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Update on Pharmacotherapies for PTSD

This presentation by Dr. Michelle Pent reviews pharmacological treatments for PTSD, characterized by symptoms such as re-experiencing trauma, hyperarousal, and avoidance. The session highlights the neurochemical basis of PTSD involving the amygdala and central nervous system, and discusses various treatment modalities, including psychotherapy (CBT, EMDR) and pharmacotherapy. Specific medications are explored, including SSRIs, SNRIs, and anxiolytics, along with their efficacy, side effects, and the importance of combining these treatments with therapy for optimal patient outcomes.

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Update on Pharmacotherapies for PTSD

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  1. Update on Pharmacotherapies for PTSD Michelle Pent, MD, MPH April 29, 2011

  2. Presentation • Anxiety-spectrum disorder • DSM-IV criteria • A: Exposure to traumatic event with perceive threat to life or physical integrity and response of intense fear • B: Re-experience of the traumatic event • C: Avoidance of stimuli associated with the trauma • D: Hyperarousal

  3. Target Symptoms • Intrusive ruminations • Nightmares • Flashbacks • Hyperarousal • Hypervigilance • Associated irritability, anger, poor focus and concentration, and physiologic distress

  4. Neurochemistry • Amygdala • Central Nervous System • Norepinephrine, Serotonin, Dopamine, GABA • Peripheral Nervous System • Sympathetic Nervous System • “Fight or flight”

  5. Treatment • Psychotherapy • Pharmacotherapy • Most evidence suggests psychotherapy is most effective • CBT • EMDR • DBT where indicated

  6. Complimentary Treatments • Yoga/Meditation • Acupuncture • Mindfulness Training • Relaxation Therapy

  7. Pharmacotherapy • Objective is to improve symptoms by minimizing anxiety • Selective Serotonin Reuptake Inhibitors • Other antidepressants • Anxiolytics • Other

  8. Selective Serotonin Reuptake Inhibitors (SSRIs) • Raise serotonin levels in the brain • Remain standard of care for anxiety disorders • Linked with • Improvement in baseline level of anxiety • Diminished intrusive ruminations

  9. SSRIs • Fluoxetine (Prozac) • Sertraline (Zoloft) • Fluvoxamine (Luvox) • Paroxetine (Paxil) • Citalopram (Celexa) • Escitalopram (Lexapro)

  10. SSRIs • Lag time before efficacy • Usually 4-6 weeks • Adequate trial a minimum of 8 weeks • Side effects • Nausea, diarrhea • Weight gain • Agitation • Sexual dysfunction

  11. Other Antidepressants • Selective Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) • Venlafaxine (Effexor) • Duloxetine (Cymbalta) • Desvenlafaxine (Pristiq) • Tricyclic Antidepressants • Amitryptyline (Elavil) • Doxepin (Sinequan)

  12. Anxiolytics • Benzodiazepines • Alpha adrenergic antagonists • Buspirone • Antihistamines

  13. Benzodiazepines • Diminish anxiety by enhancing GABA in the central nervous system • No longitudinal effect on anxiety • Significant tolerance and dependence • Essentially contraindicated in patients with history of substance abuse • Intended for short term use • Increasingly considered inappropriate for long term treatment of anxiety disorders

  14. Benzodiazepines • Diazepam (Valium) • Lorazepam (Ativan) • Alprazolam (Xanax) • Clonazepam (Klonopin) • Oxazepam (Serax) • Chlordiazepoxide (Librium) • Temazepam (Restoril)

  15. Other Anxiolytics • Buspirone (Buspar) • Serotonin agent • May cause headache, nausea • Antihistamines • Diphenhydramine (Benadryl) • Hydroxyzine (Vistaril) • Side effects include sedation, confusion at high doses

  16. Other Anxiolytics • Alpha adrenergic antagonists • Blood pressure medications • Prazosin (Minipress) • Clonidine (Catapres) • Side effects include dizziness and other complications of low blood pressure

  17. Other Anxiolytics • Gabapentin • Anticonvulsant/Mood Stabilizer • Enhances GABA in central nervous system • Some usefulness for anxiety • Limited addictive potential

  18. Use of Antipsychotics • May be useful as anxiolytics • Use does not necessarily imply psychosis • Significant sedation, weight gain, metabolic disturbance • Most commonly used • Quetiapine (Seroquel) • Olanzapine (Zyprexa) • Ziprasidone (Geodon)

  19. Treating Sleep

  20. Sleep • Review of sleep hygiene is critical • Complimentary treatments can also be effective

  21. Sleep • Benzodiazepine analogues • Eszopiclone (Lunesta) • Zolpidem (Ambien) • Addictive potential • Benzodiazepines • Short term use

  22. Sleep • Trazodone (Desyrel) • Often exacerbates nightmares • Mirtazapine (Remeron) • Associated with weight gain • Melatonin • Ramelteon (Rozerem)

  23. Sleep • Antihistamines • Alpha antagonists • Sedating antipsychotics • Seroquel, Zyprexa

  24. Choosing a Medication? • Safety • Tolerability • Efficacy • Cost

  25. Educate patient that symptoms unlikely to improve with medication in the absence of psychotherapy

  26. Questions?

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