Pharmacotherapy of combat stress, post-traumatic stress related
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For Harpriya A. (Sonia) Bhaga, MBBS and Alan D. Schmetzer, MD, member of the American Psychotherapy Association, Therapist and Teacher
A number of veterans Operation Iraqi Freedom / Operation Enduring Freedom (OIF / OEF) are returning home with signs of combat stress-related post-traumatic Stress Disorder (PTSD). In a recent study, 16.6% of the soldiers met the screening criteria for PTSD. On average, showed a significant increase illness visits, missed workdays, severity of somatic symptoms, and poorer health (Hoge et al., 2007). In another study, most of the age group of 18-24 years had a higher risk compared with veterans 40 years of age or older. The diagnosis was made early (median 13 days), and most of them have been detected in primary care clinics (Seal et al., 2007).
Returning Veterans war zone often report intrusive thoughts, flashbacks, increased vigilance, prevention of social situations, hypervigilance and nightmares. Treatment consists in the integration of mental health, primary care, physical medicine, addiction care and professional services. The passage of mental health is an analysis Veterans initial PTSD and other mental illnesses, followed by a full evaluation. Both pharmacotherapy and psychotherapy (individual, couple and group) are proposed for treatment.
From the pharmacological standpoint, several studies have shown that traditional antidepressants effective in PTSD. Inhibitors Selective serotonin reuptake (SSRIs) such as sertraline (Zoloft ®), paroxetine (Paxil ®) and fluoxetine (Prozac ®), have been widely studied for PTSD and sertraline and paroxetine have been approved by the Food and Drug Administration for PTSD. SSRIs have been found to be effective in both short-term tests and maintenance long term to prevent relapse (Asnis et al., 2004). However, previous studies have focused on posttraumatic stress disorder secondary to interpersonal trauma in a civilian context. In a multicenter, extended-release, venlafaxine (Effexor XR ®), an inhibitor of the reuptake of norepinephrine, serotonin, is been found to improve both re-experiencing and avoidance symptoms of PTSD, but not hyperstimulation. The drug was effective and well tolerated in both short term and continuation treatment of PTSD (Davidson et al., 2006). In a small study, mirtazapine (Remeron) was found to be effective, both short term and continuation treatment of combat-related stress post traumatic stress disorders, without serious side effects (Kim et al., 2005). Moreover, mirtazapine sedation may even prove beneficial in improving sleep in PTSD. In a randomized trial comparing phenelzine (a monoamine oxidase) and imipramine (tricyclic antidepressant), stress significantly reduces both the symptoms of combat-related PTSD (Kosten et al., 1991). Benzodiazepines PTSD are used for panic attacks or anxiety states. They provide temporary relief, but we risk tolerance and dependence.
Alumni combatants with PTSD have trouble falling asleep and maintaining sleep much because of the nightmares and hypervigilance combat related living. Significant Other often Patients report that mourn in his sleep and wake up may still sweaty. Prasozin and clonidine both reduce noradrenergic activity of the central nervous system. They have proven effective in reducing symptoms of hyperarousal and improved sleep (Boehnlein, 2007). Other medications used for sleep are the kind of benzodiazepine drugs such as temazepam, and no benzodiazepines such as zolpidem (Ambien ™) and ezopiclone (Lunesta ™). However, precautions must be taken about the addictive potential of these drugs (Bhaga and Schmetzer, 2006).
The presence of psychotic symptoms in PTSD may complicate the clinical picture. In one study, 20% of the 91 men in combat with post-traumatic stress of the stress involved were suffering from hallucinations and delusions, and hyperstimulation was positively associated with the onset of psychotic symptoms (Kastela, 2007). In a small study, the increase of SSRIs with olanzapine (Zyprexa), an antipsychotic atypical, was effective in treating SSRI-resistant combat the symptoms associated with PTSD, especially sleep (Stein, 2002). In another study, monotherapy with typical or atypical antipsychotics, the reduction of PTSD and psychotic symptoms, antipsychotics and seemed to offer a Another approach to treat subtype of psychotic PTSD related to combat resistance to previous antidepressant therapy (Pivac, 2006).
In general, PTSD pharmacotherapy several drugs based on our experience of post-traumatic stress in general, but well-designed studies are needed to establish specific treatment guidelines to combat stress-related PTSD.
References
Asnis GM, Kohn SR, Henderson, M., & Brown, NL (2004). SSRIs versus non-SSRIs in posttraumatic stress disorder: an update of recommendations. Drugs, 64 (4), 383-404.
Bhaga, HA, and Schmetzer, AD (2006). The new sleeping medications. Annals of the American Psychotherapy Association, 9 (2) 25-26.
Boehnlein, JK, & Kinzie, JD (2007). Reduction of the pharmacological activity of the CNS noradrenergic in PTSD: the case of clonidine and prazosin. Journal of Psychiatric Practice, 13 (2), 72-78.
Davidson, JD Baldwin, Stein DJ, Kuper E, Benattia, I. Ahmed, S., et al. (2006). Posttraumatic stress disorder venlafaxine extended release: 6-month randomized clinical trial. Archives of General Psychiatry, 63 (10), 1158-1165.
Hoge, CW, Terhakopian, A., Castro CA, Messer SC, & Engel, CC (2007). Association of posttraumatic stress disorder with somatic symptoms, visits to the attention of the health and absenteeism among veterans of the war in Iraq. American Journal of Psychiatry, 164 (1), 150-153.
Kastela, A. Franciskovi,? T., Moro, L., Roncevic-Grzeta, I., Grkovic, J., Jurca, V., et al. (2007). Psychotic symptoms in combat related PTSD. Military Medicine, 172 (3), 273-277.
Kim W, Pae CU, Chae JH, June TY, & Bahk, WM (2005). The efficacy of mirtazapine in the treatment of PTSD: A 24-therapy follow-week. Psychiatry and Clinical Neurosciences, 59 (6), 743-747.
Kosten, TR, Frank JB, Dan E, McDougle, CJ, & Giller, EL, Jr. (1991). Pharmacotherapy for posttraumatic stress disorder using phenelzine or imipramine. Journal of Nervous and Mental Disease, 179 (6), 366-370.
Martenyi, F. (2005). [Three paradigms in the treatment of posttraumatic stress disorder]. Neuropsychopharmacol Hung, 7 (1), 11-21.
Pivac, N., and Kozari?-Kovacs? D. (2006). Pharmacotherapy of treatment-resistant combat-related posttraumatic stress disorder with psychotic features. Croatian Medical Journal, 47 (3), 440-451.
Seal KH, Bertenthal D, Miner CR, Sen, S., & Marmar, C. (2007). Bringing the War Home: mental health disorders among 103,788 U.S. veterans than returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. Archives of Internal Medicine, 167 (5), 476-482.
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