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Harpriya A. (Sonya) Bhaga MBBS and Alan D. Schmetzer, MD, member of the American Psychotherapy Association, and Master Practitioner
a number of veterans from Operation Iraqi Freedom / Operation Enduring Freedom (OIF / OEF) are returning home with signs of combat stress-related posttraumatic stress disorder (PTSD). In a recent study, 16.6% of the soldiers met the screening criteria for PTSD. On average, which showed a significant increase in visits due to illness, job loss, the severity of somatic symptoms, and poorer overall health (Hoge et al., 2007). In another study, the youngest age group, 18-24 years, was an increased risk compared with veterans 40 years or older. It was the early diagnosis (median 13 days), and most of them were detected in primary care (Seal et al., 2007).
his return from the war zone, veterans often report intrusive thoughts, flashbacks, increased vigilance, prevention of social, hyper, and nightmares. The treatment consists in the integration of mental health, primary care, physical medicine, attention to substance abuse, and professional services. Mental health involves an initial screening portion of the combat veteran PTSD and other mental illnesses, followed by a full evaluation. Both pharmacotherapy and psychotherapy (individual, couple and group) are available for treatment.
From a pharmacological perspective, several studies have found the traditional antidepressants effective in PTSD. Selective inhibitors of serotonin reuptake (SSRIs) such as sertraline (Zoloft ®), paroxetine (Paxil ®) and fluoxetine (Prozac ®) have been studied extensively for PTSD, and sertraline and paroxetine have been approved by the Food and Drug Administration for PTSD. SSRIs have been found to be effective, both short-term trials and long-term maintenance therapy for prevention of relapse (Asnis et al., 2004). However, previous studies have focused primarily on PTSD secondary to interpersonal trauma in a civilian setting. In a multicenter study, venlafaxine extended release (Effexor XR ®), a serotonin reuptake inhibitor of norepinephrine, was found to improve and avoid re-experiencing symptoms of PTSD, but not hyper. The drug was well tolerated and effective in the short term and continuation treatment of PTSD (Davidson et al., 2006). In a small study, Mirtazapine (Remeron) was effective in the short term and continuation treatment of combat stress-related PTSD, with no serious side effects (Kim et al., 2005). In addition, the sedation of Mirtazapine may even prove beneficial in improving sleep in PTSD. In a randomized trial comparing phenelzine (a monoamine oxidase inhibitor) and imipramine (a tricyclic antidepressant), significantly reduced both the combat-related stress symptoms of PTSD (Kosten et al., 1991). Benzodiazepines are used for panic attacks post-traumatic stress or anxiety states. They provide temporary relief, but runs the risk of tolerance and addiction.
Veterans with PTSD is so difficult to fall asleep and maintain sleep because of vivid nightmares and hyper-linked to the fight. Significant others often report that patients with sleep screaming and may even wake up drenched in sweat. Prasozin clonidine and the decline of both the central nervous system noradrenergic activity. They have proven effective in reducing symptoms and improving sleep hyperactive (Boehnlein, 2007). Other drugs used for sleep are benzodiazepines class of drugs such as temazepam, not benzodiazepines such as zolpidem (Ambien ™) and ezopiclone (Lunesta ™). However, caution should be exercised in relation to habit formation potential of these drugs (Bhaga and Schmetzer, 2006).
The presence of psychotic symptoms in PTSD may further complicate the clinical picture. In one study, 20% of the 91 men with the fight against stress-related PTSD were found to suffer from delusions and hallucinations, hyper and was positively associated with the onset of psychotic symptoms (Kastela, 2007). In a small study, the increase of SSRIs with olanzapine (Zyprexa), an atypical antipsychotic, was effective in treating SSRI-resistant combat-related PTSD symptoms, especially sleep (Stein, 2002). In another study, monotherapy with typical or atypical antipsychotics, reducing both PTSD and psychotic symptoms and antipsychotic medication appears to offer another approach to the treatment of psychosis in the fight against the subtype of posttraumatic stress disorder related to the resistance to previous antidepressant therapy (Pivac 2006).
In general, pharmacotherapy PTSD affects several drugs based on our experience with PTSD in general, but well-designed studies are needed to establish treatment guidelines for specific combat-related stressors PTSD. References
Asnis, GM, Kohn, AR, Henderson, M., & Brown, NL (2004). SSRIs and non-SSRIs in posttraumatic stress disorder: an update of the recommendations. Drugs, 64 (4), 383-404.
Bhaga, HA, and Schmetzer, AD (2006). The newer sleeping. Annals of the American Psychotherapy Association, 9 (2), 25-26.
Boehnlein, JK, & Kinzie, JD (2007). Pharmacologic reduction of activity of the CNS noradrenergic systems in PTSD: the case of clonidine and prazosin. Journal of Psychiatric Practice, 13 (2), 72-78.
Davidson, J., Baldwin D., Stein DJ, Kuper, E., Benattia, I. Ahmed, S., et al. (2006). Treatment of posttraumatic stress disorder with venlafaxine extended release: a 6-month randomized controlled trial. Archives of General Psychiatry, 63 (10), 1158-1165.
Hoge, CW, Terhakopian, A., Castro CA, Messer, SC, & Engel, CC (2007). Association of posttraumatic stress disorder with somatic symptoms, the health care visits, and absenteeism among Iraq war veterans. American Journal of Psychiatry, 164 (1), 150-153.
Kastela, A., Franciskovi? T., Moro, L., Roncevic-Grzeta, I., Grkovic, J., Jurca, V., et al. (2007). Psychotic symptoms in combat-related PTSD. Military Medicine, 172 (3), 273-277.
Kim, W., Pae, CU, Chae JH, Jun, TY, & Bahk, WM (2005). Efficacy of Mirtazapine in the treatment of post traumatic stress disorder: A continuation of 24 weeks of therapy. Psychiatry and Clinical Neurosciences, 59 (6), 743-747.
Kosten, TR, Frank JB, Dan, E., McDougle, CJ, & Giller, EL, Jr. (1991). Pharmacotherapy for posttraumatic stress disorder using phenelzine or imipramine. Journal of Nervous and Mental Disease, 179 (6), 366-370.
Martényi, F. (2005). [Three paradigms in the treatment of post traumatic stress disorder]. Neuropsychopharmacol Hung, 7 (1), 11-21.
Pivac, N., and Kozari? Kovaci? D. (2006). Drug therapy in the fight against the resistance-related posttraumatic stress disorder with psychotic features. Croatian Medical Journal, 47 (3), 440-451.
Seal KH, Bertenthal, D., Miner, CR, Sen, S., & Marmar, C. (2007). Bringing the war back home: mental disorders among 103,788 U.S. veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. Archives of Internal Medicine, 167 (5), 476-482.
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