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Marazziti D, Carmassi C, Cappellato G, Chiarantini I, Massoni L, Mucci F, Arone A, Violi M, Palermo S, De Iorio G, Dell’Osso L. Novel Pharmacological Targets of Post-Traumatic Stress Disorders. Life (Basel) 2023; 13:1731. [PMID: 37629588 PMCID: PMC10455314 DOI: 10.3390/life13081731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 08/04/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
Post-traumatic stress disorder (PTSD) is a psychopathological condition with a heterogeneous clinical picture that is complex and challenging to treat. Its multifaceted pathophysiology still remains an unresolved question and certainly contributes to this issue. The pharmacological treatment of PTSD is mainly empirical and centered on the serotonergic system. Since the therapeutic response to prescribed drugs targeting single symptoms is generally inconsistent, there is an urgent need for novel pathogenetic hypotheses, including different mediators and pathways. This paper was conceived as a narrative review with the aim of debating the current pharmacological treatment of PTSD and further highlighting prospective targets for future drugs. The authors accessed some of the main databases of scientific literature available and selected all the papers that fulfilled the purpose of the present work. The results showed that most of the current pharmacological treatments for PTSD are symptom-based and show only partial benefits; this largely reflects the limited knowledge of its neurobiology. Growing, albeit limited, data suggests that the hypothalamic-pituitary-adrenal axis, opioids, glutamate, cannabinoids, oxytocin, neuropeptide Y, and microRNA may play a role in the development of PTSD and could be targeted for novel treatments. Indeed, recent research indicates that examining different pathways might result in the development of novel and more efficient drugs.
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Affiliation(s)
- Donatella Marazziti
- Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, 56100 Pisa, Italy (L.D.)
- Saint Camillus International University of Health and Medical Sciences, 00131 Rome, Italy
| | - Claudia Carmassi
- Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, 56100 Pisa, Italy (L.D.)
| | - Gabriele Cappellato
- Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, 56100 Pisa, Italy (L.D.)
| | - Ilaria Chiarantini
- Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, 56100 Pisa, Italy (L.D.)
| | - Leonardo Massoni
- Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, 56100 Pisa, Italy (L.D.)
| | - Federico Mucci
- Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, 56100 Pisa, Italy (L.D.)
| | - Alessandro Arone
- Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, 56100 Pisa, Italy (L.D.)
| | - Miriam Violi
- Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, 56100 Pisa, Italy (L.D.)
| | - Stefania Palermo
- Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, 56100 Pisa, Italy (L.D.)
| | - Giovanni De Iorio
- Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, 56100 Pisa, Italy (L.D.)
| | - Liliana Dell’Osso
- Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, 56100 Pisa, Italy (L.D.)
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Pharmacological Implications of Adjusting Abnormal Fear Memory: Towards the Treatment of Post-Traumatic Stress Disorder. Pharmaceuticals (Basel) 2022; 15:ph15070788. [PMID: 35890087 PMCID: PMC9322538 DOI: 10.3390/ph15070788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 06/20/2022] [Accepted: 06/21/2022] [Indexed: 02/04/2023] Open
Abstract
Post-traumatic stress disorder (PTSD) is a unique clinical mental abnormality presenting a cluster of symptoms in which patients primarily experience flashbacks, nightmares and uncontrollable thoughts about the event that triggered their PTSD. Patients with PTSD may also have comorbid depression and anxiety in an intractable and long-term course, which makes establishing a comprehensive treatment plan difficult and complicated. The present article reviews current pharmacological manipulations for adjusting abnormal fear memory. The roles of the central monoaminergic systems (including serotonin, norepinephrine and dopamine) within the fear circuit areas and the involvement of the hypothalamic-pituitary-adrenal (HPA) axis and glucocorticoid receptor (GR) are explored based on attempts to integrate current clinical and preclinical basic studies. In this review, we explain how these therapeutic paradigms function based on their connections to stages of the abnormal fear memory process from condition to extinction. This may provide useful translational interpretations for clinicians to manage PTSD.
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Reinhard MA, Seifert J, Greiner T, Toto S, Bleich S, Grohmann R. Pharmacotherapy of 1,044 inpatients with posttraumatic stress disorder: current status and trends in German-speaking countries. Eur Arch Psychiatry Clin Neurosci 2021; 271:1065-1076. [PMID: 33369692 PMCID: PMC8354906 DOI: 10.1007/s00406-020-01223-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 12/12/2020] [Indexed: 01/13/2023]
Abstract
Posttraumatic stress disorder (PTSD) is a debilitating psychiatric disorder with limited approved pharmacological treatment options and high symptom burden. Therefore, real-life prescription patterns may differ from guideline recommendations, especially in psychiatric inpatient settings. The European Drug Safety Program in Psychiatry ("Arzneimittelsicherheit in der Psychiatrie", AMSP) collects inpatients' prescription rates cross-sectionally twice a year in German-speaking psychiatric hospitals. For this study, the AMSP database was screened for psychiatric inpatients with a primary diagnosis of PTSD between 2001 and 2017. N = 1,044 patients with a primary diagnosis of PTSD were identified with 89.9% taking psychotropics. The average prescription rate was 2.4 (standard deviation: 1.5) psychotropics per patient with high rates of antidepressant drugs (72.0%), antipsychotics drugs (58.4%) and tranquilizing drugs (29.3%). The presence of psychiatric comorbidities was associated with higher rates of psychotropic drug use. The most often prescribed substances were quetiapine (24.1% of all patients), lorazepam (18.1%) and mirtazapine (15.0%). The use of drugs approved for PTSD was low (sertraline 11.1%; paroxetine 3.7%). Prescription rates of second-generation antipsychotic drugs increased, while the use of tranquilizing drugs declined over the years. High prescription rates and extensive use of sedative medication suggest a symptom-driven prescription (e.g., hyperarousal, insomnia) that can only be explained to a minor extent by existing comorbidities. The observed discrepancy with existing guidelines underlines the need for effective pharmacological and psychological treatment options in psychiatric inpatient settings.
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Affiliation(s)
- Matthias A Reinhard
- Department of Psychiatry and Psychotherapy, LMU University Hospital Munich, Nußbaumstr. 7, 80336, Munich, Bavaria, Germany.
| | - Johanna Seifert
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Timo Greiner
- Brandenburg Medical School, Immanuel Klinik Rüdersdorf, University Clinic for Psychiatry and Psychotherapy, Seebad 82/83, 15562, Rüdersdorf bei Berlin, Germany
| | - Sermin Toto
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Stefan Bleich
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Renate Grohmann
- Department of Psychiatry and Psychotherapy, LMU University Hospital Munich, Nußbaumstr. 7, 80336, Munich, Bavaria, Germany
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Early Life Adversity as a Moderator of Symptom Change following Selective Serotonin Reuptake Inhibitors and Cognitive Behavioral Therapy. COGNITIVE THERAPY AND RESEARCH 2020. [DOI: 10.1007/s10608-020-10158-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Lin CC, Huang KL, Tung CS, Liu YP. Hyperbaric oxygen therapy restored traumatic stress-induced dysregulation of fear memory and related neurochemical abnormalities. Behav Brain Res 2018; 359:861-870. [PMID: 30056129 DOI: 10.1016/j.bbr.2018.07.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 07/13/2018] [Accepted: 07/19/2018] [Indexed: 01/12/2023]
Abstract
Individuals with posttraumatic stress disorder (PTSD) are characterized by fear memory problems and hypocortisolemia of which traumatic stress-induced monoaminergic disruption over infralimbic (IL) cortex is considered the key mechanism. Hyperbaric oxygen therapy (HBOT) has recently proven its utility in treating several mental disorders but remains unexplored for PTSD. The present study aimed to examine the effects of 5-day HBO paradigm on traumatic stress (single prolonged stress, SPS, an animal model of PTSD)-induced dysregulation of fear memory/anxiety profiles and related abnormalities in IL monoamines and plasma corticosterone. Rats were randomly assigned to four groups (CON-sham, CON-HBOT, SPS-sham, and SPS-HBOT) and received Pavlovian fear conditioning test or elevated-T maze (ETM). The extracellular and tissue levels of monoamines over the IL cortex and the activity of the hypothalamus-pituitary-adrenal axis (i.e., the plasma corticosterone level and expression of the glucocorticoid receptor (GR) in the IL, hippocampus, amygdala, and hypothalamus) were measured. The results demonstrated that HBOT restored behaviorally the SPS-impaired fear extinction retrieval ability and SPS-induced conditioned anxiety, and neurochemically the SPS-reduced IL monoamines efflux level, and the corticosterone profiles. The present study shows some positive effects of HBOT in both behavioral and neurochemical profiles of PTSD outcomes.
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Affiliation(s)
- Chen-Cheng Lin
- Department of Psychiatry, Cheng Hsin General Hospital, Taipei, Taiwan; Laboratory of Cognitive Neuroscience, Department of Physiology, National Defense Medical Center, Taipei, Taiwan
| | - Kun-Lun Huang
- Hyperbaric Oxygen Therapy Center, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Graduate Institute of Aerospace and Undersea Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Che-Se Tung
- Division of Medical Research and Education, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Yia-Ping Liu
- Department of Psychiatry, Cheng Hsin General Hospital, Taipei, Taiwan; Laboratory of Cognitive Neuroscience, Department of Physiology, National Defense Medical Center, Taipei, Taiwan; Department of Psychiatry, Tri-Service General Hospital, Taipei, Taiwan.
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Rice OV, Ashby CR, Dixon C, Laurenzo W, Hayden J, Song R, Li J, Tiwari AK, Gardner EL. Selective dopamine D 3 receptor antagonism significantly attenuates stress-induced immobility in a rat model of post-traumatic stress disorder. Synapse 2018; 72:e22035. [PMID: 29704283 DOI: 10.1002/syn.22035] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 04/16/2018] [Accepted: 04/25/2018] [Indexed: 01/02/2023]
Abstract
Post-traumatic stress disorder (PTSD) is a debilitating psychiatric syndrome that occurs in individuals exposed to extremely threatening or traumatic events. In both animals and humans, dopamine (DA) function appears to be dysregulated in brain areas involved in the conditioned fear response(s) that underlie PTSD. In this study, we determined the effect of the selective DA D3 receptor antagonists YQA14A (6.25, 12.5 and 25 mg/kg i.p.) and SB-277011A (6 mg/kg i.p.) on tone-induced fear (assessed by measuring freeze time) in a modified version of the single-prolonged stress (SPS) model of PTSD in adult male Sprague-Dawley rats. Rats pretreated with vehicle and then subjected to restraint stress, forced swim and random foot shock (SPS) in the presence of a distinctive tone, displayed a significantly increased tone-induced contextual freeze time and fecal pellet mass following re-exposure to the tone. Rats pretreated with a single i.p. injection of 6.25 or 12.5 mg/kg of YQA14 or 6 mg/kg of SB-277011A showed significantly attenuated contextual freeze time in the presence of the tone when tested 14 days after exposure to SPS. Overall, our results indicate that selectively antagonizing DA D3 receptors significantly decreases freezing time caused by an environment previously associated with stress. If our findings can be extrapolated to humans with PTSD, they suggest that DA D3 receptors may play a role in the pathophysiology of PTSD, and may have therapeutic utility for the clinical management of PTSD.
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Affiliation(s)
- Onarae V Rice
- Psychology Department, Neuroscience Program, Furman University, 3300 Poinsett Highway, Greenville, South Carolina
| | - Charles R Ashby
- Department of Pharmaceutical Sciences, College of Pharmacy and Allied Health Professions, St. John's University, 8000 Utopia Parkway, Jamaica, New York
| | - Clark Dixon
- Psychology Department, Neuroscience Program, Furman University, 3300 Poinsett Highway, Greenville, South Carolina
| | - William Laurenzo
- Psychology Department, Neuroscience Program, Furman University, 3300 Poinsett Highway, Greenville, South Carolina
| | - Jason Hayden
- Psychology Department, Neuroscience Program, Furman University, 3300 Poinsett Highway, Greenville, South Carolina
| | - Rui Song
- State Key Laboratory of Toxicology and Medical Countermeasures, Beijing Key Laboratory of Neuropsychopharmacology, Beijing Institute of Pharmacology and Toxicology, Beijing, China
| | - Jin Li
- State Key Laboratory of Toxicology and Medical Countermeasures, Beijing Key Laboratory of Neuropsychopharmacology, Beijing Institute of Pharmacology and Toxicology, Beijing, China
| | - Amit K Tiwari
- Department of Pharmacology and Experimental Therapeutics, College of Pharmacy and Pharmaceutical Sciences, University of Toledo, Toledo, Ohio
| | - Eliot L Gardner
- Neuropsychopharmacology Section, Intramural Research Program, National Institute on Drug Abuse, National Institutes of Health, Baltimore, Maryland
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Tural Ü, Aker AT, Önder E, Sodan HT, Ünver H, Akansel G. Neurotrophic factors and hippocampal activity in PTSD. PLoS One 2018; 13:e0197889. [PMID: 29799860 PMCID: PMC5969740 DOI: 10.1371/journal.pone.0197889] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 05/10/2018] [Indexed: 12/15/2022] Open
Abstract
Although numerous studies have investigated the neurotrophic factors and hippocampal activity in posttraumatic stress disorder (PTSD) separately each other, it is unclear whether an association between neurotrophic factors and hippocampal activity is present. The aim of this study was to evaluate the functional changes in hippocampus before and after treatment with escitalopram and to associate these changes with peptides related to neuronal growth in patients with chronic PTSD and trauma survivors without PTSD. Fifteen earthquake survivors with chronic PTSD and thirteen drug naïve trauma exposed individuals without PTSD underwent fMRI scans in a block design. Serum levels of Nerve Growth Factor (NGF) and Brain Derived Neurotrophic Factor (BDNF) were measured before and after 12 weeks treatment with escitalopram. Baseline median serum level of NGF was significantly lower in patients with chronic PTSD than trauma survivors; however, 12 weeks of treatment with escitalopram significantly increased it. Higher activation was found both in left and right hippocampus for chronic PTSD group than trauma survivors. Treatment with escitalopram was significantly associated with suppression of the hyperactivation in left hippocampus in patients with chronic PTSD. Bilateral hyperactivation in hippocampus and lowered NGF may associate with neurobiological disarrangements in chronic PTSD. Treatment with escitalopram was significantly associated with both improvement in the severity of PTSD symptoms and biological alterations. Patients diagnosed with PTSD may have further and complicated deteriorations in hippocampal networks and neurotransmitter systems than individuals who had not been diagnosed with PTSD following the same traumatic experience.
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Affiliation(s)
- Ümit Tural
- The Nathan S. Kline Psychiatric Research Institute, Orangeburg, New York, United States of America
- Department of Psychiatry, Medical Faculty of Kocaeli University, Kocaeli, Turkey
- * E-mail:
| | - Ahmet Tamer Aker
- Department of Psychiatry, Medical Faculty of Kocaeli University, Kocaeli, Turkey
| | - Emin Önder
- Department of Psychiatry, Medical Faculty of Kocaeli University, Kocaeli, Turkey
| | - Hatice Turan Sodan
- Department of Psychiatry, Medical Faculty of Kocaeli University, Kocaeli, Turkey
| | - Hatice Ünver
- Department of Child and Adolescent Psychiatry, Medical Faculty of Marmara University, Istanbul, Turkey
| | - Gür Akansel
- Department of Radiology, Medical Faculty of Kocaeli University, Kocaeli, Turkey
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Abstract
BACKGROUND Open-label trials suggest that escitalopram (up to 20 mg/d) is an effective treatment for some, but not all posttraumatic stress disorder (PTSD) patients. Higher doses of escitalopram effectively reduced major depression symptoms in patients who had not responded to regular doses. The current study examines the efficacy, tolerability, and adherence to high-dose escitalopram in PTSD. METHODS Forty-five PTSD patients received 12 weeks of gradually increasing doses of escitalopram reaching 40 mg daily at 4 weeks. Among those, 12 participants received regular doses of antidepressants at study onset including escitalopram (n = 7). The Clinician-Administered PTSD Scale (CAPS) evaluated PTSD symptoms severity before treatment, at 3 months (upon treatment termination), and at 6 months (maintenance effect). A 20% reduction in CAPS scores was deemed clinically significant. RESULTS Adverse events and medication adherence were monitored at each clinical session. Linear mixed-models analysis showed a significant reduction of mean CAPS scores (11.5 ± 18.1 points) at 3 months and maintenance of gains by 6 months (F2,34.56 = 8.15, P = 0.001). Eleven participants (34.3%) showed clinically significant improvement at 3 months. Only 9 participants (20%) left the study. There were no serious adverse events and few mild ones with only 2 adverse events (diarrhea, 11.1%; drowsiness, 11.1%) reported by more than 10% of participants. CONCLUSION High doses of escitalopram are tolerable and well adhered to in PTSD. Their beneficial effect at a group level is due to a particularly good response in a subset of patients.Variability in prior pharmacological treatment precludes a definite attribution of the results to high doses of escitalopram.
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Celik C, Ozdemir B, Ozmenler KN, Yelboga Z, Balikci A, Oznur T, Doruk A, Bozkurt A. Efficacy of Paroxetine and Amitriptyline in Posttraumatic Stress Disorder: An Open-label Comparative Study. ACTA ACUST UNITED AC 2016. [DOI: 10.5455/bcp.20110627111141] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Cemil Celik
- Gülhane Askeri Tıp Fakültesi Psikiyatri Anabilim Dalı, Askeri Psikoloji ve Harp Psikiyatrisi Bilim Dalı, Ankara-Turkey
| | - Barbaros Ozdemir
- Gülhane Askeri Tıp Fakültesi Psikiyatri Anabilim Dalı, Askeri Psikoloji ve Harp Psikiyatrisi Bilim Dalı, Ankara-Turkey
| | - Kamil Nahit Ozmenler
- Gülhane Askeri Tıp Fakültesi Psikiyatri Anabilim Dalı, Askeri Psikoloji ve Harp Psikiyatrisi Bilim Dalı, Ankara-Turkey
| | | | | | | | - Ali Doruk
- Gülhane Askeri Tıp Fakültesi, Psikiyatri Anabilim Dalı, Ankara-Turkey
| | - Ali Bozkurt
- Gülhane Askeri Tıp Fakültesi, Psikiyatri Anabilim Dalı, Ankara-Turkey
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Treatment-refractory posttraumatic stress disorder (TRPTSD): a review and framework for the future. Prog Neuropsychopharmacol Biol Psychiatry 2016; 70:170-218. [PMID: 26854815 DOI: 10.1016/j.pnpbp.2016.01.015] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 01/29/2016] [Accepted: 01/29/2016] [Indexed: 01/04/2023]
Abstract
Post-traumatic stress disorder (PTSD) is a serious psychiatric consequence of trauma that occurs in a proportion of individuals exposed to life-threatening events. Trauma-focused psychotherapy is often recommended as first choice for those who do not recover spontaneously. But many individuals require medications. In the US, only paroxetine (PRX) and sertraline (SRT) are FDA approved for PTSD. But response and remission rates with these medications are low, so numerous other pharmacologic interventions have been tried. To date, there has not been a systematic review of the data on what are the best next-step pharmacologic strategies for individuals who fail standard treatments. To that end, we review 168 published trials of medications other than PRX or SRT and provide a detailed analysis of the 88/168 studies that describe alternative pharmacologic interventions in patients refractory to other treatment. We also review clinical factors relevant to treatment-refractory PTSD; the neurobiology of extinction, as well as evidence-based psychotherapy and neuromodulation strategies for this condition.
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Lin CC, Tung CS, Liu YP. Escitalopram reversed the traumatic stress-induced depressed and anxiety-like symptoms but not the deficits of fear memory. Psychopharmacology (Berl) 2016; 233:1135-46. [PMID: 26740318 DOI: 10.1007/s00213-015-4194-5] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 12/16/2015] [Indexed: 12/22/2022]
Abstract
RATIONALE Posttraumatic stress disorder (PTSD) is a trauma-induced mental disorder characterised by fear extinction dysfunction in which fear circuit monoamines are possibly associated. PTSD often coexists with depressive/anxiety symptoms, and selective serotonin reuptake inhibitors (SSRIs) are recommended to treat PTSD. However, therapeutic mechanisms of SSRIs underlying the PTSD fear symptoms remain unclear. OBJECTIVES Using a rodent PTSD model, we examined the effects of early SSRI intervention in mood and fear dysfunctions with associated changes of monoamines within the fear circuit areas. METHODS A 14-day escitalopram (ESC) regimen (5 mg/kg/day) was undertaken in two separate experiments in rats which previously received a protocol of single prolonged stress (SPS). In experiment 1, sucrose preference and elevated T-maze were used to index anhedonia depression and avoidance/escape anxiety profiles. In experiment 2, the percentage of freezing time was measured in a 3-day fear conditioning paradigm. At the end of our study, tissue levels of serotonin (5-HT) in the medial prefrontal cortex, amygdala, hippocampus, and striatum were measured in experiment 1, and the efflux levels of infralimbic (IL) monoamines were measured in experiment 2. RESULTS In experiment 1, ESC corrected both behavioural (depression/anxiety) and neurochemical (reduced 5-HT tissue levels in amygdala/hippocampus) abnormalities. In experiment 2, ESC was unable to correct the SPS-impaired retrieval of fear extinction. In IL, ESC increased the efflux level of 5-HT but failed to reverse SPS-reduced dopamine (DA) and noradrenaline (NA). CONCLUSIONS PTSD-induced mood dysfunction is psychopathologically different from PTSD-induced fear disruption in terms of disequilibrium of monoamines within the fear circuit areas.
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Affiliation(s)
- Chen-Cheng Lin
- Department of Physiology and Biophysics, National Defense Medical Center, Taipei, 11490, Taiwan
| | - Che-Se Tung
- Division of Medical Research and Education, Cheng Hsin General Hospital, Taipei, 11220, Taiwan
| | - Yia-Ping Liu
- Department of Physiology and Biophysics, National Defense Medical Center, Taipei, 11490, Taiwan.
- Department of Psychiatry, Tri-Service General Hospital, National Defense Medical Center, Taipei, 11490, Taiwan.
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MacNamara A, Rabinak CA, Kennedy AE, Fitzgerald DA, Liberzon I, Stein MB, Phan KL. Emotion Regulatory Brain Function and SSRI Treatment in PTSD: Neural Correlates and Predictors of Change. Neuropsychopharmacology 2016; 41:611-8. [PMID: 26111649 PMCID: PMC5130136 DOI: 10.1038/npp.2015.190] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 06/17/2015] [Accepted: 06/19/2015] [Indexed: 11/09/2022]
Abstract
Posttraumatic stress disorder (PTSD)-a chronic, debilitating condition, broadly characterized by emotion dysregulation-is prevalent among US military personnel who have returned from Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF). Selective serotonin reuptake inhibitors (SSRIs) are a first-line treatment for PTSD, but treatment mechanisms are unknown and patient response varies. SSRIs may exert their effects by remediating emotion regulatory brain activity and individual differences in patient response might be explained, in part, by pre-treatment differences in neural systems supporting the downregulation of negative affect. Thirty-four OEF/OIF veterans, 17 with PTSD and 17 without PTSD underwent 2 functional magnetic resonance imaging scans 12 weeks apart. At each scan, they performed an emotion regulation task; in the interim, veterans with PTSD were treated with the SSRI, paroxetine. SSRI treatment increased activation in both the left dorsolateral prefrontal cortex (PFC) and supplementary motor area (SMA) during emotion regulation, although only change in the SMA over time occurred in veterans with PTSD and not those without PTSD. Less activation of the right ventrolateral PFC/inferior frontal gyrus during pre-treatment emotion regulation was associated with greater reduction in PTSD symptoms with SSRI treatment, irrespective of pre-treatment severity. Patients with the least recruitment of prefrontal emotion regulatory brain regions may benefit most from treatment with SSRIs, which appear to augment activity in these regions.
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Affiliation(s)
- Annmarie MacNamara
- Department of Psychiatry, University of Illinois at Chicago, Chicago, IL, USA
| | - Christine A Rabinak
- Department of Pharmacy Practice, Wayne State University, Detroit, MI, USA
- Department of Psychiatry and Behavioral Neurosciences, Wayne State University, Detroit, MI, USA
| | - Amy E Kennedy
- Department of Psychiatry, University of Illinois at Chicago, Chicago, IL, USA
- Mental Health Service Line, Jesse Brown VA Medical Center, Chicago, IL, USA
| | - Daniel A Fitzgerald
- Department of Psychiatry, University of Illinois at Chicago, Chicago, IL, USA
- Mental Health Service Line, Jesse Brown VA Medical Center, Chicago, IL, USA
| | - Israel Liberzon
- Department of Psychiatry, University of Michigan and Mental Health Service, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Psychology, University of Michigan, Ann Arbor, MI, USA
| | - Murray B Stein
- Department of Psychiatry, University of California at San Diego, San Diego, CA, USA
- Department of Family Medicine and Public Health, University of California at San Diego, San Diego, CA, USA
- VA San Diego Healthcare System, San Diego, CA, USA
| | - K Luan Phan
- Department of Psychiatry, University of Illinois at Chicago, Chicago, IL, USA
- Mental Health Service Line, Jesse Brown VA Medical Center, Chicago, IL, USA
- Department of Psychology and the Graduate Program in Neuroscience, University of Illinois at Chicago, Chicago, IL, USA
- Department of Anatomy and Cell Biology, University of Illinois at Chicago, Chicago, IL, USA
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Alderman CP, McCarthy LC, Marwood AC. Pharmacotherapy for post-traumatic stress disorder. Expert Rev Clin Pharmacol 2014; 2:77-86. [PMID: 24422773 DOI: 10.1586/17512433.2.1.77] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Post-traumatic stress disorder (PTSD) is a serious mental illness of considerable importance from a public health perspective. Management of PTSD may involve the use of various treatment modalities, involving both nondrug treatments and pharmacotherapy. Nondrug treatment is regarded as the first-line option for PTSD and should be routinely incorporated into management plans for patients with PTSD. However, some patients do not achieve a sufficient response to nondrug therapy or are left with disabling residual symptoms in one or more areas. Antidepressants are currently the preferred medication for PTSD, with the most substantial evidence available to support the use of the selective serotonin reuptake inhibitors. Many patients with PTSD have symptoms that are resistant to initial drug treatment, meaning that it is often necessary to explore additional pharmacotherapy options to achieve optimal symptom control: antipsychotics, anti-adrenergic drugs, anxiolytics and anticonvulsants have all been advocated as treatments for PTSD. In addition to the management of core PTSD symptoms, it is also necessary for clinicians to address important associated comorbidities, most notably, substance-use disorders and mood disturbances. Interpretation of research studies of the efficacy and safety of PTSD pharmacotherapy is often difficult owing to methodological limitations and factors such as inclusion bias. Further research in fundamental neurosciences and pharmacogenomics may help to elucidate optimal pharmacotherapy options for PTSD in the future.
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Affiliation(s)
- Christopher P Alderman
- Director of Pharmacy and Senior Clinical Pharmacist (Psychiatry), Repatriation General Hospital, Daw Park, South Australia 5041, Australia and Associate Professor, Pharmacy Practice, Quality Use of Medicines and Pharmacy Research Centre, University of South Australia, South Australia 5041, Australia.
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Decreased suicidal ideation in depressed patients with or without comorbid posttraumatic stress disorder treated with selective serotonin reuptake inhibitors: an open study. Psychiatry Res 2012; 196:261-6. [PMID: 22397913 PMCID: PMC3361617 DOI: 10.1016/j.psychres.2011.11.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Revised: 10/26/2011] [Accepted: 11/15/2011] [Indexed: 11/21/2022]
Abstract
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.
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Samuels E, Khalife S, Alfonso CA, Alvarez R, Cohen MA. Early Childhood Trauma, Posttraumatic Stress Disorder, and Non-Adherence in Persons with AIDS: A Psychodynamic Perspective. ACTA ACUST UNITED AC 2011; 39:633-50. [DOI: 10.1521/jaap.2011.39.4.633] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Bajor LA, Ticlea AN, Osser DN. The Psychopharmacology Algorithm Project at the Harvard South Shore Program: an update on posttraumatic stress disorder. Harv Rev Psychiatry 2011; 19:240-58. [PMID: 21916826 DOI: 10.3109/10673229.2011.614483] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND This project aimed to provide an organized, sequential, and evidence-supported approach to the pharmacotherapy of posttraumatic stress disorder (PTSD), following the format of previous efforts of the Psychopharmacology Algorithm Project at the Harvard South Shore Program. METHOD A comprehensive literature review was conducted to determine the best pharmacological choices for PTSD patients and to update the last published version (1999) of the algorithm. We focused on optimal pharmacological interventions to address the prominent symptoms of PTSD, with additional attention to the impact that common comorbidities have on treatment choices. RESULTS We found that SSRIs and SNRIs are not as effective as previously thought, and that awareness of their long-term side effects has increased. New evidence suggests that addressing fragmented sleep and nightmares can improve symptoms (in addition to insomnia) that are frequently seen with PTSD (e.g., hyperarousal, reexperiencing). Prazosin and trazodone are emphasized at this initial step; if significant PTSD symptoms remain, an antidepressant may be tried. For PTSD-related psychosis, an antipsychotic may be added. In resistant cases, two or three antidepressants may be used in sequence. Following that, or with partial improvement and residual symptomatology, augmentation may be tried; the best options are antipsychotics, clonidine, topiramate, and lamotrigine. CONCLUSION This heuristic may be helpful in producing faster symptom resolution, fewer side effects, and increased compliance.
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Affiliation(s)
- Laura A Bajor
- Harvard Medical School, Harvard South Shore Psychiatry Residency Training Program, Brockton, MA 02301, USA
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Berger W, Mehra A, Lenoci M, Metzler TJ, Otte C, Tarasovsky G, Mellon SH, Wolkowitz OM, Marmar CR, Neylan TC. Serum brain-derived neurotrophic factor predicts responses to escitalopram in chronic posttraumatic stress disorder. Prog Neuropsychopharmacol Biol Psychiatry 2010; 34:1279-84. [PMID: 20643177 PMCID: PMC2939182 DOI: 10.1016/j.pnpbp.2010.07.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2010] [Revised: 07/03/2010] [Accepted: 07/12/2010] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Some studies have found that antidepressants increase serum brain-derived neurotrophic factor (BDNF) levels in patients with major depression and the expression of BDNF mRNA in limbic structures of rats. OBJECTIVES This study addressed whether the SSRI escitalopram increases serum BDNF levels in subjects with PTSD and whether BDNF levels are associated with treatment response. METHODS Medically healthy male subjects (N=16) with chronic PTSD completed a 12 week open-label trial of flexible dose (5-20 mg/day) escitalopram monotherapy. BDNF levels were obtained at baseline, and at weeks 4, 8 and 12. RESULTS PTSD symptoms significantly declined over the course of the 12 week escitalopram treatment. Despite a substantial improvement in PTSD symptoms, there was virtually no change in BDNF levels over time. Nevertheless, mean BDNF levels across the trial were strongly correlated with the slope of PTSD symptoms over the 12 weeks (r=0.58, p=0.018). Lower mean BDNF was associated with a greater decrease in PTSD symptoms over the course of the trial. CONCLUSIONS PTSD subjects with low BDNF levels demonstrated the largest treatment response from an agent with putative neurotrophic effects.
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Affiliation(s)
- William Berger
- Department of Psychiatry, University of California, San Francisco (UCSF), CA, USA, Psychiatry Service, San Francisco Department of Veterans Affairs Medical Center (DVAMC), San Francisco, USA, Department of Psychiatry, Universidade Federal do Rio de Janeiro (IPUB-UFRJ), Rio de Janeiro, Brazil
| | - Akhil Mehra
- Department of Psychiatry, University of California, San Francisco (UCSF), CA, USA
| | - Maryann Lenoci
- Psychiatry Service, San Francisco Department of Veterans Affairs Medical Center (DVAMC), San Francisco, USA
| | - Thomas J. Metzler
- Department of Psychiatry, University of California, San Francisco (UCSF), CA, USA, Psychiatry Service, San Francisco Department of Veterans Affairs Medical Center (DVAMC), San Francisco, USA
| | - Christian Otte
- Department of Psychiatry, University of California, San Francisco (UCSF), CA, USA, Department of Psychiatry and Psychotherapy, University Hospital Hamburg-Eppendorf, Germany
| | - Gary Tarasovsky
- Psychiatry Service, San Francisco Department of Veterans Affairs Medical Center (DVAMC), San Francisco, USA
| | - Synthia H. Mellon
- Department of Obstetrics, Gynecology and Reproductive Endocrinology, University of California, San Francisco (UCSF), CA, USA
| | - Owen M. Wolkowitz
- Department of Psychiatry, University of California, San Francisco (UCSF), CA, USA
| | - Charles R. Marmar
- Department of Psychiatry, University of California, San Francisco (UCSF), CA, USA, Psychiatry Service, San Francisco Department of Veterans Affairs Medical Center (DVAMC), San Francisco, USA, Department of Psychiatry, New York University School of Medicine, New York, USA
| | - Thomas C. Neylan
- Department of Psychiatry, University of California, San Francisco (UCSF), CA, USA, Psychiatry Service, San Francisco Department of Veterans Affairs Medical Center (DVAMC), San Francisco, USA,Corresponding author: Dr. Thomas C. Neylan, UCSF and SFVAMC (116P), 4150 Clement Street, San Francisco, CA 94121. Phone: (415) 750-6961; Fax: (415) 751-2297.
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Norrholm SD, Jovanovic T. Tailoring therapeutic strategies for treating posttraumatic stress disorder symptom clusters. Neuropsychiatr Dis Treat 2010; 6:517-32. [PMID: 20856915 PMCID: PMC2938301 DOI: 10.2147/ndt.s10951] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
According to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, posttraumatic stress disorder (PTSD) is characterized by three major symptom clusters following an event that elicited fear, helplessness, or horror. This review will examine each symptom cluster of PTSD separately, giving case study examples of patients who exhibit a preponderance of a given symptom domain. We use a translational approach in describing the underlying neurobiology that is relevant to particular symptoms and treatment options, thus showing how clinical practice can benefit from current research. By focusing on symptom clusters, we provide a more specific view of individual patient's clinical presentations, in order to better address treatment needs. Finally, the review will also address potential genetic approaches to treatment as another form of individualized treatment.
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Affiliation(s)
- Seth D Norrholm
- Atlanta VA Medical Center, Mental Health Service Line, 1670 Clairmont Rd., MHSL, 116A, Decatur, GA, USA.
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Ohmura Y, Izumi T, Yamaguchi T, Tsutsui-Kimura I, Yoshida T, Yoshioka M. The serotonergic projection from the median raphe nucleus to the ventral hippocampus is involved in the retrieval of fear memory through the corticotropin-releasing factor type 2 receptor. Neuropsychopharmacology 2010; 35:1271-8. [PMID: 20072117 PMCID: PMC3055345 DOI: 10.1038/npp.2009.229] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Several different studies have separately established that serotonin, corticotropin-releasing factor (CRF) receptors, and the hippocampus are involved in fear memory retrieval. The main aim of this study is to connect these separate studies. To assess the levels of anxiety/fear, we used the contextual fear-conditioning test and the elevated plus maze test as memory-dependent and memory-independent tasks, respectively. We injected CRF receptor antagonists or vehicle into the median raphe nucleus (MRN) 10 min before behavioral tests. As a result, 1000 ng of astressin 2B (CRF(2) receptor antagonist), but not 250 ng of antalarmin (CRF(1) receptor antagonist), significantly suppressed the expression rate of freezing behavior in the contextual fear-conditioning test. However, in the elevated plus maze test, there was no difference between astressin 2B-injected rats and saline-injected rats in the time spent in open arms. Neither the amount of exploratory behavior nor the moving distance in the EPM of astressin 2B-injected rats differed from that of vehicle-injected rats. Moreover, when we assessed the extracellular serotonin release in the ventral hippocampus in freely moving rats through in vivo microdialysis, it was shown that the blockade of the CRF(2) receptor in the MRN suppressed serotonin release in the ventral hippocampus during fear memory retrieval. These results indicated that endogenous CRF and/or related ligands that were released in the MRN could activate the CRF(2) receptor and stimulate serotonin release in the ventral hippocampus, thereby inducing fear memory retrieval.
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Affiliation(s)
- Yu Ohmura
- Department of Neuropharmacology, Hokkaido University Graduate School of Medicine, Sapporo, Japan,Department of Pharmacology, University of Michigan, Ann Arbor, MI, USA
| | - Takeshi Izumi
- Department of Neuropharmacology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Taku Yamaguchi
- Department of Neuropharmacology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Iku Tsutsui-Kimura
- Department of Neuropharmacology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Takayuki Yoshida
- Department of Neuropharmacology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Mitsuhiro Yoshioka
- Department of Neuropharmacology, Hokkaido University Graduate School of Medicine, Sapporo, Japan,Department of Neuropharmacology, Hokkaido University Graduate School of Medicine, N15 W7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan. Tel: +81 11 706 5059; Fax: +81 11 706 7872; E-mail:
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Edelmuth RCL, Nitsche MA, Battistella L, Fregni F. Why do some promising brain-stimulation devices fail the next steps of clinical development? Expert Rev Med Devices 2010; 7:67-97. [PMID: 20021241 DOI: 10.1586/erd.09.64] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Interest in techniques of noninvasive brain stimulation (NIBS) has been growing exponentially in the last decade. Recent studies have shown that some of these techniques induce significant neurophysiological and clinical effects. Although recent results are promising, there are several techniques that have been abandoned despite positive initial results. In this study, we performed a systematic review to identify NIBS methods with promising preliminary clinical results that were not fully developed and adopted into clinical practice, and discuss its clinical, research and device characteristics. We identified five devices (transmeatal cochlear laser stimulation, transcranial micropolarization, transcranial electrostimulation, cranial electric stimulation and stimulation with weak electromagnetic fields) and compared them with two established NIBS devices (transcranial magnetic stimulation and transcranial direct current stimulation) and with well-known drugs used in neuropsychiatry (pramipexole and escitalopram) in order to understand the reasons why they failed to reach clinical practice and further steps of research development. Finally, we also discuss novel NIBS devices that have recently showed promising results: brain ultrasound and transcranial high-frequency random noise stimulation. Our results show that some of the reasons for the failure of NIBS devices with promising clinical findings are the difficulty to disseminate results, lack of controlled studies, duration of research development, mixed results and lack of standardization.
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Affiliation(s)
- Rodrigo C L Edelmuth
- Laboratory of Neuromodulation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, USA
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21
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Abstract
Meta-analysis was conducted to examine dropout predictors and differences between SSRIs and placebo in randomized clinical trials (RCTs) of PTSD. Studies systematically located were SSRI versus placebo double blind RCTs of PTSD DSM diagnosis published between 1991 and 2008. Fourteen RCTs (n = 2815) met the inclusion criteria with an average duration of 10.8 weeks. Dropout rates were: 331 of 1111 (29.8%) among placebo arm and 513 of 1704 (30.3%) among SSRI participants. Random effects modeling showed that the dropout rates of SSRIs and placebo did not differ (OR = 1.05, 95% CI = 0.82-1.34), although favored SSRIs among civilian traumas (OR = 2.52, 95% CI = 1.11-5.7). Mixed effects modeling showed dropout was predicted by mixed trauma in the placebo arms, and duration and mean dose across treatments. With the exception of civilian trauma, SSRIs dropout rates were slightly lower than those of placebo. Formulae are available to guide the prediction of dropout.
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Abstract
Post-traumatic stress disorder (PTSD) is a prevalent psychiatric disorder that may result in significant social and occupational debilitation unless symptoms are recognized and treated appropriately. Considerable research effort has been devoted over the last 20 years to developing effective pharmacological treatments for this illness. At this time, the bulk of the agents investigated include antidepressants, anticonvulsants, atypical antipsychotics, benzodiazepines, and antiadrenergic agents. Herein, we review the existing evidence base for these different classes of psychotropics in PTSD. Emphasis is placed on discussion of evidence stemming from randomized placebo-controlled clinical trials wherever possible. A brief description of novel agents that have shown initial promise for PTSD treatment is also provided.
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Affiliation(s)
- Lakshmi N Ravindran
- Department of Psychiatry, University of California San Diego, 8939 Villa La Jolla Drive, Suite 200, La Jolla, CA 92037, USA
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Pharmacotherapy of PTSD: premises, principles, and priorities. Brain Res 2009; 1293:24-39. [PMID: 19332035 DOI: 10.1016/j.brainres.2009.03.037] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2009] [Accepted: 03/16/2009] [Indexed: 12/14/2022]
Abstract
Post-traumatic stress disorder (PTSD) is a prevalent anxiety disorder that results in multiple disabling symptoms. Research into the underlying neurobiology has implicated dysregulation in multiple neurotransmitter systems including norepinephrine, serotonin, and glutamate as well as the hypothalamic-pituitary axis. Understanding how these biological systems interact with each other and how they may affect key neural structures, such as the amygdala, hippocampus, and prefrontal cortex, to produce post-traumatic symptoms is critical for the development of effective pharmacological treatments. We briefly discuss the proposed biological dysfunctions underlying PTSD and how agents that target these dysfunctions may be utilized in PTSD. We then provide a review of the different pharmacological agents that have been investigated in PTSD. These drugs include: antidepressants, anti-adrenergic agents, anticonvulsants, benzodiazepines, atypical antipsychotics, and novel agents.
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Bandelow B, Zohar J, Hollander E, Kasper S, Möller HJ, Zohar J, Hollander E, Kasper S, Möller HJ, Bandelow B, Allgulander C, Ayuso-Gutierrez J, Baldwin DS, Buenvicius R, Cassano G, Fineberg N, Gabriels L, Hindmarch I, Kaiya H, Klein DF, Lader M, Lecrubier Y, Lépine JP, Liebowitz MR, Lopez-Ibor JJ, Marazziti D, Miguel EC, Oh KS, Preter M, Rupprecht R, Sato M, Starcevic V, Stein DJ, van Ameringen M, Vega J. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of anxiety, obsessive-compulsive and post-traumatic stress disorders - first revision. World J Biol Psychiatry 2009; 9:248-312. [PMID: 18949648 DOI: 10.1080/15622970802465807] [Citation(s) in RCA: 420] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
In this report, which is an update of a guideline published in 2002 (Bandelow et al. 2002, World J Biol Psychiatry 3:171), recommendations for the pharmacological treatment of anxiety disorder, obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) are presented. Since the publication of the first version of this guideline, a substantial number of new randomized controlled studies of anxiolytics have been published. In particular, more relapse prevention studies are now available that show sustained efficacy of anxiolytic drugs. The recommendations, developed by the World Federation of Societies of Biological Psychiatry (WFSBP) Task Force for the Pharmacological Treatment of Anxiety, Obsessive-Compulsive and Post-traumatic Stress Disorders, a consensus panel of 30 international experts, are now based on 510 published randomized, placebo- or comparator-controlled clinical studies (RCTs) and 130 open studies and case reports. First-line treatments for these disorders are selective serotonin reuptake inhibitors (SSRIs), serotonin-noradrenaline reuptake inhibitors (SNRIs) and the calcium channel modulator pregabalin. Tricyclic antidepressants (TCAs) are equally effective for some disorders, but many are less well tolerated than the SSRIs/SNRIs. In treatment-resistant cases, benzodiazepines may be used when the patient does not have a history of substance abuse disorders. Potential treatment options for patients unresponsive to standard treatments are described in this overview. Although these guidelines focus on medications, non-pharmacological were also considered. Cognitive behavioural therapy (CBT) and other variants of behaviour therapy have been sufficiently investigated in controlled studies in patients with anxiety disorders, OCD, and PTSD to support them being recommended either alone or in combination with the above medicines.
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Affiliation(s)
- Borwin Bandelow
- Department of Psychiatry and Psychotherapy, University of Gottingen, Gottingen, Germany.
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Abstract
Posttraumatic stress disorder (PTSD) is a psychiatric disorder that develops after a psychological trauma usually caused by a situation perceived as deeply threatening to a person's life or integrity. Complex neurobiological changes triggered by such a traumatic and stressful experience may explain a wide range of PTSD symptoms and provide the rationale for psychopharmacological treatment. Selective serotonin-reuptake inhibitors make the first-line treatment of PTSD. Clinical experience has shown that they are more effective than noradrenalin-reuptake inhibitors or tricyclic antidepressants. Antipsychotic drugs, especially atypical ones, have been shown effective in PTSD patients with psychotic characteristics or refractoriness to other treatments. Mood stabilizers seem to reduce mostly autonomous overreactions to stress, whereas the evidence for effectiveness of monoamine oxidase inhibitors is largely inconclusive. Other groups of medications, such as serotonin agonists and antagonists, new antidepressants, dual inhibitors of serotonin- and noradrenalin-reuptake, anticonvulsants, and opiate antagonists are also sometimes used in PTSD treatment. However, as shown in the present review, most clinical studies performed to date to investigate the effectiveness of different psychopharmacological agents in the therapy of PTSD have serious limitations in terms of small sample size, lack of blinding and randomization, and small effect size. More rigorously designed, comparative studies are needed to determine the usefulness, efficacy, tolerability, and safety of particular psychopharmaceutical drugs in the treatment of this therapeutically and functionally challenging disorder.
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Bogaerts S, Daalder AL, Van Der Knaap LM, Kunst MJ, Buschman J. CRITICAL INCIDENT, ADULT ATTACHMENT STYLE, AND POSTTRAUMATIC STRESS DISORDER: A COMPARISON OF THREE GROUPS OF SECURITY WORKERS. SOCIAL BEHAVIOR AND PERSONALITY 2008. [DOI: 10.2224/sbp.2008.36.8.1063] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In this paper the authors render the results of research investigating adult attachment and posttraumatic stress disorder (PTSD) in a sample of Belgian security workers. The sample contained 3 subsamples: 68 individuals who had directly experienced a critical incident, 67 individuals
who indirectly went through a critical incident, and 77 individuals who had not experienced a critical incident in the last six months. The analysis of the research results shows that the secure attachment style and the three PTSD trauma symptom clusters in DSM-IV - intrusion, avoidance/numbing,
and hyperarousal - discriminate between the three subsamples. In other words, security workers who were directly and actively confronted with a critical incident were significantly more insecurely attached and suffered significantly more from PTSD symptoms than the groups who had no or indirect
experience of a critical incident. Furthermore, trauma-focused cognitive-behavioral therapy is widely and quite efficiently used in the treatment of PTSD. Interest has been expressed in medical approaches.
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Bareggi SR, Mundo E, Dell'Osso B, Altamura AC. The use of escitalopram beyond major depression: pharmacological aspects, efficacy and tolerability in anxiety disorders. Expert Opin Drug Metab Toxicol 2007; 3:741-53. [DOI: 10.1517/17425255.3.5.741] [Citation(s) in RCA: 170] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Galvão-de Almeida A, Quarantini LC, Góis CR, Santos-Jesus R, Miranda-Scippa AMA, de Oliveira IR, da Silva Prado H, Leckman JF, Rosário MC. Obsessive-compulsive disorder: an open-label pilot trial of escitalopram. CNS Spectr 2007; 12:519-24. [PMID: 17603402 DOI: 10.1017/s1092852900021258] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Selective serotonin reuptake inhibitors are considered the most effective and well-established pharmacotherapy for the treatment of obsessive-compulsive disorder (OCD), a chronic and disabling condition. However, approximately 40% of patients do not have a significant improvement, suggesting that new medications are needed. This study was designed to investigate the treatment response to escitalopram in OCD patients. METHODS This open-label study involved 11 adult OCD outpatients diagnosed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis I Disorders. Data were collected and the treatment response was assessed by an experienced psychiatrist by using the Yale-Brown Obsessive-Compulsive Scale. Subjects received escitalopram 30 mg/day for 12 weeks starting at 10 mg/day. Dosage adjustments were made within 2 weeks, depending on the tolerability of the patient. RESULTS Six of the 11 patients (54.5%) presented a reduction of at least 40% in the baseline total Yale-Brown Obsessive-Compulsive Scale scores. CONCLUSION Despite the small sample size and the open-label nature of this trial, these data suggest that escitalopram may be a useful option for patients with OCD.
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