Psychopharmacotherapy of posttraumatic stress disorder

The Medial Prefrontal Cortex, Nucleus Accumbens, Basolateral Amygdala, and Hippocampus Regulate the Amelioration of Environmental Enrichment and Cue in Fear Behavior in the Animal Model of PTSD

A growing body of evidence showed that environmental enrichment (EE) ameliorated footshock-induced fear behavior of posttraumatic stress disorder (PTSD). However, no research comprehensively tested the effect of EE, cue, and the combination of EE and cue in footshock-induced fear behavior of PTSD symptoms. The present study addressed this issue and examined whether the medial prefrontal cortex (mPFC, including the cingulate cortex 1 (Cg1), prelimbic cortex (PrL), and infralimbic cortex (IL)), the nucleus accumbens (NAc), the basolateral amygdala (BLA), and the hippocampus (e.g., CA1, CA3, and dentate gyrus (DG)) regulated the amelioration of the EE, cue, or the combination of EE and cue. The results showed that EE or cue could reduce fear behavior. The combination of EE and cue revealed a stronger decrease in fear behavior. The cue stimulus may play an occasion setting or a conditioned stimulus to modulate the reduction in fear behavior induced by footshock. Regarding the reduction of the EE in fear behavior, the Cg1 and IL of the mPFC and the NAc upregulated the c-Fos expression; however, the BLA downregulated the c-Fos expression. The mPFC (i.e., the Cg1, PrL, and IL) and the hippocampus (i.e., the CA1, CA3, and DG) downregulated the c-Fos expression in the suppression of the cue in fear behavior. The interaction of EE and cue in reduction of fear behavior occurred in the Cg1 and NAc for the c-Fos expression. The data of c-Fos mRNA were similar to the findings of the c-Fos protein expression. These findings related to the EE and cue modulations in fear behavior may develop a novel nonpharmacological treatment in PTSD.

Advances in the pharmacotherapeutic management of post-traumatic stress disorder

Introduction: Post-traumatic stress disorder (PTSD), a mental disorder, is associated with anxiety, depression, and social awkwardness resulting from past traumatic episodes like natural disasters, accidents, terrorist attacks, war, rape, and sexual violence. It affects primarily the amygdala, cortex, and hippocampus where neurochemical changes result in altered behavior. PTSD patients display impaired fear extinction, and past events keep haunting them. The topic presents relevant sections like PTSD pharmacotherapy, associated challenges, and the novel targets and drugs for future research and therapy.Areas covered: The authors discuss the current pharmacotherapy like SSRIs, NDRIs, SNRIs, anticonvulsants, antidepressants, and benzodiazepines, used to attenuate the associated symptoms. However, the primary focus being the novel and potential targets which can be explored better to understand possible future research and advanced therapy in PTSD. For the same, an account of both preclinical and clinical studies has been covered.Expert opinion: Excessive adverse effects, limited efficacy, and lower patient compliance are some of the major challenges with conventional drugs. Moreover, they correct only fewer symptoms without halting the disease progression. Several agents are investigated in different preclinical and clinical phases, which can potentially overcome the pitfalls and limitations associated with conventional therapies.

An Emulation of Randomized Trials of Administrating Benzodiazepines in PTSD Patients for Outcomes of Suicide-Related Events

Benzodiazepines is a class of medications frequently prescribed to patients with post-traumatic stress disorder. Patients with PTSD have a notable increased risk of suicide compared to the general population. These medications have been theorized to increase suicidality and pose a risk when used in this patient population. Previous research has found little utility of using benzodiazepines in the PTSD population. However, benzodiazepines are still commonly prescribed by some clinicians for their symptomatic benefit. This study aims to identify the comparative efficacy of commonly prescribed benzodiazepines including midazolam, lorazepam, alprazolam, clonazepam, diazepam and temazepam in relation to suicide-related behaviors (SRBs). A total of 38,807 patients who had an ICD9 or ICD10 diagnosis of PTSD from January 2004 to October 2019 were identified through an electronic medical record database. Inclusion criteria include patients that initiated one of the above benzodiazepines after PTSD diagnosis. Exclusion criteria include previous history of benzodiazepine usage or history of SRBs within the last year prior to enrollment. For patients enrolled in this study, other concomitant drugs were not limited. The primary outcome was onset of SRBs with each respective benzodiazepine. SRBs were identified as ideation, attempt, or death from suicide. We emulated clinical trials of head-to-head comparison between two drugs by pooled logistic regression methods with the Firth option adjusting for baseline characteristics and post-baseline confounders. A total of 5753 patients were eligible for this study, with an average follow up of 5.82 months. The overall incidence for SRB was 1.51% (87/5753). Head-to-head comparisons identified that patients who received alprazolam had fewer SRBs compared to clonazepam (p = 0.0351) and lorazepam (p = 0.0373), and patients taking midazolam experienced fewer relative incidences of SRBs when compared to lorazepam (p = 0.0021) and clonazepam (p = 0.0297). After adjusting for the false discovery rate (FDR), midazolam still had fewer SRBs compared to lorazepam (FDR-adjusted p value = 0.0315). Certain benzodiazepines may provide a reduced risk of development of SRBs, suggesting careful consideration when prescribing benzodiazepines to the PTSD population.

Animal models of PTSD: a challenge to be met

Recent years have seen increased interest in psychopathologies related to trauma exposure. Specifically, there has been a growing awareness to posttraumatic stress disorder (PTSD) in part due to terrorism, climate change-associated natural disasters, the global refugee crisis, and increased violence in overpopulated urban areas. However, notwithstanding the increased awareness to the disorder, the increasing number of patients, and the devastating impact on the lives of patients and their families, the efficacy of available treatments remains limited and highly unsatisfactory. A major scientific effort is therefore devoted to unravel the neural mechanisms underlying PTSD with the aim of paving the way to developing novel or improved treatment approaches and drugs to treat PTSD. One of the major scientific tools used to gain insight into understanding physiological and neuronal mechanisms underlying diseases and for treatment development is the use of animal models of human diseases. While much progress has been made using these models in understanding mechanisms of conditioned fear and fear memory, the gained knowledge has not yet led to better treatment options for PTSD patients. This poor translational outcome has already led some scientists and pharmaceutical companies, who do not in general hold opinions against animal models, to propose that those models should be abandoned. Here, we critically examine aspects of animal models of PTSD that may have contributed to the relative lack of translatability, including the focus on the exposure to trauma, overlooking individual and sex differences, and the contribution of risk factors. Based on findings from recent years, we propose research-based modifications that we believe are required in order to overcome some of the shortcomings of previous practice. These modifications include the usage of animal models of PTSD which incorporate risk factors and of the behavioral profiling analysis of individuals in a sample. These modifications are aimed to address factors such as individual predisposition and resilience, thus taking into consideration the fact that only a fraction of individuals exposed to trauma develop PTSD. We suggest that with an appropriate shift of practice, animal models are not only a valuable tool to enhance our understanding of fear and memory processes, but could serve as effective platforms for understanding PTSD, for PTSD drug development and drug testing.

Anxiolytic-like effects of paeoniflorin in an animal model of post traumatic stress disorder

Post-traumatic stress disorder (PTSD) is the serious psychiatric disorder. Paeoniflorin (PF) produces the antidepressant-like properties. However, few studies are concerned about its anti-PTSD-like effects and mechanisms. To investigate these, the single prolonged stress (SPS) model was utilized. PTSD-like behavioral deficits in rats after exposure to SPS were improved by PF (10 and 20 mg/kg, i.p.), evidenced by blocking increased freezing time in contextual fear paradigm (CFP) and increased time and entries in open arms in elevated plus maze (EPM) test without affecting the locomotor activity in open field (OF) test. We also found that increased levels of corticosterone (Cort), corticotropin releasing hormone (CRH) and adrenocorticotropic hormone (ACTH) after exposure to SPS were reversed by PF (10 and 20 mg/kg, i.p.) in serum, respectively. Moreover, the decreased levels of serotonin (5-HT) and 5-Hydroxyindoleacetic acid (5-HIAA) in prefrontal cortex and hippocampus were reversed by PF (10 and 20 mg/kg, i.p.), respectively. In summary, the anti-PTSD-like activities of PF were associated with the modulation of HPA axis and 5-HT system activation.

No association between the serotonin transporter linked polymorphic region polymorphism and severity of posttraumatic stress disorder symptoms in combat veterans with or without comorbid depression

Since both posttraumatic stress disorder (PTSD) and depression are associated with disturbances in the serotoninergic system, the aim of the study was to determine the association between severity of PTSD symptoms, serotonin transporter polymorphism (5-HTTLPR) and platelet serotonin (5-HT) concentration, in male combat veterans with PTSD (n = 325), who were subdivided according to presence of comorbid depression. The methodological approach included the psychiatric diagnostic interviews and rating scales (SCID for DSM-IV, HDRS, CAPS), polymerase chain reaction for 5-HTTLPR genotyping and spectrophotofluorometric method for measuring the platelet 5-HT concentration. PTSD veterans without depression had more severe PTSD symptoms, and less severe depressive symptoms, than PTSD veterans with depression. 5-HTTLPR genotype frequencies did not differ between veterans with mild, moderate and severe PTSD symptoms, and between depressed and non-depressed PTSD veterans. No significant association was found between the severity of PTSD symptoms and 5-HTTLPR genotype. Platelet 5-HT concentration was similar in PTSD veterans, with or without comorbid depression, and between two groups subdivided according to the severity of PTSD symptoms or 5-HTTLPR genotype. The study confirmed, on ethnically homogenous groups of veterans with matched combat experience, a lack of association between the PTSD symptoms severity and 5-HTTLPR or platelet 5-HT concentration.

Efficacy and acceptability of atypical antipsychotics for the treatment of post-traumatic stress disorder: a meta-analysis of randomized, double-blind, placebo-controlled clinical trials

As some evidences demonstrated that atypical antipsychotics (AA) may be efficacious in treating post-traumatic stress disorder (PTSD), we preformed a meta-analysis of randomized, double-blind, placebo-controlled clinical trials (RCTs) of AAs for the treatment of PTSD. Two hundred and fifty one papers were searched and screened. Eight RCTs met the inclusion criteria. AAs may be superior to placebo in the treatment of PTSD, as indicated by the changes in Clinician Administered PTSD Scale (CAPS) total scores (weighted mean differences (WMD)=-5.89, 95% confidence interval (CI) [-9.21, -2.56], P=0.0005) and also in CAPS subscale intrusion (WMD=-2.58, 95% CI[-3.83, -1.33], P<0.0001 ) and subscale hyperarousal (WMD=-2.94, 95% CI[-5.45, -0.43], P=0.02). The acceptability measured by dropout rates between AAs and placebo showed no statistical difference (OR=1.24, 95%CI [0.78, 1.97], P=0.36). PTSD symptom cluster, especially in intrusion and hyperarousal. However, we should be careful to generalize the conclusion because of the small number of included trails. We expect more RCTs will be done in the future so as to clarify the specific value of AAs for PTSD.

Lamotrigine abolished aggression in a patient with treatment-resistant posttraumatic stress disorder

Lamotrigine is an antiepileptic drug with broad spectrum of actions, also approved for the treatment of bipolar disorder. Growing number of reports document the antiaggressive effect of lamotrigine in various psychiatric diseases. However, there has been only 1 study in the literature investigating the role of lamotrigine in posttraumatic stress disorder (PTSD), but its antiaggressive aspect was not observed. Although aggression is commonly associated with PTSD, there is paucity of data considering its management. We report a case of a patient with treatment-resistant PTSD, whose aggressive outbursts dominated his clinical picture and which were greatly improved after introducing lamotrigine in therapy. Our case suggests that lamotrigine may be useful in treating aggression and aggression-related symptoms in PTSD.

A new psychological intervention: "512 Psychological Intervention Model" used for military rescuers in Wenchuan Earthquake in China

OBJECTIVE

We sought to compare the efficacy of the "512 Psychological Intervention Model" (that is, "512 PIM", a new psychological intervention) with debriefing on symptoms of post-traumatic stress disorder (PTSD), anxiety and depression of Chinese military rescuers in relation to a control group that had no intervention.

METHOD

We conducted a randomized controlled trial with 2,368 military rescuers 1 month after this event and then at follow-up 1, 2 and 4 months later to evaluate changes in symptoms of PTSD, anxiety and depression based on DSM-IV criteria, respectively.

RESULTS

Baseline analysis suggested no significant differences between the study groups. Severity of PTSD, anxiety and depression decreased over time in all three groups, with significant differences between the groups in symptoms of PTSD (P < 0.01). Compared with the debriefing and control group, significant lower scores of PTSD and positive efficacy in improving symptoms of re-experiencing, avoidance and hyperarousal were found in the "512 PIM" group.

CONCLUSION

"512 PIM" was an effective psychological intervention for military rescuers in reducing symptoms of PTSD, anxiety and depression after a crisis.

Intracellular Loop 2 Peptides of the Human 5HT1a Receptor are Differential Activators of Gi

Peptide mimics of intracellular loop 2 (ic2) of the human 5HT1a receptor have been studied with respect to their ability to inhibit agonist binding via interference with receptor-G-protein coupling. These peptides give shallow concentration-effect relationships. Additionally, these peptides have been studied with respect to their ability to trigger the signal transduction system of this Gi-coupled receptor. Two signaling parameters have been quantified: concentration of intracellular cAMP and changes in incorporation into the G protein of a stable analog of GTP. In both cases, peptide mimics near midloop of ic2 actually show agonist activity with efficacy falling off toward both loop termini near TM 3 and TM 4. Previous results have suggested that the loop region near the TM3/ic2 interface is primarily responsible for receptor-G-protein coupling, while the current result emphasizes the mid-ic2 loop region's ability to activate the G protein following initial coupling. A limited number of peptides from the receptor's TM5/ic3 loop vicinity were also studied regarding agonist inhibition and G-protein activation. These peptides provide additional evidence that the human 5HT1a receptor, TM5/ic3 loop region, is involved in both coupling and activation actions. Overall, these results provide further information about potential pharmacological intervention and drug development with respect to the human 5HT1a receptor/G-protein system. Finally, the structural evidence generated here provides testable models pending crystallization and X-ray analysis of the receptor.

Patients with combat-related and war-related posttraumatic stress disorder 10 years after diagnosis

AIM

To establish how many patients diagnosed with posttraumatic stress disorder (PTSD) in 1996 used psychiatric facilities and had psychiatric symptoms 10 years later, and assess their sociodemographic characteristics, comorbid disorders, and type of treatment.

METHODS

Medical records of patients diagnosed with PTSD in 1996 were reviewed in the period 2007-2009 and the patients who contacted a psychiatrist in that period (n=85) and those who did not (n=158) were compared.

RESULTS

There were 36.7% of men and 20% of women diagnosed with PTSD in 1996 who contacted a psychiatrist in the period 2007-2009. Patients who contacted a psychiatrist and those who did not did not differ in sex, age, the number of visits and hospitalizations in 1996, and employment status. The majority of patients still had PTSD and/or were enduring personality change in the period 2007-2009, and 54.8% had some comorbidity (mostly depression, alcohol-related disorders, and personality disorders). Patients were most often treated with anxiolytics and antidepressants.

CONCLUSION

Ten years after the traumatic experience, one third of patients with PTSD received psychiatric help, regardless of their sex, age, and employment status. Half of them had comorbid disorders and the majority of them were treated with anxiolytics and antidepressants.

Tailoring therapeutic strategies for treating posttraumatic stress disorder symptom clusters

According to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, posttraumatic stress disorder (PTSD) is characterized by three major symptom clusters following an event that elicited fear, helplessness, or horror. This review will examine each symptom cluster of PTSD separately, giving case study examples of patients who exhibit a preponderance of a given symptom domain. We use a translational approach in describing the underlying neurobiology that is relevant to particular symptoms and treatment options, thus showing how clinical practice can benefit from current research. By focusing on symptom clusters, we provide a more specific view of individual patient's clinical presentations, in order to better address treatment needs. Finally, the review will also address potential genetic approaches to treatment as another form of individualized treatment.

Association of posttraumatic stress disorder with increased prevalence of metabolic syndrome

OBJECTIVE

Few studies have compared prevalence rates of metabolic abnormalities in antipsychotic-treated patients with different psychiatric disorders, including posttraumatic stress disorder (PTSD). In this study, we examined components of metabolic syndrome among middle-aged and older patients with psychiatric disorders.

METHOD

In the study, 203 outpatients older than 40 years and with psychotic symptoms that needed antipsychotic treatment were enrolled. Among them, 65 had a diagnosis of schizophrenia, 56 had dementia, 49 had mood disorder, and 33 had PTSD. Clinical evaluations included medical history, use of psychotropic and other medications, adverse effects, physical examination, and clinical laboratory tests for metabolic profiles.

RESULTS

Overall, the prevalence rates of metabolic syndrome were 72% in patients with PTSD, 60% in those with schizophrenia, 58% in those with mood disorder, and 56% in those with dementia. There were significant differences in body mass index, diastolic blood pressure, waist circumference, and high-density lipoprotein cholesterol among the 4 diagnostic groups. Posttraumatic stress disorder, schizophrenia, and mood disorder groups had significantly higher body mass indexes compared with the dementia group. The PTSD group also had significantly higher diastolic blood pressure compared with the dementia and mood disorder groups.

CONCLUSIONS

Posttraumatic stress disorder may be associated with worsened metabolic profile. The overall frequency of metabolic syndrome and its components in patients with PTSD taking antipsychotics seemed to be at least equivalent, if not slightly worse, compared with that in patients with schizophrenia, dementia, or a mood disorder.