engleski

Pharmacotherapy of psychotic posttraumatic stress disorder with antipsychotic drugs

Introduction: Combat-related posttraumatic stress disorder (CR-PTSD) comorbid with psychotic features is a severe type of PTSD and refractory to treatment. Besides antidepressants, other pharmacological strategies (typical or atypical antipsychotics) are required to treat this severe disease. Characteristics of PTSD are insomnia and nightmares, which can be severe in the psychotic PTSD. Methods: 81 male war veterans with CR-PTSD with psychotic symptoms participated in an open labeled 6-weeks study: 27 patients received fluphenazine (5-10 mg/day), 28 olanzapine (5-10 mg/day), and 26 risperidone (2-4 mg/day), as a monotherapy. The diagnosis of current and chronic CR- PTSD with psychotic features was done according to a Structured Clinical Interview (SCID), based on DSM-IV, Clinical Administrated PTSD Scale, and Hamilton Depression Rating Scale (HAMD). All patients were evaluated before and after 6 weeks of treatment using Positive and Negative Syndrome Scale (PANSS) as a primary outcome measure. Secondary outcome measures were Watson's PTSD Scale, Clinical Global Impression Severity Scale (CGI-S), CGI-improvement (CGI-I), Patient Global Impression Improvement Scale (PGI-I), and Drug Induced Extra-Pyramidal Symptoms Scale (DIEPSS). In another open-labeled study 71 war veterans with CR-PTSD and with severe insomnia and nightmares that lasted 4 weeks prior to the beginning of the study were divided into group (N=34) treated with clozapine (50 mg/day) or a group (N=37) treated with one of the sedatives (flurazepam 30 mg or zolpidem 10 mg). After 7 days the scores at the items for insomnia of the HAMD, CGI-S, and PGI-severity (PGI-S) were recorded. Results: Before the treatment age of the patients, duration of combat experience and scores in all measurement instruments did not differ. After 6 weeks, treatment with all 3 antypsychotics decreased significantly and similarly the symptoms/scores listed in PANSS positive and Watson's trauma re-experiencing subscales. Treatment with olanzapine or risperidone induced greater scores reduction in PANSS negative, general psychopathology and supplementary items subscales than flupenazine treatment. Olanzapine or risperidone decreased more the score in Watson’ s avoidance and increased arousal subscales, and scores in CGI-S, CGI-I, and PGI-I, than fluphenazine treatment. Treatment with fluphenazine induced more extrapyramidal side effects than olanzapine or risperidone treatment. The scores in insomnia subscale of HAMD, in CGI-S and PGI-S differed significantly between the clozapine and flurazepam or zolpidem treated groups. Conclusion: Treatment with atypical antipsychotic olanzapine or risperidone for 6 weeks improved significantly most of the PTSD and psychotic symptoms in war veterans with combat-related PTSD. Olanzapine and risperidone showed similarly efficacy and tolerability and induced fewer side effects than fluphenazine. Our data suggest that typical antipsychotic might have beneficial effects in war veterans with treatment-resistant psychotic combat-related PTSD. Clozapine was shown to be efficient in veterans having PTSD as well as in severe sleep disorders and nightmares due to its strong sedative and anxiolytic effect. The clozapine usages could represent a new indication within these disorders that might enable better compliance for psychotherapeutic procedures.

monotherapy; PTSD; war veterans; antipsychotics; sleep disturbances; clozapine

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