sara haack, md, mph university of washingtonictp.uw.edu/sites/default/files/ptsd_medication...feb...
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UW PACC Psychiatry and Addictions Case Conference UW Medicine | Psychiatry and Behavioral Sciences
PTSD: MEDICATION TREATMENT
SARA HAACK, MD, MPH UNIVERSITY OF WASHINGTON
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GENERAL DISCLOSURES
The University of Washington School of Medicine also gratefully acknowledges receipt of educational grant support for this activity from the Washington State Legislature through the Safety-Net Hospital Assessment, working to
expand access to psychiatric services throughout Washington State.
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SPEAKER DISCLOSURES
There are no conflicts of interest to disclose.
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OBJECTIVES
1. Review epidemiology 2. Current medications 3. Novel medications
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WHY THIS IS IMPORTANT
• Trauma is common – 39-90% of American adults
• PTSD is common – 7-12% lifetime prevalence
• Common in Primary Care – 6-25% of patients in primary care clinics have
PTSD
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DSM-5 STRESSOR CRITERION
Exposure to actual or threatened death, serious injury, or sexual violence: Directly Witnessed in person Learning the event(s) occurred to
close friend or family member. Actual or threatened death - event must have been violent or accidental.
Repeated or extreme exposure to aversive details of traumatic event
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PTSD
Intrusions (1)
Avoidance (1)
Arousal (2)
Cognitions and mood (2)
PTS D
ost raumatic tress isorder
•Flashbacks •Distressing involuntary memories •Nightmares •Physiological reactivity •Psychological distress at reminders
•Thoughts, feelings, & conversations •Activities/Places/People
•Sleep difficulties •Hypervigilance •Irritabile/aggressive behavior •Self-destructive/reckless •Startle •Concentration
•Amnesia •Negative beliefs about oneself or the world •Distorted blame of self or others •Negative trauma-related emotions •Loss of interest •Emotional detachment •Constricted affect
DSM V
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WHAT ARE WE LOOKING AT?
Watts et. al. 2013
0.48
1.26
0
0.2
0.4
0.6
0.8
1
1.2
1.4Ef
fect
Size
(g)
PTSD Treatment Effect
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COMPARING THERAPY AND MEDS
Watts et. al. 2013
0.48
1.26
0
0.2
0.4
0.6
0.8
1
1.2
1.4
SSRIs/ SNRIs CBT
Effe
ct S
ize (g
) PTSD Treatment Effect
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GUIDELINES
APA VA/ DOD ISTSS WHO NICE Uptodate
Therapy and meds both 1st line tx
Yes Yes Yes TF-CBT> meds
TF-CBT> meds TF-CBT> meds
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WHICH MEDICATIONS HAVE THE MOST CONSISTENTLY ROBUST EVIDENCE FOR TREATING PTSD?
1. citalopram, fluoxetine 2. sertraline, venlafaxine 3. Seroquel, mirtazapine 4. cannabis, ketamine
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UW PACC ©2017 University of Washington
WHICH MEDICATIONS HAVE THE MOST CONSISTENTLY ROBUST EVIDENCE FOR TREATING PTSD?
1. citalopram, fluoxetine 2. sertraline, venlafaxine 3. Seroquel, mirtazapine 4. cannabis, ketamine
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GUIDELINES
APA VA/ DOD ISTSS Uptodate
1st line Medications
SSRIs SSRIs, SNRIs Sertraline, paroxetine, fluoxetine, venlafaxine, mirtazapine, nefazodone, prazosin
SSRIs, SNRIs
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SSRIS
• Most studied, recommended • Hit all 3 symptom clusters • Best evidence
– Sertraline, paroxetine, fluoxetine
• Less evidence – Citalopram, escitalopram
• Veterans with combat-related PTSD – Evidence less robust, but still recommended
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SNRIS
• Venlafaxine most studied • ~=sertraline in head-to-head comparison • 1st line
– VA/DOD – ISTSS – Uptodate
• 2nd line – APA (2004)
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HOW TO PRESCRIBE
• Similar to treating MDD – Dosing – Time to effect – Side effects
• Discontinuation – Relapse appears higher than MDD – Davidson et al 2001: relapse 6x as likely with d/c – 1 year- indefinitely
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GUIDELINES
APA VA/ DOD ISTSS Uptodate
Optimal duration of treatment
indefinitely?
Until remission Trial of at least 8-12 weeks, 36 weeks is better
6 m- 1 yr after achieving remission
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True or false: There is evidence that adding medication to psychotherapy results in greater PTSD symptom reduction than therapy alone.
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True or false: Adding medications to trauma focused psychotherapy has been shown to significantly improve overall PTSD symptom reduction versus trauma-focused psychotherapy alone.
False
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OTHER MEDICATIONS
• Some evidence of benefit – TCAs – Mirtazapine – Atypical antipsychotics (adjunct & monotherapy) – Prazosin (global symptoms)
• Little evidence – Anticonvulsants – Bupropion – Propranolol, α2-agonists – Benzodiazepines (Harm)
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INSOMNIA TREATMENT
• Sleep hygiene • Trazodone
– Difficulty with sleep initiation
• Prazosin – Difficulty with nightmares – α1-antagonist – Some evidence of improvement in global
symptoms
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PRAZOSIN DOSING
If a random patient walked into your office and stated, “I’m on prazosin for my PTSD nightmares,” what is the most likely dose of their prazosin?
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IN STUDIES, WHAT IS THE EFFECTIVE DOSE RANGE OF PRAZOSIN?
1. 1-3 mg/ night 2. 3-6 mg/ night 3. 3-15 mg/ night 4. 12-20 mg/ night
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INSOMNIA TREATMENT
• Sleep hygiene • Trazodone
– Difficulty with sleep initiation • Prazosin
– Difficulty with nightmares – α1-antagonist – Some evidence of improvement in global
symptoms – 3-15 mg in studies, VA recommends 6 mg
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ANGER AND IRRITABILITY
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CHILDREN AND ADOLESCENTS
• Trauma-focused psychotherapy is 1st line • Medications can be used in conjunction with
therapy – Severe or prolonged symptoms – Comorbid conditions
• Small body of evidence – SSRI trials non-significant (AACP says “can consider
SSRI treatment”) – α2-agonists, α1-antagonists, SGAs, AEDs supported – Target most impairing symptoms
Source: Keeshin & Strawn 2014
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NOVEL MEDICATIONS
• MDMA • Ketamine • Cannabis
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MDMA-AP
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MDMA-AP
• Clinical response was 83% vs 25%
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KETAMINE
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KETAMINE
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CANNABIS