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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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Krystal JH, Davis LL, Neylan TC, A Raskind M, Schnurr PP, Stein MB, Vessicchio J, Shiner B, Gleason TC, Huang GD. It Is Time to Address the Crisis in the Pharmacotherapy of Posttraumatic Stress Disorder: A Consensus Statement of the PTSD Psychopharmacology Working Group. Biol Psychiatry 2017; 82:e51-e59. [PMID: 28454621 DOI: 10.1016/j.biopsych.2017.03.007] [Citation(s) in RCA: 155] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 03/02/2017] [Accepted: 03/03/2017] [Indexed: 11/19/2022]
Affiliation(s)
- John H Krystal
- Departments of Psychiatry and Neuroscience, Yale University School of Medicine, New Haven; Clinical Neuroscience Division, National Center for PTSD, West Haven, Connecticut; Psychiatry Services, VA Connecticut Healthcare System, West Haven, Connecticut.
| | - Lori L Davis
- Development Service, Tuscaloosa VA Medical Center, Tuscaloosa; Department of Psychiatry, University of Alabama School of Medicine, Birmingham, Alabama
| | - Thomas C Neylan
- Department of Psychiatry, University of California, San Francisco; San Francisco VA Medical Center, San Francisco
| | - Murray A Raskind
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington; VA Puget Sound Health Care System, Seattle, Washington
| | - Paula P Schnurr
- Executive Division, National Center for PTSD, White River Junction, Vermont; Department of Psychiatry, Geisel School of Medicine at Dartmouth, White River Junction, Vermont
| | - Murray B Stein
- Departments of Psychiatry and Family Medicine & Public Health, University of California, San Diego, La Jolla; VA San Diego Healthcare System, San Diego, California
| | - Jennifer Vessicchio
- Clinical Neuroscience Division, National Center for PTSD, West Haven, Connecticut; Psychiatry Services, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Brian Shiner
- Executive Division, National Center for PTSD, White River Junction, Vermont; Department of Psychiatry, Geisel School of Medicine at Dartmouth, White River Junction, Vermont
| | - Theresa C Gleason
- Departments of Psychiatry and Neuroscience, Yale University School of Medicine, New Haven
| | - Grant D Huang
- Department of Veterans Affairs, Office of Research & Development, Washington, DC; Cooperative Studies Program Central Office, VA Office of Research and Development, Washington, DC
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Detweiler MB, Pagadala B, Candelario J, Boyle JS, Detweiler JG, Lutgens BW. Treatment of Post-Traumatic Stress Disorder Nightmares at a Veterans Affairs Medical Center. J Clin Med 2016; 5:jcm5120117. [PMID: 27999253 PMCID: PMC5184790 DOI: 10.3390/jcm5120117] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 10/28/2016] [Accepted: 12/09/2016] [Indexed: 11/17/2022] Open
Abstract
The effectiveness of medications for PTSD in general has been well studied, but the effectiveness of medicatio.ns prescribed specifically for post-traumatic stress disorder (PTSD) nightmares is less well known. This retrospective chart review examined the efficacy of various medications used in actual treatment of PTSD nightmares at one Veteran Affairs Hospital. Records at the Salem, VA Veterans Affairs Medical Center (VAMC) were examined from 2009 to 2013 to check for the efficacy of actual treatments used in comparis.on with treatments suggested in three main review articles. The final sample consisted of 327 patients and 478 separate medication trials involving 21 individual medications plus 13 different medication combinations. The three most frequently utilized medications were prazosin (107 trials), risperidone (81 trials), and quetiapine (72 trials). Five medications had 20 or more trials with successful results (partial to full nightmare cessation) in >50% of trials: risperidone (77%, 1.0–6.0 mg), clonidine (63%, 0.1–2.0 mg), quetiapine (50%, 12.5–800.0 mg), mirtazapine (50%; 7.5–30.0 mg), and terazosin (64%, 50.0–300.0 mg). Notably, olanzapine (2.5–10.0) was successful (full remission) in all five prescription trials in five separate patients. Based on the clinical results, the use of risperidone, clonidine, terazosin, and olanzapine warrants additional investigation in clinically controlled trials as medications prescribed specifically for PTSD nightmares.
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Affiliation(s)
- Mark B Detweiler
- Staff Psychiatrist, Veterans Affairs Medical Center, Salem, VA 24153, USA.
- Department Psychiatry, Edward via College of Osteopathic Medicine, Blacksburg, VA 24060, USA.
- Virginia Tech-Carilion Clinic Psychiatry Residency Program, Roanoke, VA 24014, USA.
- Geriatric Research Group, Veterans Affairs Medical Center, Salem, VA 24153, USA.
| | | | - Joseph Candelario
- Geriatric Research Group, Veterans Affairs Medical Center, Salem, VA 24153, USA.
- Emergency Department, Veterans Affairs Medical Center, Salem, VA 24153, USA.
| | - Jennifer S Boyle
- Attending Physician, Veterans Affairs Medical Ce.nter, Syracuse, NY 13210, USA.
| | - Jonna G Detweiler
- Geriatric Research Group, Veterans Affairs Medical Center, Salem, VA 24153, USA.
| | - Brian W Lutgens
- Geriatric Research Group, Veterans Affairs Medical Center, Salem, VA 24153, 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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Detweiler MB, Khachiyants N, Detweiler JG, Ali R, Kim KY. Risperidone for post-traumatic combat nightmares: a report of four cases. ACTA ACUST UNITED AC 2014; 26:920-8. [PMID: 22155575 DOI: 10.4140/tcp.n.2011.920] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To report the response to low-dose risperidone in individuals with combat-related post-traumatic stress disorder (PTSD) combat nightmares. DESIGN Case series. SETTING Veterans Affairs Medical Center Mental Health Clinic and collaborative VA-U.S. Army Fort Bragg Warrior Transition Telepsychiatry Clinic. PRACTICE DESCRIPTION Veterans at the VA; soldiers that have severe medical and mental health problems in the Warrior Transition Telepsychiatry Clinic. MAIN OUTCOME MEASURE(S) No response: no change in frequency and/or severity of nightmares; partial response: decrease in frequency and/or severity of nightmares; full response: total cessation of recall of nightmares. RESULTS The four individuals included one active duty soldier and three veterans, ranging from 40 to 76 years of age. All served in the infantry, each in a different combat theater. Two participants had a reduction in the frequency and severity of nightmares at risperidone 1 mg at night. One veteran with blood alcohol levels greater than 300 mg/mL had a partial response with risperidone 3 mg at night. Without active substance abuse, the four individuals had a total cessation of nightmares the first night at a risperidone dose of 2 mg at night. The total cessation of nightmares with risperidone continued despite changes in concurrent antidepressants, anxiolytics, and hypnotics. No medication side effects were reported. CONCLUSION The use of low-dose risperidone (1-3 mg) at night can reduce the severity and frequency or stop the recall of PTSD combat nightmares in some veterans and active duty soldiers. Risperidone may be an effective medication for combat nightmares of PTSD and merits additional exploration.
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Affiliation(s)
- Mark B Detweiler
- Geriatric Research Group, Veterans Affairs Medical Center (VAMC), Virginia Tech-Carilion School of Medicine, Salem, Virginia, Roanoke
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Bajor LA, Ticlea AN, Osser DN. The Psychopharmacology Algorithm Project at the Harvard South Shore Program: an update on posttraumatic stress disorder. Harv Rev Psychiatry 2011; 19:240-58. [PMID: 21916826 DOI: 10.3109/10673229.2011.614483] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND This project aimed to provide an organized, sequential, and evidence-supported approach to the pharmacotherapy of posttraumatic stress disorder (PTSD), following the format of previous efforts of the Psychopharmacology Algorithm Project at the Harvard South Shore Program. METHOD A comprehensive literature review was conducted to determine the best pharmacological choices for PTSD patients and to update the last published version (1999) of the algorithm. We focused on optimal pharmacological interventions to address the prominent symptoms of PTSD, with additional attention to the impact that common comorbidities have on treatment choices. RESULTS We found that SSRIs and SNRIs are not as effective as previously thought, and that awareness of their long-term side effects has increased. New evidence suggests that addressing fragmented sleep and nightmares can improve symptoms (in addition to insomnia) that are frequently seen with PTSD (e.g., hyperarousal, reexperiencing). Prazosin and trazodone are emphasized at this initial step; if significant PTSD symptoms remain, an antidepressant may be tried. For PTSD-related psychosis, an antipsychotic may be added. In resistant cases, two or three antidepressants may be used in sequence. Following that, or with partial improvement and residual symptomatology, augmentation may be tried; the best options are antipsychotics, clonidine, topiramate, and lamotrigine. CONCLUSION This heuristic may be helpful in producing faster symptom resolution, fewer side effects, and increased compliance.
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Affiliation(s)
- Laura A Bajor
- Harvard Medical School, Harvard South Shore Psychiatry Residency Training Program, Brockton, MA 02301, USA
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Peterson AL, Luethcke CA, Borah EV, Borah AM, Young-McCaughan S. Assessment and Treatment of Combat-Related PTSD in Returning War Veterans. J Clin Psychol Med Settings 2011; 18:164-75. [DOI: 10.1007/s10880-011-9238-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Davidson JR, Zhang W, Connor KM, Ji J, Jobson K, Lecrubier Y, McFarlane AC, Newport DJ, Nutt DJ, Osser DN, Stein DJ, Stowe ZN, Tajima O, Versiani M. A psychopharmacological treatment algorithm for generalised anxiety disorder (GAD). J Psychopharmacol 2010; 24:3-26. [PMID: 18832431 PMCID: PMC2951594 DOI: 10.1177/0269881108096505] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Generalised anxiety disorder (GAD) is defined as excessive and uncontrollable worry and anxiety about everyday life situations. It is a chronic disorder, and is associated with substantial somatisation, high rates of comorbid depression and other anxiety disorders, and significant disability. The evidence base for pharmacotherapy and psychotherapy has continued to grow, and a wide range of drug choices for GAD now exists. Current guidelines for GAD generally restrict themselves to presentation of the evidence for various treatments, which, as a result, generally do not offer detailed discussion or recommendation of strategies beyond the first level of treatment, or take into account the individual circumstances of the patient. Thus, there is a lack of algorithm-based treatment guidelines for GAD. Our aim is, therefore, to present an algorithm for the psychopharmacologic management of GAD, intended for all clinicians who treat patients with GAD, where issues of pharmacotherapy are under consideration. We also hope that these GAD algorithms and other guidelines can help to identify high-priority areas that need further study. In this algorithm, we provide a sequenced approach to the pharmacotherapy of GAD, taking into account salient symptomatology and comorbidity, levels of evidence and extent of response. Special issues, including comorbidity, insomnia, suicidality, substance abuse, treatment adherence, pregnancy and lactation, cross-cultural issues, use of medication in the elderly, psychosocial treatment and dosing issues are also addressed.
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Affiliation(s)
- JR Davidson
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - W. Zhang
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - KM Connor
- Clinical Neuroscience and Ophthalmology, Merck Research Laboratories, Merck & Co., Inc., North Wales, PA, USA
| | - J. Ji
- Department of Psychological Medicine, Zhongshan Hospital, Shanghai, China; Department of Mental Health, Shanghai Medical School, Fudan University
| | - K. Jobson
- Department of Psychiatry, University of Tennessee, Knoxville, TN, USA
| | - Y. Lecrubier
- European College of Neuropsychopharmacology, Hôpital La Salpetriere, Paris, France
| | - AC McFarlane
- The University of Adelaide, Centre for Military and Veterans' Health, Adelaide, SA, Australia
| | - DJ Newport
- Women's Mental Health Program, Emory University School of Medicine, Atlanta, GA , USA
| | - DJ Nutt
- Psychopharmacology Unit, Department of Community-based Medicine, University of Bristol, Bristol, UK
| | - DN Osser
- Department of Psychiatry, Harvard Medical School, VA Boston Healthcare System, Brockton, MA, USA
| | - DJ Stein
- Department of Psychiatry and Mental Health, University of Capetown, Cape Town, South Africa
| | - ZN Stowe
- Women's Mental Health Program, Emory University School of Medicine, Atlanta, GA, USA
| | - O. Tajima
- Department of Mental Health, Kyorin University, School of Health Sciences, Tokyo, Japan
| | - M. Versiani
- Institute of Psychiatry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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Corchs F, Nutt DJ, Hood S, Bernik M. Serotonin and sensitivity to trauma-related exposure in selective serotonin reuptake inhibitors-recovered posttraumatic stress disorder. Biol Psychiatry 2009; 66:17-24. [PMID: 19268914 DOI: 10.1016/j.biopsych.2009.01.031] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2008] [Revised: 01/07/2009] [Accepted: 01/23/2009] [Indexed: 11/20/2022]
Abstract
BACKGROUND Selective serotonin reuptake inhibitors (SSRIs) are first-line treatments for posttraumatic stress disorder (PTSD). Serotonergic (5HT) attenuation of stress sensitivity is postulated from SSRIs' effects in other anxiety disorders, and we studied this in PTSD. METHODS Ten patients with PTSD fully recovered on SSRIs (Clinical Global Impression Scale-I 1 and 2) were enrolled in the study. Patients were tested on two occasions 1 week apart; in each session, they received a drink containing large neutral amino acids (LNAAs) either with (sham tryptophan depletion [STD], control) or without (acute tryptophan depletion [ATD]) tryptophan. At 5.5 hours after the drink, subjects were exposed to a trauma-related exposure challenge. Self-reports of PTSD (visual analogue scales [VAS] and the Davidson Trauma Scale [DTS]), anxiety (Spielberger State Inventory [STAI] Form Y-1), and mood (Profile of Mood States [POMS]) were obtained. Heart rate (HR), systolic (SBP) and diastolic (DBP) blood pressure were also measured. RESULTS The trauma-related exposure challenge induced anxiety on both days, with more marked responses on the ATD day according to VAS, DTS, POMS, and DBP (p < .05). A trend of significance (.1 > p > .05) was observed for STAI Form Y-1, HR, and SBP. CONCLUSIONS These data demonstrate that ATD accentuates responses to trauma-related stimuli in SSRI-recovered PTSD. They also suggest that SSRI-induced increases in serotonin function restrain PTSD symptoms, especially under provocation, supporting a role for serotonin in mediating stress resilience.
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Affiliation(s)
- Felipe Corchs
- Anxiety Disorders Unit, Department and Institute of Psychiatry, University of São Paulo, Brazil.
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Abstract
PURPOSE OF REVIEW This review provides an update on contemporary perspectives on post-traumatic stress disorder and challenges myths about the disorder and its treatment. Post-traumatic stress disorder has recently attracted public attention because of the impact of international terrorism, although the vast majority of post-traumatic stress disorder cases actually relate to civilian events such as car accidents, rape and violent robbery. This disorder requires deeper understanding and consensus among professionals. RECENT FINDINGS Advances have been made in elucidating the neurobiology of this disorder, partly by using an animal model of post-traumatic stress disorder. Recent studies have focused on memory processes and the therapeutic role played by plasticity of the hypothalamic-pituitary-adrenal axis, and how this fits (or does not fit) in with the current therapeutic interventions. Guidelines have been established by various bodies in an attempt to streamline treatment options. SUMMARY Understanding of post-traumatic stress disorder is incomplete. Future research should attempt to determine what treatments given during the 'window of opportunity' - the time from exposure until post-traumatic stress disorder develops - are effective. Care should be taken not to interfere with spontaneous recovery.
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Boehnlein JK, Kinzie JD. Pharmacologic reduction of CNS noradrenergic activity in PTSD: the case for clonidine and prazosin. J Psychiatr Pract 2007; 13:72-8. [PMID: 17414682 DOI: 10.1097/01.pra.0000265763.79753.c1] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This article reviews the neurobiologic rationale for and presents clinical guidance concerning the use of medications that reduce central nervous system noradrenergic activity in the treatment of intrusive symptoms of posttraumatic stress disorder. The authors reviewed neurobiological studies, nonclinical studies using animal models, clinical case reports, open-label drug studies, and blinded, placebo-controlled drug studies. This review of the basic science and clinical literature, and the authors' clinical experience with culturally and demographically diverse populations, indicate that clonidine and prazosin can play a useful role in treating sleep disturbance and hyperarousal in posttraumatic stress disorder, with minimal adverse effects and low financial cost.
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Affiliation(s)
- James K Boehnlein
- Department of Psychiatry, Oregon Health & Science University, Portland, OR 97239, USA.
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