Letters to the Editor
Treatment Of Posttraumatic Stress Disorder With Tiagabine
Dear Editor:
Posttraumatic stress disorder (PTSD) can be a debilitating condition with
impairment as bad as, or worse than, that caused by other psychiatric illnesses
(1). Symptomatology includes a triad of symptoms from 3 clusters: persistent
reexperiencing of the trauma (for example, intrusive and distressing recollections,
nightmares, and dissociative flashbacks); persistent avoidance of stimuli
associated with the trauma; and persistent symptoms of increased autonomic
arousal (2). Because the symptoms of PTSD can vary across the symptom clusters,
medications from different classes are needed to treat patients. Based
on the hypothesis that kindling of the limbic nuclei occurs following the
trauma (3–5), anticonvulsants such as carbamezapine and valproate were
used to treat PTSD as far back as the mid-1980s to the early 1990s, (6,7).
Newer anticonvulsants such as lamotrigene, gabapentin, and topiramate have
also been used (8–10).
I present the case of a patient diagnosed with PTSD and major depressive
disorder (MDD) who had taken multiple medications in the past and received
benefit from tiagabine. To date, there are no reports in the literature
describing the use of tiagabine to treat PTSD.
Case Report
Mr A is a 43-year-old man with a history of PTSD and MDD. His illness caused
significant impairment over the years, and he had been treated with the
following agents: sertraline, paroxetine, fluoxetine, buproprion augmented
with lithium, trazadone, nefazodone, gabapentin, and topiramate.
Upon consultation, Mr A agreed to a trial of venlafaxine extended release
(XR), started at 37.5 mg daily and titrated to 225 mg daily over 3 weeks.
After 1 month, he noted an improvement in his depressive symptoms, but
he was still experiencing intrusive thoughts, nightmares, and hypervigilance.
He agreed to a trial of tiagabine, initiated at 2 mg daily. His dosage
was increased by weekly 2 mg increments to 8 mg daily, at which level he
began to notice an improvement in his intrusive thoughts and nightmares—even
through the traumatic events of September 11, 2001, which provided a flood
of external cues. He occasionally takes zolpidem tartrate 10 mg for insomnia,
but over the past 6 months he has improved significantly, to the point
of returning to work full-time. He cannot recall feeling this stable during
the last 10 years.
Tiagabine is FDA-approved as an adjunct anticonvulsant for the treatment
of partial seizures (11). It is thought to exert its action by inhibiting
GABA from the synaptic cleft (12,13). Tiagabine has also been shown to
have antikindling potency (14), making it a potential candidate in treating
PTSD. This patient’s improvement might have been due to a combination of
agents, but the addition of tiagabine clearly led to a reduction in the
reexperiencing symptoms. Further controlled studies are needed to investigate
the efficacy of tiagabine in treating PTSD.
References
1. Tucker P, Zaninelli R, Ye-hunda R, Ruggiero L, Dillingham K, Pitts CD,
and others. Paroxetine in the treatment of chronic posttraumatic stress
disorder results of a placebo controlled flexible dosage trial. J Clin
Psychiatry 2001,62:11:860–8.
2. American Psychiatric Association. Diagnostic and statistical manual
of mental disorders. 4th ed. Washington (DC): American Psychiatric Association;
1994.
3. Post RM, Kopanda RT. Cocaine, kindling and psychoses. Am J Psychiatry
1976;133:627–34.
4. Post RM, Rubinow DR, Ballenger JC. Conditioning and sensitization in
the longitudinal course of affective illness. Br J Psychiatry 1986;149:191–201.
5. Post RN, Weiss SN, Smith M, McCann LH, Li H, McCann U. Kindling versus
quenching; implications for the evaluation and treatment of posttraumatic
stress disorder. Ann NY Acad Sci 1997;821:285–95.
6. Lipper S, Davidson JR, Grady TA, Edinger JD, Hammet ER, Mahorne SL,
and others. Preliminary study of carbamezpine in posttraumatic stress disorder.
Psychosomatics 1986;27:849–54.
7. Fesler FA. Valproate in combat-related posttraumatic stress disorder,
J Clin Psychiatry 1991;52:361–4.
8. Hertzberg MA, Butterfield MI, Feldman ME, Beckham JC, Sutherland SM,
Connor KM, and others. A preliminary study of lamotrigine for the treatment
of posttraumatic stress disorder. Biol Psychiatry 1999;5:1226–9.
9. Hammer MB, Brodrick PS, Labbate LA. Gabapentin in PTSD: a retrospective
clinical series of adjunctive-therapy. Ann Clin Psychiatry 2001;13:141–6.
10. Berlant J, Van Kammen DP. Open label topiramate as primary or adjunctive
therapy in chronic civilian posttraumatic stress disorder: a preliminary
report. J Clin Psychiatry 2002;63:1:15–20.
11. Tiagabine for epilepsy. The Medical Letter 1997;20:21–3.
12. Suzdak PD, Jansen JA. A review of the preclinical pharmacology of tiagabine:
a potent and selective anticonvulsant GABA uptake inhibitor. Epilepsia
1995;36:612–26.
13. Leach JP, Sills GJ, Majid A, Butler E, Carswell A, Thompson CG, and
others. Effects of tiagabine and vigabatrin on GABA uptake into primary
cultures of rat cortical astrocytes. Seizure 1996;5:229–34.
14. Dalby NO, Nielsen EB. Tiagabine exerts an anti-epileptogenic effect
in amygdala kindling epileptogenic in the rat. Neurosci Lett 1997;229:135–7.
Timothy Berigan, DDS, MD
Tucson, Arizona
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