SSRIs top agents in treating posttraumatic stress disorder.
Although selective serotonin reuptake inhibitors are the recommended first-line treatment for posttraumatic stress disorder (PTSD), there are adjunctive agents, she noted.
SSRIs enhance global functioning and are generally well tolerated, but disadvantages include a high rate of sexual dysfunction and increased risk of an activation reaction. "So I suggest starting with a low dose initially," said Dr. David, director of the posttraumatic stress disorder program at the Miami Veterans Affairs Medical Center.
Both sertraline (Zoloft) and paroxetine (Paxil) have been evaluated in multicenter, randomized controlled trials and are approved for PTSD. Other agents showing favorable results in open trials include fluoxetine, citalopram, and fluvoxamine, she said at the meeting, which was cosponsored by the Florida Psychiatric Society.
Other serotonergic agents include nefazodone and trazodone. Nefazodone has no sexual dysfunction or weight-gain effects, but it carries a black box warning about hepatic failure and is used less often today. Trazodone has modest effects when used alone but can reverse insomnia associated with SSRI use when used in combination. With trazodone, "you have to warn men about priapism, although it is rare," she added.
Results of research assessing tricyclic antidepressants for PTSD have been mixed and modest.
"A patient with comorbid pain and difficulty sleeping might benefit from an SSRI plus a low-dose tricyclic," said Dr. David, also of the University of Miami.
Investigators assessed the MAO inhibitor phenelzine in randomized controlled trials and open trials, but it is not suggested as a first- or second-line choice, she said.
Mood stabilizers improved PTSD reexperiencing and hyperarousal symptoms compared with placebo in studies and "can make a big difference in people's lives." Dr. David said. Advantages include antikindling and neuroprotective effects. Disadvantages include requirements for blood test monitoring and twice- or thrice-daily dosing with older agents.
Noradrenergic agents are not widely used despite studies showing efficacy in PTSD, Dr. David said. There are reports of decreases in reexperiencing and hyperarousal symptoms. Low cortisol level might be associated with PTSD, she added. "People who cannot shut down the adrenergic system after flight-or-fight response may be at higher risk for PTSD, but it is not yet proven."
Atypical neuroleptic agents show benefit in studies for trauma-related psychotic symptoms such as hallucinations.
Patients also demonstrated improvements in reexperiencing and hyperarousal symptoms at low doses. These agents, however, are not approved by the Food and Drug Administration, are not first line, and are not for PTSD monotherapy, Dr. David said.
Other treatment tactics include patient education, patient and family involvement, anger management, stress management, relaxation training, and individual or group cognitive-behavioral psychotherapy aimed at managing distortions.
Comorbidity makes treatment even more challenging because it increases the prevalence of self-destructive impulses and behaviors, concurrent medical illness, and functional impairment, Dr. David said. An estimated 80% of patients with PTSD have at least one other psychiatric disorder such as depression, anxiety disorder, or alcohol/substance abuse.
BY DAMIAN MCNAMARA
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|Title Annotation:||Psychiatry; Selective serotonin reuptake inhibitors|
|Publication:||Internal Medicine News|
|Date:||Oct 1, 2004|
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