Antidepressants Often Just a First Step in PTSD: Following Initial SSRIs, Adrenergic Antagonists, Anticonvulsants, Atypical Antipsychotics Often Used

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Natural disasters, terrorism, and war make headlines against a day-to-day background of criminal violence and childhood abuse, and a substantial proportion of trauma victims go on to develop lasting symptoms, making posttraumatic stress disorder among the most common psychiatric disorders. Its estimated lifetime prevalence in the United States is 7.8%.

Although psychosocial interventions, particularly exposure therapy, have been shown efficacious, many patients will prefer or require pharmacotherapy in the course of their illness.

Dr. Lori L. Davis, director of research at the Veterans Affairs Medical Center in Tuscaloosa, Ala., most often opts for both, particularly when posttraumatic stress disorder (PTSD) is still acute.

"We're seeing a fair number of new patients from Iraq," she said. "Our approach with them is to be proactive in treatment--to stress recovery and rehabilitation rather than chronic disability."

"PTSD is a self-fueling illness. It's as though you're being exposed to the trauma every time you reexperience it," Dr. Davis said. "It's better to treat assertively and dampen the hyperarousal that accompanies symptoms than to wait and see if time will heal."

The literature and usual practice agree that antidepressants are first-line medications, with the emphasis on use of selective serotonin reuptake inhibitors (SSRIs), a class that includes the only two agents approved for the disorder, sertraline (Zoloft) and paroxetine (Paxil).

"I also think of other antidepressants, and I've grown fond of mirtazapine [Remeron]," which is both serotonergic and noradrenergic and also has potent sedative effects, Dr. Davis said. It reduces the need for a second medication, such as a hypnotic or low-dose trazodone (Desyrel) at bedtime, and in many cases can quickly reduce hypervigilance and hyperarousal as well as insomnia.

About half of patients will respond to monotherapy with the first agent; others will require a change in antidepressant or additional medications, she said.

Dr. Mark B. Hamner often adds another antidepressant, rather than switching, if there has been some response to the first. Bupropion (Wellbutrin) may improve sexual dysfunction and aid smoking cessation, in addition to augmenting the therapeutic response.

He also uses buspirone (BuSpar) at a dosage of 30-40 mg/day to potentiate the effect of the antidepressant, particularly for patients who remain highly anxious despite the SSRI. Cyproheptadine, at 4-16 mg, may be helpful when sleep disturbance is prominent, and in some cases may reverse sexual dysfunction, said Dr. Hamner, professor of psychiatry and behavioral sciences at the Medical University of South Carolina

and medical director of the PTSD clinical team at the Veterans Affairs Medical Center, Charleston.

In choosing which medication to add, Dr. Jose M. Canive addresses the symptoms that are most troublesome. Establishing a good relationship with the patient will facilitate this approach and also lay the groundwork for honest disclosure about adherence, which can be problematic in this population, he said.

"Nightmares are the biggest challenge," said Dr. Canive, director of psychiatry research at the Albuquerque Veterans Affairs Medical Center and professor of psychiatry and neuroscience at the University of New Mexico. He has some good results with cyproheptadine and has found that atypical antipsychotics have been helpful in some cases.

"I've used [the [alpha]-1 adrenergic antagonist Minipress] prazosin for sleep disturbances with prominent nightmares, with fairly good results," Dr. …

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