Potential Overuse of Antipsychotic Drugs for PTSD Patients is Under Review

By Annette M. Boyle

FORT DETRICK, MD — In the wake of a memo from Assistant Secretary of Defense Jonathan Woodson, MD, expressing concern about potential over-prescription of antipsychotic drugs for treatment of post-traumatic stress disorder, the Army and VA have launched an interagency research program to evaluate the effectiveness of several other medications to treat common PTSD symptoms.

“There is a real need to better understand the various medications currently being used off-label by providers to treat combat-related PTSD,” Maj. Gary H. Wynn, research psychiatrist with the Neurotrauma and Psychological Health Project Management Office at the U.S. Army Medical Materiel Development Activity (USMMDA) told U.S. Medicine.

An expert panel of researchers and providers from the DoD, VA, academia and civilian sectors determined that, “the most pressing need was better understanding of the treatments for sleep problems associated with combat-related PTSD,” Wynn said.

Army Research Psychiatrist Maj. Gary Wynn, Center for Military Psychiatry and Neuroscience at Walter Reed Army Institute of Research, speaks to fellow psychiatrists at the American Psychiatric Association Annual Meeting this year.

Woodson’s memo to the assistant secretaries of all military branches noted that the use of atypical or second-generation antipsychotics had increased from 0.1% to 1.0% servicewide from 2002 to 2009, driven in large part by the off-label use of these medications to treat sleep dysfunction and irritability or anger. According to the memo, “Seroquel, an atypical antipsychotic, was prescribed to 1.4% of Army [servicemembers]SMs and 0.7% of Marines in Fiscal Year 2010.”

Col. Carol W. Labadie, PharmD, U.S. Army Pharmacy Consultant/Pharmacy Program Manager for the Army Surgeon General, questioned the specific numbers in the memo but concurred that the number of prescriptions for antipsychotics has been rising significantly. She told U.S.Medicine that about 1% of all soldiers were prescribed antipsychotics in 2010.

“Seroquel accounted for about 0.4%, with all other antipsychotics about 0.8%, but the trend has definitely been going up,” Labadie noted.

Difficulty sleeping is a primary symptom of PTSD and a common side effect of the two drugs that are approved by the Food and Drug Administration for the treatment of the disorder, sertraline (Zoloft) and paroxetine (Paxil), said Labadie. Antipsychotics such as Seroquel and resperidone may cause sleepiness in some patients, which has led to their use in treating this troubling aspect of PTSD.

A memo from Army Chief of Staff Herbert A. Coley, however, cautioned health-care providers in April that use of atypical antipsychotics raises “numerous concerns with potential long-term adverse health effects (e.g., weight gain, glucose dysregulation, cardiac effects, extrapyramidal effects), and these medications have shown disappointing results in clinical trials in the treatment of PTSD. Risperidone specifically has been given a D-level recommendation in the VA/DoD CPG (harm outweighs benefits) based on the results of a large multicenter VA cooperative study.”

The same memo also advised providers that, “although benzodiazepines have frequently been used ‘as needed’ and continuously for anxiety disorders, including to augment evidence-based treatment modalities in PTSD, there is evidence to suggest that benzodiazepines may actually potentiate the acquisition of fear responses and worsen recovery from trauma.” In addition, the high rate of comorbid alcohol misuse and substance-use disorders and difficulty discontinuing the drugs contraindicate use of benzodiazepines in patients with PTSD, it said.

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