatic stress disorder (PTSD). By examining the behavioral profile in a Pavlovian fear conditioning paradigm together with tissue/efflux levels of dopamine (DA) and norepinephrine (NE) and their reuptake abilities across the fear circuit areas in rats that experienced single prolonged stress (SPS, a rodent model of PTSD), we demonstrated that SPS-impaired extinction retrieval was concomitant with the changes of central DA/NE in a dissociable manner. For tissue levels, diminished DA and increased NE were both observed in the mPFC and AMYG. DA efflux and synaptosomal DA transporter were consistently reduced in the AMYG/vHPC, whereas SPS reduced NE efflux in the infralimbic cortex and synaptosomal NE transporter in the mPFC. Furthermore, a lower expression of synaptosomal VMAT2 was observed in the mPFC, AMYG, and vHPC after SPS. Finally, negative correlations were observed between retrieval freezing and DA in the mPFC/AMYG; nevertheless, the phenomena became invalid after SPS. Our results suggest that central catecholamines are crucially involved in the retrieval of fear extinction in which DA and NE play distinctive roles across the fear circuit areas.
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Role and clinical implications of atypical antipsychotics in anxiety disorders, obsessive-compulsive disorder, trauma-related, and somatic symptom disorders: a systematized review. Int Clin Psychopharmacol 2016; 31:249-58. [PMID: 26974213 DOI: 10.1097/yic.0000000000000127] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Atypical antipsychotics (AAs) may play a role in the treatment of anxiety disorders, obsessive-compulsive disorder (OCD), and trauma-related disorders. No reviews on their differential use in these different disorders have been performed recently. The aim of this systematized review was to obtain data on efficacy and comparative effectiveness of AAs as a treatment of anxiety disorders, OCD, and trauma-related disorders to provide guidance for clinicians on when and which AA to use. We searched on PubMed, Psychnet, and Cochrane Libraries from inception to July 2015. Search results were limited to randomized, placebo-controlled trials of adult patients. Evidence of efficacy was considered the presence of positive results in two or more double-blind placebo-controlled studies. Our systematized search identified 1298 papers, of which 191 were subjected to a full-text review and 56 were included. Quetiapine extended-release showed a role in both acute and maintenance treatment of uncomplicated generalized anxiety disorder, whereas more studies are needed before drawing practical recommendations on the use of olanzapine and risperidone; aripiprazole and risperidone are effective in resistant OCD as augmentation treatments. Risperidone and olanzapine add-on may have a role in resistant or chronic post-traumatic stress disorder patients, although only risperidone addition can be recommended on the basis of the criterion of two or more positive placebo-controlled trials. This systematized review supports the evidence that only a few AAs are effective in only a minority of the off-label conditions in which they are currently used and confirms that AAs are not all the same. Their use should be on the basis of a balance between efficacy and side effects, and the characteristics as well as the preference of the patient.
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