The Psychiatrist's Role
The psychiatrist can play important roles in evaluation, case management, and pharmacotherapy. In addition, the psychiatrist can provide the patient with appropriate additional referrals. The psychiatrist's prescription and management of the patient's medications is often pivotal to overall improvement. A main function of medications is to provide a degree of relief in order to facilitate patients' participation in psychotherapy. In most cases, combined pharmacological and psychotherapeutic treatment for PTSD is more effective than either conducted alone. The following topics are described below:
- Associated Psychophysiological Changes
- Medications
- Comorbidities and Medication Selection
Associated Psychophysiological Changes
Research indicates that PTSD may be associated with stable and enduring neurobiological alterations of both the central and autonomic nervous systems. Neuropharmacologic and neuroendocrine abnormalities have been detected in the noradrenergic, hypothalamic-pituitary-adrenocortical, and endogenous opioid systems - all of which have direct effects on physiology, mental health, and adaptive functioning.
More specifically psychophysiological alterations associated with PTSD include hyperarousal of the sympathetic nervous system, increased sensitivity and augmentation of the acoustic-startle-eyeblink reflex, a reduced pattern of auditory evoked cortical potentials, and sleep abnormalities. PTSD results in vulnerabilities to abnormalities of thyroid functioning and other hormone fluctuations, and increased susceptibility to infections and immunologic disorders. Other associated difficulties include problems with pain perception, pain tolerance, chronic pain, and gastrointestinal disturbance.
Medications
Unfortunately, there is a paucity of published literature on pharmacotherapy for PTSD. Further, the complexity of PTSD makes it difficult to predict which classes of drugs might be expected to improve which clusters of symptoms.
In most, but not all, trials, improvement has been achieved with tricyclic antidepressants such as imipramine, amitriptyline, or possibly nortriptyline or desipramine. Desipramine and nortriptyline generally have less anticholinergic, sedative, or orthostatic hypotension effects and may be useful for the elderly patient. Additionally the monoamine oxidase inhibitors (MAOIs; e.g., phenelzine), the selective serotonin reuptake inhibitors (SSRIs; e.g., fluoxetine), and propanolol have offered improvement.
Choice of medication may be tailored to specific focal symptoms. For example, intrusive and avoidant symptoms may be improved with tricyclics, MAOIs, SSRIs, and possibly valproate. However, these may prove to be more recalcitrant to psychopharmacological treatment than other symptoms. The SSRIs (e.g., fluoxetine, paroxetine, sertraline) are effective for symptoms such as rage, aggression, impulsivity, and suicidal behaviors. However, because of medication side effects such as arousal or insomnia, the SSRIs may be intolerable for some patients.
ln general, pharmacological treatment may begin with an SSRI. However, should this prove to be too stimulating, a 5HT2 antagonist (e.g., nefazadone) may be warranted. General dose ranges for the SSRIs are: fluoxetine (20-60mg); sertraline (50-200mg); paroxetine (10-50mg). Titrating the dose upward too fast or stopping too soon are often the reasons for the apparent ineffectiveness of the SSRIs.
Therefore, the SSRI should be increased gradually toward the higher dosage spectrum and should continue at this level for three months. At this point, the patient should be reevaluated for residual PTSD symptoms. To address symptoms not otherwise controlled by SSRIs, other medications may then be added to the regimen. To assist the patient and inform any other health care provider, give the patient a wallet card stating your prescribed medications.
Comorbidities and Medication Selection
Adding further complication to the choice of medications is the likely presence of one or more comorbid medical and psychiatric disorders. For example, a careful screening must be made for the presence of a Bipolar disorder. In this case, because of their arousal features, SSRIs as first line medications are contraindicated. Treatment may begin with valproic acid, carbamazepine, gabapentin, venlafaxine, or bupropion. Once the patient is stabilized SSRIs may then be cautiously added to the drug regimen.
When selecting medications, the clinician must try to prescribe a drug that might be expected to improve PTSD symptoms and the comorbid disorder(s) concurrently. Unfortunately little is known about the influence of comorbid disorders on choice of medications because most drug trials have not attempted to balance the various experimental groups with respect to comorbidities. However, taken as a whole, the most common comorbid disorders (depression, panic disorder, obsessive-compulsive disorder, and chemical abuse or dependency) respond to SSRI treatment.
The complex symptoms of PTSD require careful monitoring and management. For example, the SSRIs (as with many other antidepressant agents) can potentially interact with many other drugs metabolized by the liver. In addition, the effectiveness of any antidepressant may be affected by other drug therapy. Further, drug-drug interactions may pose risks. Therefore, as with any medication, it is necessary to review medication profiles prior to prescribing any agent.
As always, physicians should be alert to the likelihood of dropout from medical care as a result of medication side effects and should, therefore, take prophylactic steps to increase compliance with treatments. A watchful eye can aid in preventing compliance problems, recidivism, dropout, and complications. In particular, adequate dosing and length of trial is necessary. Many American Indian and Alaska Native veterans who suffer from PTSD also drink heavily and providers should be especially cautious of interactions between alcohol and medications.
