Post-traumatic Stress Disoder (PTSD)

Treatment

Pharmacological Treatment

There are only a handful of controlled trials on the older antidepressants (Marshall et al., 1996). Unfortunately, these trials also show significant limitations; not all are of sufficient duration, the sample sizes are often small, and patients have been limited to veterans. Despite these limitations, it is of some interest that desipramine, a predominantly noradrenergic agent, was the one agent that did not prove effective for PTSD. A meta-analysis of the pharmacotherapy of PTSD suggests that effect size may correlate with increased serotonergic action (Penava, 1996). Similarly, in a retrospective study of different pharmacotherapeutic treatments of PTSD, noradrenergic agents had significantly less efficacy than serotonergic ones (Dow and Kline, 1997).

Although increased anxiety is a characteristic of PTSD, benzodiazepines have not proven effective in trials, but may cause a rebound effect on discontinuation (Braun et al., 1990). There is as yet an undetermined role for the anticonvulsant drugs in the treatment of PTSD due to limited studies (Davidson, 1997).

More recently, there has been increased attention to the newer selective serotonin reuptake inhibitors in PTSD. Several SSRIs have appeared useful in open trials of PTSD in different populations. Fluoxetine was found effective in both veterans (McDougle et al., 1991b; Shay et al., 1992; Nagy et al., 1993) and in a small study of civilians (Davidson et al., 1991). Fluvoxamine was found useful in Dutch World War II resistance fighters (De Boer et al., 1991), and in American veterans (Marmar et al., 1996) and civilians (Davidson et al., 1998). Sertraline was effective in veterans (Kline et al., 1994) and in female rape survivors (Rothbaum et al., 1996). There is also evidence for the efficacy of serotonin reuptake inhibitor and 5-HT-2 antagonists, with open trials of trazodone in veterans (Hertzberg et al., 1996) and nefazodone in civilians (Davidson et al., 1998) proving effective.

Controlled trials have now also been completed on a number of the SSRIs, although to date few have been published. Van der Kolk et al (1994) undertook a 5 week placebo-controlled trial of fluoxetine (up to 60mg daily) in 31 war veterans and 33 civilians. Fluoxetine was effective for PTSD in the total sample, although when samples were analysed separately, efficacy was seen only in the civilian sub-group. Also of interest was the finding that fluoxetine was particularly effective in re-experiencing symptoms, numbing, depression, affective liability, and interpersonal relationship impairment, but had little improvement other symptoms such as hyperarousal.

Questions remain about the optimal dose and duration of SSRI treatment in PTSD. Marshal recommends that successful treatment should be continued for 6-months to a year; in accordance with other affective and anxiety disorders. Thereafter the treatment can be tapered to discontinuation (Marshall et al., 1996). It is clear that more dose-ranging- and maintenance pharmacotherapy studies are important in this area. Hopefully, the next few years will also see the publication of additional controlled trials of SSRIs in PTSD. Finally, there is a little published research on pharmacotherapy augmentation strategies in resistant-PTSD.

Psychological Treatment

Pharmacotherapy should be provided in conjunction with PTSD-focused psychotherapy (Marshall et al., 1996). The avoidance symptomatology in PTSD responds more readily to the combination of the therapies than to the pharmacological treatment alone.

There are various successful strategies employed in the psychological approach to PTSD treatment (Ebbinghaus et al., 1996). Good effects have been achieved with such techniques as cognitive, behavioural, psychodynamic and exposure therapies (Solomon et al., 1992). These are offered in conjunction with relaxation therapy which brings rapid short-term relief (Foa et al., 1991).

The importance of psychoeducation for patients in the understanding of this disorder must not underestimated.

Conclusions

There is a reasonable theoretical rationale and a growing empirical basis for prescribing SSRIs in PTSD. Indeed, there is some evidence that serotonergic agents may be more effective than noradrenergic agents in the treatment of PTSD. Open-label studies of various SSRIs, including citalopram, are promising. Nevertheless, there remains a dearth of published controlled trials in this area, and additional dose-ranging and maintenance studies need to be done.

Certainly, neurobiological research on PTSD offers the promise of new treatments for PTSD in the future. The development of agents which act to block CRF may ultimately be useful in normalising hpa axis  function. Anticonvulsants, which may reverse various processes of sensitisation, would also seem to require further study in PTSD. The selective serotonin reuptake inhibitors are currently receiving increased attention for the treatment of PTSD, and preliminary results point to their efficacy.