Pharmacotherapy for post traumatic stress disorder (PTSD)

COMBINED MIRTAZAPINE AND SSRI TREATMENT OF PTSD: A PLACEBO-CONTROLLED TRIAL

BACKGROUND

Combined treatment with a selective serotonin reuptake inhibitor (SSRI) plus mirtazapine has shown superior efficacy in some studies of depression, but has not been studied in posttraumatic stress disorder (PTSD). This study aimed to assess acceptability of combined sertraline plus mirtazapine treatment for PTSD and to estimate its effect size relative to sertraline plus placebo.

METHODS

Thirty-six adults with PTSD were randomized to 24 weeks of double-blind treatment with sertraline plus mirtazapine or sertraline plus placebo. Outcomes were analyzed with mixed effects models.

RESULTS

The combined treatment group showed a significantly greater remission rate (P = .042) and improvement in depressive symptoms (P = .023) than the sertraline plus placebo group. There were no significant group differences in the two primary outcomes of treatment retention and PTSD severity, or in other secondary outcomes (sleep impairment, sexual functioning, quality of life, and physical and mental functioning), but the combined treatment group showed numerical advantages on all of these outcomes, and effect sizes relative to sertraline plus placebo ranged from small to moderate (d = .26-.63). Both treatments were well-tolerated, with significantly increased appetite but not weight gain in the combined treatment group.

CONCLUSION

Findings suggest that combined treatment of PTSD with sertraline plus mirtazapine may have clinically meaningful advantages in symptomatic improvement, relative to SSRI treatment alone, and acceptable tolerability. Combined treatment with an SSRI plus mirtazapine in PTSD deserves additional study as initial treatment or as an augmentation strategy for nonresponders to an SSRI.

Emerging drugs for the treatment of anxiety

INTRODUCTION

Anxiety disorders are among the most prevalent and disabling psychiatric disorders in the United States and worldwide. Basic research has provided critical insights into the mechanism regulating fear behavior in animals and a host of animal models have been developed in order to screen compounds for anxiolytic properties. Despite this progress, no mechanistically novel agents for the treatment of anxiety have come to market in more than two decades.

AREAS COVERED

The current review will provide a critical summary of current pharmacological approaches to the treatment of anxiety and will examine the pharmacotherapeutic pipeline for treatments in development. Anxiety and related disorders considered herein include panic disorder, social anxiety disorder, generalized anxiety disorder and post-traumatic stress disorder. The glutamate, neuropeptide and endocannabinoid systems show particular promise as future targets for novel drug development.

EXPERT OPINION

In the face of an ever-growing understanding of fear-related behavior, the field awaits the translation of this research into mechanistically novel treatments. Obstacles will be overcome through close collaboration between basic and clinical researchers with the goal of aligning valid endophenotypes of human anxiety disorders with improved animal models. Novel approaches are needed to move basic discoveries into new, more effective treatments for our patients.

Post-traumatic stress disorder--a diagnostic and therapeutic challenge

BACKGROUND

In Germany, the one-month prevalence of post-traumatic stress disorder (PTSD) is in the range of 1% to 3%. Soldiers, persons injured in accidents, and victims of domestic violence increasingly seek medical help for symptoms of emotional stress. Days lost from work and monetary compensation for emotional disturbances are markedly on the rise. The term "PTSD" is commonly used uncritically and imprecisely, with too little regard for the existing diagnostic criteria. It is at risk of turning into a nonspecific collective term for emotional stress of any kind.

METHODS

We selectively reviewed the literature in the PubMed database and pertinent journals, with additional consideration of the recommendations and guidelines of medical societies from Germany and abroad.

RESULTS

The characteristic types of reactions seen in PTSD are nightmares and an intense, repetitive, intrusive "reliving" of the traumatic event(s). Emotional traumatization manifests itself not only as PTSD but also through major effects on other mental and somatic diseases. An early, trauma-focused behavioral therapeutic intervention involving several sessions, generally on an outpatient basis, can prevent the development of PTSD. The most important components of effective treatment are a focus on the particular trauma experienced and confrontation with the patient's memories of the trauma. The best existing evidence is for cognitive therapy, behavioral therapy according to the exposure paradigm of Foa, and eye movement desensitization and reprocessing therapy. The most recent meta-analysis reveals effect strengths of g = 1.14 for all types of psychotherapy and g = 0.42 for all types of pharmacotherapy taken together (with considerable differences among psychotherapeutic methods and among drugs). The efficacy of psychodynamic therapy, systemic therapy, body-oriented therapy, and hypnotherapy has not been adequately documented in randomized controlled trials.

CONCLUSION

PTSD can be precisely diagnosed and effectively treated when the diagnostic criteria and guideline recommendations are taken into account. Referral for trauma-focused psychotherapy should be considered if the acute symptoms persist for several weeks.

Update on the management of post-traumatic stress disorder

Post-traumatic stress disorder occurs in people exposed to life-threatening trauma. GPs may be seeing more patients with post-traumatic stress disorder as military personnel return from overseas deployments. The condition can present in various ways. To reduce the likelihood of missed or delayed diagnosis GPs can screen at-risk populations. A comprehensive assessment is recommended. Specialist referral may be required, particularly if there are other mental health problems. Trauma-focused psychological therapies should be offered as the first line of treatment for post-traumatic stress disorder. Usually 8-12 sessions are needed for a therapeutic effect. If drug treatment is needed, selective serotonin reuptake inhibitors are the first line. Other drugs used in post-traumatic stress disorder include antipsychotics, anticonvulsants and prazosin.

Vintage treatments for PTSD: a reconsideration of tricyclic drugs

Serotonin (SSRI) and serotonin-norepinephrine (SNRI) reuptake inhibitors (SSRI) are the first-line recommended drug treatments for post-traumatic stress disorder (PTSD); but despite their benefits, much residual pathology remains and no new drugs have yet emerged with a clearly demonstrated benefit for treating the disorder. A case is made that tricyclic drugs deserve a closer look, based on their ability to affect several of the main neurotransmitters that are relevant to PTSD. Their promising efficacy, which was shown 30 years ago, had not been followed up, until a recent trial of desipramine found advantages over a SSRI in PTSD with comorbid alcohol dependence. Opportunities exist for studying newer and purportedly safer tricyclic formulations, as well as further the work with older, established compounds. A reappraisal of their risk:benefit ratio seems in order, when treating PTSD.

Cannabinoid modulation of fear extinction brain circuits: a novel target to advance anxiety treatment

Anxiety disorders, such as post-traumatic stress (PTSD), panic, and phobic disorders, can be conceptualized as a failure to inhibit inappropriate fear responses. A common, effective treatment strategy involves repeated presentations to the feared cue without any danger (extinction). However, extinction learning has a number of important limitations, and enhancing its effects, generalizability and durability via cognitive enhancers may improve its therapeutic impact. In this review we focus specifically on the role of the cannabinoid system in fear extinction learning and its retention. We address the following questions: What are the neural circuits mediating fear extinction?; Can we make fear extinction more effective?; Can cannabinoids facilitate fear extinction in humans?; How might the cannabinoid system effect fear extinction? Collectively, translational evidence suggest that enhancing cannabinoid transmission may facilitate extinction learning and its recall, and that the cannabinoid system is a potential pharmacological target for improving the active learning that occurs during exposure-based behavioral treatments prompting future research in terms of mechanisms research, novel treatment approaches ('cognitive enhancers'), and pharmacotherapeutic drug discovery.

Escitalopram in the prevention of posttraumatic stress disorder: a pilot randomized controlled trial

BACKGROUND

A small literature suggests that pharmacotherapy may be useful in the prophylaxis of posttraumatic stress disorder in patients presenting with major trauma. There is relatively little data, however, on the use of selective serotonin reuptake inhibitors (SSRIs) in this context.

METHODS

24 week, double-blind placebo controlled study. 31 participants presenting immediately after trauma, and meeting diagnostic criteria for full or partial acute stress disorder were randomized to treatment with 10-20 mg of escitalopram or placebo daily for 24 weeks. 2 participants were excluded from the analysis due to early drop out, leaving 29 participants (escitalopram = 12, placebo = 17) for inclusion in an intent- to- treat analysis. Participants were followed up until 56 weeks, and assessed with the Clinician Administered PTSD Scale (CAPS). A mixed model repeated measures analysis of variance (RMANOVA) was undertaken to determine the efficacy of the intervention on the CAPS score.

RESULTS

There was a significant reduction in CAPS score over the course of treatment (F(7, 142) = 41. 58, p < 0.001) in both the escitalopram and placebo groups, with a greater reduction in CAPS score in the placebo group F(7, 142) = 2.12, p = 0.045. There were improvements on all secondary measures, including the Clinical Global Impressions scale, and scales assessing depression, anxiety and disability. Only functional disability outcomes (F(7, 141) = 2.13, p = .04), were significantly different between treatment and placebo groups. In the sample as a whole, improvement in scores were maintained at the 52 week follow-up. Side effects were comparable between the groups.

CONCLUSIONS

These data are consistent with other recent work indicating that the SSRIs may not be efficacious in the prevention of PTSD. Nevertheless, the small sample size and baseline differences between groups limit the explanatory power of the study. Although a consideration of the possibility of medication prophylaxis in PTSD remains important, both from conceptual and clinical perspectives, caution is needed with regards to the use of SSRIs until their efficacy can be proven.

TRIAL REGISTRATION

Clinical Trials NCT00300313.

Mental health interventions for traumatized asylum seekers and refugees: What do we know about their efficacy?

BACKGROUND

The prevalence of trauma-related problems among refugees and asylum seekers is extremely high due to adverse experiences associated with forced migration. Although the literature presents a considerable number of guidelines and theoretical frameworks for working with traumatized refugees and asylum seekers, the efficacy, feasibility and applicability of these interventions have little empirical evidence.

AIMS

The purpose of this article is to critically review the literature to provide a rationale for developing culturally sensitive, evidence-based interventions for refugees and asylum seekers.

METHODS

A literature review integrating research findings on interventions designed especially for traumatized asylum seekers and refugees was conducted. Retained studies had to use some quantitative measurements of post-traumatic stress and to have pre- and post-measurements to evaluate the efficacy of the intervention. Studies included in this review cover a wide variety of interventions, including trauma-focused interventions, group therapy, multidisciplinary interventions and pharmacological treatments.

RESULTS

The majority of studies with traumatized refugees and asylum seekers reported positive outcomes of the intervention in reducing trauma-related symptoms. There is evidence to support the suitability of cognitive-behavioral therapy (CBT) and narrative exposure therapy (NET) in certain populations of refugees. Other intervention studies are limited by methodological considerations, such as lack of randomization, absence of control group and small samples.

CONCLUSIONS

This review has again highlighted the shortage of guiding frameworks available to investigators and clinicians who are interested in tailoring interventions to work with refugees and asylum seekers. Theoretical, ethical and methodological considerations for future research are discussed.

Translational evidence for a role of endocannabinoids in the etiology and treatment of posttraumatic stress disorder

INTRODUCTION

Posttraumatic stress disorder (PTSD) is a prevalent, chronic, and disabling anxiety disorder that may develop following exposure to a traumatic event. Despite the public health significance of PTSD, relatively little is known about the etiology or pathophysiology of this disorder, and pharmacotherapy development to date has been largely opportunistic instead of mechanism-based. Recently, an accumulating body of evidence has implicated the endocannabinoid system in the etiology of PTSD, and targets within this system are believed to be suitable for treatment development.

METHODS

Herein, we describe evidence from translational studies arguing for the relevance of the endocannabinoid system in the etiology of PTSD. We also show mechanisms relevant for treatment development.

RESULTS

There is convincing evidence from multiple studies for reduced endocannabinoid availability in PTSD. Brain imaging studies show molecular adaptations with elevated cannabinoid type 1 (CB1) receptor availability in PTSD which is linked to abnormal threat processing and anxious arousal symptoms.

CONCLUSION

Of particular relevance is evidence showing reduced levels of the endocannabinoid anandamide and compensatory increase of CB1 receptor availability in PTSD, and an association between increased CB1 receptor availability in the amygdala and abnormal threat processing, as well as increased severity of hyperarousal, but not dysphoric symptomatology, in trauma survivors. Given that hyperarousal symptoms are the key drivers of more disabling aspects of PTSD such as emotional numbing or suicidality, novel, mechanism-based pharmacotherapies that target this particular symptom cluster in patients with PTSD may have utility in mitigating the chronicity and morbidity of the disorder.

Diagnosis and management of sleep disorders in posttraumatic stress disorder:a review of the literature

OBJECTIVE

International and societal conflicts and natural disasters can leave physical and mental scars in people who are directly affected by these traumatic experiences. Posttraumatic stress disorder (PTSD) is the clinical manifestation of these experiences in the form of re-experiencing the trauma, avoidance of trauma-related stimuli, and persistent symptoms of hyperarousal. There is growing evidence that sleep disruption that occurs following trauma exposure may in fact contribute to the pathophysiology of PTSD and poor clinical outcomes. The purpose of this review is to highlight the importance of recognition and management of sleep disorders in patients with PTSD.

DATA SOURCES

English-language, adult research studies published between 1985 and April 2014 were identified via the PubMed database. The search terms used were PTSD AND sleep disorders.

STUDY SELECTION

The search identified 792 original and review articles. Of these, 53 articles that discussed or researched sleep disorders in PTSD were selected. Fourteen randomized controlled trials of therapy for PTSD are included in this review.

RESULTS

Impaired sleep is a common complaint mainly in the form of nightmares and insomnia among people with PTSD. Sleep apnea and periodic limb movement disorder are particularly prevalent in patients with PTSD and, yet, remain unrecognized. Although selective serotonin reuptake inhibitors are effective in improving PTSD global symptoms, they have a variable and modest effect on sleep disorder symptoms. Cognitive-behavioral treatment targeted to sleep and/or the use of the centrally acting selective α1 antagonist prazosin have been more successful in treating insomnia and nightmares in PTSD than other classes of medications. In view of the high occurrence of sleep apnea and periodic leg movement disorder, a thorough sleep evaluation and treatment are warranted.

CONCLUSIONS

Patients with PTSD have a high prevalence of sleep disorders and should be queried for insomnia, nightmares, periodic limb movement disorder, and sleep-disordered breathing.

Proinflammatory milieu in combat-related PTSD is independent of depression and early life stress

BACKGROUND

Chronic inflammation may be involved in combat-related post-traumatic stress disorder (PTSD) and may help explain comorbid physical diseases. However, the extent to which combat exposure per se, depression, or early life trauma, all of which are associated with combat PTSD, may confound the relationship between PTSD and inflammation is unclear.

METHODS

We quantified interleukin (IL)-6, IL-1β, tumor necrosis factor (TNF)-α, interferon (IFN)-γ, and C-reactive protein (CRP) in 51 combat-exposed males with PTSD and 51 combat-exposed males without PTSD, and assessed PTSD and depression severity as well as history of early life trauma. To decrease the possibility of Type I errors, we summed standardized scores of IL-1β, IL-6, TNFα, IFNγ and CRP into a total "pro-inflammatory score". PTSD symptom severity was assessed with the Clinician Administered PTSD Scale (CAPS) rating scale.

RESULTS

Subjects with PTSD had significantly higher pro-inflammatory scores compared to combat-exposed subjects without PTSD (p=0.006), and even after controlling for early life trauma, depression diagnosis and severity, body mass index, ethnicity, education, asthma/allergies, time since combat and the use of possibly confounding medications (p=0.002). Within the PTSD group, the pro-inflammatory score was not significantly correlated with depressive symptom severity, CAPS total score, or with the number of early life traumas.

CONCLUSIONS

Combat-related PTSD in males is associated with higher levels of pro-inflammatory cytokines, even after accounting for depression and early life trauma. These results, from one of the largest studies of inflammatory cytokines in PTSD to date, suggest that immune activation may be a core element of PTSD pathophysiology more so than a signature of combat exposure alone.

Cannabinoids prevent the effects of a footshock followed by situational reminders on emotional processing

Posttraumatic stress disorder (PTSD) can develop following exposure to a traumatic event. Hence, what we do in the first few hours after trauma exposure may alter the trajectory of PTSD. We examined whether cannabinoids can prevent the effects of a single footshock followed by situational reminders (SRs) on emotional processing. Rats were exposed to a footshock (1.5 mA, 10 s) on day 1 followed by exposure to SRs of the shock on days 3 and 5. The CB1/2 receptor agonist WIN55,212-2 or vehicle were injected intraperitoneally 2 h after the shock. After 1 week, PTSD-like symptoms were examined. Exposure to SRs exacerbated the effects of the shock as rats exposed to shock and SRs, but not shock alone, showed impaired extinction of the traumatic event, impaired plasticity in the hippocmapal-accumbens pathway, enhanced latency to startle, and altered expression of CB1 receptors (CB1r) and glucocorticoid receptors (GRs) in the CA1, basolateral amygdala (BLA) and prefrontal cortex (PFC). WIN55,212-2 prevented the effects of the shock and SRs on extinction, plasticity, and startle response. WIN55,212-2 normalized the shock/SR-induced upregulation in CB1r in the PFC, and CA1 and GRs in the CA1, with no effect on BLA downregulation of CB1r and GRs. Shock and SRs caused lasting (1 week) alterations in emotional processing associated with changes in GR and CB1r expression in brain areas related to PTSD. WIN55,212-2 administered after trauma exposure prevented these alterations via PFC- and CA1-CB1r and CA1-GRs.

Posttraumatic stress disorder in adults: impact, comorbidity, risk factors, and treatment

During the last 30 years, there has been a substantial increase in the study of posttraumatic stress disorder (PTSD). Several high-profile traumatic events, such as the wars in Afghanistan and Iraq, and the terrorist attacks of September 11 on the World Trade Center, have led to a greater public interest in the risk and protective factors for PTSD. In this In Review paper, I discuss some of the important advances in PTSD. The paper provides a concise review of the evolution of PTSD diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, impact of PTSD in the community, an overview of the established risk factors for developing PTSD, and assessment and treatment. Throughout the paper, controversies and clinical implications are discussed.

An electronic health record driven algorithm to identify incident antidepressant medication users

OBJECTIVE

We validated an algorithm designed to identify new or prevalent users of antidepressant medications via population-based drug prescription records.

PATIENTS AND METHODS

We obtained population-based drug prescription records for the entire Olmsted County, Minnesota, population from 2011 to 2012 (N=149,629) using the existing electronic medical records linkage infrastructure of the Rochester Epidemiology Project (REP). We selected electronically a random sample of 200 new antidepressant users stratified by age and sex. The algorithm required the exclusion of antidepressant use in the 6 months preceding the date of the first qualifying antidepressant prescription (index date). Medical records were manually reviewed and adjudicated to calculate the positive predictive value (PPV). We also manually reviewed the records of a random sample of 200 antihistamine users who did not meet the case definition of new antidepressant user to estimate the negative predictive value (NPV).

RESULTS

161 of the 198 subjects electronically identified as new antidepressant users were confirmed by manual record review (PPV 81.3%). Restricting the definition of new users to subjects who were prescribed typical starting doses of each agent for treating major depression in non-geriatric adults resulted in an increase in the PPV (90.9%). Extending the time windows with no antidepressant use preceding the index date resulted in only modest increases in PPV. The manual abstraction of medical records of 200 antihistamine users yielded an NPV of 98.5%.

CONCLUSIONS

Our study confirms that REP prescription records can be used to identify prevalent and incident users of antidepressants in the Olmsted County, Minnesota, population.

Are PTSD treatment choices and treatment beliefs related to depression symptoms and depression-relevant treatment rationales?

Given high rates of depression and low rates of treatment utilization among individuals with posttraumatic stress disorder (PTSD), we examined how depression symptoms impact PTSD treatment beliefs and preference (prolonged exposure (PE), sertraline, or PE plus sertraline). We also examined whether PTSD treatment rationales tailored to individuals with symptoms of depression impact PTSD treatment preference/beliefs. Undergraduates (N = 439) were given an "imagine self" scenario where they either had symptoms of PTSD or PTSD and depression in the future. Trauma-exposed community members (N = 203) reported their own PTSD and depression symptoms. All participants watched standardized treatment rationales for PE and sertraline that were systematically manipulated to include information on depression or not. Across both samples, depression symptoms were associated with significantly increased odds of selecting combination treatment relative to PE alone. For those in the community sample who received the depression-relevant treatment rationale, higher depression symptoms were associated with significantly greater PE credibility and more positive reactions toward PE. Taken together, depression may be associated with a greater preference for combination treatment. However, treatment providers may be able to improve treatment beliefs about PE by offering a treatment rationale that explains that PE tends to help improve symptoms of PTSD and depression.

Depression and anxiety in people with epilepsy

Many recent epidemiological studies have found the prevalence of depression and anxiety to be higher in people with epilepsy (PWE) than in people without epilepsy. Furthermore, people with depression or anxiety have been more likely to suffer from epilepsy than those without depression or anxiety. Almost one-third of PWE suffer from depression and anxiety, which is similar to the prevalence of drug-refractory epilepsy. Various brain areas, including the frontal, temporal, and limbic regions, are associated with the biological pathogenesis of depression in PWE. It has been suggested that structural abnormalities, monoamine pathways, cerebral glucose metabolism, the hypothalamic-pituitary-adrenal axis, and interleukin-1b are associated with the pathogenesis of depression in PWE. The amygdala and the hippocampus are important anatomical structures related to anxiety, and γ-aminobutyric acid and serotonin are associated with its pathogenesis. Depression and anxiety may lead to suicidal ideation or attempts and feelings of stigmatization. These experiences are also likely to increase the adverse effects associated with antiepileptic drugs and have been related to poor responses to pharmacological and surgical treatments. Ultimately, the quality of life is likely to be worse in PWE with depression and anxiety than in PWE without these disorders, which makes the early detection and appropriate management of depression and anxiety in PWE indispensable. Simple screening instruments may be helpful for in this regard, particularly in busy epilepsy clinics. Although both medical and psychobehavioral therapies may ameliorate these conditions, randomized controlled trials are needed to confirm that.

Pharmacotherapy in the aftermath of trauma; opportunities in the 'golden hours'

Several lines of research have demonstrated that memories for fearful events become transiently labile upon re-exposure. Activation of molecular mechanisms is required in order to maintain retrieved information. This process is called reconsolidation. Targeting reconsolidation - as in exposure-based psychotherapy - offers therefore a potentially interesting tool to manipulate fear memories, and subsequently to treat disorders such as post-traumatic stress disorder (PTSD). In this paper we discuss the evidence for reconsolidation in rodents and humans and highlight recent studies in which clinical research on normal and abnormal fear extinction reduction of the expression of fear was obtained by targeting the process of reconsolidation. We conclude that reconsolidation presents an interesting opportunity to modify or alter fear and fear-related memories. More clinical research on normal and abnormal fear extinction is required.

Evaluation of a corticotropin releasing hormone type 1 receptor antagonist in women with posttraumatic stress disorder: study protocol for a randomized controlled trial

BACKGROUND

Pharmacologic treatment options for posttraumatic stress disorder (PTSD) are limited in number and effectiveness. Medications currently in use to treat PTSD were originally approved based on their efficacy in other disorders, such as major depression. Substantial research in PTSD suggests that increased activity of corticotropin releasing hormone (CRH)-containing circuits are involved in the pathophysiology of the disease. This Phase II trial aims to evaluate the efficacy of a CRH type 1 receptor (CRHR1) antagonist in the treatment of PTSD.

METHODS/DESIGN

Currently untreated adult women, ages 18 to 65 years, with a primary psychiatric diagnosis of PTSD of at least 3 months' duration, are being enrolled in a parallel-group, double-blind, placebo-controlled, randomized clinical trial evaluating the efficacy and safety of GSK561679, a novel CRHR1 receptor antagonist. GSK561679 (or matching placebo) is prescribed at a fixed dose of 350 mg nightly for six weeks. The primary trial hypothesis is that GSK561679 will reduce symptoms of PTSD, as measured by the Clinician-Administered PTSD Scale (CAPS), significantly more than placebo after six weeks of treatment. Putative biological markers of PTSD which may influence treatment response are measured prior to randomization and after five weeks' exposure to the study medication, including: fear conditioning and extinction using psychophysiological measures; variants of stress-related genes and gene expression profiles; and indices of HPA axis reactivity. In addition, the impact of PTSD and treatment on neuropsychological performance and functional capacity are assessed at baseline and after the fifth week of study medication. After completion of the six-week double blind treatment period, subjects enter a one-month follow-up period to monitor for sustained response and resolution of any adverse effects.

DISCUSSION

Considerable preclinical and human research supports the hypothesis that alterations in central nervous system CRH neuronal activity are a potential mediator of PTSD symptoms. This study is the first to assess the efficacy of a specific antagonist of a CRH receptor in the treatment of PTSD. Furthermore, the biological and neuropsychological measures included in this trial will substantially inform our understanding of the mechanisms of PTSD.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT01018992.Registered 6 November 2009. First patient randomized 14 January 2010.

PTSD and comorbid AUD: a review of pharmacological and alternative treatment options

BACKGROUND

Although posttraumatic stress disorder (PTSD) and alcohol use disorders (AUD) frequently co-occur there are no specific treatments for individuals diagnosed with these comorbid conditions. The main objectives of this paper are to review the literature on pharmacological options for PTSD and comorbid AUD, and to summarize promising behavioral and alternative interventions for those with these dual diagnoses.

METHODS

We conducted a comprehensive search on PsycINFO and MEDLINE/PubMed databases using Medical Subject Headings terms in various combinations to identify articles that used pharmacotherapy for individuals with dual diagnoses of PTSD and AUD. Similar strategies were used to identify articles on behavioral and alternative treatments for AUD and PTSD. We identified and reviewed six studies that tested pharmacological treatments for patients with PTSD and comorbid AUD.

RESULTS

The literature on treatment with US Food and Drug Administration approved medications for patients with dual diagnosis of PTSD and AUD is very limited and inconclusive. Promising evidence indicates that topiramate and prazosin may be effective in reducing PTSD and AUD symptoms in individuals with comorbidity. Seeking safety has had mixed efficacy in clinical trials. The efficacy of other behavioral and alternative treatments (mindfulness-based, yoga, and acupuncture) is more difficult to evaluate since the evidence comes from small, single studies without comparison groups.

CONCLUSION

There is a clear need for more systematic and rigorous study of pharmacological, behavioral, and alternative treatments for patients with dual diagnoses of PTSD and AUD.

Depression sudden gains and transient depression spikes during treatment for PTSD

OBJECTIVE

We know little about how change unfolds in depression symptoms during posttraumatic stress disorder (PTSD) treatment or how patient characteristics predict depression symptom change. This study examined critical transition points in depression symptoms during PTSD treatment, namely, depression sudden gains, which are rapid symptom improvements and transient depression spikes, which are transient depression worsenings. Social support, one of the strongest predictors of PTSD development, was examined as a predictor of depression symptom discontinuities.

METHOD

At pretreatment, 200 participants (76.6% female; 64.9% Caucasian; age M = 37.1, SD = 11.3 years) completed measures of PTSD severity (PTSD Symptom Scale-Self-Report), depression severity (Beck Depression Inventory), general social support (Inventory of Socially Supportive Behaviors; Social Support Questionnaire), and trauma-related social support (Social Reactions Questionnaire). During 10 weeks of prolonged exposure (PE) or sertraline, depression was assessed weekly.

RESULTS

Overall, 18.0% of participants experienced a depression sudden gain, and 22.5% experienced a transient depression spike. The presence of a depression sudden gain predicted better treatment outcome, β = -4.82, SE = 1.17, p = .001, 95% CI [-6.79, -2.90]. Higher perceptions of negative trauma-related reactions, albeit modestly, were associated with experiencing a transient depression spike (r = .18, p = .01). There were no differences in rates of depression sudden gains or transient depression spikes between treatments.

CONCLUSIONS

Encouragingly, rapid improvements in depression symptoms are beneficial for PTSD treatment outcome, but transient spikes in depressive symptoms do not strongly influence outcome. Understanding symptom discontinuities may help us to personalize current PTSD treatment options.

Improving recovery-Learning from patients' experiences after injury: a qualitative study

OBJECTIVES

To explore experiences of patients after injury and identify implications for clinical care and support within the hospital setting and primary care.

DESIGN

Semi-structured telephone administered qualitative interviews with purposive sampling and thematic qualitative analysis.

PARTICIPANTS

Patients who have experienced an unintentional injury and attended hospital.

SETTING

Bristol, Surrey and Swansea.

RESULTS

Key issues that emerged were: most patients reported mixed experiences of hospital care but some described the delivery of care as depersonalising; the need for clinicians to provide adequate, timely and realistic information to patients about their injury and treatment to inform their expectations of recovery; the impact of pain at the time of the injury and for an extended period afterwards; the experience of injury on patients' emotional state with possible implications for longer term mental health issues; the pivotal role of physiotherapy care in providing practical and individualised strategies for recovery; and the importance of social support for recovery.

CONCLUSIONS

Trauma patients' recovery needs to be supported by information protocols. The social circumstances of patients need to be considered at the point of discharge and during recovery. There is a need to identify people who may be experiencing mental health issues for timely referral to assessment services and appropriate care. Signposting to support groups may also be helpful for those with life changing injuries. Improved pain management would help alleviate discomfort and stress. Physiotherapy has a key role to play in supporting patients in recovery.

Psychological therapies for chronic post-traumatic stress disorder (PTSD) in adults

BACKGROUND

Post-traumatic stress disorder (PTSD) is a distressing condition, which is often treated with psychological therapies. Earlier versions of this review, and other meta-analyses, have found these to be effective, with trauma-focused treatments being more effective than non-trauma-focused treatments. This is an update of a Cochrane review first published in 2005 and updated in 2007.

OBJECTIVES

To assess the effects of psychological therapies for the treatment of adults with chronic post-traumatic stress disorder (PTSD).

SEARCH METHODS

For this update, we searched the Cochrane Depression, Anxiety and Neurosis Group's Specialised Register (CCDANCTR-Studies and CCDANCTR-References) all years to 12th April 2013. This register contains relevant randomised controlled trials from: The Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). In addition, we handsearched the Journal of Traumatic Stress, contacted experts in the field, searched bibliographies of included studies, and performed citation searches of identified articles.

SELECTION CRITERIA

Randomised controlled trials of individual trauma-focused cognitive behavioural therapy (TFCBT), eye movement desensitisation and reprocessing (EMDR), non-trauma-focused CBT (non-TFCBT), other therapies (supportive therapy, non-directive counselling, psychodynamic therapy and present-centred therapy), group TFCBT, or group non-TFCBT, compared to one another or to a waitlist or usual care group for the treatment of chronic PTSD. The primary outcome measure was the severity of clinician-rated traumatic-stress symptoms.

DATA COLLECTION AND ANALYSIS

We extracted data and entered them into Review Manager 5 software. We contacted authors to obtain missing data. Two review authors independently performed 'Risk of bias' assessments. We pooled the data where appropriate, and analysed for summary effects.

MAIN RESULTS

We include 70 studies involving a total of 4761 participants in the review. The first primary outcome for this review was reduction in the severity of PTSD symptoms, using a standardised measure rated by a clinician. For this outcome, individual TFCBT and EMDR were more effective than waitlist/usual care (standardised mean difference (SMD) -1.62; 95% CI -2.03 to -1.21; 28 studies; n = 1256 and SMD -1.17; 95% CI -2.04 to -0.30; 6 studies; n = 183 respectively). There was no statistically significant difference between individual TFCBT, EMDR and Stress Management (SM) immediately post-treatment although there was some evidence that individual TFCBT and EMDR were superior to non-TFCBT at follow-up, and that individual TFCBT, EMDR and non-TFCBT were more effective than other therapies. Non-TFCBT was more effective than waitlist/usual care and other therapies. Other therapies were superior to waitlist/usual care control as was group TFCBT. There was some evidence of greater drop-out (the second primary outcome for this review) in active treatment groups. Many of the studies were rated as being at 'high' or 'unclear' risk of bias in multiple domains, and there was considerable unexplained heterogeneity; in addition, we assessed the quality of the evidence for each comparison as very low. As such, the findings of this review should be interpreted with caution.

AUTHORS' CONCLUSIONS

The evidence for each of the comparisons made in this review was assessed as very low quality. This evidence showed that individual TFCBT and EMDR did better than waitlist/usual care in reducing clinician-assessed PTSD symptoms. There was evidence that individual TFCBT, EMDR and non-TFCBT are equally effective immediately post-treatment in the treatment of PTSD. There was some evidence that TFCBT and EMDR are superior to non-TFCBT between one to four months following treatment, and also that individual TFCBT, EMDR and non-TFCBT are more effective than other therapies. There was evidence of greater drop-out in active treatment groups. Although a substantial number of studies were included in the review, the conclusions are compromised by methodological issues evident in some. Sample sizes were small, and it is apparent that many of the studies were underpowered. There were limited follow-up data, which compromises conclusions regarding the long-term effects of psychological treatment.

A factor analysis of posttraumatic stress disorder symptoms using data pooled from two venlafaxine extended-release clinical trials

BACKGROUND

Confirmatory factor analysis (CFA) of Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) three-factor posttraumatic stress disorder (PTSD) diagnostic criteria was conducted to determine fit for this patient population. An exploratory factor analysis (EFA) of alternate symptom structures was planned to identify symptoms that cluster in this population. The response of symptom factors to treatment with venlafaxine extended release (ER) was explored.

METHODS

Baseline 17-item Clinician-Administered PTSD Scale (CAPS-SX17) data were pooled from patients enrolled in two double-blind, randomized, placebo-controlled trials. The CFA was conducted using maximum likelihood and weighted, least-squares factor extraction methods. The EFA was performed using a polychoric correlation covariance matrix and Pearson correlation matrix.

RESULTS

Data from a pooled population of 685 patients (venlafaxine ER: n = 339; placebo: n = 346) were analyzed. CFA rejected the DSM-IV three-factor structure. The EFA identified a different three-factor structure as the best fit: factor 1 included reexperiencing symptoms, factor 2 included symptoms of altered mood and cognition, whereas factor 3 comprised avoidance and arousal symptoms. All DSM-IV symptom factors and all factors in the identified three-factor model responded positively to venlafaxine ER treatment.

CONCLUSIONS

Data are consistent with literature failing to confirm the three-factor structure of DSM-IV PTSD, and they support the DSM-5 inclusion of a symptom cluster addressing altered mood and cognition in PTSD. The efficacy of venlafaxine ER in reducing a range of symptom clusters in PTSD is consistent with its multiple mechanisms of action.

Neural responses during emotional processing before and after cognitive trauma therapy for battered women

Therapy for combat and accident-related posttraumatic stress disorder (PTSD) has been reported to influence amygdala and anterior cingulate cortex (ACC) response during emotional processing. It is not yet understood how therapy influences different phases of emotional processing, and whether previous findings generalize to other PTSD populations. We hypothesized that cognitive trauma therapy for battered women (CTT-BW) would alter insula, amygdala, and cingulate responses during anticipation and presentation of emotional images. Fourteen female patients with PTSD related to domestic violence completed the Clinician Administered PTSD Scale (CAPS) and functional magnetic resonance imaging (fMRI) before and after CTT-BW. The fMRI task involved cued anticipation followed by presentation of positive versus negative affective images. CTT-BW was associated with decreases in CAPS score, enhanced ACC and decreased anterior insula activation during anticipation, and decreased dorsolateral prefrontal cortex and amygdala response during image presentation (negative-positive). Pre-treatment ACC activation during anticipation and image presentation exhibited positive and negative relationships to treatment response, respectively. Results suggest that CTT-BW enhanced efficiency of neural responses during preparation for upcoming emotional events in a way that reduced the need to recruit prefrontal-amygdala responses during the occurrence of the event. Results also suggest that enhancing ACC function during anticipation may be beneficial for PTSD treatment.

Treatment of traumatized refugees with sertraline versus venlafaxine in combination with psychotherapy - study protocol for a randomized clinical trial

BACKGROUND

Sufficient evidence is lacking to draw final conclusions on the efficiency of medical and psychological treatments of traumatized refugees with PTSD. The pharmacological treatments of choice today for post-traumatic stress disorder are antidepressants from the subgroup selective serotonin reuptake inhibitors, especially sertraline. The evidence for the use of selective serotonin reuptake inhibitors in the treatment of complex post-traumatic stress disorder in traumatized refugees is very limited. Venlafaxine is a dual-action antidepressant that works on several pathways in the brain. It influences areas in the brain which are responsible for the enhanced anxiety and hyper-arousal experienced by traumatized refugees and which some studies have found to be enlarged among patients suffering from post-traumatic stress disorder.

DESIGN

This study will include approximately 150 patients, randomized into two different groups treated with either sertraline or venlafaxine. Patients in both groups will receive the same manual-based cognitive behavioral therapy, which has been especially adapted to this group of patients. The treatment period will be 6 to 7 months. The trial endpoints will be post-traumatic stress disorder and depressive symptoms and social functioning, all measured on validated ratings scales. Furthermore the study will examine the relation between a psycho-social resources and treatment outcome based on 15 different possible outcome predictors.

DISCUSSION

This study is expected to bring forward new knowledge on treatment and clinical evaluation of traumatized refugees and the results are expected to be used in reference programs and clinical guidelines.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01569685.

Big effects of small RNAs: a review of microRNAs in anxiety

Epigenetic and regulatory elements provide an additional layer of complexity to the heterogeneity of anxiety disorders. MicroRNAs (miRNAs) are a class of small, noncoding RNAs that have recently drawn interest as epigenetic modulators of gene expression in psychiatric disorders. miRNAs elicit their effects by binding to target messenger RNAs (mRNAs) and hindering translation or accelerating degradation. Considering their role in neuronal differentiation and synaptic plasticity, miRNAs have opened up new investigative avenues in the aetiology and treatment of anxiety disorders. In this review, we provide a thorough analysis of miRNAs, their targets and their functions in the central nervous system (CNS), focusing on their role in anxiety disorders. The involvement of miRNAs in CNS functions (such as neurogenesis, neurite outgrowth, synaptogenesis and synaptic and neural plasticity) and their intricate regulatory role under stressful conditions strongly support their importance in the aetiology of anxiety disorders. Furthermore, miRNAs could provide new avenues for the development of therapeutic targets in anxiety disorders.

Recent progress in understanding the pathophysiology of post-traumatic stress disorder: implications for targeted pharmacological treatment

Post-traumatic stress disorder (PTSD) is a common and chronic anxiety disorder that can result after exposure to a traumatic event. Though our understanding of the aetiology of PTSD is incomplete, several neurobiological systems have been implicated in the pathophysiology and vulnerability towards developing PTSD after trauma exposure. We aimed to provide a concise review of benchmark findings in important neurobiological systems related to the aetiology and maintenance of PTSD symptomology. Specifically, we discuss functional aetiologies in the noradrenergic, serotonergic, endogenous cannabinoid and opioid systems as well as the hypothalamic-pituitary adrenal (HPA) axis. This article provides a succinct framework to appreciate the current understanding of neurobiological mechanisms related to the pathophysiology of PTSD and how these findings may impact the development of future, targeted pharmacological treatments for this debilitating disorder.

Pharmacological approaches to the treatment of complicated grief: rationale and a brief review of the literature

Complicated grief (CG) is a common and often under-acknowledged cause of profound impairment experienced after the loss of a loved one. Although both clinical and basic research suggests that pharmacological agents might be of use in the treatment of CG, research on pharmacological approaches to this condition is still scarce. Three open-label trials and one randomized trial on bereavement-related depression suggest that tricyclic antidepressants may be effective, although they may be more efficacious for depressive symptoms than for grief-specific symptoms. Four open-label trials (total number of participants, 50) of selective serotonin reuptake inhibitors (SSRIs) have yielded results, providing very preliminary support that they might be effective in the treatment of CG, both as a standalone treatment and in conjunction with psychotherapeutic interventions. These more recent studies have shown an effect on both depression and grief-specific scales. Furthermore, therapeutic interventions for CG may be more effective in conjunction with SSRI administration. Given the small number of pharmacological studies to date, there is a need for randomized trials to test the potential efficacy of pharmacological agents in the treatment of CG.

Comparison of the effectiveness of trauma-focused cognitive behavioral therapy and paroxetine treatment in PTSD patients: design of a randomized controlled trial

BACKGROUND

The two most common interventions for Posttraumatic Stress Disorder (PTSD) are pharmacological treatment with SSRIs such as paroxetine and psychological treatment such as Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). International guidelines recommend trauma-focused psychological interventions for all PTSD patients as first-line treatment (NICE). However, no clear-cut evidence is available to support this recommendation.

METHODS/DESIGN

In order to compare pharmacological treatment (paroxetine) and psychological treatment (TF-CBT) in (cost-) effectiveness on the short and the long term, we will randomize 90 patients with chronic PTSD to either paroxetine (24 weeks) or TF-CBT (10-12 weeks). We will assess symptom severity and costs before and after the intervention with the Clinician Administered PTSD Scale (CAPS), the Clinical Global Impression Scale (CGI) and the Trimbos/iMTA questionnaire for Costs associated with Psychiatric Illness (TiC-P).

DISCUSSION

This study is unique for its direct comparison of the most commonly used psychological intervention (TF-CBT) and pharmacological intervention (paroxetine) on (cost-) effectiveness on the short and the long term. The anticipated results will provide relevant evidence concerning long-term effects and relapse rates and will be beneficial in reducing societal costs. It may also provide information on who may benefit most from which type of intervention. Some methodological issues will be discussed.

TRIAL REGISTRATION

Dutch Trial registration: NTR2235.

Posttraumatic stress disorder symptoms mediate the relationship between traumatic experiences and drinking behavior among women attending alcohol-serving venues in a South African township

OBJECTIVE

South Africa has high rates of traumatic experiences and alcohol abuse or dependence, especially among women. Traumatic experiences often result in symptoms of posttraumatic stress disorder (PTSD), and PTSD has been associated with hazardous drinking. This article examines the relationship between traumatic events and hazardous drinking among women who patronized alcohol-serving venues in South Africa and examines PTSD as a mediator of this relationship.

METHOD

A total of 560 women were recruited from a Cape Town township. They completed a computerized assessment that included alcohol consumption, history of traumatic events, and PTSD symptoms. Mediation analysis examined whether PTSD symptoms mediated the relationship between the number of traumatic event categories experienced (range: 0-7) and drinking behavior.

RESULTS

The mean Alcohol Use Disorders Identification Test score in the sample was 12.15 (range: 0-34, SD = 7.3), with 70.9% reaching criteria for hazardous drinking (AUDIT > 8). The mean PTSD score was 36.32 (range: 17-85, SD = 16.3),with 20.9% meeting symptom criteria for PTSD (PTSD Checklist with 20.9% meeting symptom criteria for PTSD (PTSD Checklist-Civilian Version ≥ 50). Endorsement of traumatic experiences was high, including adult emotional (51.8%), physical (49.6%), and sexual (26.3%) abuse; childhood physical (35.0%) and sexual (25.9%) abuse; and other types of trauma (83%). All categories of traumatic experiences, except the "other" category, were associated with hazardous drinking. PTSD symptoms mediated 46% of the relationship between the number of traumatic categories experienced and drinking behavior.

CONCLUSIONS

Women reported high rates of hazardous drinking and high levels of PTSD symptoms, and most had some history of traumatic events. There was a strong relationship between traumatic exposure and drinking levels, which was largely mediated by PTSD symptoms. Substance use interventions should address histories of trauma in this population, where alcohol may be used in part to cope with past traumas.

Central administration of oxytocin receptor ligands affects cued fear extinction in rats and mice in a timepoint-dependent manner

RATIONALE

Oxytocin (OXT) has been proposed as a potential therapeutic agent for post-traumatic stress disorder (PTSD).

OBJECTIVES

We aimed to verify whether pharmacological manipulation of the brain OXT system affects cued fear conditioning and fear extinction.

METHODS

Male rats and mice were intracerebroventricularly administered synthetic OXT (rats, 0.1 or 1.0 μg/5 μl; mice, 0.1 or 0.5 μg/2 μl) and/or an OXT receptor antagonist (OXTR-A; rats, 0.75 μg/5 μl) either prior to fear conditioning or extinction training.

RESULTS

Preconditioning administration of OXT did not affect fear conditioning in rats, but decreased fear expression and facilitated fear extinction. In contrast, preconditioning blockade of OXT neurotransmission by OXTR-A did not affect fear conditioning or fear expression, but impaired fear extinction. When administered before extinction training, OXT impaired fear extinction in both rats and mice, indicating that the effects of OXT on fear extinction are conserved across species. This impairment was OXTR-mediated, as the inhibitory effect of OXT on fear extinction was abolished by prior treatment with OXTR-A. The impaired fear extinction was not a result of reduced locomotion in rats, whereas an apparent decrease in fear expression and facilitation of fear extinction with the higher OXT dose in mice was the result of behavioral hyperactivity.

CONCLUSIONS

These results suggest that increasing OXT neurotransmission during traumatic events is likely to prevent the formation of aversive memories. In contrast, OXT treatment before fear extinction training, which would be the comparable timepoint for psychotherapy in PTSD patients, rather delays fear extinction and, therefore, caution is needed before recommending OXT for the treatment of PTSD.

Cannabinoid facilitation of fear extinction memory recall in humans

A first-line approach to treat anxiety disorders is exposure-based therapy, which relies on extinction processes such as repeatedly exposing the patient to stimuli (conditioned stimuli; CS) associated with the traumatic, fear-related memory. However, a significant number of patients fail to maintain their gains, partly attributed to the fact that this inhibitory learning and its maintenance is temporary and conditioned fear responses can return. Animal studies have shown that activation of the cannabinoid system during extinction learning enhances fear extinction and its retention. Specifically, CB1 receptor agonists, such as Δ9-tetrahydrocannibinol (THC), can facilitate extinction recall by preventing recovery of extinguished fear in rats. However, this phenomenon has not been investigated in humans. We conducted a study using a randomized, double-blind, placebo-controlled, between-subjects design, coupling a standard Pavlovian fear extinction paradigm and simultaneous skin conductance response (SCR) recording with an acute pharmacological challenge with oral dronabinol (synthetic THC) or placebo (PBO) 2 h prior to extinction learning in 29 healthy adult volunteers (THC = 14; PBO = 15) and tested extinction retention 24 h after extinction learning. Compared to subjects that received PBO, subjects that received THC showed low SCR to a previously extinguished CS when extinction memory recall was tested 24 h after extinction learning, suggesting that THC prevented the recovery of fear. These results provide the first evidence that pharmacological enhancement of extinction learning is feasible in humans using cannabinoid system modulators, which may thus warrant further development and clinical testing. This article is part of a Special Issue entitled 'Cognitive Enhancers'.

Prevalence and trends of benzodiazepine use among Veterans Affairs patients with posttraumatic stress disorder, 2003-2010

BACKGROUND

Although the Veterans Affairs and Department of Defense (VA/DoD) clinical guidelines for management of posttraumatic stress disorder (PTSD) recommend against routine benzodiazepine use, little is known about the trends and clinical and prescription profiles of benzodiazepine use since these guidelines were released in 2004.

METHODS

This retrospective study included 64,872 patients with a PTSD diagnosis received from care at facilities in VA Northwest Veterans Integrated Service Network (VISN 20) during 2003-2010. Annual prevalence of any use was defined as any prescription for benzodiazepines, and long-term use was defined as >90 days' supply, in a year. Gender-specific logistic regressions were fit to estimate any and long-term benzodiazepine use, test for linear trends over 8-years and explore factors associated with trends.

RESULTS

The trend of age-adjusted benzodiazepine use over 8-years rose significantly from 25.0 to 26.8% among men and 31.2 to 38.8% among women. Long-term use in men and women increased from 15.4 to 16.4% and 18.0 to 22.7%, respectively. Comorbid psychiatric and alcohol use disorders (AUD) were associated with a greater increase in long-term use of benzodiazepines. In 2010, 61% of benzodiazepine users received >90 days' supply. Among those prescribed benzodiazepines long-term, 11% had AUD and 47% were also prescribed opioids long-term.

CONCLUSION

Despite VA/DoD clinical guidelines recommending against routine use of benzodiazepines for PTSD, the adjusted prevalence of long-term use increased among men and women with PTSD in VISN 20. Widespread concomitant use of benzodiazepines and opioids suggests risk management systems and research on the efficacy and safety of these medications are needed.

Decreased suicidal ideation in depressed patients with or without comorbid posttraumatic stress disorder treated with selective serotonin reuptake inhibitors: an open study

Comorbidity of posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) is associated with higher morbidity including suicidal ideation and behavior. Selective serotonin reuptake inhibitors (SSRIs) are a known treatment for PTSD, MDD and comorbid PTSD and MDD. Since the patients with comorbid MDD and PTSD (PTSD-MDD) are sicker, we hypothesize a poorer response to treatment compared to patients with MDD only. Ninety-six MDD patients were included in the study: 76 with MDD only and 20 with PTSD-MDD. Demographic and clinical parameters at baseline were assessed. We examined clinical parameters before and after 3 months of open SSRI treatment in subjects with PTSD-MDD and compared this group to individuals with MDD only. At baseline, PTSD-MDD patients had higher Hamilton Depression Rating Scale and Buss-Durkee Hostility Scale scores compared with MDD only subjects. There was a significant decrease in scores on the Hamilton Depression Rating Scale, Beck Depression Inventory, Beck Hopelessness Scale, and Beck Scale for Suicidal Ideation after 3 months of treatment with SSRIs in both groups. The magnitude of improvement in Beck Scale for Suicidal Ideation scores was greater in the PTSD-MDD group compared to the MDD only subjects. Symptoms of depression including suicidal ideation improved in MDD patients with or without comorbid PTSD after 3 months of treatment with SSRIs but improvement in suicidal ideation was greater in the PTSD-MDD group. Our finding has not supported the hypothesis that a response to treatment is poorer in the PTSD-MDD group which may indicate that sicker patients benefit more from the treatment.

Loop diuretics have anxiolytic effects in rat models of conditioned anxiety

A number of antiepileptic medications that modulate GABA(A) mediated synaptic transmission are anxiolytic. The loop diuretics furosemide (Lasix) and bumetanide (Bumex) are thought to have antiepileptic properties. These drugs also modulate GABA(A) mediated signalling through their antagonism of cation-chloride cotransporters. Given that loop diuretics may act as antiepileptic drugs that modulate GABAergic signalling, we sought to investigate whether they also mediate anxiolytic effects. Here we report the first investigation of the anxiolytic effects of these drugs in rat models of anxiety. Furosemide and bumetanide were tested in adult rats for their anxiolytic effects using four standard anxiety models: 1) contextual fear conditioning; 2) fear-potentiated startle; 3) elevated plus maze, and 4) open-field test. Furosemide and bumetanide significantly reduced conditioned anxiety in the contextual fear-conditioning and fear-potentiated startle models. At the tested doses, neither compound had significant anxiolytic effects on unconditioned anxiety in the elevated plus maze and open-field test models. These observations suggest that loop diuretics elicit significant anxiolytic effects in rat models of conditioned anxiety. Since loop diuretics are antagonists of the NKCC1 and KCC2 cotransporters, these results implicate the cation-chloride cotransport system as possible molecular mechanism involved in anxiety, and as novel pharmacological target for the development of anxiolytics. In view of these findings, and since furosemide and bumetanide are safe and well tolerated drugs, the clinical potential of loop diuretics for treating some types of anxiety disorders deserves further investigation.

BDNF function as a potential mediator of bipolar disorder and post-traumatic stress disorder comorbidity

Bipolar disorder (BD) and post-traumatic stress disorder (PTSD) frequently co-occur among psychiatric patients, leading to increased morbidity and mortality. Brain-derived neurotrophic factor (BDNF) function is associated with core characteristics of both BD and PTSD. We propose a neurobiological model that underscores the role of reduced BDNF function resulting from several contributing sources, including the met variant of the BDNF val66met (rs6265) single-nucleotide polymorphism, trauma-induced epigenetic regulation and current stress, as a contributor to the onset of both illnesses within the same person. Further studies are needed to evaluate the genetic association between the val66met allele and the BD-PTSD population, along with central/peripheral BDNF levels and epigenetic patterns of BDNF gene regulation within these patients.

The impact of injuries study. multicentre study assessing physical, psychological, social and occupational functioning post injury--a protocol

BACKGROUND

Large numbers of people are killed or severely injured following injuries each year and these injuries place a large burden on health care resources. The majority of the severely injured are not fully recovered 12-18 months later. Psychological disorders are common post injury and are associated with poorer functional and occupational outcomes. Much of this evidence comes from countries other than the UK, with differing health care and compensation systems. Early interventions can be effective in treating psychological morbidity, hence the scale and nature of the problem and its impact of functioning in the UK must be known before services can be designed to identify and manage psychological morbidity post injury.

METHODS/DESIGN

A longitudinal multi-centre study of 680 injured patients admitted to hospital in four areas across the UK: Nottingham, Leicester/Loughborough, Bristol and Surrey. A stratified sample of injuries will ensure a range of common and less common injuries will be included. Participants will complete a baseline questionnaire about their injury and pre-injury quality of life, and follow-up questionnaires 1, 2, 4, and 12 months post injury. Measures will include health and social care utilisation, perceptions of recovery, physical, psychological, social and occupational functioning and health-related quality of life. A nested qualitative study will explore the experiences of a sample of participants, their carers and service providers to inform service design.

DISCUSSION

This study will quantify physical, psychological, social and occupational functioning and health and social care utilisation following a range of different types of injury and will assess the impact of psychological disorders on function and health service use. The findings will be used to guide the development of interventions to maximise recovery post injury.

The effect of early trauma exposure on serotonin type 1B receptor expression revealed by reduced selective radioligand binding

CONTEXT

Serotonergic dysfunction is implicated in the pathogenesis of posttraumatic stress disorder (PTSD), and recent animal models suggest that disturbances in serotonin type 1B receptor function, in particular, may contribute to chronic anxiety. However, the specific role of the serotonin type 1B receptor has not been studied in patients with PTSD.

OBJECTIVE

To investigate in vivo serotonin type 1B receptor expression in individuals with PTSD, trauma-exposed control participants without PTSD (TC), and healthy (non-trauma-exposed) control participants (HC) using positron emission tomography and the recently developed serotonin type 1B receptor selective radiotracer [(11)C]P943.

DESIGN

Cross-sectional positron emission tomography study under resting conditions.

SETTING

Academic and Veterans Affairs medical centers.

PARTICIPANTS

Ninety-six individuals in 3 study groups: PTSD (n = 49), TC (n = 20), and HC (n = 27). Main Outcome Measure  Regional [(11)C]P943 binding potential (BP(ND)) values in an a priori-defined limbic corticostriatal circuit investigated using multivariate analysis of variance and multiple regression analysis.

RESULTS

A history of severe trauma exposure in the PTSD and TC groups was associated with marked reductions in [(11)C]P943 BP(ND) in the caudate, the amygdala, and the anterior cingulate cortex. Participant age at first trauma exposure was strongly associated with low [(11)C]P943 BP(ND). Developmentally earlier trauma exposure also was associated with greater PTSD symptom severity and major depression comorbidity.

CONCLUSIONS

These data suggest an enduring effect of trauma history on brain function and the phenotype of PTSD. The association of early age at first trauma and more pronounced neurobiological and behavioral alterations in PTSD suggests a developmental component in the cause of PTSD.

Brain stimulation in posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) is a complex, heterogeneous disorder that develops following trauma and often includes perceptual, cognitive, affective, physiological, and psychological features. PTSD is characterized by hyperarousal, intrusive thoughts, exaggerated startle response, flashbacks, nightmares, sleep disturbances, emotional numbness, and persistent avoidance of trauma-associated stimuli. The efficacy of available treatments for PTSD may result in part from relief of associated depressive and anxiety-related symptoms in addition to treatment of core symptoms that derive from reexperiencing, numbing, and hyperarousal. Diverse, heterogeneous mechanisms of action and the ability to act broadly or very locally may enable brain stimulation devices to address PTSD core symptoms in more targeted ways. To achieve this goal, specific theoretical bases derived from novel, well-designed research protocols will be necessary. Brain stimulation devices include both long-used and new electrical and magnetic devices. Electroconvulsive therapy (ECT) and Cranial electrotherapy stimulation (CES) have both been in use for decades; transcranial magnetic stimulation (TMS), magnetic seizure therapy (MST), deep brain stimulation (DBS), transcranial Direct Current Stimulation (tDCS), and vagus nerve stimulation (VNS) have been developed recently, over approximately the past twenty years. The efficacy of brain stimulation has been demonstrated as a treatment for psychiatric and neurological disorders such as anxiety (CES), depression (ECT, CES, rTMS, VNS, DBS), obsessive-compulsive disorder (OCD) (DBS), essential tremor, dystonia (DBS), epilepsy (DBS, VNS), Parkinson Disease (DBS), pain (CES), and insomnia (CES). To date, limited data on brain stimulation for PTSD offer only modest guidance. ECT has shown some efficacy in reducing comorbid depression in PTSD patients but has not been demonstrated to improve most core PTSD symptoms. CES and VNS have shown some efficacy in reducing anxiety, findings that may suggest possible utility in relieving PTSD-associated anxiety. Treatment of animal models of PTSD with DBS suggests potential human benefit. Additional research and novel treatment options for PTSD are urgently needed. The potential usefulness of brain stimulation in treating PTSD deserves further exploration.

A double-blind randomized controlled trial to study the efficacy of topiramate in a civilian sample of PTSD

OBJECTIVE

To evaluate the efficacy and tolerability of topiramate in patients with posttraumatic stress disorder (PTSD).

METHOD

We conducted a 12-week double-blind, randomized, placebo-controlled study comparing topiramate to placebo. Men and women aged 18-62 years with diagnosis of PTSD according to DSM-IV were recruited from the outpatient clinic of the violence program of Federal University of São Paulo Hospital (Prove-UNIFESP), São Paulo City, between April 2006 and December 2009. Subjects were assessed for the Clinician-Administered Posttraumatic Stress Scale (CAPS), Clinical Global Impression, and Beck Depression Inventory (BDI). After 1-week period of washout, 35 patients were randomized to either group. The primary outcome measure was the CAPS total score changes from baseline to the endpoint.

RESULTS

82.35% of patients in the topiramate group exhibited improvements in PTSD symptoms. The efficacy analysis demonstrated that patients in the topiramate group exhibited significant improvements in reexperiencing symptoms: flashbacks, intrusive memories, and nightmares of the trauma (CAPS-B; P= 0.04) and in avoidance/numbing symptoms associated with the trauma, social isolation, and emotional numbing (CAPS-C; P= 0.0001). Furthermore, the experimental group demonstrated a significant difference in decrease in CAPS total score (topiramate -57.78; placebo -32.41; P= 0.0076). Mean topiramate dose was 102.94 mg/d. Topiramate was generally well tolerated.

CONCLUSION

Topiramate was effective in improving reexperiencing and avoidance/numbing symptom clusters in patients with PTSD. This study supports the use of anticonvulsants for the improvement of symptoms of PTSD.

Functional impairment in adults with past posttraumatic stress disorder: findings from primary care

BACKGROUND

Although many patients with posttraumatic stress disorder (PTSD) experience a reduction in posttraumatic symptoms over time, little is currently known about the extent of their residual functional impairment. This study examines functional impairment in primary care patients with a history of PTSD as compared to patients with current PTSD, and those who never developed PTSD following exposure to trauma.

METHODS

The sample consisted of 321 trauma-exposed low-income, predominantly Hispanic adults attending a large urban primary care practice. PTSD was assessed with the Lifetime Composite International Diagnostic Interview and other psychiatric disorders with the SCID-I. Physical and mental health-related quality of life was assessed with the Medical Outcome Health Survey (SF-12), and functional impairment with items from the Sheehan Disability Scale and Social Adjustment Scale Self-Report.

RESULTS

Logistic regression analyses controlling for gender, psychiatric comorbidity, and interpersonal traumas showed that although patients with past PTSD function significantly better than patients with current PTSD, they experience persisting deficits in mental health-related quality of life compared to trauma-exposed patients who never developed PTSD. Overall, results revealed a continuum of severity in psychiatric comorbidity, functioning, and quality of life, with current PTSD associated with the most impairment, never having met criteria for PTSD with the least impairment, and history of PTSD falling in between.

CONCLUSIONS

In this primary care sample, adults with a history of past PTSD but no current PTSD continued to report enduring functional deficits, suggesting a need for ongoing clinical attention.

Bleeding after percutaneous endoscopic gastrostomy is linked to serotonin reuptake inhibitors, not aspirin or clopidogrel

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is an invasive procedure that can result in bleeding. Guidelines recommend discontinuing clopidogrel for 7 to 10 days, but not withholding aspirin, before PEG. Serotonin reuptake inhibitors (SRIs) have been associated with an increased risk of GI bleeding.

OBJECTIVE

To determine whether there is an association between periprocedural aspirin, clopidogrel, or SRI use and bleeding in patients who underwent PEG tube placement.

DESIGN

Retrospective cohort study.

SETTING

Large quaternary-care academic medical center.

PATIENTS

A total of 990 patients (525 men) with a median age of 69.8 years who underwent PEG from January 1999 to April 2009.

INTERVENTIONS

PEG tube placement.

MAIN OUTCOME MEASUREMENTS

GI bleeding.

RESULTS

Sixteen patients (1.6%) had evidence of bleeding during the first 48 hours after PEG, and 12 patients (1.2%) had evidence of bleeding between 48 hours and 14 days after PEG. Thirty-six patients (3.6%) received high-dose aspirin (>325 mg), 27 patients (2.7%) received clopidogrel (75 mg), and 99 patients (10%) received an SRI before PEG. Twenty-four patients (2.4%) received high-dose aspirin, 25 patients (2.5%) received clopidogrel, and 130 patients (13.1%) received an SRI after PEG. Multivariate analysis demonstrated no association between periprocedural use of aspirin (at any dose) or clopidogrel and post-PEG bleeding. However, SRIs administered 24 hours or less before PEG were associated with a significantly higher odds of post-PEG bleeding (adjusted odds ratio 4.1; 95% CI, 1.1-13.4; P = .04).

LIMITATIONS

Retrospective, single-center study with limited statistical power despite a relatively large cohort of patients.

CONCLUSIONS

Use of aspirin or clopidogrel before or after PEG was not associated with procedure-related bleeding. SRI use in the 24 hours before PEG was associated with an increased risk of bleeding.

Review of biological mechanisms and pharmacological treatments of comorbid PTSD and substance use disorder

Posttraumatic stress disorder (PTSD) and alcohol/substance use disorder (A/SUD) are frequently comorbid. Comorbidity is associated with poorer psychological, functional, and treatment outcomes than either disorder alone. This review outlines biological mechanisms that are potentially involved in the development and maintenance of comorbid PTSD and A/SUD including neurotransmitter and hypothalamic-pituitary-adrenal dysregulation, structural differences in the brain, and shared genetic risk factors. The literature regarding pharmacological treatments that have been investigated for comorbid PTSD and A/SUD is also reviewed. Empirical data for each proposed mechanism and pharmacological approach is reviewed with the goal of making recommendations for future research. This article is part of a Special Issue entitled 'Post-Traumatic Stress Disorder'.

A diagnostic dilemma between psychosis and post-traumatic stress disorder: a case report and review of the literature

INTRODUCTION

Post-traumatic stress disorder is defined as a mental disorder that arises from the experience of traumatic life events. Research has shown a high incidence of co-morbidity between post-traumatic stress disorder and psychosis.

CASE PRESENTATION

We report the case of a 32-year-old black African woman with a history of both post-traumatic stress disorder and psychosis. Two years ago she presented to mental health services with auditory and visual hallucinations, persecutory delusions, suicidal ideation, recurring nightmares, hyper-arousal, and initial and middle insomnia. She was prescribed trifluoperazine (5 mg/day) and began cognitive-behavioral therapy for psychosis. Her psychotic symptoms gradually resolved over a period of three weeks; however, she continues to experience ongoing symptoms of post-traumatic stress disorder. In our case report, we review both the diagnostic and treatment issues regarding post-traumatic stress disorder with psychotic symptoms.

CONCLUSIONS

There are many factors responsible for the symptoms that occur in response to a traumatic event, including cognitive, affective and environmental factors. These factors may predispose both to the development of post-traumatic stress disorder and/or psychotic disorders. The independent diagnosis of post-traumatic stress disorder with psychotic features remains an open issue. A psychological formulation is essential regarding the appropriate treatment in a clinical setting.