Posttraumatic Stress Disorder (PTSD) is one of the most common and difficult disorders to treat in veterans. Estimates vary, but experts believe that between 10 and 20 percent of Iraq and Afghanistan veterans struggle with the disorder. Considering that nearly three million men and women have deployed to these countries in support of combat operations, this translates to approximately 300,000 to 600,000 affected individuals.
Challenges With Current Medications
Although talk therapies are effective, many veterans are prescribed medication along with talk therapy or as a solitary treatment. Medication choices are limited, however.
The only medications approved for PTSD by the Food and Drug Administration are paroxetine (Paxil) and sertraline (Zoloft). Unfortunately, these medications provide limited benefits for many veterans. In fact, some studies show that they are minimally or no better than placebo (often referred to as a “sugar pill”).
And then there are the side effects. Sertraline, paroxetine and similar medications cause myriad problems. In addition to gastrointestinal problems like nausea, diarrhea and constipation, typical “PTSD” medications can cause irritability, insomnia and sexual dysfunction. Because of questionable efficacy and tolerability issues, clinicians and researchers are constantly searching for new medications that can help.
The Growing Popularity Of Antipsychotics
The use of antipsychotic medications in the treatment of veterans with PTSD has garnered considerable attention over the past several years. Although the joint PTSD guidelines of the Veterans Administration and Department of Defense do not recommend the use of antipsychotics as a primary treatment for the disorder and warn clinicians about the use of these meds, the reality is that they are often used. This practice is particularly true for treatment resistant cases. It is not uncommon for a clinician to become frustrated, if not outright desperate, when it comes to finding an effective medication for PTSD. In some cases, they turn to antipsychotics.
Are They Effective?
The usefulness of antipsychotics in PTSD is debatable and the results have been mixed. For example, some smaller studies have shown that certain antipsychotics are useful as a supplemental treatment for the disorder. Relatively none exist claiming it is effective as a standalone medication.
However, in contrast to these smaller studies, a relatively large study a few years back with nearly 300 veterans found that the antipsychotic risperidone did no better than placebo. This study changed the prescribing habits of many clinicians. Where previously some were comfortable using these meds, the finding that risperidone was not effective gave them pause.
The Latest Data
To shed more light on whether or not antipsychotics are useful for military-related PTSD, researchers gave 88 Veterans Administration patients either a placebo (sugar pill) or the antipsychotic quetiapine (Seroquel). The participants were followed for three months and evaluated on a variety of outcome measures during that time.
The results were supportive of using the antipsychotic, quetiapine, for PTSD. Over the course of the study, those who got the medication got better compared to those who did not. Specifically, the medication seemed to help most with re-experiencing (thoughts and images of the traumatic experience, nightmares) and hyperarousal (being on alert, jittery, being easily startled) symptoms.
An unexpected, but welcomed finding is that some veterans saw improvement in their depression. This result is important as depression and PTSD often go hand-in-hand. In fact, the Diagnostic and Statistical Manual of Mental Disorders added a depressive component to the diagnostic criteria of PTSD in its latest edition.
Still A Bit Early
Although this study seems promising, until more research is done, I think antipsychotic medications should be used cautiously and only when other medications and talk therapies have failed. These medications can cause significant side effects to include weight gain and increases in blood sugar and cholesterol. These “metabolic” problems can lead to increased risk of Type II diabetes, hypertension, stroke, and cardiovascular disease. Although very small, there is also a risk of the movement disorder tardive dyskinesia and other related disorders.
In my opinion, cognitive and exposure therapies should continue to be the first-line treatments for military-related PTSD. Even with the concern about long-term efficacy and tolerability, they present less serious risks than antipsychotic medications. And if medication is needed, those approved for PTSD and with substantial scientific support should come next.
*This article is based on a previous column written by Dr. Moore and published in Military Times.