Olanzapine in the treatment of post-traumatic stress disorder: a pilot study

Clinical outcomes of recommended active pharmacotherapy agents from NICE guideline for post-traumatic stress disorder: Network meta-analysis

BACKGROUND

Post-traumatic stress disorder (PTSD) is a mental disorder that can emerge after an individual experiences a traumatic event such as physical abuse, sexual/relationship violence, combat exposure, witnessing death, or serious injury. This study aimed to identify the most suitable drugs for the management of PTSD based on a network meta-analysis (NMA).

METHODS

Six databases (Ovid Medline, EMBase, CENTRAL, PsycINFO, Ovid Health and Psychosocial Instruments, and Web of Science) were searched from inception to September 6, 2022.

RESULTS

Thirty articles with a total of 5170 participants were included. Compared with placebo, active drugs including olanzapine (SMD = -0.66, 95% CI: -1.19 to -0.13), risperidone (SMD = -0.23, 95% CI: -0.42 to -0.03), quetiapine (SMD = -0.49, 95% CI: -0.93 to -0.04), venlafaxine (SMD = -0.29, 95% CI: -0.42 to -0.16), sertraline (SMD = -0.23, 95% CI: -0.34 to -0.11), paroxetine (SMD = -0.48, 95% CI: -0.60 to -0.36) and fluoxetine (SMD = -0.27, 95% CI: -0.42 to -0.12), significantly reduced the total clinician-administered PTSD scale score.

CONCLUSION

The results of this study support the use of paroxetine, venlafaxine, and quetiapine as first-line treatment for PTSD. In addition, quetiapine is recommended for patients with PTSD affected by symptoms of hyperarousal and re-experience disorder. Clinicians should prescribe medications based on the severity of PTSD symptoms and other conditions to develop the best treatment strategy for this patient population.

Pharmacological Management of Nightmares Associated with Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) can be a chronic and disabling condition. Post-traumatic nightmares (PTNs) form a core component of PTSD and are highly prevalent in this patient population. Nightmares in PTSD have been associated with significant distress, functional impairment, poor health outcomes, and decreased quality of life. Nightmares in PTSD are also an independent risk factor for suicide. Nightmare cessation can lead to improved quality of life, fewer hospital admissions, lower healthcare costs, and reduced all-cause mortality. Effective treatment of nightmares is critical and often leads to improvement of other PTSD symptomatology. However, approved pharmacological agents for the treatment of PTSD have modest effects on sleep and nightmares, and may cause adverse effects. No pharmacological agent has been approved specifically for the treatment of PTNs, but multiple agents have been studied. This current narrative review aimed to critically appraise proven as well as novel pharmacological agents used in the treatment of PTNs. Evidence of varying quality exists for the use of prazosin, doxazosin, clonidine, tricyclic antidepressants, trazodone, mirtazapine, atypical antipsychotics (especially risperidone, olanzapine and quetiapine), gabapentin, topiramate, and cyproheptadine. Evidence does not support the use of venlafaxine, β-blockers, benzodiazepines, or sedative hypnotics. Novel agents such as ramelteon, cannabinoids, ketamine, psychedelic agents, and trihexyphenidyl have shown promising results. Large randomized controlled trials (RCTs) are needed to evaluate the use of these novel agents. Future research directions are identified to optimize the treatment of nightmares in patients with PTSD.

Pharmacotherapy for post traumatic stress disorder (PTSD)

BACKGROUND

Posttraumatic stress disorder (PTSD) is a prevalent and disabling disorder. Evidence that PTSD is characterised by specific psychobiological dysfunctions has contributed to a growing interest in the use of medication in its treatment.

OBJECTIVES

To assess the effects of medication for reducing PTSD symptoms in adults with PTSD.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; Issue 11, November 2020); MEDLINE (1946-), Embase (1974-), PsycINFO (1967-) and PTSDPubs (all available years) either directly or via the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR). We also searched international trial registers. The date of the latest search was 13 November 2020.

SELECTION CRITERIA

All randomised controlled trials (RCTs) of pharmacotherapy for adults with PTSD.

DATA COLLECTION AND ANALYSIS

Three review authors (TW, JI, and NP) independently assessed RCTs for inclusion in the review, collated trial data, and assessed trial quality. We contacted investigators to obtain missing data. We stratified summary statistics by medication class, and by medication agent for all medications. We calculated dichotomous and continuous measures using a random-effects model, and assessed heterogeneity.

MAIN RESULTS

We include 66 RCTs in the review (range: 13 days to 28 weeks; 7442 participants; age range 18 to 85 years) and 54 in the meta-analysis.  For the primary outcome of treatment response, we found evidence of beneficial effect for selective serotonin reuptake inhibitors (SSRIs) compared with placebo (risk ratio (RR) 0.66, 95% confidence interval (CI) 0.59 to 0.74; 8 studies, 1078 participants), which improved PTSD symptoms in 58% of SSRI participants compared with 35% of placebo participants, based on moderate-certainty evidence.  For this outcome we also found evidence of beneficial effect for the noradrenergic and specific serotonergic antidepressant (NaSSA) mirtazapine: (RR 0.45, 95% CI 0.22 to 0.94; 1 study, 26 participants) in 65% of people on mirtazapine compared with 22% of placebo participants, and for the tricyclic antidepressant (TCA) amitriptyline (RR 0.60, 95% CI 0.38 to 0.96; 1 study, 40 participants) in 50% of amitriptyline participants compared with 17% of placebo participants, which improved PTSD symptoms. These outcomes are based on low-certainty evidence. There was however no evidence of beneficial effect for the number of participants who improved with the antipsychotics (RR 0.51, 95% CI 0.16 to 1.67; 2 studies, 43 participants) compared to placebo, based on very low-certainty evidence. For the outcome of treatment withdrawal, we found evidence of a harm for the individual SSRI agents compared with placebo (RR 1.41, 95% CI 1.07 to 1.87; 14 studies, 2399 participants). Withdrawals were also higher for the separate SSRI paroxetine group compared to the placebo group (RR 1.55, 95% CI 1.05 to 2.29; 5 studies, 1101 participants). Nonetheless, the absolute proportion of individuals dropping out from treatment due to adverse events in the SSRI groups was low (9%), based on moderate-certainty evidence. For the rest of the medications compared to placebo, we did not find evidence of harm for individuals dropping out from treatment due to adverse events.

AUTHORS' CONCLUSIONS

The findings of this review support the conclusion that SSRIs improve PTSD symptoms; they are first-line agents for the pharmacotherapy of PTSD, based on moderate-certainty evidence. The NaSSA mirtazapine and the TCA amitriptyline may also improve PTSD symptoms, but this is based on low-certainty evidence. In addition, we found no evidence of benefit for the number of participants who improved following treatment with the antipsychotic group compared to placebo, based on very low-certainty evidence. There remain important gaps in the evidence base, and a continued need for more effective agents in the management of PTSD.

Pharmacological therapy for post-traumatic stress disorder: a systematic review and meta-analysis of monotherapy, augmentation and head-to-head approaches

Background: Pharmacological approaches are widely used for post-traumatic stress disorder (PTSD) despite uncertainty over efficacy. Objectives: To determine the efficacy of all pharmacological approaches, including monotherapy, augmentation and head-to-head approaches (drug versus drug, drug versus psychotherapy), in reducing PTSD symptom severity. Method: A systematic review and meta-analysis of randomised controlled trials were undertaken; 115 studies were included. Results: Selective serotonin reuptake inhibitors (SSRIs) were found to be statistically superior to placebo in reduction of PTSD symptoms but the effect size was small (standardised mean difference -0.28, 95% CI -0.39 to -0.17). For individual monotherapy agents compared to placebo in two or more studies, we found small statistically significant evidence for the antidepressants fluoxetine, paroxetine, sertraline, venlafaxine and the antipsychotic quetiapine. For pharmacological augmentation, we found small statistically significant evidence for prazosin and risperidone. Conclusions: Some medications have a small positive effect on reducing PTSD symptom severity and can be considered as potential monotherapy treatments; these include fluoxetine, paroxetine, sertraline, venlafaxine and quetiapine. Two medications, prazosin and risperidone, also have a small positive effect when used to augment pharmacological monotherapy. There was no evidence of superiority for one intervention over another in the small number of head-to-head comparison studies.

Prolonged Exposure and Sertraline Treatments for Posttraumatic Stress Disorder Also Improve Multiple Indicators of Social Functioning

Trauma survivors with posttraumatic stress disorder (PTSD) frequently also suffer from difficulties in social functioning that range across emotional, cognitive, and environmental domains. A detailed evaluation of the differential impacts of effective PTSD treatments on social functioning is needed. Men and women (N = 200) with chronic PTSD received 10 weeks of prolonged exposure (PE) or sertraline in a randomized clinical trial and were followed for 24 months. A secondary data analysis examined changes in social functioning with regard to fear of intimacy; receipt of social support; and distress, avoidance, and negative cognitions in social situations. Effects were examined between treatments over time, controlling for baseline functioning. There were large, durable improvements across all indices. Compared to sertraline, PE was more efficient at reducing fear of intimacy and distress from negative social cognitions by posttreatment, ds = 0.94-1.14. Patients who received sertraline continued to improve over the course of follow-up, ds = 0.54-1.17. The differential speed of therapeutic effects may argue for more direct mechanisms in cognitive behavioral interventions versus cascade effects in serotonin reuptake inhibitors. Notably, both treatments produced substantial social benefits for trauma survivors with social functioning difficulties, and effect sizes were comparable to typical reductions in PTSD, depression, and anxiety.

Comparative Efficacy and Acceptability of Pharmaceutical Management for Adults With Post-Traumatic Stress Disorder: A Systematic Review and Meta-Analysis

The current clinical guidelines on post-traumatic stress disorder (PTSD) recommend selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) of drugs. However, there is uncertainty about the efficacy of other drugs and selecting which treatments work best for which patients. This meta-analysis evaluated efficacy and acceptability of pharmaceutical management for adults with PTSD. Randomized-controlled trials, which reported active comparators and placebo-controlled trials of pharmaceutical management for adults with PTSD, from the Ovid Medline, EMBase, CENTRAL, PsycINFO, Ovid Health and Psychosocial Instruments, and ISIWeb of Science, were searched until June 21, 2019. In terms of efficacy, all active drugs demonstrated superior effect than placebo (SMD = -0.33; 95% CI, -0.43 to -0.23). The medications were superior to placebo in reducing the symptom of re-experiencing, avoidance, hyperarousal, depression, and anxiety. For acceptability, medicine interventions for PTSD showed no increase in all-cause discontinuation compared with placebo. Nevertheless, in terms of safety, medicine interventions indicated a higher risk of adverse effect compared with placebo (RR = 1.47, 95% CI: 1.24 to 1.75). Compared with placebo, the SSRIs and atypical antipsychotics drugs had significant efficacy whether in patients with severe or extremely severe PTSD status. However, only atypical antipsychotics (SMD = -0.29, 95% CI: -0.48 to -0.10) showed superior efficacy than placebo in veterans. Medication management could be effective in intervention of PTSD, which demonstrated a sufficient improvement in the core symptoms. This meta-analysis supports the status of SSRIs and SNRIs as recommended pharmacotherapy. However, patients with different clinical characteristics of PTSD should consider individualized drug management.

Drug treatment strategies for insomnia in patients with post-traumatic stress disorder

INTRODUCTION

Insomnia is among the most reported sleep disturbances in patients with post-traumatic stress disorder (PTSD). The pervasiveness of this disorder among trauma-inflicted civilians and military personnel has been associated with reduced quality of life, impaired psychosocial functioning including cognitive impairments, negative mood swings, cardiovascular complications, and increased utilization of medical services.

AREAS COVERED

This review describes the current state of science with respect to the impact of the most dispensed pharmacological interventions for posttraumatic insomnia. At the present, there are no established treatment algorithms for PTSD-related insomnia. Pharmacotherapy offers an alternative treatment modality for patients with PTSD who fail or decline cognitive behavioral therapy (CBT). Selection of a hypnotic/sedative agent should be based on the patient's history, precipitating and perpetuating factors of insomnia, side effect profile, and potential medication-related interactions. Antipsychotics and benzodiazepines appear ineffective or are associated with significant harm in treating PTSD-related insomnia.

EXPERT OPINION

In the absence of randomized controlled trials, prescription patterns have been guided by anecdotal reports and expert opinion. Due to the complexity and multifactorial etiology of insomnia in PTSD, clinical investigations should examine available pharmacologic agents in comparative trials or in combination with CBT or complementary therapies to assess both short-term and long-term sleep outcomes in this population.

Posttraumatic stress disorder with secondary psychotic features (PTSD-SP): Diagnostic and treatment challenges

Trauma exposure leads to various psychiatric disorders including depression, anxiety, bipolar disorders, personality disorders, psychotic disorders, and trauma related disorders, especially posttraumatic stress disorder (PTSD). There are some overlapping symptoms of both PTSD and psychosis that make diagnosis challenging. Despite this overlap, the evidence of PTSD with comorbid psychosis as a distinct entity lies in the research showing biologic, genetic and treatment management differences between psychotic PTSD, non-psychotic PTSD, psychotic disorders and healthy controls. There is emerging evidence that PTSD with secondary psychotic features (PTSD-SP) might be a discrete entity of PTSD with known risk factors that increase its prevalence. This review has presented evidence for individuals with PTSD-SP being distinct in genetics and neurobiological factors. Individuals with PTSD and comorbid psychosis can benefit from evidence based psychotherapy (EBT). There is not enough evidence to recommend second generation antipsychotics (SGA) for PTSD-SP given that risperidone and quetiapine are the only SGAs studied in randomized controlled trials. Hence, developing an operational diagnostic criteria and treatment framework for clinical and research use is critical.

Management of nightmares in patients with posttraumatic stress disorder: current perspectives

Nightmares are considered the hallmark of posttraumatic stress disorder (PTSD). Although the characteristics of these distressing dreams may vary with the type of traumatic event, the pathophysiology exposes central dysfunction of brain structures at the level of the hippocampus, amygdala, and locus coeruleus, modulated by neurochemical imbalance in nor-adrenergic, dopaminergic, and serotonin pathways. Underlying comorbid conditions, including other sleep disorders, may contribute to worsening symptoms. Addressing sleep disruption can alleviate the severity of these nocturnal events and augment the effectiveness of other PTSD treatments. The expansion of behavioral treatment modalities for PTSD-related nightmares has been encouraging, but the core of these interventions is heavily structured around memory manipulation and imagery rescripting. A lack of a standardized delivery and a high dropout rate continue to pose significant challenges in achieving successful outcomes. The efficacy of existing pharmacological studies, such as α-adrenergic blocking agents, antidepressants, and atypical antipsychotics, has been undermined by methodological limitations and absence of large randomized controlled trials. This review is aimed at reviewing the available treatment strategies for alleviating nightmares in subjects with PTSD. Given the intricate relationship between PTSD and nightmares, future clinical trials have to adopt a more pragmatic approach focused not only on efficacy of novel interventions but also on adjunctive iteration of existing therapies tailored to individual socio-cultural background.

Pharmacological treatment of post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) causes significant distress and is often associated with markedly reduced functioning. Recent reviews have consistently recommended trauma-focused psychological therapies as a first-line treatment for PTSD. Pharmacological treatments have also been recommended but not as consistently. This article reviews the available trials of the pharmacological treatment of PTSD and discusses their implications.

Treatment of Post-Traumatic Stress Disorder Nightmares at a Veterans Affairs Medical Center

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.

Treatment-refractory posttraumatic stress disorder (TRPTSD): a review and framework for the future

Post-traumatic stress disorder (PTSD) is a serious psychiatric consequence of trauma that occurs in a proportion of individuals exposed to life-threatening events. Trauma-focused psychotherapy is often recommended as first choice for those who do not recover spontaneously. But many individuals require medications. In the US, only paroxetine (PRX) and sertraline (SRT) are FDA approved for PTSD. But response and remission rates with these medications are low, so numerous other pharmacologic interventions have been tried. To date, there has not been a systematic review of the data on what are the best next-step pharmacologic strategies for individuals who fail standard treatments. To that end, we review 168 published trials of medications other than PRX or SRT and provide a detailed analysis of the 88/168 studies that describe alternative pharmacologic interventions in patients refractory to other treatment. We also review clinical factors relevant to treatment-refractory PTSD; the neurobiology of extinction, as well as evidence-based psychotherapy and neuromodulation strategies for this condition.

PSYCHOTHERAPY VERSUS PHARMACOTHERAPY FOR POSTTRAUMATIC STRESS DISORDER: SYSTEMIC REVIEW AND META-ANALYSES TO DETERMINE FIRST-LINE TREATMENTS

BACKGROUND

Current clinical practice guidelines (CPGs) for posttraumatic stress disorder (PTSD) offer contradictory recommendations regarding use of medications or psychotherapy as first-line treatment. Direct head-to-head comparisons are lacking.

METHODS

Systemic review of Medline, EMBASE, PILOTS, Cochrane Central Register of Controlled Trials, PsycINFO, and Global Health Library was conducted without language restrictions. Randomized clinical trials ≥8 weeks in duration using structured clinical interview-based outcome measures, active-control conditions (e.g. supportive psychotherapy), and intent-to-treat analysis were selected for analyses. Independent review, data abstraction, and bias assessment were performed using standardized processes. Study outcomes were grouped around conventional follow-up time periods (3, 6, and 9 months). Combined effect sizes were computed using meta-analyses for medication versus control, medication pre-/posttreatment, psychotherapy versus control, and psychotherapy pre-/posttreatment.

RESULTS

Effect sizes for trauma-focused psychotherapies (TFPs) versus active control conditions were greater than medications versus placebo and other psychotherapies versus active controls. TFPs resulted in greater sustained benefit over time than medications. Sertraline, venlafaxine, and nefazodone outperformed other medications, although potential for methodological biases were high. Improvement following paroxetine and fluoxetine treatment was small. Venlafaxine and stress inoculation training (SIT) demonstrated large initial effects that decreased over time. Bupropion, citalopram, divalproex, mirtazapine, tiagabine, and topiramate failed to differentiate from placebo. Aripiprazole, divalproex, guanfacine, and olanzapine failed to differentiate from placebo when combined with an antidepressant.

CONCLUSIONS

Study findings support use of TFPs over nontrauma-focused psychotherapy or medication as first-line interventions. Second-line interventions include SIT, and potentially sertraline or venlafaxine, rather than entire classes of medication, such as SSRIs. Future revisions of CPGs should prioritize studies that utilize active controls over waitlist or treatment-as-usual conditions. Direct head-to-head trials of TFPs versus sertraline or venlafaxine are needed.

Role and clinical implications of atypical antipsychotics in anxiety disorders, obsessive-compulsive disorder, trauma-related, and somatic symptom disorders: a systematized review

Atypical antipsychotics (AAs) may play a role in the treatment of anxiety disorders, obsessive-compulsive disorder (OCD), and trauma-related disorders. No reviews on their differential use in these different disorders have been performed recently. The aim of this systematized review was to obtain data on efficacy and comparative effectiveness of AAs as a treatment of anxiety disorders, OCD, and trauma-related disorders to provide guidance for clinicians on when and which AA to use. We searched on PubMed, Psychnet, and Cochrane Libraries from inception to July 2015. Search results were limited to randomized, placebo-controlled trials of adult patients. Evidence of efficacy was considered the presence of positive results in two or more double-blind placebo-controlled studies. Our systematized search identified 1298 papers, of which 191 were subjected to a full-text review and 56 were included. Quetiapine extended-release showed a role in both acute and maintenance treatment of uncomplicated generalized anxiety disorder, whereas more studies are needed before drawing practical recommendations on the use of olanzapine and risperidone; aripiprazole and risperidone are effective in resistant OCD as augmentation treatments. Risperidone and olanzapine add-on may have a role in resistant or chronic post-traumatic stress disorder patients, although only risperidone addition can be recommended on the basis of the criterion of two or more positive placebo-controlled trials. This systematized review supports the evidence that only a few AAs are effective in only a minority of the off-label conditions in which they are currently used and confirms that AAs are not all the same. Their use should be on the basis of a balance between efficacy and side effects, and the characteristics as well as the preference of the patient.

Pharmacotherapies for Posttraumatic Stress Disorder: A Meta-Analysis

The purpose of this study was to assess the acceptability and efficacy of all types of pharmacotherapeutic agents in reducing the symptoms of posttraumatic stress disorder (PTSD). In this systematic meta-analysis, the dropout and response rates of various pharmacotherapy and placebo treatments reported by randomized clinical trials were compared. A total of 34 reports that described the acceptability and efficacy of PTSD pharmacotherapies were retrieved and analyzed. Of them, 30 trials examined the dropout rate as an index of acceptability and revealed the superiority of the PTSD pharmacotherapy to placebos (odds ratio, 0.75; 95% confidence interval, 0.66-0.86; n = 4313). The response rate was determined in 20 trials as an index of efficacy, showing that the PTSD pharmacotherapies were superior to the placebos (odds ratio, 1.47; 95% confidence interval, 1.34-1.62; n = 2166). Pharmacotherapy is an important component of the care of patients with PTSD.

Pharmacology for sleep disturbance in PTSD

Symptoms of sleep disturbance, particularly nightmares and insomnia, are a central feature of post-traumatic stress disorder (PTSD). Emerging evidence suggests that specific treatment of PTSD-related sleep disturbance improves other symptoms of the disorder, which in turn suggests that such disturbance may be fundamental to development and maintenance of the disorder. This mini-review focuses on pharmacological treatment of sleep disturbance in adult PTSD (specifically, studies testing the efficacy of antidepressants, adrenergic inhibiting agents, antipsychotics and benzodiazepine and non-benzodiazepine hypnotics). We conclude that only prazosin, an adrenergic inhibiting agent, has had its efficacy established by multiple randomised controlled trials. There is also high-level evidence supporting use of eszopiclone, as well as risperidone and olanzapine as adjunct therapy. Antidepressants such as sertraline, venlafaxine and mirtazapine, benzodiazepines such as alprazolam and clonazepam and non-benzodiazepine hypnotics such as zolpidem appear ineffective in treating PTSD-related sleep disturbance. Most studies that report reduced frequency of nightmares and insomnia also report decreases in overall symptom severity. Such findings suggest that (i) sleep disruption is central to PTSD; (ii) treating sleep disruption may be an effective way to address other symptoms of the disorder and (iii) PTSD symptoms tend to cluster together in predictable ways.

Failed efficacy of ziprasidone in the treatment of post-traumatic stress disorder

Background

Post-traumatic stress disorder (PTSD) is a chronic anxiety disorder that is often difficult to treat. Patients suffering from PTSD often fail to respond to antidepressants and may have a high incidence of positive symptoms of psychosis, though antipsychotic medications have been minimally studied in this population. The aim of this study was to assess the impact of the atypical antipsychotic ziprasidone (Geodon) on PTSD symptom clusters, as well as comorbid major depressive disorder. To our knowledge, this is the first completed randomized controlled trial investigating the potential efficacy and tolerability of ziprasidone in patients with chronic PTSD.

Methods

We conducted a 9-week prospective, randomized, double-blind, placebo-controlled trial of ziprasidone in 30 patients diagnosed with PTSD and comorbid depression. After screening and randomization, patients completed nine weekly study visits at which treatment safety and efficacy were evaluated. Primary measures of efficacy included total and subscale scores from the Clinician-Administered PTSD Scale (CAPS), while the Hamilton Rating Scale for Depression (HAM-D), Hamilton Anxiety Scale (HAM-A), Clinical Global Impression (CGI), and Treatment Outcome PTSD Scale (TOP-8) were implemented as secondary efficacy measures.

Results

We observed no significant effect of treatment on reduction of PTSD or depression symptoms from pre- to post-treatment.

Conclusions

Our findings suggest that ziprasidone treatment may not significantly improve symptoms of PTSD or comorbid depression, though further study is needed.

Complex Trauma in Adolescents and Adults: Effects and Treatment

Complex trauma involves multiple exposures to adverse events over the lifespan. Such experiences are associated with a variety of psychological outcomes, including a decreased threshold for the development of posttraumatic stress disorder as well as self-capacity problems and dysfunctional behaviors. Psychological interventions that increase affect regulation, support titrated processing of memories and cognitions, and emphasize the therapeutic relationship seem to be most helpful for complex trauma effects. Pharmacologic treatments have some efficacy in the treatment of the posttraumatic stress components of complex posttraumatic outcomes but are generally less successful in reducing self-related problems and symptoms.

A pilot randomized placebo-controlled trial of adjunctive aripiprazole for chronic PTSD in US military Veterans resistant to antidepressant treatment

Many individuals with post-traumatic stress disorder (PTSD) experience persistent symptoms despite pharmacological treatment with antidepressants. Several open-label monotherapy and adjunctive studies have suggested that aripiprazole (a second-generation antipsychotic) may have clinical utility in PTSD. However, there have been no randomized placebo-controlled trials of aripiprazole use for PTSD. We thus conducted a pilot randomized controlled trial of adjunctive aripiprazole versus placebo among Veterans with chronic PTSD serving in the US military since 11 September 2001 to assess the feasibility, safety, tolerability, and therapeutic potential of aripiprazole. Sixteen Veterans were randomized, and 14 completed at least 4 weeks of the study; 12 completed the entire 8-week trial. Outcome measures included the Clinician-Administered PTSD Scale (CAPS), PTSD Checklist, Beck Depression Inventory, Second Edition, and Positive and Negative Syndrome Scale scores. Aripiprazole was well-tolerated in this cohort, and improvements in CAPS, PTSD Checklist, Beck Depression Inventory, Second Edition, and Positive and Negative Syndrome Scale scores were as hypothesized. Although CAPS change scores did not reach statistical significance, aripiprazole outperformed placebo by 9 points on the CAPS in the last observation carried forward analysis compared with the placebo group (n = 7 per group), and by 20 points in the group randomized to aripiprazole that completed the entire study (n = 5) compared with the placebo group (n = 7). Results suggest promise for aripiprazole as an adjunctive strategy for the treatment of PTSD.

Pharmacotherapy for post-traumatic stress disorder: systematic review and meta-analysis

BACKGROUND

Pharmacological treatment is widely used for post-traumatic stress disorder (PTSD) despite questions over its efficacy.

AIMS

To determine the efficacy of all types of pharmacotherapy, as monotherapy, in reducing symptoms of PTSD, and to assess acceptability.

METHOD

A systematic review and meta-analysis of randomised controlled trials was undertaken; 51 studies were included.

RESULTS

Selective serotonin reuptake inhibitors were found to be statistically superior to placebo in reduction of PTSD symptoms but the effect size was small (standardised mean difference -0.23, 95% CI -0.33 to -0.12). For individual pharmacological agents compared with placebo in two or more trials, we found small statistically significant evidence of efficacy for fluoxetine, paroxetine and venlafaxine.

CONCLUSIONS

Some drugs have a small positive impact on PTSD symptoms and are acceptable. Fluoxetine, paroxetine and venlafaxine may be considered as potential treatments for the disorder. For most drugs there is inadequate evidence regarding efficacy for PTSD, pointing to the need for more research in this area.

The potential role of atypical antipsychotics for the treatment of posttraumatic stress disorder

Despite the fact that the majority of currently available treatment guidelines propose antidepressants as the first-line pharmacological therapy for posttraumatic stress disorder (PTSD), a substantial portion of patients fail to show an adequate response following this type of treatment. In this context, a number of small, open-label studies and randomized controlled clinical trials (RCTs) have found atypical antipsychotics (AAs) to be a beneficial treatment for patients with PTSD. Thus, the present meta-analysis was conducted to enhance the sample size power and further the current understanding of the role of AAs for the treatment of PTSD. An extensive search of several databases identified 12 appropriate RCTs and available data from 9 of these (n = 497) were included in the final meta-analysis. AAs may have potential benefits for the treatment of PTSD as indicated by changes from baseline of the total score on the Clinician Administered PTSD Scale (CAPS; standardized mean difference [SMD] = -0.289, 95% confidence intervals [CIs] = -0.471, -0.106), P = 0.002). Additionally, AAs were found to be significantly more effective (P < 0.0001) than a placebo in terms of change from baseline for the intrusion sub-score on the CAPS (SMD = -0.373, 95% CIs = -0.568, -0.178) but there were no significant reductions for the avoidance and hyperarousal sub-symptoms. The responder rate and rate of improvement of depressive symptoms were also significantly higher in the AA group than the placebo group (P = 0.004 and P < 0.0001, respectively). However, the present results should be interpreted carefully and be translated into clinical practice only with due consideration of the limited quality and quantity of existing RCTs included in this analysis.

Almost all antipsychotics result in weight gain: a meta-analysis

Introduction

Antipsychotics (AP) induce weight gain. However, reviews and meta-analyses generally are restricted to second generation antipsychotics (SGA) and do not stratify for duration of AP use. It is hypothesised that patients gain more weight if duration of AP use is longer.

Method

A meta-analysis was conducted of clinical trials of AP that reported weight change. Outcome measures were body weight change, change in BMI and clinically relevant weight change (7% weight gain or loss). Duration of AP-use was stratified as follows: ≤6 weeks, 6–16 weeks, 16–38 weeks and >38 weeks. Forest plots stratified by AP as well as by duration of use were generated and results were summarised in figures.

Results

307 articles met inclusion criteria. The majority were AP switch studies. Almost all AP showed a degree of weight gain after prolonged use, except for amisulpride, aripiprazole and ziprasidone, for which prolonged exposure resulted in negligible weight change. The level of weight gain per AP varied from discrete to severe. Contrary to expectations, switch of AP did not result in weight loss for amisulpride, aripiprazole or ziprasidone. In AP-naive patients, weight gain was much more pronounced for all AP.

Conclusion

Given prolonged exposure, virtually all AP are associated with weight gain. The rational of switching AP to achieve weight reduction may be overrated. In AP-naive patients, weight gain is more pronounced.

Co-occurrence of anxiety and bipolar disorders: clinical and therapeutic overview

BACKGROUND

Anxiety commonly co-occurs with bipolar disorders (BDs), but the significance of such "co-morbidity" remains to be clarified and its optimal treatment adequately defined.

METHODS

We reviewed epidemiological, clinical, and treatment studies of the co-occurrence of BD and anxiety disorder through electronic searching of Pubmed/MEDLINE and EMBASE databases.

RESULTS

Nearly half of BD patients meet diagnostic criteria for an anxiety disorder at some time, and anxiety is associated with poor treatment responses, substance abuse, and disability. Reported rates of specific anxiety disorders with BD rank: panic ≥ phobias ≥ generalized anxiety ≥ posttraumatic stress ≥ obsessive-compulsive disorders. Their prevalence appears to be greater among women than men, but similar in types I and II BD. Anxiety may be more likely in depressive phases of BD, but relationships of anxiety phenomena to particular phases of BD, and their temporal distributions require clarification. Adequate treatment trials for anxiety syndromes in BD patients remain rare, and the impact on anxiety of treatments aimed at mood stabilization is not clear. Benzodiazepines are sometimes given empirically; antidepressants are employed cautiously to limit risks of mood switching and emotional destabilization; lamotrigine, valproate, and second-generation antipsychotics may be useful and relatively safe.

CONCLUSIONS

Anxiety symptoms and syndromes co-occur commonly in patients with BD, but "co-morbid" phenomena may be part of the BD phenotype rather than separate illnesses.

Pharmacotherapy of post-traumatic stress disorder: a family practitioner’s guide to management of the disease

Post-traumatic stress disorder is a difficult to treat, yet common disorder, which is associated with significant morbidity, mortality and societal burden. Comprehensive management of post-traumatic stress disorder must include both psychotherapeutic and pharmacologic components. The current evidence-based pharmacologic management approaches to post-traumatic stress disorder, suggests that first-line treatments for monotherapy are the selective serotonin reuptake inhibitors, sertraline, paroxetine and fluoxetine. Other potential options include other monotherapies including venlafaxine, mirtazapine, tricyclic antidepressants, monoamine oxidase inhibitors, as well as adjunctive usage of atypical antipsychotics, lamotrigine, trazadone and a number of adrenergic agents. A trial of therapy should be at least 8 weeks and continue for at the very least 12 months, but is likely to be much longer. In light of the risks of untreated post-traumatic stress disorder (e.g., suicide and impaired psychosocial functioning), therapy may need to be continued for 2 years or more. Pharmacologic therapy instituted at the time of acute psychologic trauma shows promise for the prevention of post-traumatic stress disorder in the future and warrants further study.

Emerging roles for atypical antipsychotics in chronic post-traumatic stress disorder

Post-traumatic stress disorder is an anxiety disorder that may occur after the individual is exposed to severe psychologic trauma such as combat, sexual assault, or childhood physical or sexual abuse. Chronic post-traumatic stress disorder may result in considerable psychologic pain and suffering for the individual in addition to significant functional impairment. In addition to the heterogeneity of symptoms that occur in post-traumatic stress disorder, there may also be extensive comorbidity with other anxiety disorders, mood disorders, psychotic disorders, and other psychiatric disorders. This complicates the treatment picture. Currently, accepted treatments for post-traumatic stress disorder include psychotherapy, in particular cognitive behavioral-based approaches and antidepressant medication. However, many patients are refractory to these initial treatments or have only a partial response. In light of this, may clinicians combine additional classes of psychotropic agents and different psychotherapeutic approaches to enhance treatment response. This article reviews the literature on the use of atypical antipsychotics in the treatment of post-traumatic stress disorder. Most of the research to date has involved combat veterans partially responsive or refractory to treatment, namely with antidepressants. Studies have shown improvement across post-traumatic stress disorder symptom clusters, as well as improvement in comorbid psychotic symptoms or disorders. More research is needed to confirm these recent findings and further delineate the role of atypical antipsychotics in the treatment of post-traumatic stress disorder. Currently, possible indications for their use include treatment-resistant post-traumatic stress disorder and post-traumatic stress disorder with comorbid psychotic features.

Effects of an antipsychotic restriction policy in a veteran population

Introduction: Recent trials have failed to demonstrate differences in efficacy between first generation antipsychotics (FGAs) and second generation antipsychotics (SGAs). To reduce costs, many health care systems have restricted the availability of SGAs through use of prior authorizations. Restrictions for the off-label use of SGAs and the use of dual-antipsychotic therapy have also been implemented in many health care systems. At the South Texas Veterans Health Care System (STVHCS), a restricted drug request (RDR) method has been implemented to manage costs and improve patient safety. Risperidone, due to its lower cost and equal efficacy, is the first-line option of SGAs. If one wishes to prescribe an SGA other than risperidone, an RDR is submitted and reviewed by Veterans Integrated Service Network (VISN) pharmacists. Since the introduction of these policies at the STVHCS, the impact of the RDR has not been assessed.

Rationale: The primary aim of this study was to determine the effects of the RDR policy on the care of STVHCS veterans as evidenced by changes in hospitalization rates of veterans with a denied request for an SGA due to initial criterion failure. Secondary outcomes included: impact of antipsychotic RDR denial on mental health as evidenced by changes in no-shows and cancellations for follow-up psychiatric appointments, psychiatric emergency department visits, presence of suicidal ideation, change in weight, hemoglobin A1c, number of psychotropic medications prescribed, and extrapyramidal symptoms.

Methods: A retrospective chart review of veterans denied an initial SGA request was conducted from 3 months prior to denial to 3 months post request denial (index date). Data collected included: patient demographics, indication for SGA request, reason for SGA denial, length of time for request evaluation, number of psychiatric hospitalizations, number of no-shows and cancellations for mental health appointments, number of psychiatric emergency department visits, number of reports of suicidal ideation or attempts, weight, hemoglobin A1c lab results, presence of extrapyramidal symptoms, and number of prescribed psychotropic medications. The health care utilization data collected pre- and post-index date, were compared. Results were analyzed using Fisher's Exact, 2-tailed standardized t-tests, and descriptive statistics appropriately matched to data type.

Results: Results for both primary and secondary outcomes were not statistically significant. No differences were found in the number of veterans hospitalized pre- versus post-index date [0/33 (0%) versus 2/33 (6%), p=0.492.] The most requested indication for an SGA was PTSD [22/33 (66.7%)] and the most frequently denied SGA was quetiapine [16/33 (48.5%)].

Conclusions: Although outcomes were not statistically significant, several valuable conclusions were drawn from this research. Positive outcomes from a RDR policy were seen by the limitations placed on inappropriate medication prescribing. Also, it was observed that the number of approvals for SGAs was almost three times higher than denials. A subsequent finding from this research is the apparent lack of metabolic monitoring for veterans prescribed SGAs. Further research on these observations, as well as conducting a pharmacoeconomic analysis on the RDR policy, would also be beneficial information for health care providers.

Weight gain and other metabolic adverse effects associated with atypical antipsychotic treatment of children and adolescents: a systematic review and meta-analysis

OBJECTIVES

The aims of this study were to provide a systematic review and meta-analysis of the effects of atypical antipsychotics in children and adolescents on weight gain (primary objective) and other metabolic parameters (secondary objective).

METHODS

A systematic literature review and meta-analysis of double-blind, randomized, controlled trials were conducted. The data sources used were as follows: EMBASE, PubMed, BIOSIS, International Pharmaceutical Abstracts, The Cochrane database (Clinical Trials), Clinical Trials Government Registry, The metaRegister of Controlled Trials, WHO (World Health Organization) Clinical Trials Registry Platform, and PsycINFO(®). Hand searching was also carried out by examining the reference lists of identified studies. Double-blind, randomized, controlled trials investigating the metabolic adverse effects (weight gain, lipid, glucose, and prolactin level abnormalities) associated with atypical antipsychotic use in children and adolescents aged ≤ 18 years were included, irrespective of whether the investigation of adverse effects was a primary or secondary endpoint.

RESULTS

We identified 21 studies of drug versus placebo that met the inclusion criteria, with a total of 2,455 patients, 14 studies for risperidone (1,331 patients), three for olanzapine (276 patients), and four for aripiprazole (848 patients). Compared with placebo, the mean weight increases for each drug were olanzapine 3.45 kg (95 % CI 2.93-3.98), risperidone 1.77 kg (95 % CI 1.35-2.20), and aripiprazole 0.94 kg (95 % CI 0.65-1.24). Regarding other metabolic abnormalities, eight studies reported statistically significant increases in prolactin with risperidone; two reported a statistically significant increase in glucose, total cholesterol, and prolactin with olanzapine; and three studies reported a statistically significant decrease in prolactin with aripiprazole. Data on lipid, glucose, and prolactin level changes were too limited to allow us to perform a meta-analysis.

CONCLUSIONS

Olanzapine, risperidone, and aripiprazole were all associated with statistically significant weight gain. Olanzapine was associated with the most weight gain and aripiprazole the least. For the secondary outcome, although a number of active comparator trials were identified, data were not available for meta-analysis and were too limited to allow firm conclusions to be drawn.

A review of atypical antipsychotics and their utility in post-traumatic stress disorder

Post traumatic stress disorder (PTSD) is a chronic and debilitating mental illness. Atypical antipsychotics are often utilized for treatment of PTSD despite the limited data. The purpose of this article is to review published clinical trials of atypical antipsychotics used in the treatment of PTSD. Certain patients may benefit from therapy with an atypical antipsychotic, particularly for those with hyper-arousal or re-experiencing symptom clusters. At this time, guidelines suggest against the use of risperidone as augmentation therapy in patients with PTSD. Data are only available for olanzapine, quetiapine, and aripiprazole; however, data were conflicting, not very robust, and studies had limited sample sizes and narrow demographics. It is important to provide proper patient education and weigh the risks versus benefits of therapy with an atypical antipsychotic as metabolic side effects are well documented.

Targeting memory processes with drugs to prevent or cure PTSD

INTRODUCTION

Post-traumatic stress disorder (PTSD) is a chronic debilitating psychiatric disorder resulting from exposure to a severe traumatic stressor and an area of great unmet medical need. Advances in pharmacological treatments beyond the currently approved SSRIs are needed.

AREAS COVERED

Background on PTSD, as well as the neurobiology of stress responding and fear conditioning, is provided. Clinical and preclinical data for investigational agents with diverse pharmacological mechanisms are summarized.

EXPERT OPINION

Advances in the understanding of stress biology and mechanisms of fear conditioning plasticity provide a rationale for treatment approaches that may reduce hyperarousal and dysfunctional aversive memories in PTSD. One challenge is to determine if these components are independent or reflect a common underlying neurobiological alteration. Numerous agents reviewed have potential for reducing PTSD core symptoms or targeted symptoms in chronic PTSD. Promising early data support drug approaches that seek to disrupt dysfunctional aversive memories by interfering with consolidation soon after trauma exposure, or in chronic PTSD, by blocking reconsolidation and/or enhancing extinction. Challenges remain for achieving selectivity when attempting to alter aversive memories. Targeting the underlying traumatic memory with a combination of pharmacological therapies applied with appropriate chronicity, and in combination with psychotherapy, is expected to substantially improve PTSD treatment.

Olanzapine monotherapy in posttraumatic stress disorder: efficacy in a randomized, double-blind, placebo-controlled study

OBJECTIVES

Although there have been important advances in the treatment of posttraumatic stress disorder (PTSD), many patients fail to respond to first-line pharmacotherapy. Limited evidence suggests that second generation antipsychotics may have a role to play as monotherapy in PTSD.

METHODS

We undertook a randomized, placebo-controlled study using flexible-dose olanzapine monotherapy for 8 weeks in 28 adult male and female participants (mean age: 40.75 ± 11.59 years) with non-combat related chronic PTSD. Data were analysed with repeated measures analysis of variance, using an intention to treat, last observation carried forward approach.

RESULTS

The olanzapine group (n = 14) demonstrated significantly greater improvement on the Clinician Administered PTSD Scale from baseline to endpoint than the placebo group (n = 14) (F = 5.71, p = 0.018). Olanzapine was generally well tolerated, with no serious adverse events recorded. Substantial weight gain (6-10 kg) was, however, reported in 6/14 participants in the olanzapine group.

CONCLUSIONS

To our knowledge, this is the first controlled evidence of the efficacy of olanzapine monotherapy in an exclusively non-combat related chronic PTSD group. Despite the small sample size, these data suggest that olanzapine may have a role in the treatment of PTSD. These findings warrant replication in a larger sample.

Evidence-based pharmacotherapy of post-traumatic stress disorder (PTSD)

Post-traumatic stress disorder (PTSD) is a prevalent and disabling disorder. Recognition of neurobiological abnormalities associated with this condition suggests the potential efficacy of medication in its treatment. Nevertheless, questions regarding the efficacy of medications remain, despite general endorsement by clinical practice guidelines of selective serotonin reuptake inhibitors (SSRIs) as first-line agents in treating PTSD. This paper reviews evidence from randomized controlled trials (RCTs) for the efficacy of acute and long-term pharmacotherapy for PTSD, including the treatment of refractory PTSD. In addition, we conducted a systematic meta-analysis to compare the efficacy of different medications in treating PTSD. The effects of methodological study features (including year of publication, duration, number of centres) and sample characteristics (proportion of combat veterans, gender composition) were also tested. The largest body of evidence for short- and long-term efficacy of medication currently exists for SSRIs, with promising initial findings for the selective noradrenergic reuptake inhibitor venlafaxine and the atypical antipsychotic risperidone. Treatment effect was predicted by number of centres and recency of the study, with little evidence that sample characteristics predicted response. Evidence for the effectiveness of benzodiazepines is lacking, despite their continued use in clinical practice. Finally, the α1 antagonist prazosin and the atypical antipsychotics show some efficacy in treatment-resistant PTSD. Adequately powered trials that are designed in accordance with best-practice guidelines are required to provide conclusive evidence of clinically relevant differences in efficacy between agents in treating PTSD, and to help estimate clinical and methodological predictors of treatment response.

The Psychopharmacology Algorithm Project at the Harvard South Shore Program: an update on posttraumatic stress disorder

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.

Pharmacological treatment of PTSD - established and new approaches

A large proportion of humans will experience a traumatic event at least once in their lifetime, with up to 10% then going on to developing posttraumatic stress disorder (PTSD). In this review we will discuss established pharmacological interventions for PTSD as well as highlight novel therapeutic strategies undergoing extensive pre-clinical research as well as ongoing clinical research. Such strategies include prophylactic treatments and use of pharmacotherapy as adjunctive treatment with established trauma-focused psychological therapies. These potential treatment approaches include modulation of stress effects on memory consolidation after trauma (e.g., glucocorticoid, corticotropin-releasing factor and norepinephrine signalling modulators), as well as putative cognitive enhancers that target mechanisms of conditioned fear extinction and reconsolidation (e.g., glucocorticoid receptor modulators and modulators of glutamate signalling such as positive allosteric modulators of glutamate receptors, glycine transporter inhibitors, or glycine agonists). We will discuss evidence for and against these potential novel treatment strategies and their limitations. This article is part of a Special Issue entitled 'Post-Traumatic Stress Disorder'.

Review of atypical antipsychotics in anxiety

Atypical antipsychotics are increasingly used for treatment of anxiety disorders, either in mono- or combination therapy. This is the first review reporting on the use of atypical antipsychotics in monotherapy or augmentation in patients with primary anxiety disorders or anxiety (disorders) comorbid to schizophrenia, bipolar disorder (BPD) and major depressive disorder (MDD). We included 49 open-label trials, 32 randomized, placebo-controlled trials (RCTpls) and five randomized controlled trials without placebo arm with almost 6000 patients (open-label: 1710, randomized: 4145). An increasing number of RCTpls show promising results in 27-71% of patients with primary or comorbid anxiety disorders who were treated with monotherapy atypical antipsychotics or augmentation therapy. However, methodological flaws of included studies may limit conclusions of this review and larger placebo-controlled trials are warranted comparing standard treatment with monotherapy and augmentation therapy of atypical antipsychotics and placebo. In addition, higher dropout rates and side effects from treatment with atypical antipsychotics may limit the use of atypical antipsychotics in patients with anxiety disorders.

A psychopharmacological treatment algorithm for generalised anxiety disorder (GAD)

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.

Anxiolytic-like property of risperidone and olanzapine as examined in multiple measures of fear in rats

Atypical antipsychotics are also used in the treatment of anxiety-related disorders. Clinical and preclinical evidence regarding their intrinsic anxiolytic efficacy has been mixed. In this study, we examined the potential anxiolytic-like effects of risperidone and olanzapine, and compared them with haloperidol, chlordiazepoxide (a prototype of sedative-anxiolytic drug) or citalopram (a selective serotonin reuptake inhibitor). We used a composite of two-way avoidance conditioning and acoustic startle reflex model and examined the effects of drug treatments during the acquisition phase (Experiment 1) or extinction phase (Experiments 2 and 3) on multiple measures of conditioned and unconditioned fear/anxiety-like responses. In Experiment 4, we further compared risperidone, olanzapine, haloperidol, citalopram and chlordiazepoxide in a standard elevated plus maze test. Results revealed three distinct anxiolytic-like profiles associated with risperidone, olanzapine and chlordiazepoxide. Risperidone, especially at 1.0mg/kg, significantly decreased the number of avoidance responses, 22kHz ultrasonic vocalization, avoidance conditioning-induced hyperthermia and startle reactivity, but did not affect defecations or time spent on the open arms. Olanzapine (2.0mg/kg, sc) significantly decreased the number of avoidance responses, 22kHz vocalization and amount of defecations, but it did not inhibit startle reactivity and time spent on the open arms. Chlordiazepoxide (10mg/kg, ip) significantly decreased the number of 22kHz vocalization, avoidance conditioning-induced hyperthermia and amount of defecations, and increased time spent on the open arms, but did not decrease avoidance responses or startle reactivity. Haloperidol and citalopram did not display any anxiolytic-like property in these tests. The results highlight the importance of using multiple measures of fear-related responses to delineate behavioral profiles of psychotherapeutic drugs.

Pharmacotherapy of post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is a prevalent psychiatric disorder that may result in significant social and occupational debilitation unless symptoms are recognized and treated appropriately. Considerable research effort has been devoted over the last 20 years to developing effective pharmacological treatments for this illness. At this time, the bulk of the agents investigated include antidepressants, anticonvulsants, atypical antipsychotics, benzodiazepines, and antiadrenergic agents. Herein, we review the existing evidence base for these different classes of psychotropics in PTSD. Emphasis is placed on discussion of evidence stemming from randomized placebo-controlled clinical trials wherever possible. A brief description of novel agents that have shown initial promise for PTSD treatment is also provided.

Post-traumatic stress disorder: emerging concepts of pharmacotherapy

Post-traumatic stress disorder (PTSD) can result from a traumatic experience that elicits emotions of fear, helpless or horror. Most individuals remain asymptomatic or symptoms quickly resolve, but in a minority intrusive imagery and nightmares, emotional numbing and avoidance, and hyperarousal persist for decades. PTSD is associated with psychiatric and medical co-morbidities, increased risk for suicide, and with poor social and occupational functioning. Psychotherapy and pharmacotherapy are common treatments. Whereas, research supports the efficacy of the cognitive behavioral psychotherapies, there is insufficient evidence to unequivocally support the efficacy of any specific pharmacotherapy. Proven effective pharmacologic agents are sorely needed to treat core and targeted PTSD symptoms, and for prevention. This review describes current and emerging pharmacotherapies that advance these goals.

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.

Pharmacotherapy of PTSD: premises, principles, and priorities

Post-traumatic stress disorder (PTSD) is a prevalent anxiety disorder that results in multiple disabling symptoms. Research into the underlying neurobiology has implicated dysregulation in multiple neurotransmitter systems including norepinephrine, serotonin, and glutamate as well as the hypothalamic-pituitary axis. Understanding how these biological systems interact with each other and how they may affect key neural structures, such as the amygdala, hippocampus, and prefrontal cortex, to produce post-traumatic symptoms is critical for the development of effective pharmacological treatments. We briefly discuss the proposed biological dysfunctions underlying PTSD and how agents that target these dysfunctions may be utilized in PTSD. We then provide a review of the different pharmacological agents that have been investigated in PTSD. These drugs include: antidepressants, anti-adrenergic agents, anticonvulsants, benzodiazepines, atypical antipsychotics, and novel agents.

Pharmacologic alternatives to antidepressants in posttraumatic stress disorder: a systematic review

The selective serotonin reuptake inhibitors (SSRIs) are considered the first-line pharmacological treatment for PTSD. However, even when treated with this class of drugs, response rates rarely exceed 60% and less than 20-30% of the patients achieve full remission. The aim of this study was to address this limitation by systematically reviewing the options left for the treatment of PTSD when patients do not respond satisfactorily to or tolerate SSRIs. A systematic review covering all original articles, letters and brief reports published in any language until October 2008 was conducted through searches in the ISI/Web of Science, PubMed and PILOTS databases. The search terms included the pharmacological class of each agent or its generic name plus "PTSD" or "stress disorder" in the title, in the abstract or as a keyword. Sixty-three articles were selected, covering the following categories: antipsychotics, anticonvulsants, adrenergic-inhibiting agents, opioid antagonists, benzodiazepines and other agents. None of the identified agents reached the level A of scientific evidence, 5 reached level B, 7 level C and 13 level D. The non-antidepressant agent with the strongest scientific evidence supporting its use in PTSD is risperidone, which can be envisaged as an effective add-on therapy when patients did not fully benefit from previous treatment with SSRIs. Prazosin, an adrenergic-inhibiting agent, is a promising alternative for cases of PTSD where nightmares and insomnia are prominent symptoms. So far, there is no consistent empirical support for using benzodiazepines in the prevention or in the treatment of PTSD, although these drugs could alleviate some associated non-specific symptoms, such as insomnia or anxiety. Further controlled clinical trials and meta-analysis are needed to guide clinicians in their search of effective pharmacological alternatives to antidepressants in PTSD.

Anxiety disorders: a comprehensive review of pharmacotherapies

This article reviews the evidence from randomized, placebo-controlled trials and meta-analyses of pharmacological treatments of the following anxiety disorders: generalized anxiety disorder, panic disorder, social anxiety disorder, and post-traumatic stress disorder. There is evidence from multiple randomized, placebo-controlled trials to support the use of selective serotonin reuptake inhibitors as first-line pharmacotherapy in these disorders, and a number of the selective serotonin reuptake inhibitors have received US Food and Drug Administration approval for these indications. Serotonin-norepinephrine reuptake inhibitors are now emerging as first-line treatments for these anxiety disorders alongside the selective serotonin reuptake inhibitors and have been US Food and Drug Administration-approved for some of these indications as well. Benzodiazepines are also effective treatments for anxiety disorders, and although this medication class has the advantage of a rapid onset of action, their use is limited by their potential for abuse and lack of antidepressant properties. In addition to reviewing the clinical trials that have investigated the anxiolytic effects of these commonly used medications, we review the evidence for novel uses of other agents, including anticonvulsants and atypical antipsychotics, in anxiety disorders.

Psychopharmacotherapy of posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) is a psychiatric disorder that develops after a psychological trauma usually caused by a situation perceived as deeply threatening to a person's life or integrity. Complex neurobiological changes triggered by such a traumatic and stressful experience may explain a wide range of PTSD symptoms and provide the rationale for psychopharmacological treatment. Selective serotonin-reuptake inhibitors make the first-line treatment of PTSD. Clinical experience has shown that they are more effective than noradrenalin-reuptake inhibitors or tricyclic antidepressants. Antipsychotic drugs, especially atypical ones, have been shown effective in PTSD patients with psychotic characteristics or refractoriness to other treatments. Mood stabilizers seem to reduce mostly autonomous overreactions to stress, whereas the evidence for effectiveness of monoamine oxidase inhibitors is largely inconclusive. Other groups of medications, such as serotonin agonists and antagonists, new antidepressants, dual inhibitors of serotonin- and noradrenalin-reuptake, anticonvulsants, and opiate antagonists are also sometimes used in PTSD treatment. However, as shown in the present review, most clinical studies performed to date to investigate the effectiveness of different psychopharmacological agents in the therapy of PTSD have serious limitations in terms of small sample size, lack of blinding and randomization, and small effect size. More rigorously designed, comparative studies are needed to determine the usefulness, efficacy, tolerability, and safety of particular psychopharmaceutical drugs in the treatment of this therapeutically and functionally challenging disorder.

Pharmacotherapy for older veterans diagnosed with posttraumatic stress disorder in Veterans Administration

OBJECTIVES

Despite increasing numbers of older veterans diagnosed with posttraumatic stress disorder (PTSD) in veterans administration (VA), limited research has focused on pharmacotherapy of PTSD among the elderly.

DESIGN

The authors examined pharmacotherapy provided to patients carrying a clinical diagnosis of PTSD in VA.

SETTING

Data on outpatients treated at VA nationally were utilized.

PARTICIPANTS

Patients were veterans over 45 years of age diagnosed with PTSD in FY 2004 (N = 244,947) grouped into five age cohorts with patients 45-55 as the reference group.

MEASURES

Psychotropic prescriptions were examined. Descriptive statistics and multivariable logistic regression adjusting for confounding characteristics, including receipt of VA service connected disability benefits which may create incentives to artificially maintain historical diagnoses, were used to identify the relationship of age to receipt of psychotropic medications net of these factors. All analyses were repeated using data only from nonservice connected veterans.

RESULTS

Most older veterans received psychotropic medication and among these, 88.3% were prescribed antidepressants, 61.2% anxiolytics/sedative hypnotics, and 32.9% antipsychotics. A pronounced monotonic trend showed decrease use of any psychotropic medication and of each subclass with age. Medication use was higher among those treated in specialty mental health clinics than among those treated exclusively in primary care or medical clinics and interaction analysis of age by clinic type showed significantly more steeply declining use of medications with age among patients treated in specialty mental health clinics. Data from nonservice connected veterans revealed the same patterns.

CONCLUSION

Diverse psychotropic medication classes are used to treat veterans diagnosed with PTSD in VA with declining use among older veterans. Medication utilization is greater in mental health clinics but declined more steeply with age, perhaps reflecting the greater sensitivity of specialists to the risks of elderly veterans. Older veterans diagnosed with PTSD appear to receive conservative, cautious treatment although observed patterns of care may reflect some degree of undertreatment.

Disturbed sleep in post-traumatic stress disorder: secondary symptom or core feature?

Sleep disturbances are often viewed as a secondary symptom of post-traumatic stress disorder (PTSD), thought to resolve once PTSD has been treated. Specific screening, diagnosis and treatment of sleep disturbances is therefore not commonly conducted in trauma centres. However, recent evidence shows that this view and consequent practices are as much unhelpful as incorrect. Several sleep disorders-nightmares, insomnia, sleep apnoea and periodic limb movements-are highly prevalent in PTSD, and several studies found disturbed sleep to be a risk factor for the subsequent development of PTSD. Moreover, sleep disturbances are a frequent residual complaint after successful PTSD treatment: a finding that applies both to psychological and pharmacological treatment. In contrast, treatment focusing on sleep does alleviate both sleep disturbances and PTSD symptom severity. A growing body of evidence shows that disturbed sleep is more than a secondary symptom of PTSD-it seems to be a core feature. Sleep-focused treatment can be incorporated into any standard PTSD treatment, and PTSD research needs to start including validated sleep measurements in longitudinal epidemiologic and treatment outcome studies. Further clinical and research implications are discussed, and possible mechanisms for the role of disturbed (REM) sleep in PTSD are described.