Letters to the Editor
Quetiapine Reduces Flashbacks in Chronic Posttraumatic Stress Disorder
Dear Editor:
Chronic posttraumatic stress disorder (PTSD) is a severe and resistant disorder involving complex symptom clusters and comorbid psychiatric diagnoses that often respond poorly to antidepressants (1–3). Combination therapy is almost always necessary, with antidepressants associated with mood stabilizers and, more recently, with atypical antipsychotics, for which there are preliminary efficacy data (3–13).
We treated 5 patients with chronic PTSD: 3 men with PTSD after Bosnia missions some 10 years ago and 2 women, 1 of whom was physically attacked by her husband during their divorce 2 years earlier and 1 of whom was raped by a stranger.
All 5 patients had already been treated with combination therapy using selective serotonin reuptake inhibitors (SSRIs) or venlafaxine plus gabapentin, and 1 patient had been prescribed lamotrigine. This last patient was the only one who presented with psychotic symptoms. All patients had seen an improvement in anxiety, aggressivity, and sleep but were still haunted by flashbacks.
Quetiapine was gradually added to their regimen, up to 150 mg or 200 mg daily, and all 4 patients noted a dramatic reduction in their diurnal flashbacks, without excessive sedation. The flashbacks, which occurred many times daily, became much less frequent, happening only a few times (or fewer) weekly. In all 5 patients, we were able to gradually reduce gabapentin, and in 3 of the 5 patients, we stopped it completely.
Chronic PTSD is now commonly treated with combination therapy. Atypical antipsychotics seem very popular as adjunctive agents in this disabling disorder (4). Still, there are few controlled data to support this practice.
In several case reports, risperidone has shown efficacy in treating flashbacks and other intrusive symptoms that relate to traumatic events, as well as in treating irritable aggression (5–8). One controlled study with risperidone targeted psychotic features in combat veterans with chronic PTSD. In this trial, positive and negative psychotic symptoms improved, compared with the placebo group, but core PTSD symptoms measured by total Clinician Administered PTSD Scale (CAPS) score did not differ from those in the placebo group (9).
Another small controlled trial with olanzapine (15 civilians randomized to monotherapy or placebo), did not differentiate the active drug from the placebo, although an open-label study suggested benefits for olanzapine in 48 veterans with chronic PTSD (10,11). In this last study, however, one-third of subjects failed to complete the trial, largely because of adverse events or noncompliance (11).
A case report found clozapine useful in a treatment-refractory patient with combat-associated PTSD and psychosis (12).
With respect to using quetiapine as an adjunctive treatment, Hamner and others completed an open-label trial in 20 refractory patients with PTSD, and the results are encouraging. The average dosage of quetiapine was 100 mg daily, with a range of 25 mg to 300 mg daily. Patients experienced improved sleep and a reduction in the frequency and intensity of nightmares. The total CAPS rating and the symptom clusters were also significantly improved by quetiapine (13).
In our experience, quetiapine adjunctive treatment has reduced flashbacks in 5 chronically affected PTSD patients— flashbacks being one of the core and most painful symptoms in PTSD.
Use of quetiapine as adjunctive treatment and monotherapy for PTSD needs assessment in well-designed clinical trials with larger samples, because it may represent an interesting treatment option in PTSD.
References
1. Davis LL, English BA, Ambrose SM, and others. Pharmacotherapy for post-traumatic stress disorder: a comprehensive review. Expert Opin Pharmacother 2001;2:1583–95.
2. Khouzam HR, Donelly NJ. Post-traumatic stress disorder. Safe, effective management in the primary care setting. Postgrad Med 2001;110:67–70,77–8.
3. Hamner MB, Labbate LA. Pharmacotherapy of post-traumatic stress disorder. Inter Drug Ther News 2002;37:33–9.
4. Sernyak MJ, Kosten TR, Fontana A, and others. Neuroleptic use in the treatment of post-traumatic stress disorder. Psychiatr Q 2001;72:197–213.
5. Krashin D, Oates EW. Risperidone as an adjunct therapy for post-traumatic stress disorder. Mil Med 1999;164:605–6.
6. Eidelman I, Seedat S, Stein DJ. Risperidone in the treatment of acute stress disorder in physically traumatized in-patients. Depress Anxiety 2000;11:187–8.
7. Leyba CM, Wampler TP. Risperidone in PTSD. Psych Serv 1998;49:245–6.
8. Monnelly Ep, Ciraulo DA. Risperidone effects on irritable aggression in post-traumatic stress disorder. J Clin Psychopharmacol 1999;19:377–8.
9. Hamner MB, Ulmer HG, Faldowski RA, and others. A randomized controlled trial of risperidone for psychotic features in PTSD. Neuropsychopharmacol 2000;23:(Suppl 120).
10. Butterfield MI, Becker ME, Connor KM, and others. Olanzapine in the treatment of post-traumatic stress disorder: a pilot study. Int Clin Psychopharmacol 2001;16:197–203.
11. Petty F, Brannan S, Casada J, and others. Olanzapine treatment for post-traumatic stress disorder: an open-label study. Int Clin Psychopharmacol 2001;16:331–7.
12. Hamner MB. Clozapine treatment for a veteran with comorbid psychosis and PTSD. Am J Psychiatry 1996;153:841.
13. Hamner MB, Deitsch SE, Brodrick PS, and others. Quetiapine treatment in PTSD: an open trial of adjunctive therapy. J Clin Psychopharmacol (forthcoming).
Marie-Josée Filteau, MD, FRCPC;
Jacinthe Leblanc, Pharm, BCPP;
Roch-Hugo Bouchard, MD, FRCPC
Quebec City, Quebec
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