IRAQ WAR CLINICIAN GUIDE

Iraq War Clinician Guide 170 Appendix H
Accordingly, the acceptability of
phamiacotltcrapy and oltemative treatninit
modalities to the patient is onecrierion
on wliehto bas decisiotis to prescribe
medicatio~t. A~totlter might be the
presence of significantly severe comorbid
psycltiatric coliditions that are
respo~lsiveto medications that also treat
PTSD. Medication ~niight alsobe favored
as a tirst litte choice when the i~ilensity
of PTSD andlor cotnohid depressio~tor
aliniev symptonE are interferingsith a
~.
patient's ability to engagein, or tolerate.
a psycLotlienpzutic i~ltenmtion. Medicntio~iueatment
m y also be indicated
witen there is no access to contpetenr
PTSD-focused psychotherapy and when
syniptons persist beyond a reasonable
course of neatlnent.
InWhat Medications Can We
Have Confidence?
At presetit two medicalions. the
selective serotonin raptake inhibitors
(SSllls) sznraline and poxerine, have
received approral hmtlte 1JS Food and
Drug Administration as i~tdicated treatments
for PTSD. Favorable results with
ollter SSRls such ns fluoxetioe,fluvoxanline,
and citalopram have also been
reported. Inaddilionrotheirbroad-spectninl
capacity to reduce tlte se\,erity of
all three PTSDsymptomcluste~.SSKls
Iiave other beneficial properties such as
efficacy against disorders freqite~itly
cians because
of side
and bec,
suppon
C~CGCY
ed. On the odter
hand, randomized L-
clinical trials with newer
alltidepressants (eg, nefwdone, venlafarine,
and bupropion) are currently
in progress and there arc repons of positiw
red& from open label tiials \\:ill1
these agenls.'
Otherclases of niedicationshave nut
been tested as definitively as the aforemrotioned
antidepressa~tts, although
tlicre arz both theoretical and empirical
resons to cossidera~tti-adrenergicage~tts
(eg, clonidise, prapranolol, guanfncine.
md pnzosi~l),aniiconwlsantshnwdstnbiliren
(eg, carbmazepitte, valproate,
lamotrigine, and gnbapntin), and nt)pical
antipsychotic agents (eg, rispzridone
and~lanzapine).~
It must be ernpttasized that ben~odi-
nzepines do not appear to 1ta~
specific
efficacy for PTSD symptoms? altltough
they can intprovc sleep and improw
generalized anxiety.
Research on lnedicarion for cltildren
\\ltlt PTSD is quite limited (for review
see Donnelley and Amaya-Jackson').
Children presznt unique challenges in
that their PTSD may be coiltorbid with
atknlion-deficitl~yperactivity disorder,
schoolpltobia, illicit drug use. and other
cxtentalizing,disn~ptive,oroppositional
defiantdisorders. Often, it is the disrupti\?e
behavior. :tggresivesess.or impolsive
acting our is cliildreli !\,it11 PTSD
that is tlte chief treatniellt target. Helping
cltildre~to gain better self-control
through trealalent of these extemaliziag
behavioral sytuptonv, with stintulants
comorbid ~$,itl~ PTSD (eg, depression,
panic disorder, socialphobia, and obsessir,e-cornpulsiw
disorder),enltnncement
of global function,reduction of associated
syntptolns (eg, soicida1ity.aggrcssivity,
impulsi\*ily), and a lous profile cf
side effecls. Selective semtonin rettptake
inhibitorsare clearly first line treatment
~O~PTSD.~,'
Older a~aidegrzssa~tts (eg. tricyclic (destroa~tipltetanti~ie or
antidepresm~tts[TCAs] and nionoan~ine
oxidasc iohibitors [MAOIs]) have also
proven to be effective treartneitts for
PTSD but are lcss preferred by clini-
methylplteitidate),
alpha-2 agonisrs (clonidine
or gitanfacinc), or tltc antidepress:tnr
bupropion, is often n precursor to tlte
trr.atmeltl of their PTSD [xr se. As dis-
t
,*,:'
(
'< ''
cussed below, children nlerir special
consideration in the pharnncologic
nuna age ti tent of PTSD and oflen require
the use of nlultiplr medicatio~ts.
DO Medications Have a Role In
Alleviating Acute Traumatic
Distress and Preventing PTSD7
We are at a preliminary stage ill
research on acute phmucotlterapy as
an early isterventionfor acutely traumatized
individuals.wilh veiy little scientific
information to guide us.
It is reasonable to postt~lale that
aetidepresmlit mdicmions, for mltielt
rhsre is demonstratedeficacy in PTSD
(se bclorr), could be useful in an early
stage of the disorder. The only published
data concents the treatnient of
children !vith acute stress disorder
related to bum illjuries in !\,ltich 83%of
the I? cues trented with imipnmine
responded favonbly, in comparison to
only 38% of the 13 cnses \\,lto received
clilonl hyd~ate.~
Althoughone might eapct that benzodiazepines
\voitld anieliorate acute
rraitlnatic distress, this w not drmon-
straedin the published co~~trolled st~~dy
of this question wlticlt involved alprazolam
and clonazepani.'
Basd on tindings liinliinp noradrenergic
activiry to fe~r-c~tlianced ox~nory.
Pilntan attd colleagues condt~cted a
placelw-contmlled trial of propn~lolol
administered lo emergency depannrnt
patients* Pmpranolol inlen~ention ex-
DEPARTMENT OF VETERANS AFFAIRS
NATIONAL CENTER FOR PTSD