Pharmacotherapy of PTSD: Current Status and Controversies

Identifying individuals with undiagnosed post-traumatic stress disorder in a large United States civilian population - a machine learning approach

BACKGROUND

The proportion of patients with post-traumatic stress disorder (PTSD) that remain undiagnosed may be substantial. Without an accurate diagnosis, these patients may lack PTSD-targeted treatments and experience adverse health outcomes. This study used a machine learning approach to identify and describe civilian patients likely to have undiagnosed PTSD in the US commercial population.

METHODS

The IBM® MarketScan® Commercial Subset (10/01/2015-12/31/2018) was used. A random forest machine learning model was developed and trained to differentiate between patients with and without PTSD using non-trauma-based features. The model was applied to patients for whom PTSD status could not be confirmed to identify individuals likely and unlikely to have undiagnosed PTSD. Patient characteristics, symptoms and complications potentially related to PTSD, treatments received, healthcare costs, and healthcare resource utilization were described separately for patients with PTSD (Actual Positive PTSD cohort), patients likely to have PTSD (Likely PTSD cohort), and patients without PTSD (Without PTSD cohort).

RESULTS

A total of 44,342 patients were classified in the Actual Positive PTSD cohort, 5683 in the Likely PTSD cohort, and 2,074,471 in the Without PTSD cohort. While several symptoms/comorbidities were similar between the Actual Positive and Likely PTSD cohorts, others, including depression and anxiety disorders, suicidal thoughts/actions, and substance use, were more common in the Likely PTSD cohort, suggesting that certain symptoms may be exacerbated among those without a formal diagnosis. Mean per-patient-per-6-month healthcare costs were similar between the Actual Positive and Likely PTSD cohorts ($11,156 and $11,723) and were higher than those of the Without PTSD cohort ($3616); however, cost drivers differed between cohorts, with the Likely PTSD cohort experiencing more inpatient admissions and less outpatient visits than the Actual Positive PTSD cohort.

CONCLUSIONS

These findings suggest that the lack of a PTSD diagnosis and targeted management of PTSD may result in a greater burden among undiagnosed patients and highlights the need for increased awareness of PTSD in clinical practice and among the civilian population.

Anxiolytic effect of minocycline in posttraumatic stress disorder model of Syrian hamsters

OBJECTIVE

The objective was to study the anxiolytic effect of minocycline in resident-intruder social conflict in submissive hamsters post resident intrusion model using open field test (OFT) and elevated plus maze (EPM) and serum cortisol levels.

MATERIALS AND METHODS

Fifty-two singly housed male Syrian hamsters were used, post standardization of an animal model. Resident intrusion was done (5 min), in which smaller hamsters were placed in the cage of larger hamster, and the behavior of smaller hamster was noted. Eight submissive hamsters per group (disease control, lorazepam group as a positive control, and the test drug was minocycline) were used, and the drug was administered immediately post resident intrusion, intraperitoneally. Behavioral tests, namely OFT and EPM, were done followed by retro-orbital blood collection for serum cortisol estimation. The level of significance was set at P < 0.05.

RESULTS

The minocycline group showed a statistically significant decrease in serum cortisol levels compared to the disease control group. Among all the variables pertaining to both the behavioral tests, namely EPM and OFT, the results indicated an anxiolytic effect, which was statistically significant compared to the disease control group.

CONCLUSION

As per the biochemical test using serum cortisol levels and behavioral tests in the form of EPM and OFT, the study concluded that the anxiolytic effect of minocycline is at least comparable to the positive control, lorazepam.

Symptom structure of PTSD and co-morbid depressive symptoms - a network analysis of combat veteran patients

BACKGROUND

Despite extensive research, symptom structure of posttraumatic stress disorder (PTSD) is highly debated. The network approach to psychopathology offers a novel method for understanding and conceptualizing PTSD. However, extant studies have mainly used small samples and self-report measures among sub-clinical populations, while also overlooking co-morbid depressive symptoms.

METHODS

PTSD symptom network topology was estimated in a sample of 1489 treatment-seeking veteran patients based on a clinician-rated PTSD measure. Next, clinician-rated depressive symptoms were incorporated into the network to assess their influence on PTSD network structure. The PTSD-symptom network was then contrasted with the network of 306 trauma-exposed (TE) treatment-seeking patients not meeting full criteria for PTSD to assess corresponding network differences. Finally, a directed acyclic graph (DAG) was computed to estimate potential directionality among symptoms, including depressive symptoms and daily functioning.

RESULTS

The PTSD symptom network evidenced robust reliability. Flashbacks and getting emotionally upset by trauma reminders emerged as the most central nodes in the PTSD network, regardless of the inclusion of depressive symptoms. Distinct clustering emerged for PTSD and depressive symptoms within the comorbidity network. DAG analysis suggested a key triggering role for re-experiencing symptoms. Network topology in the PTSD sample was significantly distinct from that of the TE sample.

CONCLUSIONS

Flashbacks and psychological reactions to trauma reminders, along with their strong connections to other re-experiencing symptoms, have a pivotal role in the clinical presentation of combat-related PTSD among veterans. Depressive and posttraumatic symptoms constitute two separate diagnostic entities, but with meaningful between-disorder connections, suggesting two mutually-influential systems.

Bias-contingent attention bias modification and attention control training in treatment of PTSD: a randomized control trial

BACKGROUND

Randomized control trials (RCTs) comparing attention control training (ACT) and attention bias modification (ABM) in posttraumatic stress disorder (PTSD) have shown mixed results. The current RCT extends the extant literature by comparing the efficacy of ACT and a novel bias-contingent-ABM (BC-ABM), in which direction of training is contingent upon the direction of pre-treatment attention bias (AB), in a sample of civilian patients with PTSD.

METHODS

Fifty treatment-seeking civilian patients with PTSD were randomly assigned to either ACT or BC-ABM. Clinician and self-report measures of PTSD and depression, as well as AB and attention bias variability (ABV), were acquired pre- and post-treatment.

RESULTS

ACT yielded greater reductions in PTSD and depressive symptoms on both clinician-rated and self-reported measures compared with BC-ABM. The BC-ABM condition successfully shifted ABs in the intended training direction. In the ACT group, there was no significant change in ABV or AB from pre- to post-treatment.

CONCLUSIONS

The current RCT extends previous results in being the first to apply ABM that is contingent upon AB at pre-treatment. This personalized BC-ABM approach is associated with significant reductions in symptoms. However, ACT produces even greater reductions, thereby emerging as a promising treatment for PTSD.

Correlations of Four Genetic Single Nucleotide Polymorphisms in Brain-Derived Neurotrophic Factor with Posttraumatic Stress Disorder

OBJECTIVE

To investigate the correlations of four genetic single nucleotide polymorphisms (SNPs) of brain-derived neurotrophic factor (BDNF) with posttraumatic stress disorder (PTSD).

METHODS

A total of 300 patients with sporadic PTSD and 150 healthy subjects (the control group) were selected according to the diagnostic criteria of PTSD (DSM-IV), and the genotypes of the BDNF SNPs G-712A, C270T, rs6265, and rs7103411 were detected by polymerase chain reaction and direct DNA sequencing to determine intergroup differences in the genotypes and allele frequencies; the p values were corrected with the permutation test.

RESULTS

The genotypes and allele frequencies of the SNPs G-712A, rs6265, and rs7103411 of BDNF showed no significant intergroup differences (p>0.05). However, the genotype and allele frequencies of C270T showed significant differences between the PTSD group and the control group (p<0.05).

CONCLUSION

The SNP C270T of BDNF may be associated with PTSD. Individuals carrying the polymorphic T allele of C270T may be more likely to suffer from PTSD.

Newer insights into the role of miRNA a tiny genetic tool in psychiatric disorders: focus on post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is a mental disorder occurring in about 2-9% of individuals after their exposure to life-threatening events, such as severe accidents, sexual abuse, combat or a natural catastrophe. Because PTSD patients are exposed to trauma, it is likely that epigenetic modifications have an important role in disease development and prognosis. For the past two decades, abnormal expression of the epigenetic regulators microRNAs (miRs) and miR-mediated gene regulation have been given importance in a variety of human diseases, such as cancer, heart disease and viral infection. Emerging evidence supports a role for miR dysregulation in psychiatric and neurological disorders, including schizophrenia, bipolar disorder, anxiety, major depressive disorder, autism spectrum disorder and Tourette's syndrome. Recently mounting of evidence supports the role of miR both in preclinical and clinical settings of psychiatric disorders. Abnormalities in miR expression can fine-tune the expression of multiple genes within a biological network, suggesting that miR dysregulation may underlie many of the molecular changes observed in PTSD pathogenesis. This provides strong evidence that miR not only has a critical role in PTSD pathogenesis, but can also open up new avenues for the development of diagnostic tools and therapeutic targets for the PTSD phenotype. In this review, we revisit some of the recent evidence associated with miR and PTSD in preclinical and clinical settings. We also discuss the possible clinical applications and future use of miRs in PTSD therapy.

Post-traumatic stress disorder: ethical and legal relevance to the criminal justice system

Post-Traumatic Stress Disorder is a major public health concern in both civilian and military populations, across race, age, gender, and socio-economic status. While PTSD has been around for centuries by some name or another, its definition and description also continue to evolve. Within the last few years, the American Psychological Association has published the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders, which includes some major changes in the diagnostic criteria for PTSD. Recent data on epidemiology, etiological theories, and empirically supported methods of treatment, as well as implications for legal processes and criminal justice system personnel, are discussed.

Psychopharmacological treatment for military posttraumatic stress disorder: an integrative review

PURPOSE

Posttraumatic stress disorder (PTSD) is a serious mental health disorder. The current first-line psychopharmacologic treatment for PTSD is selective serotonin reuptake inhibitors (SSRIs). Recently, the efficacy of SSRIs has been challenged in favor of propranolol use. This article reviews the origins of PTSD, its impact within the veteran population, psychopharmacological treatment of PTSD, and current literature on the use of propranolol for PTSD treatment.

DATA SOURCES

The search strategies used included ProQuest, Medline, CINAHL, and Psychiatry Online and were searched using the key terms: PTSD, psychopharmacological treatment, SSRIs, propranolol, military, and veterans in multiple combinations.

CONCLUSIONS

Studies to date indicate that (a) SSRIs are only moderately effective as a first-line treatment for PTSD and less so for military personnel, (b) propranolol has the ability to attenuate traumatic memory in primary and tertiary use, and (c) ethical and moral consideration as well as further research and testing is needed for substantiating propranolol as a first-line PTSD psychopharmacological treatment.

IMPLICATIONS FOR PRACTICE

Current research has shown propranolol to be an effective treatment option for PTSD.

Salem VAMC-U.S. Army Fort Bragg Warrior Transition Clinic telepsychiatry collaboration: 12-month operation clinical perspective

OBJECTIVE

To describe the clinical experience in the first Veterans Affairs (VA)-U.S. Army Warrior Transition Clinic (WTC) telepsychiatry operation (September 2008-August 2009).

MATERIALS

Joint VA and U.S. Army records.

METHODS

Analysis of intake, follow-up, and last visit records.

RESULTS

One hundred twenty active-duty U.S. Army soldiers were seen (394 clinic visits). Ninety-eight soldiers had one or more combat tours, principally in Iraq and Afghanistan. Posttraumatic stress disorder was diagnosed in 50.0% of the cases by the WTC telepsychiatrists. The majority of the soldiers had medical comorbidities, especially chronic pain (75.0%), in addition to mental health problems. Several of the soldiers were recovering from trauma (20.8%) and/or surgery (23.3%), 11.7% exhibited traumatic brain injuries, and 17.5% had headaches. Disrupted relationships (74.2%) were notable for non-family members, especially military cohorts such as other persons in the same WTC squad or platoon.

CONCLUSION

The observations in this report come from a cross-section of soldiers who were triaged to meet WTC admission criteria. As this is the prototype VA-U.S. Army telepsychiatry collaboration, there are no comparative data at this time. The nature of the medical and psychiatric problems treated in the military WTC represents an index of the more severe combat trauma treated on military bases from ongoing combat operations and may predict future VA-U.S. Army collaborative telepsychiatry clinic experiences.