IRAQ WAR CLINICIAN GUIDE

Iraq War Clinician Guide 171 Appendix H
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lhibited abenefici~ltrei~d, altl~ougltn~ost What Are the Major
md,variably, weight gain and problems
statistical comparisons were nonsignifi- Conslderatims Regarcling with glucoseregulation.
cant. Ho\ve\,er, it is interestingthat early Medicationlolerability for There niiy be \wys in \r,hich spcitic
propr:lrolol treatment significa~~tly PTSD Patients? tolerability issues for psychiatric nudreduced
physiological mctivity lo traa- Medication tolenbilityaffects adhec ications interact with the diag~losis of
ml stimuli among the patiella who ence to pltartnacothenl~y over the PTSD. For example, the sexual side
received his medication shortly afier course of trrdtment. Fs\,onble tolenbil- effectsuf SSRIsmay serve asbarriers to
tl~eiraceem~tmntiatio~t. ity findings from the recent large scale sexual intimacy r\,itllin the contest of
studies that led la Food and Drug PTSD-related en~otiottal iiumbing 2nd
What lsthe Bestway to Monitor Adntinistntion approval for sennline diniinished closeness with others. it is
Clinical Response and to and paroletine are not surprising in in~ponaattllatclinici~nsinfom~patieitts
Determinean Adequate Response view of the tlo\\, well-establislied safsty of these potential sideeffccts and assess
to Treatment? and si(leeffectprolile of the SSRi nled- the status of sexual limctioning on an
Strictly speaking. clinical response ication class. Multicenter studies have ongoing basis. Ailothertolerability conis
best ntonitored with instruments that sliow~lvariablerates af sidccffectssuch cern is the propnsity for SSRls and
llleasurz PTSD synlptom severity. as asthenia, diarrhea, abnornlal ejacula- other antidepressa~~tsto produce activa-
Then is a wide choicc of both self-rat- tion, impotence. Inausca, dry mouth. tion side effects which m ~y esscerbate
ing scales and stractared clinicnl inter- insomnia, and s~mnolence.'~" These PTSD-related arousal symptoms. It is
views that may be used with both side effects arc often !mild and transient therefore prudent to adopt the stmlegy
ndults and children. Selectio11 of a and do tlot typinlly necessitrtediscon- of "starting low and going slow" wit11
given instrument will depend on rlte tinuation of trenttneat. While recent potentially activating nxdications
balance between time a\,ailable, ptient Inqe multi-sire trials Ihavz provided beca~~se they may esacerbaleorproduce
compliance, clinical concerns, and sci-
physinl restlessness ;u~d iasomnia durentific
necessity.
ing the course of tnattnent.
For rigorous research ~TO~OCOIS,rve It is important that the
recommend lnorc labor-intensive struc-
~ ~ f fo ~ define e f realistic
What's the Next Step When the
tured intervielrs such as tllc Clinici:~
Responseto FiW Line Medications
Administend PTSDSnlz (CAPS)' or goals for treatment that sina adequate?
PTSD Symptont Scale Inten~iew (PSSare
both desirable and
It is inilanant at the outset to define
1)'O for adults or CAPS for Children
realistiegoals for treatment that are both
(CAPS-C)" that provide greater com- obtainable. rlesirable and obtainable.'* Altltough
pleresess and acc~~ncy in exchange for
clinical trials read to emphasize rcducthe
estn effon.There are also a tluniber more extensive infortnation011 SSRl tol- tion in PTSD sytuptom severity, it my
of reliable and valid self-nting ques- enbiliry in PTSD patients, clinicians be that the nmnagcnlent of suicidal
tionsaires for nleasuring PTSD symp- should consider tolenbiliry issues for bel~svior,st~bs~ancemisuse,socialisolatom
se\,erity that ha\,e good psycl~omet- other nledications used in PTSD treat- tion, and contorbid psychopatl~ology is
ric prnprtic~."-'~ ment.*For erample,TCAs can produce the first order of business, and improve-
Since PTSD is usually associated anticholinergic effects. orthoslatic ments in global function and qltality of
\vitB conlorbid diagnoses and impaired hypotension, and prolong cardiac con- life the ultimategoal.
fu~lclionnl status, it is sot uncommon 10 ductios. Monoamine oxidasc inhibiron When treatlllent goals are achiewd.
~ilonitor other psy~lt~~~all~~logi~al lnecessitatc dietary nvl medicatiolr incdication should be contin~lcd for a
indices along \r*ith PTSD pr se. It has restricrions to avoid hypnessive crisis. reasonable inrerval (see question
become stateof tile an for lreatnlent ti- Antiadrenergic azents can lo\\,er blood lxlow). \\'hen treatmela has been con>als
for PTSD to define optiolal out- pressure and a~tticonv~tlsaots can pro- pletely inctTecti\,e or lhasproducal intolconlcs
in ternls of redaced severity of duce gastrointestinal and lhcn~atological erable side effects it should be discoeanxiety
and depression in atlrlition to problems. Atypical antipsycl~olic tinaed. A more typical scenario is wlten
PTSD per st, global ioiprovemcnt, and ;tpnts, while frce of the nc~~rologicnl an adcquarcclinicaltrial of anledication
to i~rluden~easure!nctltof general func- toxicity of coni:e~~rion:rl tne~~roleptics. has been partially succcssfill but
tion and qualily of life. still have thc poteiilinl to cause scdarios improw~ixnt falls far short of treatmel~t
PSYCHIPITRICANNALS33:l 1 JANUARY2003 59
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DEPARTMEhT OF VETERANS AFFAIRS
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MTIONAL CEhTER FOR PTSD