Pharmacotherapy of Combat-stress-related Post Traumatic Stress Disorder

ANNALS Winter 2007and addiction.
This 1-credit continuing education opportunity isVeterans with PTSD find it hard both to fall asleep and
co-sponsored by the American College of Forensicto maintain sleep due to hyperarousal and vivid
Examiners International (ACFEI) and the Americannightmares related to combat. Significant others often
Psychotherapy Association. ACFEI maintainsreport that patients scream in their sleep and may
responsibility for all continuing education accreditations.even wake up soaked in sweat. Prasozin and clonidine
This article is approved by the following for 1 continuingboth decrease the central nervous system's
education credit:noradrenergic activity. They have been found to be
APA provides this continuing education credit foreffective in decreasing hyperarousal symptoms and
Diplomates.improving sleep (Boehnlein, 2007). Other drugs used for
The American College of Forensic Examinerssleep are the benzodiazepine class of drugs, like
International is approved by the Americantemazepam, and non-benzodiazepines, like zolpidem
Psychological Association to sponsor continuing(Ambien™) and ezopiclone
education for psychologists. ACFEI maintains(Lunesta™). However, caution must
responsibility for this program and its content.be taken regarding the habit-forming potential of these
The American College of Forensic Examinersdrugs (Bhagar and Schmetzer, 2006).
International is accredited by the Accreditation CouncilThe presence of psychotic symptoms in PTSD can
for Continuing Medical Education to provide continuingfurther complicate the clinical picture. In one study, 20%
medical education for physicians. This activity has beenof the 91 males with combat-stress-related PTSD
planned and implemented in accordance with thewere found to be suffering from hallucinations and
Essential Areas and Policies of the Accreditationdelusions, and hyperarousal was positively associated
Council for Continuing Medical Education (ACCME).with the occurrence of psychotic symptoms (Kastelan,
The American College of Forensic Examiners2007). In a small study, augmentation of SSRI with
International designates this educational activity for aolanzapine (Zyprexa), an atypical antipsychotic, was
maximum of 1 hour AMA PRA Category 1effective in treating SSRI-resistant combat-related
Credits™.. Physicians should onlyPTSD symptoms, especially sleep (Stein, 2002). In
claim credit commensurate with the extent of theiranother study, monotherapy with typical or atypical
participation in the activity.antipsychotics, reduced both PTSD and psychotic
By Harpriya A. (Sonya) Bhagar, MBBS and Alan D.symptoms, and antipsychotics seemed to offer
Schmetzer, MD, Fellow of the Americananother approach to treat the psychotic subtype of
Psychotherapy Association, and Master Therapistcombat-related PTSD resistant to previous
A number of veterans from Operation Iraqi Freedomantidepressant therapy (Pivac, 2006).
Operation Enduring Freedom (OIF/OEF) are returningOverall, PTSD pharmacotherapy involves several
home with signs of combat-stress-related Postdrugs based on our experience with PTSD in general,
Traumatic Stress Disorder (PTSD). In a recent study,but well-designed studies are needed to establish
16.6% of the soldiers met the screening criteria fortreatment guidelines specifically for
PTSD. On average, they showed a significant increasecombat-stress-related PTSD.
in sick visits, missed workdays, severity of somaticReferences
symptoms, and poorer overall health (Hoge et al.,Asnis, G. M., Kohn, S. R., Henderson, M., & Brown, N. L.
2007). In another study, the youngest age group, 18-24(2004). SSRIs versus non-SSRIs in post traumatic
years, was at greater risk compared with veterans 40stress disorder: an update with recommendations.
years of age or above. Diagnosis was made earlyDrugs, 64(4), 383-404.
(median of 13 days), and most of them were detectedBhagar, H. A., & Schmetzer, A. D. (2006). The newest
in primary care clinics (Seal et al., 2007).medicines for sleep. Annals of American
Upon return from the war zone, veterans frequentlyPsychotherapy Association, 9(2), 25-26.
report intrusive thoughts, flashbacks, increasedBoehnlein, J. K., & Kinzie, J. D. (2007). Pharmacologic
vigilance, avoidance of social situations, hyperarousal,reduction of CNS noradrenergic activity in PTSD: The
and nightmares. Treatment involves integration ofcase for clonidine and prazosin. Journal of Psychiatric
mental health, primary care, physical medicine, attentionPractice, 13(2), 72-78.
to substance abuse, and vocational services. TheDavidson, J., Baldwin D., Stein, D.J., Kuper, E., Benattia, I.,
mental health portion involves an initial screening of theAhmed, S., et al. (2006). Treatment of post traumatic
combat veteran for PTSD and other mental illnesses,stress disorder with venlafaxine extended release: a
followed by a full assessment. Both pharmacotherapy6-month randomized controlled trial. Archives of
and psychotherapy (individual, couple, and group) areGeneral Psychiatry, 63(10), 1158-1165.
offered for treatment.Hoge, C. W., Terhakopian, A., Castro, C. A., Messer, S.
From a pharmacological perspective, several studiesC., & Engel, C. C. (2007). Association of post traumatic
have found the traditional anti-depressants effective instress disorder with somatic symptoms, health care
PTSD. Selective serotonin reuptake inhibitors (SSRIs),visits, and absenteeism among Iraq war veterans.
like sertraline (ZoloftÂ(R)), paroxetineAmerican Journal of Psychiatry,164(1), 150-153.
(PaxilÂ(R)), and fluoxetine (ProzacÂ(R)),Kastelan, A., Franciskovi,? T., Moro, L., Roncevic-Grzeta,
have been studied extensively for PTSD, andI., Grkovic, J., Jurcan, V., et al. (2007). Psychotic
sertraline and paroxetine have been approved by thesymptoms in combat-related post traumatic stress
Food and Drug Administration for PTSD. SSRIs havedisorder. Military Medicine, 172(3), 273-277.
been found to be effective both in short-term trials andKim, W., Pae, C. U., Chae, J. H., Jun, T. Y., & Bahk, W. M.
long-term maintenance treatment for relapse(2005). The effectiveness of mirtazapine in the
prevention (Asnis et al., 2004). However, earlier studiestreatment of post-traumatic stress disorder: A
have focused mainly on PTSD secondary to24-week continuation therapy. Psychiatry and Clinical
interpersonal trauma in a civilian setting. In a multicenterNeurosciences, 59(6), 743-747.
study, venlafaxine extended release (EffexorKosten, T. R., Frank, J. B., Dan, E., McDougle, C. J., &
XRÂ(R)), a serotonin norepinephrine reuptakeGille, E. L., Jr. (1991). Pharmacotherapy for posttraumatic
inhibitor, was found to improve both the re-experiencingstress disorder using phenelzine or imipramine. Journal
and the avoidance symptoms of PTSD, but notof Nervous and Mental Disease, 179(6), 366-370.
hyperarousal. The drug was effective and wellMartényi, F. (2005). [Three paradigms in
tolerated in both short-term and continuation treatmentthe treatment of posttraumatic stress disorder].
of PTSD (Davidson et al., 2006). In a small study,Neuropsychopharmacol Hung, 7(1), 11-21.
mirtazapine (Remeron) was found to be effective inPivac, N., & Kozari?-Kovaci,? D. (2006).
both short-term and continuation treatment ofPharmacotherapy of treatment-resistant
combat-stress-related PTSD without any serious sidecombat-related posttraumatic stress disorder with
effects (Kim et al., 2005). In addition, sedation frompsychotic features. Croatian Medical Journal, 47(3),
mirtazapine can even prove beneficial in improving440-451.
sleep in PTSD. In a randomized trial comparingSeal, K. H., Bertenthal, D., Miner, C. R., Sen, S., & Marmar,
phenelzine (a monoamine oxidase inhibitor) andC. (2007). Bringing the war back home: mental health
imipramine (a tricyclic antidepressant), both significantlydisorders among 103,788 US veterans returning from
reduced combat stress related PTSD symptomsIraq and Afghanistan seen at Department of Veterans
(Kosten et al., 1991). Benzodiazepines are used inAffairs facilities. Archives of Internal Medicine, 167(5),
PTSD for panic attacks or anxiety states. They476-482.
provide temporary relief but run the risk of tolerance