| ANNALS Winter 2007 | | | | Veterans with PTSD find it hard both to fall asleep and |
| This 1-credit continuing education opportunity is | | | | to maintain sleep due to hyperarousal and vivid |
| co-sponsored by the American College of Forensic | | | | nightmares related to combat. Significant others often |
| Examiners International (ACFEI) and the American | | | | report that patients scream in their sleep and may |
| Psychotherapy Association. ACFEI maintains | | | | even wake up soaked in sweat. Prasozin and clonidine |
| responsibility for all continuing education accreditations. | | | | both decrease the central nervous system’s |
| This article is approved by the following for 1 continuing | | | | noradrenergic activity. They have been found to be |
| education credit: | | | | effective in decreasing hyperarousal symptoms and |
| APA provides this continuing education credit for | | | | improving sleep (Boehnlein, 2007). Other drugs used for |
| Diplomates. | | | | sleep are the benzodiazepine class of drugs, like |
| The American College of Forensic Examiners | | | | temazepam, and non-benzodiazepines, like zolpidem |
| International is approved by the American | | | | (Ambien™) and ezopiclone (Lunesta™). However, |
| Psychological Association to sponsor continuing | | | | caution must be taken regarding the habit-forming |
| education for psychologists. ACFEI maintains | | | | potential of these drugs (Bhagar and Schmetzer, |
| responsibility for this program and its content. | | | | 2006). |
| The American College of Forensic Examiners | | | | The presence of psychotic symptoms in PTSD can |
| International is accredited by the Accreditation Council | | | | further complicate the clinical picture. In one study, 20% |
| for Continuing Medical Education to provide continuing | | | | of the 91 males with combat-stress-related PTSD |
| medical education for physicians. This activity has been | | | | were found to be suffering from hallucinations and |
| planned and implemented in accordance with the | | | | delusions, and hyperarousal was positively associated |
| Essential Areas and Policies of the Accreditation | | | | with the occurrence of psychotic symptoms (Kastelan, |
| Council for Continuing Medical Education (ACCME). | | | | 2007). In a small study, augmentation of SSRI with |
| The American College of Forensic Examiners | | | | olanzapine (Zyprexa), an atypical antipsychotic, was |
| International designates this educational activity for a | | | | effective in treating SSRI-resistant combat-related |
| maximum of 1 hour AMA PRA Category 1 Credits™.. | | | | PTSD symptoms, especially sleep (Stein, 2002). In |
| Physicians should only claim credit commensurate with | | | | another study, monotherapy with typical or atypical |
| the extent of their 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 American | | | | another approach to treat the psychotic subtype of |
| Psychotherapy Association, and Master Therapist | | | | combat–related PTSD resistant to previous |
| A number of veterans from Operation Iraqi Freedom | | | | antidepressant therapy (Pivac, 2006). |
| Operation Enduring Freedom (OIF/OEF) are returning | | | | Overall, PTSD pharmacotherapy involves several |
| home with signs of combat-stress-related Post | | | | drugs 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 for | | | | treatment guidelines specifically for |
| PTSD. On average, they showed a significant increase | | | | combat-stress-related PTSD. |
| in sick visits, missed workdays, severity of somatic | | | | References |
| 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, | | | | (2004). SSRIs versus non-SSRIs in post traumatic |
| 18–24 years, was at greater risk compared with | | | | stress disorder: an update with recommendations. |
| veterans 40 years of age or above. Diagnosis was | | | | Drugs, 64(4), 383–404. |
| made early (median of 13 days), and most of them | | | | Bhagar, H. A., & Schmetzer, A. D. (2006). The newest |
| were detected in primary care clinics (Seal et al., 2007). | | | | medicines for sleep. Annals of American |
| Upon return from the war zone, veterans frequently | | | | Psychotherapy Association, 9(2), 25–26. |
| report intrusive thoughts, flashbacks, increased | | | | Boehnlein, 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 of | | | | case for clonidine and prazosin. Journal of Psychiatric |
| mental health, primary care, physical medicine, attention | | | | Practice, 13(2), 72–78. |
| to substance abuse, and vocational services. The | | | | Davidson, J., Baldwin D., Stein, D.J., Kuper, E., Benattia, I., |
| mental health portion involves an initial screening of the | | | | Ahmed, 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 pharmacotherapy | | | | 6-month randomized controlled trial. Archives of |
| and psychotherapy (individual, couple, and group) are | | | | General Psychiatry, 63(10), 1158–1165. |
| offered for treatment. | | | | Hoge, C. W., Terhakopian, A., Castro, C. A., Messer, S. |
| From a pharmacological perspective, several studies | | | | C., & Engel, C. C. (2007). Association of post traumatic |
| have found the traditional anti-depressants effective in | | | | stress disorder with somatic symptoms, health care |
| PTSD. Selective serotonin reuptake inhibitors (SSRIs), | | | | visits, and absenteeism among Iraq war veterans. |
| like sertraline (Zoloft®), paroxetine (Paxil®), and | | | | American Journal of Psychiatry,164(1), 150–153. |
| fluoxetine (Prozac®), have been studied extensively | | | | Kastelan, A., Franciskovi,? T., Moro, L., Roncevic-Grzeta, |
| for PTSD, and sertraline and paroxetine have been | | | | I., Grkovic, J., Jurcan, V., et al. (2007). Psychotic |
| approved by the Food and Drug Administration for | | | | symptoms in combat-related post traumatic stress |
| PTSD. SSRIs have been found to be effective both in | | | | disorder. Military Medicine, 172(3), 273–277. |
| short-term trials and long-term maintenance treatment | | | | Kim, W., Pae, C. U., Chae, J. H., Jun, T. Y., & Bahk, W. M. |
| for relapse prevention (Asnis et al., 2004). However, | | | | (2005). The effectiveness of mirtazapine in the |
| earlier studies have focused mainly on PTSD | | | | treatment of post-traumatic stress disorder: A |
| secondary to interpersonal trauma in a civilian setting. In | | | | 24-week continuation therapy. Psychiatry and Clinical |
| a multicenter study, venlafaxine extended release | | | | Neurosciences, 59(6), 743–747. |
| (Effexor XR®), a serotonin norepinephrine reuptake | | | | Kosten, T. R., Frank, J. B., Dan, E., McDougle, C. J., & |
| inhibitor, was found to improve both the re-experiencing | | | | Gille, E. L., Jr. (1991). Pharmacotherapy for posttraumatic |
| and the avoidance symptoms of PTSD, but not | | | | stress disorder using phenelzine or imipramine. Journal |
| hyperarousal. The drug was effective and well | | | | of Nervous and Mental Disease, 179(6), 366–370. |
| tolerated in both short-term and continuation treatment | | | | Martényi, F. (2005). [Three paradigms in the |
| of PTSD (Davidson et al., 2006). In a small study, | | | | treatment of posttraumatic stress disorder]. |
| mirtazapine (Remeron) was found to be effective in | | | | Neuropsychopharmacol Hung, 7(1), 11–21. |
| both short-term and continuation treatment of | | | | Pivac, N., & Kozari?-Kovaci,? D. (2006). |
| combat-stress-related PTSD without any serious side | | | | Pharmacotherapy of treatment-resistant |
| effects (Kim et al., 2005). In addition, sedation from | | | | combat-related posttraumatic stress disorder with |
| mirtazapine can even prove beneficial in improving | | | | psychotic features. Croatian Medical Journal, 47(3), |
| sleep in PTSD. In a randomized trial comparing | | | | 440–451. |
| phenelzine (a monoamine oxidase inhibitor) and | | | | Seal, K. H., Bertenthal, D., Miner, C. R., Sen, S., & Marmar, |
| imipramine (a tricyclic antidepressant), both significantly | | | | C. (2007). Bringing the war back home: mental health |
| reduced combat stress related PTSD symptoms | | | | disorders among 103,788 US veterans returning from |
| (Kosten et al., 1991). Benzodiazepines are used in | | | | Iraq and Afghanistan seen at Department of Veterans |
| PTSD for panic attacks or anxiety states. They | | | | Affairs facilities. Archives of Internal Medicine, 167(5), |
| provide temporary relief but run the risk of tolerance | | | | 476–482. |
| and addiction. | | | | |