Current concepts in pharmacotherapy for posttraumatic stress disorder

Comparative Effectiveness of Direct-Acting Antivirals for Posttraumatic Stress Disorder in Veterans Affairs Patients With Hepatitis C Virus Infection

We recently conducted an exploratory study that indicated that several direct-acting antivirals (DAAs), highly effective medications for hepatitis C virus (HCV) infection, were also associated with improvement in posttraumatic stress disorder (PTSD) among a national cohort of US Department of Veterans Affairs (VA) patients treated between October 1, 1999, and September 30, 2019. Limiting the same cohort to patients with PTSD and HCV, we compared the associations of individual DAAs with PTSD symptom improvement using propensity score weighting. After identifying patients who had available baseline and endpoint PTSD symptom data as measured with the PTSD Checklist (PCL), we compared changes over the 8-12 weeks of DAA treatment. The DAAs most prescribed in conjunction with PCL measurement were glecaprevir/pibrentasvir (GLE/PIB; n = 54), sofosbuvir/velpatasvir (SOF/VEL; n = 54), and ledipasvir/sofosbuvir (LDV/SOF; n = 145). GLE/PIB was superior to LDV/SOF, with a mean difference in improvement of 7.3 points on the PCL (95% confidence interval (CI): 1.1, 13.6). The mean differences in improvement on the PCL were smaller between GLE/PIB and SOF/VEL (3.0, 95% CI: -6.3, 12.2) and between SOF/VEL and LDV/SOF (4.4, 95% CI: -2.4, 11.2). While almost all patients were cured of HCV (92.5%) regardless of the agent received, PTSD outcomes were superior for those receiving GLE/PIB compared with those receiving LDV/SOF, indicating that GLE/PIB may merit further investigation as a potential PTSD treatment.

Post-traumatic stress disorder: a psychiatric disorder requiring urgent attention

Post-traumatic stress disorder (PTSD) is a severe and heterogenous psychiatric disorder that was first defined as a mental disorder in 1980. Currently, the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) and the International Classification of Diseases 11th Edition (ICD-11) offer the most widely accepted diagnostic guidelines for PTSD. In both diagnostic categories, experiencing a traumatic event (TE) is the necessary criterion for diagnosing PTSD. The TEs described in the DSM-5 include actual or threatened death, serious injury, sexual violence, and other extreme stressors, either directly or indirectly. More than 70% of adults worldwide are exposed to a TE at least once in their lifetime, and approximately 10% of individuals develop PTSD after experiencing a TE. The important features of PTSD are intrusion or re-experiencing fear memories, pervasive sense of threat, active avoidance, hyperarousal symptoms, and negative alterations of cognition and mood. Individuals with PTSD have high comorbidities with other psychiatric diseases, including major depressive disorder, generalized anxiety disorder, and substance use disorder. Multiple lines of evidence suggest that the pathophysiology of PTSD is complex, involving abnormal neural circuits, molecular mechanisms, and genetic mechanisms. A combination of both psychotherapy and pharmacotherapy is used to treat PTSD, but has limited efficacy in patients with refractory PTSD. Because of the high prevalence, heavy burden, and limited treatments, PTSD is a psychiatric disorder that requires urgent attention. In this review, we summarize and discuss the diagnosis, prevalence, TEs, pathophysiology, and treatments of PTSD and draw attention to its prevention.

Dog training alleviates PTSD symptomatology by emotional and attentional regulation

Background

Post-Traumatic Stress Disorder (PTSD) symptoms include re-experiencing, avoidance, hyperarousal, and cognitive deficits, reflecting both emotional and cognitive dysregulation. In recent years, non-pharmacological approaches and specifically animal-assisted therapy have been shown to be beneficial for a variety of disorders such as Attention-Deficit/Hyperactivity Disorder, Autism Spectrum Disorder, and PTSD. However, little is mentioned in the literature about the reciprocal effects of the animal-human interaction.

Objective

To evaluate the effects of a one-year dog training programme on PTSD symptomatology in youngsters with PTSD and on dogs' behaviour.

Methods

Fifty-three adolescents, previously exposed to interpersonal trauma, were clinically diagnosed with PTSD and assigned to a dog-training programme group (n = 30) and a control group (n = 23) that engaged in other training programmes (e.g. cooking, hairstyling, etc.). Both groups were evaluated at baseline and following 12-months by The Clinician-Administered PTSD Scale for DSM-5 in Children and Adolescents (CAPS-CA-5) and Beck-Depression Inventory (BDI). Additionally, we physiologically measured both emotional and attention dysregulation.

Results

Post-12-months training, a significant alleviation of PTSD symptomatology accompanied by lower depression severity was observed in the dog-training group, compared with a insignificant recovery in the control group. Furthermore, improved emotional and attentional regulation was observed in the dog-training group. Measuring the dogs' behaviour revealed increased anxiety and decreased selective attention performance, which was inversely correlated with the beneficial effects observed in the dog-training programme group.

Conclusions

Our findings emphasize the role of emotional and attentional regulations on the dog-handler interface, as evidence-based support for the beneficial effects of the dog-training programme, as either a non-pharmacological intervention or as complementary to anti-depressants treatment of PTSD. Though pharmacological treatments increase the patients' well-being by treating certain PTSD symptoms, our suggested dog-training programme seems to influence the PTSD diagnostic status, thus may be implemented in civilians and veterans with PTSD.

Four Decades of Military Posttraumatic Stress: Protocol for a Meta-analysis and Systematic Review of Treatment Approaches and Efficacy

BACKGROUND

Over 85% of active members of the Canadian Armed Forces have been exposed to potentially traumatic events linked to the development of posttraumatic stress disorder (PTSD). At the time of transition to civilian life, as high as 1 in 8 veterans may be diagnosed with PTSD. Given the high prevalence of PTSD in military and veteran populations, the provision of effective treatment considering their unique challenges and experiences is critical for mental health support and the well-being of these populations.

OBJECTIVE

This paper presents the protocol for a meta-analysis and systematic review that will examine the effectiveness of treatment approaches for military-related PTSD.

METHODS

This PROSPERO-preregistered meta-analysis is being conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and Cochrane guidelines. A comprehensive search of the literature was conducted using the databases PsycInfo, Medline, Embase, CINAHL, and ProQuest Dissertation & Theses. Effect sizes will be computed based on changes in PTSD symptom scores over time across studies using validated PTSD scales. A multilevel meta-analysis will examine the overall effects, between-study effects, and within-study effects of available evidence for PTSD treatments in military populations. Effect sizes will be compared between pharmacotherapeutic, psychotherapeutic, and alternative/emerging treatment interventions. Finally, meta-regression and subgroup analyses will explore the moderating roles of clinical characteristics (eg, PTSD symptom clusters), treatment approaches (eg, therapeutic orientations in psychotherapy and alternative therapies and classifications of drugs in pharmacotherapy), as well as treatment characteristics (eg, length of intervention) on treatment outcomes.

RESULTS

The literature search was completed on April 14, 2021. After the removal of duplicates, a total of 12,002 studies were screened for inclusion. As of July 2021, title and abstract screening has been completed, with 1469 out of 12,002 (12.23%) studies included for full-text review. Full review is expected to be completed in the summer of 2021, with initial results expected for publication by early winter of 2021.

CONCLUSIONS

This meta-analysis will provide information on the current state of evidence on the efficacy and effectiveness of various treatment approaches for military-related PTSD and identify factors that may influence treatment outcomes. The results will inform clinical decision-making for service providers and service users. Finally, the findings will provide insights into future treatment development and practice recommendations to better support the well-being of military and veteran populations.

TRIAL REGISTRATION

PROSPERO CRD42021245754; https://tinyurl.com/y9u57c59.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/33151.

Induced pluripotent stem cell-derived neural progenitor cell transplantation promotes regeneration and functional recovery after post-traumatic stress disorder in rats

Post-traumatic stress disorder (PTSD) is a mental disorder characterized by hippocampal neuron loss and cognitive dysfunction. The aim of the present study was to investigate the potential functional outcomes of transplantation of induced pluripotent stem cell-derived neural progenitor cells (iPSC-NPCs) for treating PTSD. Human induced pluripotent stem cell (iPSCs), differentiated into neural progenitor cells (NPCs) in vitro, were transplanted into the brain of rat. Following iPSC-NPCs transplantation, cognitive function was determined. The open field test and fear condition test indicated that long-term iPSC-NPCs transplantation ameliorated cognitive dysfunction and reduced freezing time in PTSD rats. Following testing, the brain of rat was analyzed using immunocytochemistry and immunofluorescence. The results revealed that iPSC-NPCs differentiated into neurons replacing the loss of hippocampus neurons, and iPSC-NPCs transplantation showed higher expression of glial fibrillary acidic protein (GFAP) and increased number of NeuN compared with the control group. Moreover, western blot analysis suggested enhanced expression of brain-derived neurotrophic factor (BDNF) in hippocampus tissue of iPSC-NPCs transplanted rats in comparison to the PBS group. Collectively, these findings showed that iPSC-NPCs could promote regeneration and motor function recovery in PTSD model.

Intermittent hypoxia improves behavioral and adrenal gland dysfunction induced by posttraumatic stress disorder in rats

Nonpharmacological treatments of stress-induced disorders are promising, since they enhance endogenous stress defense systems, are free of side effects, and have few contraindications. The present study tested the hypothesis that intermittent hypoxia conditioning (IHC) ameliorates behavioral, biochemical, and morphological signs of experimental posttraumatic stress disorder (PTSD) induced in rats with a model of predator stress (10-day exposure to cat urine scent, 15 min daily followed by 14 days of stress-free rest). After the last day of stress exposure, rats were conditioned in an altitude chamber for 14 days at a 1,000-m simulated altitude for 30 min on day 1 with altitude and duration progressively increasing to 4,000 m for 4 h on day 5. PTSD was associated with decreased time spent in open arms and increased time spent in closed arms of the elevated X-maze, increased anxiety index, and increased rate of freezing responses. Functional and structural signs of adrenal cortex degeneration were also observed, including decreased plasma concentration of corticosterone, decreased weight of adrenal glands, reduced thickness of the fasciculate zone, and hydropic degeneration of adrenal gland cells. The thickness of the adrenal fasciculate zone negatively correlated with the anxiety index. IHC alleviated both behavioral signs of PTSD and morphological evidence of adrenal cortex dystrophy. Also, IHC alone exerted an antistress effect, which was evident from the increased time spent in open arms of the elevated X-maze and a lower number of rats displaying freezing responses. Therefore, IHC of rats with experimental PTSD reduced behavioral signs of the condition and damage to the adrenal glands.

NEW & NOTEWORTHY Intermittent hypoxia conditioning (IHC) has been shown to be cardio-, vaso-, and neuroprotective. For the first time, in a model of posttraumatic stress disorder (PTSD), this study showed that IHC alleviated both PTSD-induced behavioral disorders and functional and morphological damage to the adrenal glands. Also, IHC alone exerted an antistress effect. These results suggest that IHC may be a promising complementary treatment for PTSD-associated disorders.

Melatonin ameliorates cognitive memory by regulation of cAMP-response element-binding protein expression and the anti-inflammatory response in a rat model of post-traumatic stress disorder

BACKGROUND

Post-traumatic stress disorder (PTSD) is an important psychological disease that can develop following the physical experience or witnessing of traumatic events. The psychopathological response to traumatic stressors increases inflammation in the hippocampus and induces memory deficits. Melatonin (MTG) plays critical roles in circadian rhythm disorders, Alzheimer's disease, and other neurological disorders. However, the cognitive efficiency of MTG and its mechanisms of action in the treatment of PTSD remain unclear. Thus, the present study investigated the effects of MTG on spatial cognitive impairments stimulated by single prolonged stress (SPS) in rats, an animal model of PTSD. Male rats received intraperitoneal (i.p.) administration of various doses of MTG for 21 consecutive days after the SPS procedure.

RESULTS

SPS-stimulated cognitive impairments in the object recognition task and Morris water maze were reversed by MTG treatment (25 mg/kg, i.p). Additionally, MTG significantly increased cognitive memory-related decreases in cAMP-response element-binding (CREB) protein and mRNA levels in the hippocampus. Our results also demonstrate that MTG significantly inhibited SPS-stimulated cognitive memory impairments by inhibiting the expression of proinflammatory cytokines, including tumor necrosis factor-α (TNF-α), and interleukin-6 (IL-6) in the rat brain.

CONCLUSION

The present results indicate that MTG can be beneficial for SPS-stimulated memory impairments via changes in CREB expression and proinflammatory mediators. Thus, MTG may be a prophylactic strategy for the prevention or mitigation of the progression of some features of the PTSD pathology.

Prior treadmill exercise promotes resilience to vicarious trauma in rats

BACKGROUND

Post-traumatic stress disorder (PTSD) is a serious psychological condition, which can develop both from physically experiencing and also from witnessing traumatic events. There is evidence that physical exercise can have a positive impact on the symptoms of PTSD. Relevant to this, in our previous pre-clinical work, beneficial effects of treadmill exercise were reported on PTSD-like behaviors in a social defeat paradigm, a rat model of direct physical trauma. However, the role of exercise on vicariously acquired PTSD-like phenotype was not examined.

OBJECTIVE

In this study, we utilized a rodent PTSD model, which mimics both the physical as well as the witness experience of trauma, and examined the impact of moderate treadmill exercise in mitigating vicariously acquired PTSD-like behaviors in rats.

METHODS

Our PTSD model is a modified social defeat paradigm, which involves aggressive encounters between a large Long-Evans male rat (resident) and a smaller Sprague-Dawley male rat (intruder), resulting in intruder social defeat. The cage mate of the intruder is positioned to witness intruder defeat. Rats were grouped as control (CON), social defeat (SD), exercise (EX), trauma witness (TW), and exercise prior to trauma witness (EX-TW). After acclimatization for 7days, the exercised groups were subjected to a daily 30-min treadmill exercise regimen for 14days. On day 21, the SD group was exposed for 7days of social defeat, while the TW groups witnessed social defeat. On days 28-34, behavioral and cognitive tests including short-term (STM) and long-term (LTM) memory function, anxiety- and depression-like behaviors were conducted.

RESULTS

TW and SD rats demonstrated the highest levels of anxiety- and depression-like behaviors, while EX-TW rats did not exhibit anxiety- and depression-like behaviors. TW and SD rats showed no impairments in STM. However, TW and SD rats showed impairments in LTM, and exercise rescued LTM impairments in EX-TW rats.

CONCLUSIONS

This study demonstrates that rats subjected to direct experience or witness of social defeat exhibited PTSD-like behaviors, while moderate treadmill exercise prevented trauma witness-induced behavioral impairments. These studies have important translational value suggesting that prior treadmill exercise might provide resilience to stressful stimuli and perhaps mitigate the witnessing effects of traumatic events.

Treatment of Post-Traumatic Stress Disorders with the Alpha-1 Adrenergic Antagonist Prazosin

OBJECTIVE

The present review aims to assess the clinical efficacy and safety of the α-1-adrenergic antagonist prazosin as primary pharmacologic treatment for post-traumatic stress disorder (PTSD).

METHOD

A systematic review was performed using keywords (i.e., prazosin, α-1-adrenergic antagonist, α-1-blocker, post-traumatic stress disorder) in the databases PubMed/Medline (1966-May 2016), Embase (1966-May 2016), ScienceDirect (1823-May 2016), OvidSP (1946-May 2016) and Nature (1845-May 2016). To be considered for inclusion, studies had to test the efficacy of prazosin either alone or added to ongoing treatment in adults with PTSD, use validated tools to assess and monitor the disorders, allow comparisons on the basis of univariate analyses (i.e., p-values of t-tests and effect sizes) and list the identified adverse reactions.

RESULTS

12 studies were included: 5 randomized controlled trials, 4 open-label prospective trials and 3 retrospective file reviews. The evaluation concerned 276 patients exposed to civilian trauma (19%) or war trauma (81%). Prazosin significantly decreases trauma nightmares, avoidance, hypervigilance and improves patient status in all studies. No significant difference of blood pressure was observed at the end of trials.

CONCLUSIONS

Beyond the methodological and clinical biases of these studies, the present review not only confirms the effectiveness and good tolerability of prazosin, but also suggests its possible use as primary pharmacologic treatment for PTSD. Uncertainties remain, however, regarding the prescription modalities and dosages.

Pain in an era of armed conflicts: Prevention and treatment for warfighters and civilian casualties

Chronic pain is a common squealae of military- and terror-related injuries. While its pathophysiology has not yet been fully elucidated, it may be potentially related to premorbid neuropsychobiological status, as well as to the type of injury and to the neural alterations that it may evoke. Accordingly, optimized approaches for wounded individuals should integrate primary, secondary and tertiary prevention in the form of thorough evaluation of risk factors along with specific interventions to contravene and mitigate the ensuing chronicity. Thus, Premorbid Events phase may encompass assessments of psychological and neurobiological vulnerability factors in conjunction with fostering preparedness and resilience in both military and civilian populations at risk. Injuries per se phase calls for immediate treatment of acute pain in the field by pharmacological agents that spare and even enhance coping and adaptive capabilities. The key objective of the Post Injury Events is to prevent and/or reverse maladaptive peripheral- and central neural system's processes that mediate transformation of acute to chronic pain and to incorporate timely interventions for concomitant mental health problems including post-traumatic stress disorder and addiction We suggest that the proposed continuum of care may avert more disability and suffering than the currently employed less integrated strategies. While the requirements of the armed forces present a pressing need for this integrated continuum and a framework in which it can be most readily implemented, this approach may be also instrumental for the care of civilian casualties.

Post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) occurs in 5-10% of the population and is twice as common in women as in men. Although trauma exposure is the precipitating event for PTSD to develop, biological and psychosocial risk factors are increasingly viewed as predictors of symptom onset, severity and chronicity. PTSD affects multiple biological systems, such as brain circuitry and neurochemistry, and cellular, immune, endocrine and metabolic function. Treatment approaches involve a combination of medications and psychotherapy, with psychotherapy overall showing greatest efficacy. Studies of PTSD pathophysiology initially focused on the psychophysiology and neurobiology of stress responses, and the acquisition and the extinction of fear memories. However, increasing emphasis is being placed on identifying factors that explain individual differences in responses to trauma and promotion of resilience, such as genetic and social factors, brain developmental processes, cumulative biological and psychological effects of early childhood and other stressful lifetime events. The field of PTSD is currently challenged by fluctuations in diagnostic criteria, which have implications for epidemiological, biological, genetic and treatment studies. However, the advent of new biological methodologies offers the possibility of large-scale approaches to heterogeneous and genetically complex brain disorders, and provides optimism that individualized approaches to diagnosis and treatment will be discovered.

Efficacy and acceptability of atypical antipsychotics for the treatment of post-traumatic stress disorder: a meta-analysis of randomized, double-blind, placebo-controlled clinical trials

As some evidences demonstrated that atypical antipsychotics (AA) may be efficacious in treating post-traumatic stress disorder (PTSD), we preformed a meta-analysis of randomized, double-blind, placebo-controlled clinical trials (RCTs) of AAs for the treatment of PTSD. Two hundred and fifty one papers were searched and screened. Eight RCTs met the inclusion criteria. AAs may be superior to placebo in the treatment of PTSD, as indicated by the changes in Clinician Administered PTSD Scale (CAPS) total scores (weighted mean differences (WMD)=-5.89, 95% confidence interval (CI) [-9.21, -2.56], P=0.0005) and also in CAPS subscale intrusion (WMD=-2.58, 95% CI[-3.83, -1.33], P<0.0001 ) and subscale hyperarousal (WMD=-2.94, 95% CI[-5.45, -0.43], P=0.02). The acceptability measured by dropout rates between AAs and placebo showed no statistical difference (OR=1.24, 95%CI [0.78, 1.97], P=0.36). PTSD symptom cluster, especially in intrusion and hyperarousal. However, we should be careful to generalize the conclusion because of the small number of included trails. We expect more RCTs will be done in the future so as to clarify the specific value of AAs for PTSD.

Sleep disturbances and suicidal ideation in a sample of treatment-seeking Canadian Forces members and veterans

This study examines the association between suicidal ideation and sleep disturbances in a sample of treatment-seeking Canadian Forces members and veterans, after controlling for probable posttraumatic stress disorder (PTSD), major depressive disorder (MDD), generalised anxiety disorder (GAD), and alcohol use disorder (AUD). Subjects included members and veterans of Canadian Forces seeking treatment at a hospital-based Operational Stress Injury Clinic (n=404). Sleep disturbances and nightmares were measured using individual items on the PTSD Checklist - Military Version (PCL - M), while the suicidality item of the Patient Health Questionnaire (PHQ-9) was used as a stand-alone item to assess presence or absence of suicidal ideation. Regression analyses were used to determine the respective impact of (1) insomnia and (2) nightmares on suicidal ideation, while controlling for presence of probable PTSD, MDD, GAD, and AUD. We found that 86.9% of patients reported having problems falling or staying asleep and 67.9% of patients reported being bothered by nightmares related to military-specific traumatic events. Neither sleep disturbances nor nightmares significantly predicted suicidal ideation; instead, probable MDD emerged as the most significant predictor. The clinical implications of these findings and their potential impact on treatment guidelines are discussed.

Moderate treadmill exercise rescues anxiety and depression-like behavior as well as memory impairment in a rat model of posttraumatic stress disorder

Post-traumatic stress disorder (PTSD) is a condition which can develop from exposure to a severe traumatic event such as those occurring during wars or natural disasters. Benzodiazepines and selective serotonin reuptake inhibitors (SSRIs) are considered the gold standard for PTSD treatment, but their side effects pose a serious problem. While regular physical exercise is regarded as a mood elevator and known to enhance cognitive function, its direct role in rescuing core symptoms of PTSD including anxiety and depression-like behaviors and cognitive impairment is unclear. In the present study using the single-prolonged stress (SPS) rat model of PTSD (2h restrain, 20 min forced swimming, 15 min rest, and 1-2 min diethyl ether exposure), we examined the beneficial effect of moderate treadmill exercise on SPS-induced behavioral deficits including anxiety and depression-like behaviors and memory impairment. Male Wistar rats were randomly assigned into four groups: control (sedentary), exercised, SPS (no exercise), or SPS-exercised. Rats were exercised on a rodent treadmill for 14 consecutive days. Rats in all groups were tested for anxiety-like behaviors using open field (OF), light-dark and elevated-plus maze tests. All rats were tested for short-term and long-term memory in the radial arm water maze test. Rats were then sacrificed, blood was collected (for corticosterone levels), and individual organs (spleen, adrenals, and thymus) harvested. Results suggest that moderate physical exercise ameliorates SPS-induced behavioral deficits in rats.

Effects of participation in a mindfulness program for veterans with posttraumatic stress disorder: a randomized controlled pilot study

OBJECTIVE

To assess outcomes associated with Mindfulness-Based Stress Reduction (MBSR) for veterans with PTSD.

METHODS

Forty-seven veterans with posttraumatic stress disorder (PTSD; 37 male, 32 Caucasian) were randomized to treatment as usual (TAU; n = 22), or MBSR plus TAU (n = 25). PTSD, depression, and mental health-related quality of life (HRQOL) were assessed at baseline, posttreatment, and 4-month follow-up. Standardized effect sizes and the proportion with clinically meaningful changes in outcomes were calculated.

RESULTS

Intention-to-treat analyses found no reliable effects of MBSR on PTSD or depression. Mental HRQOL improved posttreatment but there was no reliable effect at 4 months. At 4-month follow-up, more veterans randomized to MBSR had clinically meaningful change in mental HRQOL, and in both mental HRQOL and PTSD symptoms. Completer analyses (≥ 4 classes attended) showed medium to large between group effect sizes for depression, mental HRQOL, and mindfulness skills.

CONCLUSIONS

Additional studies are warranted to assess MBSR for veterans with PTSD.

Examining the association between psychiatric illness and suicidal ideation in a sample of treatment-seeking Canadian peacekeeping and combat veterans with posttraumatic stress disorder PTSD

OBJECTIVE

Our study examines the association between suicidal ideation and and self-reported symptoms of posttraumatic stress disorder (PTSD), major depressive disorder (MDD), generalized anxiety disorder (GAD), and alcohol use disorder (AUD) in a sample of treatment-seeking Canadian combat and peacekeeping veterans; and identifies potential predictors of suicidal ideation.

METHODS

Actively serving Canadian Forces and Royal Canadian Mounted Police members and veterans seeking treatment at the Parkwood Hospital Operational Stress Injury Clinic (n = 250) completed measures including the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire, the Alcohol Use Disorder Identification Test, and the PTSD Checklist-Military Version (PCL-M) between January 2002 and December 2010. Regression analyses were used to determine the respective impact of PTSD, and self-reported symptoms of MDD, GAD, AUD, and anxiety on suicidal ideation.

RESULTS

Most people met PCL-M screening criteria for PTSD (73.6%, n = 184), while 70.8% (n = 177) screened positively for a probable major depressive episode. PTSD symptom was significantly associated with suicidal ideation (β = 0.412, P < 0.001). After controlling for self-reported depressive symptom severity, AUD severity, and generalized anxiety, PTSD severity was no longer significantly associated with suicidal ideation (β = 0.043, P = 0.58).

CONCLUSIONS

Although PTSD alone is associated with suicidal ideation, after controlling for common comorbid psychiatric illnesses, self-reported depressive symptom severity emerged as the most significant predictor of suicidal ideation. These findings support the importance of screening for comorbidities, particularly an MDD, as potentially modifiable conditions that are strongly related to suicidal ideation in military personnel's endorsing criteria for PTSD.

A pharmacotherapeutic approach to the management of chronic posttraumatic stress disorder

Due to relatively recent and ongoing world events (eg, terrorist attacks, wars, and natural disasters), there has been a shift in attention from some of the more common psychiatric illnesses to one of the more elusive, namely, posttraumatic stress disorder (PTSD). PTSD is a severe, and often chronic, condition that can lead to significant morbidity and mortality. Although originally a condition seen primarily among war veterans, PTSD is now becoming more prevalent in the general community. PTSD often presents concurrently with other conditions, such as depression, bipolar, anxiety/panic disorders, and alcohol and drug abuse. Because of this, PTSD often goes unrecognized and is underdiagnosed in clinical practice. Thus, an opportunity for pharmacist intervention exists, both in the institution and in the community. With proper education and training, pharmacists can be efficient in screening for signs and symptoms of PTSD, triaging appropriate patients, and can play an integral role in managing the diverse array of drug therapy options for PTSD.

A chinese herbal formula to improve general psychological status in posttraumatic stress disorder: a randomized placebo-controlled trial on sichuan earthquake survivors

Introduction. Posttraumatic stress disorder (PTSD) is accompanied by poor general psychological status (GPS). In the present study, we investigated the effects of a Chinese herbal formula on GPS in earthquake survivors with PTSD. Methods. A randomized, double-blind, placebo-controlled trial compared a Chinese herbal formula, Xiao-Tan-Jie-Yu-Fang (XTJYF), to placebo in 2008 Sichuan earthquake survivors with PTSD. Patients were randomized into XTJYF (n = 123) and placebo (n = 122) groups. Baseline-to-end-point score changes in the three global indices of the Symptom Checklist-90-Revised (SCL-90-R) and rates of response in the SCL global severity index (GSI) were the primary endpoints. A subanalysis of the nine SCL factors and the sleep quality score were secondary endpoints. Results and Discussion. Compared to placebo, the XTJYF group was significantly improved in all three SCL global indices (P = 0.001~0.028). More patients in the XTJYF group reported “much improved” than the placebo group (P = 0.001). The XTJYF group performed significantly better than control in five out of nine SCL factors (somatization, obsessive-compulsive behavior, depression, anxiety, and hostility (P = 0.001~0.036)), and in sleep quality score (P < 0.001). XTJYF produced no serious adverse events. These findings suggest that XTJYF may be an effective and safe treatment option for improving GPS in patients with PTSD.

Predictors of treatment response in Canadian combat and peacekeeping veterans with military-related posttraumatic stress disorder

Military-related posttraumatic stress disorder (PTSD) is a significant psychiatric condition associated with severe psychosocial dysfunction. This study examined the predictors of treatment outcome in a group of veterans with military-related PTSD. Participants were 102 Canadian combat and peacekeeping veterans who received treatment at a specialized outpatient clinic for veterans with psychiatric disorders resulting from military operation. Analysis demonstrated a significant decrease in PTSD severity during the 1-year period (Yuan-Bentler χ [86, N = 99] = 282.45, p < 0.001). We did not find chronicity, alcohol use, and anxiety or depression severity as significant predictors for PTSD symptom decline. However, initial depression significantly predicted anxiety symptom decline, and initial anxiety predicted depression symptom decline. This study demonstrated that, despite considerable comorbidity, significant treatment gains, including remission of PTSD, can be achieved in an outpatient setting in veterans with chronic military-related PTSD.

Aripiprazole augmentation in the treatment of military-related PTSD with major depression: a retrospective chart review

BACKGROUND

In this chart review, we attempted to evaluate the benefits of adding aripiprazole in veterans with military-related PTSD and comorbid depression, who had been minimally or partially responsive to their existing medications.

METHODS

A retrospective chart review of patients who received an open-label, flexible-dose, 12- week course of adjunctive aripiprazole was conducted in 27 military veterans meeting DSM-IV criteria for PTSD and comorbid major depression. Concomitant psychiatric medications continued unchanged, except for other antipsychotics which were discontinued prior to initiating aripiprazole. The primary outcome variable was a change from baseline in the PTSD checklist-military version (PCL-M) and the Beck Depression Inventory (BDI-II).

RESULTS

PTSD severity (Total PCL scores) decreased from 56.11 at baseline to 46.85 at 12-weeks (p < 0.0001 from Wilcoxon signed rank test) and the depression severity decreased from 30.44 at baseline to 20.67 at 12-weeks (p < 0.0001 from Wilcoxon signed rank test). Thirty seven percent (10/27) were considered responders, as defined by a decrease in total PCL scores of at least 20 percent and 19% (5/27) were considered as responders as defined by a decrease in total BDI score of at least 50%.

CONCLUSIONS

The addition of aripiprazole contributed to a reduction in both PTSD and depression symptomatology in a population that has traditionally demonstrated poor pharmacological response. Further investigations, including double-blind, placebo-controlled studies, are essential to confirm and further demonstrate the benefit of aripiprazole augmentation in the treatment of military related PTSD.

Multi-component treatment for posttraumatic nightmares in Vietnam veterans: two case studies

Posttraumatic nightmares (PTNMs) are trauma-related distressing dreams that cause a person to wake up. PTNMs can be a devastating addition to the clinical picture of posttraumatic stress disorder (PTSD), because they can result in increased levels of PTSD symptoms and overall distress and decreased sleep; they are also often resistant to typical PTSD treatments. While specialized treatments have been developed and empirically examined in the civilian population, these treatments have not been thoroughly explored with the Veteran population, despite the fact that 50%-88% of Vietnam Veterans experience chronic PTNMs. This article presents two case reports involving Vietnam Veterans. These reports describe the initial investigation of a variant of a treatment that has been successful in treating chronic PTNMs in the civilian population and has been modified to meet the needs of the Veteran population. Analyses revealed that both Veterans reported moderate reductions in sleep disturbances over the course of treatment, as well as clinically significant reductions in PTSD and depressive symptoms across assessments. These preliminary findings provide encouraging data that warrant further study. Limitations and future research are discussed.

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.

The traumatic impact of Hurricane Katrina on children in New Orleans

This article reviews the traumatic impact of Hurricane Katrina on the children of New Orleans. After describing the events comprising the trauma, it reviews the historical context of hurricanes in New Orleans and the social and political challenges that affected the area's response. It then considers the consequences of Hurricane Katrina in terms of disruption of services and governmental and nongovernmental responses to the psychologic needs created by the storm. The authors review preliminary studies about the affects of the hurricane on children and adolescents and conclude with a consideration of the lessons learned from both practice and policy perspectives.

Acute stress disorder and posttraumatic stress disorder: a prospective study of prevalence, course, and predictors in a sample with major burn injuries

This is one of the largest prospective studies of patients with major burn injuries to use psychometrically sound methods to track and predict posttraumatic stress disorder (PTSD) across 2 years after burn. The principal objectives were to investigate the utility of self-report measures in detecting acute stress disorder (ASD) and PTSD, and in tracking and predicting PTSD. Participants were adult patients admitted for treatment of a major burn injury. The Stanford Acute Stress Reaction Questionnaire (SASRQ) was used to assess ASD symptomatology at discharge (n = 178), and the Davidson Trauma Scale was used to assess PTSD symptoms at scheduled follow-ups at 1 (n = 151), 6 (n = 111), 12 (n = 105), and 24 (n = 71) months after burn. The prevalence of in-hospital ASD was 23.6%, and 35.1, 33.3, 28.6, and 25.4% of the participants met PTSD criteria at 1, 6, 12, and 24 months, respectively. Clinically significant and reliable change in PTSD symptomatology during the 24 months was uncommon. SASRQ diagnostic cutoff and total scores each robustly predicted PTSD at the first three follow-ups and all four follow-ups, respectively. A SASRQ empirically derived cutoff score (> or =40) yielded moderate-high sensitivities (0.67-0.71) and specificities (0.75-0.80), and predicted PTSD at each follow-up. In conclusion, ASD and PTSD are prevalent following major burn injuries, ASD symptomatology can reliably predict PTSD up to 24 months later, and, once established, PTSD usually persists. Research is needed to determine whether early recognition and treatment of persons with in-hospital ASD can improve long-term outcomes.

Activation of the serotonin 5-HT2C receptor is involved in the enhanced anxiety in rats after single-prolonged stress

We have recently confirmed that exposure of rats to the single-prolonged stress (SPS) paradigm induces enhanced hypothalamic-pituitary-adrenal (HPA) axis negative feedback and enhanced anxiety, and found that these changes develop time-dependently following stress exposure, suggesting that it could model the neuroendocrinological and behavioral abnormalities of the post-traumatic stress disorder (PTSD) patients. In the present study, microarray analysis was performed using RNA from the hippocampus, amygdala and anterior cingulate cortex of SPS rats and unstressed controls to unveil the molecular changes underlying SPS-induced behavioral changes. Thirty-one genes were found whose time course of expression corresponded to that of behavioral changes. One gene, 5-hydroxytryptamine2C (5-HT2C) receptor, was identified as a putative candidate. The overexpression of the gene in the amygdala of SPS rats was confirmed using real-time PCR 7 days after the SPS exposure. This molecule was then pharmacologically validated using FR260010 (N-[3-(4-methyl-1H-imidazol-1-yl)phenyl]-5,6-dihydrobenzo[h]quinazolin-4-amine dimethanesulfonate), a selective 5-HT2C receptor antagonist. FR260010 (1-10 mg/kg, s.c.) significantly inhibited the enhancement of anxiety in SPS rats. These results demonstrate for the first time that activation of the brain 5-HT2C receptor is involved in the development of behavioral abnormality in this model. This suggests that selective 5-HT2C receptor antagonists might provide novel therapeutic avenues for PTSD treatment.

An epidemiologic approach to the development of early trauma focused intervention

Early, trauma-focused intervention development has emphasized unidirectional trajectories that begin with basic research and efficacy trials followed later by effectiveness and dissemination studies. In this article, the authors present methods derived from social and clinical epidemiology that constitute foundational research in the development of early trauma-focused intervention. They also describe how population-based practice research may serve to feed back and inform what has been conceptualized as earlier stages of intervention development such as efficacy trials. Examples of relevant epidemiologic research methods are presented to illustrate these points. The authors posit that the continued application of population-based methods may produce treatments that can be feasibly applied to the unique patient, provider, organizational, and community contexts relevant to early interventions for survivors of trauma.

The Management of Post Traumatic Stress Disorder (PTSD) in the Primary Care Setting

Recent geopolitical events, including the terrorist attacks on the United States on September 11, 2001, and ongoing military operations in Iraq, have raised awareness of the often severe psychological after-effects of these and other types of traumatic events. Post traumatic stress disorder (PTSD) represents the most severe of these sequelae. PTSD is an under-recognized and under-treated chronic anxiety disorder associated with significant psychosocial morbidity, substance abuse, and a number of other negative health outcomes. Fortunately, the biologic underpinnings of this complex disorder and new advances in treatment are being realized. Early detection by primary care providers and rapid initiation of treatment are the keys to successful management of the disorder.

Mental health status of vulnerable tsunami-affected communities: a survey in Aceh Province, Indonesia

The authors determined the prevalence of severe emotional distress and depressive symptoms using the Hopkins Symptoms Checklist-25 (HSCL; Derogatis, Lipman, Rickels, Uhlenhuth, & Covi, 1974) in tsunami-affected communities that had experienced armed conflict arising from the ongoing independence movement in Aceh Province, Indonesia. We also evaluated determinants of severe emotional distress. The data were collected for the purposes of a mental health assessment. In our sample (N = 262), 83.6% demonstrated severe emotional distress, and 77.1% demonstrated depressive symptoms. In multivariate regression models, severe emotional distress was positively associated with the number of tsunami-related deaths among household members. Our data suggests a need for effective interventions in this vulnerable population.

Pharmacologic reduction of CNS noradrenergic activity in PTSD: the case for clonidine and prazosin

This article reviews the neurobiologic rationale for and presents clinical guidance concerning the use of medications that reduce central nervous system noradrenergic activity in the treatment of intrusive symptoms of posttraumatic stress disorder. The authors reviewed neurobiological studies, nonclinical studies using animal models, clinical case reports, open-label drug studies, and blinded, placebo-controlled drug studies. This review of the basic science and clinical literature, and the authors' clinical experience with culturally and demographically diverse populations, indicate that clonidine and prazosin can play a useful role in treating sleep disturbance and hyperarousal in posttraumatic stress disorder, with minimal adverse effects and low financial cost.

PTSD and stress sensitisation: a tale of brain and body Part 1: human studies

Post-traumatic stress disorder (PTSD) is a chronic, debilitating psychiatric disorder that can follow exposure to extreme stressful experiences. It is characterised by hyperarousal and increased startle responses, re-experiencing of the traumatic event, withdrawal or avoidance behaviour and emotional numbing. The focus of this review is on aspects that have received less attention. PTSD develops only in a substantial minority of people exposed to traumatic stress, and possible individual traits that increase vulnerability are discussed. An overview is given of the wide variety of physiological disturbances that accompany PTSD and may contribute to disability, including neuroendocrine, cardiovascular, gastrointestinal and immune function and pain sensitivity. Brain imaging and pharmacological studies have generated some insight into the circuitry that may be involved in the generation of PTSD symptoms. Major limitations of human studies so far are the issue of causality and our lack of understanding of the underlying molecular substrates in the brain, which are easier to address in relevant animal models and will be discussed in a companion paper.

Injury increases the risk for PTSD: an examination of potential neurobiological and psychological mediators

A growing number of common traumatic events involve both physical and emotional injuries. In contrast to previously held beliefs, the rapidly growing body of literature shows quite convincingly that physical injury, over and above exposure to the traumatic event itself, increases rather than decreases the risk for posttraumatic stress disorder (PTSD). A pertinent question becomes how bodily injury contributes to the risk of developing PTSD. In this article, we review contemporary findings regarding the neurobiological and psychological mechanisms by which bodily injury may augment or independently contribute to chronic posttraumatic stress. In addition, we propose three theoretical pathways through which physical injury can increase the risk for PTSD. These pathways are: additive, unique, and recovery impeding. Finally, we highlight unresolved issues pertaining to each one of these pathways and propose directions for future research to address them.

A primary care perspective of posttraumatic stress disorder for the Department of Veterans Affairs

Posttraumatic stress disorder (PTSD) is a major mental disorder associated with significant morbidity, psychosocial impairment, and disability. The diagnosis of PTSD can be missed in a primary care setting, as patients frequently present with somatic complaints or depression and are often reluctant to discuss their traumatic experiences. As recent studies of veterans returning from the Gulf War and the Iraqi War suggest high rates of PTSD, the U.S. Department of Veterans Affairs (VA) Hospitals are gearing up to face this challenge. It is important to screen these veterans for symptoms of PTSD and make an appropriate referral if required. In this article, we attempt to review PTSD with a special focus on the VA population. In addition to discussing the epidemiology, diagnosis, and treatment options for PTSD, we also suggest screening questions for both combat-related and military sexual trauma-related PTSD.

[From the biology of trauma to secondary preventive pharmalogical measures for post-traumatic stress disorders]

Of all the psychological complications that an individual is likely to present with when confronted with an exceptional event, the Post-Traumatic Stress Disorder is characterized by being progressive, frequent, invalidating, strongly associated with comorbidity, and having the tendency to become chronic if it is not detected clinically. By definition, it is threatening and produces an intense fear reaction. The traumatic event is a situation of extreme stress, not only capable of altering the physical and psychological homeostasis of the individual, but is also recognized as determinant in the aetiopathology of complications. The intensity of this distress can be identified clinically and physiologically, and is currently considered as an important risk factor for the development of PTSD later on, together with other pre-, peri- and post-traumatic factors. In fact, the most studied field is the therapeutic approach, in particular drug treatment, of the fully-constituted disorder, although this actually represents tertiary prevention. Even though primary prevention seems to concern Medicine very little, any prospect of performing secondary prevention should begin by rapid identification of the risk or vulnerability factors and should allow a population at risk from developing complications to be defined. Its potential therapeutic impact brings together psychotherapeutic and drug treatment, since it is only this combination that seems able to allow the most favourable clinical outcome to be achieved for an individual, who is confronted by an out-of-the-ordinary event. The aims of secondary prevention strategies are, for example, to reduce the incidence of acute PTSD in patients seen following the event. The benefits for the individual and for the society can easily be measured in terms of the consequences on his/her social, professional and family life, or in terms of cost. The usefulness of this prevention can also be measured by the possible ways that other conditions, comorbid to PTSD, are controlled, such as anxiety disorders, depression and substance abuse, for example. Secondary prevention strategies may also be aimed at determining the therapeutic impact, by preventing or moderating the appearance of an acute stress, or even by contributing in avoiding the onset of chronic PTSD. Psychopharmacology of the immediate and post-immediate disorders, however, remains a field which has been studied very little. Reduction or control of the high, prolonged level of hyperarousal phenomena or hypersensitization of the hypothalamo-pituitary axis, would contribute to the comfort of the individual, and would participate in the prevention of PTSD. Based on current knowledge of the neurobiology of trauma, we look into the existing and potential pharmacological possibilities. Even though benzodiazepines tend to have an important role, knowledge of other drugs and therapeutic groups is rapidly increasing. In this review, we will see that the efficacy of anti-adrenergic drugs and certain other anxiolytics is now well-documented, this opening the door to their use in the future. Other drug groups offer interesting, well-proven approaches, such as serotoninergic drugs, CRF or NPY antagonists, NMDA antagonists, anticonvulsants or other GABAergic agents. In view of this disorder, which represents a true public health problem, we consider that it is now possible to widen the horizons of our drug therapy, in combination with any necessary psychotherapeutic treatment, to reach the heart of the traumatic event, that often upsets the victims, both by the psychological suffering it induces, and the loss of his/her social, family and professional references and support structures.

Post-traumatic stress disorder in women: epidemiological and treatment issues

Although women are exposed to proportionately fewer traumatic events in their lifetime than men, they have a higher lifetime risk of post-traumatic stress disorder (PTSD). In addition to gender-differential rates of rape and sexual assault, including greater exposure to intimate partner violence, the preponderance of PTSD in women may be attributable to factors other than trauma type, such as sensitisation of stress hormone systems in response to early adverse experiences, inherent neuroendocrine factors, subjective interpretation of the event, and peritraumatic dissociation. Women with PTSD arguably experience a greater symptom burden, longer course of illness and have worse quality-of-life outcomes than men. An expanding knowledge base of the psychobiological alterations in PTSD is providing stimulus for the development of improved pharmacological and psychosocial treatment options. Recent randomised controlled studies conducted in large samples of women with chronic PTSD indicate that: (i) SSRIs have efficacy on all three symptom clusters of PTSD and should be used as first-line pharmacotherapy; and (ii) cognitive behavioural strategies (e.g. prolonged exposure treatment and cognitive processing) are effective in sexually and non-sexually assaulted women. Studies also suggest that female gender may be associated with better response rates to pharmacotherapy. Emerging empirical data on the potential usefulness of antiadrenergic agents and preventive cognitive behavioural treatments in managing acute trauma reactions and stemming the emergence of PTSD are paving the way for further work in this area. However, additional innovative treatments are needed for traumatised women and for female children/adolescents presenting with acute stress reactions and PTSD.

A Brief Screening Instrument to Detect Posttraumatic Stress Disorder in Outpatient Gynecology

OBJECTIVE

Posttraumatic stress disorder (PTSD) is a serious anxiety disorder triggered by the experience of trauma. One in 4 individuals exposed to trauma will develop PTSD. Victims of trauma are frequent users of health care, but screening is rarely done and most sequelae remain undetected. Our objectives were 1) to document the prevalence of a trauma history among women seeking routine gynecologic care and 2) to evaluate a 4-item screening instrument for PTSD for triaging women with a trauma history for further evaluation.

METHODS

We conducted a cross-sectional survey of women presenting to the University of North Carolina outpatient gynecology clinic for an annual examination. Written surveys included medical history and health status, trauma history (including type), and PTSD symptoms using the screening instrument. Patients with trauma who agreed to further participation received a structured clinical interview to diagnose PTSD.

RESULTS

Seventy-six percent of patients (N = 292) completed the survey, and 88 (30%) reported a history of 1 or more traumatic event or events. Thirty-two of the 88 completed the psychiatric assessment, and 25 of 32 (78%) met Diagnostic and Statistical Manual of Mental Disorders, 4th edition criteria for PTSD. Mean age was 34 years, 49% were African American, and 46% were unmarried. Compared with the structured clinical interview, the screening instrument performed with a sensitivity of 72% (95% confidence interval [CI] 0.51-0.88) and a specificity of 71% (95% CI 0.29-0.96), corresponding to a positive likelihood ratio of 2.52 (95% CI 0.76-8.34) and a negative likelihood ratio of 0.39 (95% CI 0.18-0.86).

CONCLUSION

Trauma was common in this population. Including a screening instrument for trauma and PTSD on clinic intake surveys has promise for use as a triage tool. Use of such an instrument could meaningfully increase detection of PTSD among women receiving routine preventive care.

LEVEL OF EVIDENCE

III