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PTSD Meds For Based On Military

Posted by Phillipa on September 4, 2009, at 21:15:35

Sending this to my Son who works in DC for the Veterans Through DAV. Thought might also interest others as also alchohol involved in study. Phillipa

From Medscape Medical News
Naltrexone, Disulfiram Decrease Alcohol Dependence Symptoms in Veterans With PTSD
Deborah Brauser



Read more September 4, 2009 Treatment with disulfiram and/or naltrexone decreases symptoms of alcohol dependence (AD) in psychiatrically stable veterans with posttraumatic stress disorder (PTSD), and desipramine may be as effective as paroxetine in lowering the symptoms of both PTSD and AD in more acute patients, according to 2 new trials. The findings were reported in a poster presentation at the Military Health Research Forum 2009 in Kansas City, Missouri.

In the first study, "Veterans with PTSD and AD simultaneously had better alcohol outcomes when treated with the opiod antagonist naltrexone, disulfiram, or a combination of both than they did on placebo," reported lead investigator Ismene Petrakis, MD, professor of psychiatry at Yale University School of Medicine and acting chief of psychiatry at the Veterans Affairs (VA) Connecticut Health Care System in West Haven. "We concluded that both naltrexone and disulfiram can be used safely and effectively in individuals with both comorbidities."

In the second study, which just concluded, Dr. Petrakis said preliminary results suggest that a noradrenergic reuptake inhibitor may be as effective as a serotonin reuptake inhibitor in treating symptoms of both PTSD and alcohol consumption.

More Serious Symptoms

The combination of PTSD and AD is a serious clinical condition for veterans. Those who suffer from both illnesses concurrently generally experience more psychosocial and medical problems, more frequent relapses, and more serious symptoms than patients without comorbid disorders, reported Dr. Petrakis.

Research has shown that medications have been effective in treating alcoholism, clinical depression, and (in some cases) some symptoms of PTSD.

However, treatments that have been developed for either PTSD or AD really just target 1 disorder, said Dr. Petrakis. "So the focus of our research has been to try and develop treatments that are really effective for people who have both."

In the first study, the investigators originally enrolled 254 veterans with alcoholism (or AD) and another psychiatric disorder, such as depression, from 3 VA sites. They sought to evaluate whether naltrexone and disulfiram (the 2 medications approved to treat alcoholism at the time) were effective in this patient population. The investigators then decided to focus on just the subgroup of patients who had PTSD.

"Being the VA, we were especially interested in [PTSD], which is an important VA issue," explained Dr. Petrakis.

Her team evaluated the 93 alcohol-dependent patients (mean age, 46.3 years; 98% men; 78% white) who were diagnosed with comorbid PTSD and were psychiatrically stable to measure outcomes such as alcohol use and cravings and adverse effects of the study medications.

A total of 81 patients were randomized and split into 2 groups. The first received either a 50 mg/day dose of naltrexone (n = 25) or matching placebo (n = 15), and the second group received either the same naltrexone dosage plus a 250 mg/day dose of disulfiram (n = 18) or the disulfiram plus placebo (n = 23). All patient groups received treatment for 12 weeks.

Fewer Cravings, Less Relapse

At the end of the study, results showed that the patients treated with naltrexone, disulfiram, or the combination had better overall alcohol outcome rates, including less cravings and less relapse, than those treated with placebo.

In addition, no serious adverse events were reported in any of the groups.

"I have to say we were a little surprised to find that those who had a diagnosis of PTSD did particularly well on medication to treat alcoholism," said Dr. Petrakis. "I don't think we expected to see that necessarily.

"Clinically, for patients who have both disorders, their AD treatment often depends on where they're seen. If it's in an alcohol or substance-abuse specialty clinic, they may be more likely to get medications that treat alcoholism because that's how the clinicians are thinking. But if they go to a PTSD specialty treatment clinic, then those may be the medications given," Dr. Petrakis added.

These findings, she said, suggest that medications to treat alcoholism may also be the most effective for this patient population.

The Next Step

In the second trial, investigators compared 2 antidepressants to evaluate their effectiveness in reducing the symptoms of PTSD as well as AD in veterans with acute cases of both disorders.

"In the first study we just used medications to treat alcoholism, and the patients were often on other [medications] to treat their PTSD symptoms," said Dr. Petrakis. In this study, which Dr. Petrakis calls "the next step," they recruited only individuals with AD and PTSD and no other disorders to treat both comorbidities right from the start. "So this study was aimed at being a little more comprehensive in the treatment," Dr. Petrakis added.

A total of 69 patients (mean age, 48 years; 94% men) from 2 VA sites were randomized and received either a 40 mg/day dose of paroxetine or a 200 mg/day dose of desipramine. In addition, the 2 groups later received either an additional 50 mg/day dose of naltrexone or a matching placebo.

"One of the study drugs [paroxetine] was a serotonin-type antidepressant, which is commonly used in PTSD, and the other drug was a noradrenergic antidepressant, which affects a different receptor system in the brain," explained Dr. Petrakis. "We wanted to compare them to see whether there were any differences in effectiveness and if the addition of naltrexone would help decrease AD outcomes."

The primary measures included symptoms of PTSD, alcohol consumption, self-reported cravings, and adverse effects.

The preliminary results suggest that both desipramine and paroxetine were evenly matched in decreasing symptoms of PTSD and alcohol consumption and that both were safe.

"As a group, the subjects got better overall," said Dr. Petrakis. "That implies that the noradrenergic medication, which isn't as commonly used in PTSD treatment, is helpful in reducing symptoms, which suggests that there is more than one antidepressant that can be used in this disorder."

Although the data are still being analyzed to determine whether the addition of naltrexone further reduced alcohol consumption, preliminary results show no advantage to the augmentation.

Timely Findings

"Overall, I think the findings of both studies are timely and clinically important as we try to find new treatments for these particular patients," said Dr. Petrakis.

For the future, she advised clinicians who treat PTSD to get a thorough substance abuse history to see whether that may be contributing to the problem. "Similarly, patients who present for alcohol problems often have had traumatic events in their lives, and a high number will have PTSD. If you don't know what you're treating, it's hard to be effective.

"There are treatments now that are effective in treating both disorders. So clinicians should give hope to their patients that there are things that really can help them," concluded Dr. Petrakis.

In a new study that just launched, the research group is now examining the alpha-1 adrenergic receptor antagonist prazosin in treating both PTSD and AD.

Expanding Treatment Options

"I would say that this is a very important area of study, although a lot of work still needs to be done," said Barbara Terry-Koroma, PhD, the Psychological Health and Traumatic Brain Injury Research Program manager at the Congressionally Directed Medical Research Program in an interview with Medscape Psychiatry. Dr. Terry-Koroma was not involved with these trials.

"If you're able to remove 1 of the challenges that the PTSD patient has, in this case AD, than you've certainly provided a better quality of life for them and for their family members," she said. "From that perspective, the whole concept is great."

Dr. Terry-Koroma added that although patients with both PTSD and AD are often treated with a battery of behavioral interventions, these types of studies open the door for more pharmacologic management.

"That's really the value of this type of research it begins to expand the health care provider's options. Certainly there already exists some pharmacologic interventions, but this type of research holds a potential to expand the field in that area," she said.

"Hopefully, from studies like this one, drugs will be identified which will ultimately impact the standard of care for PTSD patients who have AD and other cormorbidities across the line," Dr. Terry-Koroma concluded.

The studies were funded by the VA-Mental Illness Research Education Clinical Center. Dr. Petrakis and Dr. Terry-Koroma have disclosed no relevant financial relationships.

Military Health Research Forum (MHRF) 2009: Abstract P3-4. Presented September 1

 

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