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MEDICATIONS FOR SYMPTOMS OF PTSD JAMES ROSE PA-C • This is your standard bullet/content slide VETERANS HEALTH ADMINISTRATION 0 PTSD Medications • • • • • • Not curative …(yet) I draw the analogy of treating HTN or Diabetes: reduce downstream effects Require significant education (placebo effect) Generally, the worse the symptoms, the better the response (and less side effect problems) Directly address stigma: “We tend to disparage what we do not understand” Motivation is 90% of the battle VETERANS HEALTH ADMINISTRATION This slide is meant for a full page graphic or image only. No text or title. 2 WHAT YOU GET WHEN YOU GIVE SILLY STRING TO A BIOGENETICIST VETERANS HEALTH ADMINISTRATION 3 Norepinephrine and PTSD • • Acute Response – – – – – Flight response Fear Sympathetic activation Conditioning Consolidating memory VETERANS HEALTH ADMINISTRATION Symptom Sequelae – – – – Hypervigilance Autonomic arousal Fear Exaggerated startle response – Flashbacks – Intrusive memories Serotonin and PTSD • Acute Response • Symptom Sequelae – Fight response – Aggression – Aggressive retaliation – Violence – Self defense – Suicide attempts – Rage – Impulsivity – Attenuation of fear – Depression – Anxiety/panic VETERANS HEALTH ADMINISTRATION Monoamines and Amino Acid Neurotransmitters – Monoamines are neurotransmitters that modulate fast-acting amino acid neurotransmitters, gamma-aminobutyric acid (GABA), and glutamate – GABA and glutamate are the major fast-acting inhibitory and excitatory neurotransmitters, respectively, in the CNS. VETERANS HEALTH ADMINISTRATION GABA and PTSD • Acute Response • Symptom Sequelae – Anxiolytic – Anxiety – Neuromodulation – Reexperiencing (kindling) – Cognitive function – Impulsivity – Hormonal modulation – Hyperarousal – Decreased release of CRF VETERANS HEALTH ADMINISTRATION Sensory Information About Harmful Stimuli Auditory cortex and auditory thalamus Lateral nucleus of amygdala ++ Glutamate -- GABA Central nucleus of amygdala + + VETERANS HEALTH ADMINISTRATION ++ 5-HT DR Hypothalamus ++CORTISOL CRF Pituitary Adrenal ACTH PTSD Meds • SSRIs – – – – – – – Citalopram, Fluoxetine, Escitalopram, Sertraline Only class with FDA approval Impacts B,C,D,E criteria Safe “Broad Spectrum” (Depression, Anxiety) Side effects: Libido, Weight (either way) Improves Serotonin activity VETERANS HEALTH ADMINISTRATION Medications • SNRIs – – – – – – Venlafaxine, Desvenlafaxine, Duloxetine Affect Serotonin and Norepinepherine receptors Evidence for efficacy in PTSD similar to SSRIs Theoretically more “energizing” May be helpful in chronic pain (Duloxetine) Monitor blood pressure/ slow titrate up and down VETERANS HEALTH ADMINISTRATION Medications • Adrenergic Inhibitors (Blood Pressure Meds) – – – – – – – (Prazocin, Propranolol, Clonidine) Reduce autonomic response to memories Evidence of benefit in traumatic memories Perhaps will affect memory implantation (“morning after” pill) Not a “Psych” drug Side effects: Orthostasis, sexual May inhibit extinction (if engaged in PE/CPT) VETERANS HEALTH ADMINISTRATION Medications • Mood Stabilizers (AEDs) – – – – – – – – Valproic acid, Carbamazepine, Topiramate, Lamotrigine. Originally marketed for Seizure Disorder (AED) Enhance GABA (negative feedback) activity Little direct evidence for efficacy in PTSD I use for anger/irritability (with SSRI) Helpful in TBI (emotional lability) Side effects:Weight, sedation, tremor, metabolic, labs Potential to affect retention/deployment VETERANS HEALTH ADMINISTRATION Medications • Atypical Antipsychotics – – – – – – – Olanzepine, Quetiapine, Risperidone, Aripiprazole Act on Serotonin and Dopamine receptors Indicated for Schizophrenia, Bipolar Disorder, Depression (Aripiprazole only) Helpful for nightmares/mood (secondary indication) Significant side effects (metabolic, weight, labs) Expensive Potential effect on retention/deployment VETERANS HEALTH ADMINISTRATION Medications • “Other” Meds I use….. – – – – – – Trazodone (sleep) Doxepin/Amitriptyline (sleep/depression) Mirtazepine (sleep/poor appetite/depression) Ambien (sleep) Benzodiazepines (sleep/panic “PRN”) (May inhibit extinction) Bupropion (counter sexual side effects of SSRIs) VETERANS HEALTH ADMINISTRATION