SSRIs for Veterans with Posttraumatic Stress Disorder To the Editor: I was impressed that the authors of the board review questions in family medicine (May 2006) chose to include a large number of psychiatry questions. I was, however, disappointed that their research led them to believe that a selective serotonin reuptake inhibitor (SSRI) would be least likely to help a veteran with posttraumatic stress disorder (PTSD). Current recommendations for combat-related PTSD encourage the use of psychotherapy and medications.1 Among medications used within the United States and abroad for veterans with PTSD, the SSRIs are not only considered first-line treatment but are the only category of medications recommended by the American Psychiatric Association (APA) “with substantial clinical confidence.” According to the APA’s 2004 practice guidelines, either clonidine or prazosin would have been the agent least likely to help the veteran in question.2 Recent research, however, has suggested that prazosin may indeed be effective in the treatment of both nightmares and cued physiologic distress in individuals with PTSD.3-5
Wendi M. Waits, MD Psychiatrist, US Army Tallil, Iraq
1. Lineberry TW, Ramaswamy S, Bostwick JM, et al. Traumatized troops: how to treat combat-related post-traumatic stress disorder. Current Psychiatry. 2006; 5(5):39-52.
2. Ursano RJ, Bell C, Eth S, et al, for the Work Group on ASD and PTSD and the Steering Committee on Practice Guidelines. Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Am J Psychiatry. 2004; 161(suppl 11): 3-31.
3. Raskind MA, Thompson C, Petrie EC, et al. Prazosin reduces nightmares in combat veterans with posttraumatic stress disorder. J Clin Psychiatry. 2002; 63:565-568.
4. Daly CM, Doyle ME, Radkind M, et al. Clinical case series: the use of prazosin for combat-related recurrent nightmares among Operation Iraqi Freedom combat veterans. Mil Med. 2005;170:513-515.
5. Taylor FB, Lowe K, Thompson C, et al. Daytime prazosin reduces psychological distress to trauma-specific cues in civilian trauma posttraumatic stress disorder. Biol Psychiatry. 2006; 59:577-581.
Disclaimer The views expressed in this letter are those of the author and do not reflect the official policy or position of the US Department of the Army, the US Department of Defense, the US government, or the units and institutions with which the author is affiliated.
The author replies: PTSD, especially in combat veterans, can be a severe, chronic illness that is often refractory to standard pharmacologic interventions.1 Dr Waits is correct in noting that SSRIs—sertraline and paroxetine in particular—are the first-line agents for PTSD. They reduce symptoms in all 3 clusters of symptoms associated with PTSD (hyperarousal, avoidance, and flashbacks) and have relatively few side effects. These agents have been studied extensively but have been found to be more effective in females or in civilians with trauma-induced PTSD than in combat-related PTSD.2 Some studies did not show a greater response with SSRIs than with placebo in male combat veterans with severe, chronic PTSD.3 Although some small, open-label studies have shown fluvoxamine to be effective in improving sleep disturbances in combat veterans, other studies have shown a high attrition rate with use of fluvoxamine.4 In a head-to-head study comparing amitriptyline hydrochloride with fluoxetine hydrochloride, fluoxetine was more effective for the treatment of acute PTSD symptoms, such as flashbacks and nightmares.5 Prazosin has been shown to be highly beneficial for combat-related nightmares,6 and clonidine has been successful in reducing nightmares, hypervigilance, and startle reactions.7 Because of proven efficacy, particularly in civilian-induced PTSD, SSRIs continue to be studied in this context. Recently, fluoxetine was shown useful for both acute PTSD and for relapse prevention of PTSD in combat veterans as compared with placebo.8 Ongoing studies are investigating medical management of this condition, including a federally funded randomized, double-blind, placebo-controlled, parallel assignment efficacy trial of prazosin versus paroxetine in combat stress symptoms in Operation Iraqi Freedom/Operation Enduring Freedom returnees. Physicians need to remember that PTSD is a complex problem, which may not always be responsive to first-line agents. Other agents must therefore be considered, depending on the symptoms.
Samuel Sandowski, MD South Nassau Communities Oceanside, NY
1. Stein MB, Kline NA, Matloff JL. Adjunctive olanzapine for SSRI-resistant combat-related PTSD: a double-blind, placebo-controlled study. Am J Psychiatry. 2002; 159:1777-1779.
2. Davis LL, English BA, Ambrose SM, et al. Pharmacotherapy for post-traumatic stress disorder: a comprehensive review. Expert Opin Pharmacother. 2001; 2:1583-1595.
3. Hertzberg MA, Feldman ME, Beckham JC, et al. Lack of efficacy for fluoxetine in PTSD: a placebo controlled trial in combat veterans. Ann Clin Psychiatry. 2000; 12:101-105.
4. Escalona R, Canive JM, Calais LA, et al. Fluvoxamine treatment in veterans with combat-related post-traumatic stress disorder. Depress Anxiety. 2002; 15:29-33.
5. Cavaljuga S, Licanin I, Mulabegovic N, et al. Therapeutic effects of two antidepressant agents in the treatment of posttraumatic stress disorder (PTSD). Bosn J Basic Med Sci. 2003; 3(2): 12-16.
6. Daly CM, Doyle ME, Radkind M, et al. Clinical case series: the use of prazosin for combat-related recurrent nightmares among Operation Iraqi Freedom combat veterans. Mil Med. 2005; 170:513-515.
7. Lange JT, Lange CL, Cabaltica RB. Primary care treatment of post-traumatic stress disorder. Am Fam Physician. 2000; 62: 1035-1040, 1046.
8. Martenyi F, Soldatenkova V. Fluoxetine in the acute treatment and relapse prevention of combat-related post-traumatic stress disorder: analysis of the veteran group of a placebo-controlled, randomized clinical trial. Eur Neuropsychopharmacol. 2006; 16:340-349.
Mild Acute Mountain Sickness To the Editor: In the board review questions in emergency medicine section (May 2006), the answer to question 9 is wrong. The question involves the treatment of acute mountain sickness, and the answer states that the only therapy that is not indicated for this condition is immediate descent (option B).
This is a classic board review question, and the first therapy recommended is always “immediate descent.” The other therapies listed are appropriate for high-altitude pulmonary edema and high-altitude cerebral edema; the patient had no symptoms for either of these. Even in such cases, the initial treatment is always immediate descent.
Erik Olson, MD Central Kentucky Emergency Services Louisville, Ky
The author replies: I would like to thank Dr Olson for his comments. This board review question illustrates a case of mild acute mountain sickness (AMS), with an emphasis on “mild.” Immediate descent is not required in mild AMS, because the symptoms may resolve over time, assuming that the patient does not ascend further.1 In addition, ibuprofen, acetazolamide, and dexamethasone have all been shown to decrease the severity and duration of symptoms associated with AMS.2 Descent becomes mandatory only when symptoms are not improving, or if the patient exhibits signs of high-altitude cerebral edema.1 Reasonable treatment for this patient would include rest at the present altitude; analgesia, acetazolamide, or dexamathasone; close neurologic monitoring; and descent if the patient deteriorates.
Kurt Weber, MD Department of Emergency Medicine Orlando Regional Medical Center Orlando, Fla
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