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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: 12] [Impact Index Per Article: 6.0] [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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Exploring the transmucosal permeability of cyclobenzaprine: A comparative preformulation by standardized and controlled ex vivo and in vitro permeation studies. Int J Pharm 2021; 601:120574. [PMID: 33831487 DOI: 10.1016/j.ijpharm.2021.120574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 03/30/2021] [Accepted: 03/31/2021] [Indexed: 12/16/2022]
Abstract
As part of early drug development, preformulation studies are used to comprehensively explore the properties of new drugs. In particular, this includes the biopharmaceutical characterization and evaluation of impacting factors (e.g. excipients, microenvironmental conditions etc.) by permeation studies. To overcome the limitations of current studies, a novel standardized ex vivo procedure using esophageal mucosa as surrogate has been established successfully and applied to preformulation studies for oromucosal delivery of cyclobenzaprine hydrochloride, a tricyclic muscle relaxant with potential for psychopharmacotherapeutic use. By using the standardized ex vivo permeation process, a twofold enhancement of permeability (0.98 ± 0.16 to 1.96 ± 0.10 * 10-5 cm/s) was observed by adjustment and controlling of microenvironmental pH, empowering a targeted and effective development of sublingual formulations. Predictivity and suitability were superior compared to in vitro experiments using artificial biomimetic membranes, revealing a determination coefficient (R2) of 0.995 vs. 0.322 concerning pH-dependent permeability of cyclobenzaprine. In addition, diffusion properties were extensively examined (e.g. influence of mucosal thicknesses, tissue freezing etc.). The alignment of the study design regarding physiologically/clinically relevant conditions resulted in ex vivo data that allowed for the estimation of plasma AUC levels in the extend of reported in vivo ranges.
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Veen C, Jacobs G, Philippens I, Vermetten E. Subanesthetic Dose Ketamine in Posttraumatic Stress Disorder: A Role for Reconsolidation During Trauma-Focused Psychotherapy? Curr Top Behav Neurosci 2019; 38:137-162. [PMID: 29637527 DOI: 10.1007/7854_2017_34] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Despite efforts to develop more effective therapies, PTSD remains a difficult disorder to treat. Insight into the dynamic nature of memory formation and its required molecular machinery can provide an opportunity to target pathological memories for emotionally arousing events. As memories become labile upon retrieval, novel information can update the strength and course of these consolidated memories. Targeting the process of reconsolidation may offer a relevant approach to attenuate fearful and traumatic memories. Specific molecular mechanisms that are required for reconsolidation of arousing information include an intact functioning of the glutamatergic signaling pathways and, more specifically, the integrity of NMDA receptors. Ketamine, a noncompetitive NMDA-receptor antagonist, is receiving increasing interest for a variety of psychiatric indications. This compound can also be an interesting candidate for targeting emotional memories. We explore whether single intravenous infusion of a subanesthetic dose of ketamine can be considered as a viable augmentation strategy for trauma-focused psychotherapy in patients with PTSD. As a consequence, a systematic approach is needed to assess the pharmacodynamic effects of ketamine in relation to both psychotherapy and its pharmacokinetics prior to its application in patient populations. By using a "question-based drug development plan," we can explore such aspects for novel drugs, and we formulated five additional topics that need to be addressed concerning the psychotherapeutic approach and phase orientation of pharmacological assisted psychotherapy.
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Affiliation(s)
- Cato Veen
- Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands.
| | - Gabriel Jacobs
- Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands
- Centre for Human Drug Research, Leiden, The Netherlands
| | | | - Eric Vermetten
- Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands
- Arq Psychotrauma Research Group, Diemen, The Netherlands
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Raber J, Arzy S, Bertolus JB, Depue B, Haas HE, Hofmann SG, Kangas M, Kensinger E, Lowry CA, Marusak HA, Minnier J, Mouly AM, Mühlberger A, Norrholm SD, Peltonen K, Pinna G, Rabinak C, Shiban Y, Soreq H, van der Kooij MA, Lowe L, Weingast LT, Yamashita P, Boutros SW. Current understanding of fear learning and memory in humans and animal models and the value of a linguistic approach for analyzing fear learning and memory in humans. Neurosci Biobehav Rev 2019; 105:136-177. [PMID: 30970272 DOI: 10.1016/j.neubiorev.2019.03.015] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 01/30/2019] [Accepted: 03/18/2019] [Indexed: 01/04/2023]
Abstract
Fear is an emotion that serves as a driving factor in how organisms move through the world. In this review, we discuss the current understandings of the subjective experience of fear and the related biological processes involved in fear learning and memory. We first provide an overview of fear learning and memory in humans and animal models, encompassing the neurocircuitry and molecular mechanisms, the influence of genetic and environmental factors, and how fear learning paradigms have contributed to treatments for fear-related disorders, such as posttraumatic stress disorder. Current treatments as well as novel strategies, such as targeting the perisynaptic environment and use of virtual reality, are addressed. We review research on the subjective experience of fear and the role of autobiographical memory in fear-related disorders. We also discuss the gaps in our understanding of fear learning and memory, and the degree of consensus in the field. Lastly, the development of linguistic tools for assessments and treatment of fear learning and memory disorders is discussed.
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Affiliation(s)
- Jacob Raber
- Department of Behavioral Neuroscience, ONPRC, Oregon Health & Science University, Portland, OR, USA; Departments of Neurology and Radiation Medicine, and Division of Neuroscience, ONPRC, Oregon Health & Science University, Portland, OR, USA.
| | - Shahar Arzy
- Department of Medical Neurobiology, Hebrew University, Jerusalem 91904, Israel
| | | | - Brendan Depue
- Departments of Psychological and Brain Sciences and Anatomical Sciences and Neurobiology, University of Louisville, Louisville, KY, USA
| | - Haley E Haas
- Department of Psychiatry and Behavioral Science, Emory University School of Medicine, Atlanta, GA, USA
| | - Stefan G Hofmann
- Department of Psychological and Brain Sciences, Boston University, Boston, MA, USA
| | - Maria Kangas
- Department of Psychology, Macquarie University, Sydney, Australia
| | | | - Christopher A Lowry
- Department of Integrative Physiology and Center for Neuroscience, University of Colorado Boulder, Boulder, CO, USA
| | - Hilary A Marusak
- Department of Pharmacy Practice, Wayne State University, Detroit, MI, USA
| | - Jessica Minnier
- School of Public Health, Oregon Health & Science University, Portland, OR, USA
| | - Anne-Marie Mouly
- Lyon Neuroscience Research Center, CNRS-UMR 5292, INSERM U1028, Université Lyon, Lyon, France
| | - Andreas Mühlberger
- Department of Psychology (Clinical Psychology and Psychotherapy), University of Regensburg, Regensburg, Germany; PFH - Private University of Applied Sciences, Department of Psychology (Clinical Psychology and Psychotherapy Research), Göttingen, Germany
| | - Seth Davin Norrholm
- Department of Psychiatry and Behavioral Science, Emory University School of Medicine, Atlanta, GA, USA
| | - Kirsi Peltonen
- Faculty of Social Sciences/Psychology, Tampere University, Tampere, Finland
| | - Graziano Pinna
- The Psychiatric Institute, Department of Psychiatry, University of Illinois at Chicago, Chicago, IL, USA
| | - Christine Rabinak
- Department of Pharmacy Practice, Wayne State University, Detroit, MI, USA
| | - Youssef Shiban
- Department of Psychology (Clinical Psychology and Psychotherapy), University of Regensburg, Regensburg, Germany; PFH - Private University of Applied Sciences, Department of Psychology (Clinical Psychology and Psychotherapy Research), Göttingen, Germany
| | - Hermona Soreq
- Department of Biological Chemistry, Edmond and Lily Safra Center of Brain Science and The Institute of Life Sciences, Hebrew University, Jerusalem 91904, Israel
| | - Michael A van der Kooij
- Translational Psychiatry, Department of Psychiatry and Psychotherapy, Universitatsmedizin der Johannes Guttenberg University Medical Center, Mainz, Germany
| | | | - Leah T Weingast
- Department of Psychiatry and Behavioral Science, Emory University School of Medicine, Atlanta, GA, USA
| | - Paula Yamashita
- School of Public Health, Oregon Health & Science University, Portland, OR, USA
| | - Sydney Weber Boutros
- Department of Behavioral Neuroscience, ONPRC, Oregon Health & Science University, Portland, OR, USA
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Bernardy NC, Friedman MJ. Pharmacological management of posttraumatic stress disorder. Curr Opin Psychol 2017; 14:116-121. [DOI: 10.1016/j.copsyc.2017.01.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 12/30/2016] [Accepted: 01/03/2017] [Indexed: 01/04/2023]
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Cordova MJ, Riba MB, Spiegel D. Post-traumatic stress disorder and cancer. Lancet Psychiatry 2017; 4:330-338. [PMID: 28109647 PMCID: PMC5676567 DOI: 10.1016/s2215-0366(17)30014-7] [Citation(s) in RCA: 241] [Impact Index Per Article: 34.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 10/14/2016] [Accepted: 11/17/2016] [Indexed: 11/28/2022]
Abstract
Being diagnosed with and treated for cancer is highly stressful and potentially traumatic. An extensive literature has evaluated the prevalence, predictors, and correlates of cancer-related post-traumatic stress disorder (PTSD) symptoms and diagnoses. In this qualitative review of cancer-related PTSD literature, we highlight conceptual, methodological, and diagnostic issues, and identify clinical implications and areas for future research. Cancer-related PTSD has been documented in a minority of patients with cancer and their family members, is positively associated with other indices of distress and reduced quality of life, and has several correlates and risk factors (eg, prior trauma history, pre-existing psychiatric conditions, poor social support). The literature on treatment of cancer-related PTSD is sparse. Existing literature on cancer-related PTSD has used DSM-IV-TR diagnostic criteria; the revised DSM-5 PTSD criteria have important implications for the assessment of cancer-related distress. Application of PTSD diagnosis to patients with cancer has been critiqued on conceptual and methodological grounds, and important differential diagnosis considerations should be taken into account. Psychosocial assessment of patients with cancer should include careful evaluation of pre-cancer diagnosis trauma and psychiatric history, and diagnostic interviewing should consider concurrent conditions (eg, adjustment disorder). Treatment of cancer-related PTSD should be approached with caution and be informed by existing evidence-based approaches for traumatic stress.
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Affiliation(s)
| | - Michelle B Riba
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - David Spiegel
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA.
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Davidson J. Pharmacotherapy of post-traumatic stress disorder: going beyond the guidelines. BJPsych Open 2016; 2:e16-e18. [PMID: 29018563 PMCID: PMC5609778 DOI: 10.1192/bjpo.bp.116.003707] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 10/27/2016] [Accepted: 10/31/2016] [Indexed: 01/04/2023] Open
Abstract
SUMMARY This article discusses the study of Harpaz-Rotem and associates, who examined patterns of medication use in first-diagnosed veterans with post-traumatic stress disorder (PTSD). It considers the difference between practice guidelines and actual prescribing; selectively identifies issues with antidepressants, antipsychotics, benzodiazepines and prazosin; and reviews the possible impact of new medications in the pipeline. DECLARATION OF INTERESTS In the past 36 months, J.D. has received compensation for consulting with Edgemont, Turing and Tonix Pharmaceuticals; royalties in connection with publications by Springer, Guilford and McFarland Publishers and use of the Connor-Davidson Resilience Scale, Davidson Trauma Scale, Social Phobia Inventory (SPIN) and Mini-SPIN; service on the INTRuST Data Safety and Monitoring Board, University of California, San Diego. COPYRIGHT AND USAGE © The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.
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Affiliation(s)
- Jonathan Davidson
- Jonathan Davidson, MB, BS, FRCPsych, Department of Psychiatry & Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
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Harpaz-Rotem I, Rosenheck R, Mohamed S, Pietrzak R, Hoff R. Initiation of pharmacotherapy for post-traumatic stress disorder among veterans from Iraq and Afghanistan: a dimensional, symptom cluster approach. BJPsych Open 2016; 2:286-293. [PMID: 27703791 PMCID: PMC5016711 DOI: 10.1192/bjpo.bp.115.002451] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 08/03/2016] [Accepted: 08/14/2016] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The pharmacological treatment of post-traumatic stress disorder (PTSD) is extremely challenging, as no specific agent has been developed exclusively to treat this disorder. Thus, there are growing concerns among the public, providers and consumers associated with its use as the efficacy of some agents is still in question. AIMS We applied a dimensional and symptom cluster-based approach to better understand how the heterogeneous phenotypic presentation of PTSD may relate to the initiation of pharmacotherapy for PTSD initial episode. METHOD US veterans who served in the conflicts in Iraq and Afghanistan and received an initial PTSD diagnosis at the US Veterans Health Administration between 2008 and 2011 were included in this study. Veterans were followed for 365 days from initial PTSD diagnosis to identify initiation for antidepressants, anxiolytics/sedatives/hypnotics, antipsychotics and prazosin. Multivariable analyses were used to assess the relationship between the severity of unique PTSD symptom clusters and receiving prescriptions from each medication class, as well as the time from diagnosis to first prescription. RESULTS Increased severity of emotional numbing symptoms was independently associated with the prescription of antidepressants, and they were prescribed after a substantially shorter period of time than other medications. Anxiolytics/sedatives/hypnotics prescription was associated with heightened re-experiencing symptoms and sleep difficulties. Antipsychotics were associated with elevated re-experiencing and numbing symptoms and prazosin with reported nightmares. CONCLUSIONS Prescribing practices for military-related PTSD appear to follow US VA/DoD clinical guidelines. Results of this study suggest that a novel dimensional and symptom cluster-based approach to classifying the phenotypic presentation of military-related PTSD symptoms may help inform prescribing patterns for PTSD. DECLARATION OF INTEREST None. COPYRIGHT AND USAGE © The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.
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Affiliation(s)
- Ilan Harpaz-Rotem
- , PhD, VACHS, The National Center for PTSD, Department of Veterans Affairs, West Haven, CT; VACHS, The Northeast Program Evaluation Center (NEPEC), Department of Veterans Affairs, West Haven, CT; Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Robert Rosenheck
- , MD, VACHS, VISN1 Mental Illness Research and Clinical Center (MIRECC), Department of Veterans Affairs, West Haven, CT; Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Somaia Mohamed
- , MD PhD, VACHS, The Northeast Program Evaluation Center (NEPEC), Department of Veterans Affairs, West Haven, CT; Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Robert Pietrzak
- , MPH PhD, VACHS, The National Center for PTSD, Department of Veterans Affairs, West Haven, CT; Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Rani Hoff
- , MPH PhD, VACHS, The National Center for PTSD, Department of Veterans Affairs, West Haven, CT; VACHS, The Northeast Program Evaluation Center (NEPEC), Department of Veterans Affairs, West Haven, CT; Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
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Abstract
Refugees are a highly traumatized and culturally diverse group of patients who present many clinical challenges. Refugees have a high prevalence of traumas from torture, ethnic cleansing, and the effects of long civil wars. The most common diagnoses associated with the effects of such traumas are posttraumatic stress disorder (PTSD) or PTSD with comorbid depression; however, psychosis and neurocognitive disorders are also common. For those with PTSD, a suggested treatment approach is long-term supportive psychotherapy with drug treatment directed at reducing the most disruptive symptoms, such as insomnia, nightmares, and irritability or psychosis. The author recommends a sedative tricyclic antidepressant, clonidine or prazosin, and aripiprazole as a useful combination of medications to provide rapid relief. In addition to PTSD, long-term studies indicate a high prevalence of diabetes and hypertension in traumatized refugees. It is therefore important to perform a thorough evaluation for these disorders that includes the measurement of blood pressure and a blood test for diabetes. When managed with such a medical approach, refugees are generally accepting of psychiatric treatment and can obtain relief from the symptoms associated with the massive trauma and losses they have experienced.
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