Dr. Messer is physician of Behavioral Health at SMDC Medical Center in Duluth, Minnesota. Dr. Haller is senior research scientist of Education and Research at SMDC Health System.

Disclosure: The authors report no affiliation with or financial interest in any organization that may pose a conflict of interest.

Acknowledgments: The authors thank John Grabowski, PhD, for critical review of the manuscript and helpful suggestions.

Please direct all correspondence to: Irina V. Haller, PhD, MS, Senior Research Scientist, Division of Research, SMDC Health System, 503 E. Third Street, Duluth, MN 55805; Tel: 218-786-8185; Fax: 218-727-8159; E-mail: ihaller@smdc.org.


 

Abstract

Patients not responding to conventional treatment for depression are classified as having treatment-resistant depression (TRD). Electroconvulsive therapy is effective in ~50% of the patients diagnosed with TRD. Recent reports of rapid antidepressant effect with a single dose of ketamine suggest a potential benefit for TRD patients. However, there are no studies characterizing optimal dosing parameters (eg, frequency and inter-dose interval). The following case describes the effects of two ketamine administration regimens in a patient with a 15-year history of depression.

 

Focus Points

• Treatment-resistant depression affects up to 15% of patients with major depressive disorder, and there are few options after electroconvulsive therapy failure.
• Ketamine can be administered in an outpatient setting with nurse monitoring during the infusion.
• Adverse events associated with ketamine infusions are rare and can be avoided by using ideal body weight for dosing.
• Multiple infusions may increase the length of remission.  However, optimal dose, frequency, and inter-dose interval for ketamine administration require further study.

 

Introduction

Despite substantial advances in the therapeutic options for managing patients with major depressive disorder (MDD), treatment-resistant depression (TRD) continues to be a serious public health problem. It is estimated that up to 15% of patients diagnosed with MDD do not respond to conventional treatments and can be classified as treatment resistant.1 Attempting successive pharmacologic trials in the quest for an effective agent increases risk for the patient and can produce significant health, social, and economic burdens.2

A growing body of evidence indicates that N-methyl-d-aspartate (NMDA) receptor antagonists significantly and rapidly improve depressive symptoms in MDD patients. Two randomized controlled trials, one including TRD patients, reported a rapid antidepressant response from a single infusion of ketamine in patients with MDD.3,4 However, there are no available data or general guidelines on optimal dose, frequency, or inter-dose interval for ketamine administration to sustain remission. This case delineates a dosing regimen and may provide guidance to achieving sustained remission in TRD patients.

 

Case Report

In January 2008, a 46-year old female with MDD was hospitalized for a course of electroconvulsive therapy (ECT). Successive interventions over 15 years had included trials of 24 psychotropic medications and 273 ECT treatments, 251 of which were bilateral. No intervention had produced remission but only a short-lived response to treatment. She had no history of an Axis II diagnosis, chemical dependency or other major medical illnesses.

ECT during this admission was administered with ketamine as the anesthetic at 2 mg/kg given over 60 seconds. Surgical anesthesia occurred ~30 seconds after the end of intravenous injection and lasted ~10 minutes. There was no significant change in depression symptoms with the ketamine used as an anesthetic during the ECT treatment. Alternative treatments were reviewed for potential use. In addition to no significant recovery from her depression, the long-term use of ECT caused problems with memory loss and focused attention. She was unable to remember much of her history over the previous 15 years. Re-learning the information became futile since each course of ECT would eliminate what had been gained.

Based on recent reports of rapid antidepressant effect of single dose ketamine in MDD patients,3,4 the authors of this case report reviewed the information available with the patient and obtained her consent. They discussed potential side effects known to be associated with the anesthetic dose of ketamine, such as psychosis during or after the treatment, elevations in liver enzymes, hypertension, a harlequin-like skin change, and malignant hyperthermia. At lower doses used for antidepressant treatment4 reported in the literature, side effects included perceptual disturbances, confusion, elevations in blood pressure, euphoria, dizziness, and increased libido, as well as gastrointestinal distress, increased thirst, headache, metallic taste, and constipation. These side effects appeared to abate within 80 minutes after the infusion. Ketamine was administered at 0.5 mg/kg of ideal body weight (IBW) over 40 minutes on February 28, 2008.

The first ketamine treatment led to a dramatic remission of depressive symptoms: the Beck Depression Inventory (BDI) score decreased from 22 to 6 (Figure). Three additional infusions administered every other day over 5 days produced remission lasting 17 days after the last infusion in this series. Three series of six ketamine infusions given every other day except weekends were repeated over the next 16 weeks (Figure). Each infusion sequence produced remission lasting 16, 28, and 16 days, respectively, followed by a relapse. After three remission/relapse cycles and before relapse could occur after the fourth infusion series, a maintenance ketamine regimen was established on August 27, 2008 using 0.5 mg/kg IBW at a 3-week inter-dose interval. The authors’ estimation for the maintenance dosing interval was based on the time frame between remission and relapse for this patient. Relapse to depression was prevented by treating prior to the onset of a relapse.

 

As shown in the Figure, with maintenance infusions the patient has been in remission for >15 months. No concurrent pharmacotherapeutic agents have been administered or required during this time period, no adverse events have emerged, and there has been no cognitive impairment as is typical with ECT, polypharmacy, or from MDD itself.

Generally, weight-based dosing (eg, mg/kg) is a sound pharmacologic strategy. However, data and experience with weight-based dosing in a previous patient who was substantially overweight5 resulted in perceptual distortion, though antidepressant benefit was evident. In consultation with the authors’ Anesthesia department, they selected IBW to establish the dosing regimen. The Metropolitan Life Insurance weight tables6 can be used to determine IBW based on sex, age, height, and body frame.

For this case, ketamine infusions were administered with nursing supervision as a day patient procedure and treatment was well tolerated. Vital signs were monitored during the infusion. No psychotic or dissociative symptoms were noted during or after the ketamine infusions and no other adverse events occurred. Ketamine was safe in an outpatient setting without cognitive or physical impairment once ketamine was metabolized (usually within 2 hours post infusion). Repeated administration did not produced tachyphylaxis or tolerance.

Maintenance ketamine treatments described here continue to sustain this patient’s recovery from depression. Moreover, in this patient, maintenance treatments were more effective than the recurrent series of infusions for maintaining recovery.

 

Conclusion

While there is no consensus regarding the definition of TRD,2,7 it is generally regarded as a resistance to treatment when the patient has not experienced a 50% reduction in depressive symptoms after ≥2 courses of appropriate antidepressant, given in an adequate dose and duration.

As indicated by the designation TRD, there are no consistently effective interventions. Options include medications from various classes of antidepressants either alone or in combination with other psychotropics, or ECT alone or in combination with a range of medications. ECT is given in a series of treatments and with TRD may also be given as a maintenance treatment. Most current treatments for TRD take several weeks to achieve full clinical effect. In comparison, ketamine in this case had a rapid onset of action.

The cost implications of ECT must also be taken into consideration when this becomes the primary antidepressant intervention. Ketamine treatments require infusion capability and ongoing nursing observation. The cost and personnel needed for a ketamine treatment are far less than that of ECT since no charges associated with anesthesia or operating room use are needed. The data from our institution suggest that the charges associated with one ketamine treatment are ~33% of the charges for one ECT.

The combination of ketamine and ECT has received very little attention in the literature. Although others have noted a potential benefit from using ketamine during ECT either as induction treatment8 or an anesthetic,9 the authors did not see any changes in mood symptoms in this patient when ketamine was used as an anesthetic to ECT. This lack of response could be attributed to the patient’s significant exposure to ECT. Alternatively, antidepressant benefit may be attenuated by the amnestic effect of ECT or anesthetic doses, with the latter suggesting a “state-dependent” effect.

A growing body of evidence suggests that the glutamatergic system, known to play a role in neuronal plasticity and cellular resilience, is also involved in the pathophysiology and treatment of MDD.10-12 Ketamine, an NMDA receptor antagonist with rapid antidepressant effect, emerged as a potential agent for treatment of mood disorders,3,4 specifically TRD. Zarate and colleagues12 have described the putative mechanism of action of NMDA receptor antagonists. It is postulated that the NMDA-glutamate receptor complex signals morphologic changes that produce cell loss or atrophy. Ketamine, a high-affinity NMDA-receptor antagonist, causes the release of brain-derived neurotrophic factor (BDNF). The presence of BDNF increases the size of cells and increases arborization of dendrites which is reduced under circumstances of stress in animal models that are analogous to depression. The function of BDNF is considered to be a part of the antidepressant effect of electroconvulsive treatments, antidepressants, and ketamine.

Optimal ketamine regimens to sustain remission have not been defined. Previously, the authors successfully treated two patients with TRD using a series of ketamine infusions5 over a 12-day period. The patient who received two ketamine treatments separated by 6 days was symptom-free for 18 days and the patient who received six ketamine treatments (every other day over 12-day period) was symptom-free for 29 days.5 As reported by others, remission was followed by relapse.

In the case described here, a maintenance ketamine treatment was more successful in preventing relapse of depression than repeated series of infusions. It may also have some economic and quality of life advantages compared to ECT. As NMDA receptor antagonist action on TRD is explored, a maintenance treatment protocol requires further investigation as a means to sustain recovery from depression.  PP

 

References

1.    Burrows GD, Norman TR, Judd FK. Definition and differential diagnosis of treatment-resistant depression. Int Clin Psychopharmacol. 1994;9(suppl 2):5-10.
2.    Greden JF. The burden of disease for treatment-resistant depression. J Clin Psychiatry. 2001;62(suppl 16):26-31.
3.    Berman RM, Cappiello A, Anand A, et al. Antidepressant effects of ketamine in depressed patients. Biol Psychiatry. 2000;47(4):351-354.
4.    Zarate CA Jr, Singh JB, Carlson PJ, et al. A randomized trial of an N-methyl-D-aspartate antagonist in treatment-resistant major depression. Arch Gen Psychiatry. 2006;63(8):856-864.
5.    Messer MM, Haller IV, Larson P, Pattison-Crisostomo J, Gessert CE. The use of a series of ketamine infusions in two patients with treatment resistant depression. J Neuropsychiatry Clin Neurosci. In press.
6.    Metropolitan Life Insurance Company. Weight Charts. Available at: www.coping.org/weightmgt/strategies/Weight%20Charts.doc. Accessed February 23, 2010.
7.    Berlim MT, Turecki G. What is the meaning of treatment resistant/refractory major depression (TRD)? A systematic review of current randomized trials. Eur Neuropsychopharmacol. 2007;17(11):696-707.
8.    Ostroff R, Gonzalis M, Sanacora G. Antidepressant effect of ketamine during ECT. Am J Psychiatry. 2005;162(7):1385-1386.
9.    Okamoto N, Nakai T, Sakamoto K, Nagafusa Y, Higuchi T, Nishikawa T. Rapid antidepressant effect of ketamine anesthesia during electroconvulsive therapy of treatment-resistant depression: Comparing ketamine and propofol anesthesia. J ECT. November 19, 2009 [Epub ahead of print].
10.    Paul IA, Skolnick P. Glutamate and depression: clinical and preclinical studies. Ann N Y Acad Sci. 2003;1003:250-272.
11.    Rot M, Chaney D, Mathew S. Intravenous ketamine for treatment-resistant major depressive disorder. Primary Psychiatry. 2008;15(4):39-47.
12.    Zarate CA Jr, Du J, Quiroz J, et al. Regulation of cellular plasticity cascades in the pathophysiology and treatment of mood disorders: role of the glutamatergic system. Ann N Y Acad Sci. 2003;1003:273-291.

Return

 

Dr. Feusner is psychobiology research fellow, Dr. Cameron is associate clinical professor, and Dr. Bystritsky is professor of psychiatry and behavioral sciences and director of the Anxiety Disorders Program at the David Geffen School of Medicine at the University of California–Los Angeles.

Disclosure: Dr. Feusner receives grant support from the National Institutes of Health. Dr. Cameron reports no affiliation with or financial interest in any organization that may pose a conflict of interest. Dr. Bystritsky is a consultant to Jazz; on the speaker’s bureau of Forest; and receives grant support from Cephalon, GlaxoSmithKline, Merck, Pfizer, and Wyeth.

Please direct all correspondence to Alexander Bystritsky, MD, PhD, Department of Psychiatry and Biobehavioral Sciences, 300 UCLA Medical Plaza, Rm. 2335,

Los Angeles, CA 90095-8346; Tel: 310-206-5133; Fax: 310-206-8387; E-mail: abystritsky@mednet.ucla.edu.


 

 

Abstract

Panic disorder affects millions of people worldwide, causing considerable suffering and loss of productivity. It is often associated with other psychiatric and substance use disorders. Fortunately, understanding the neurobiological, behavioral, and psychological factors involved in panic disorder has helped guide the development of effective pharmacotherapies and psychotherapies. The antidepressant class of selective serotonin reuptake inhibitors is a first-line defense, based on efficacy data, safety, and ease of use. However, there is also strong evidence for the efficacy of tricyclic antidepressants, benzodiazepines, and monoamine oxidase inhibitors. Cognitive-behavioral therapy (CBT) is most evidently the psychotherapy of choice for panic disorder, and can result in the maintenance of long-term improvements. Selection of treatment for the individual patient depends on the severity of illness, comorbid conditions, patient choice, and availability of psychotherapy. Pharmacotherapy and CBT combined in a rational and coordinated manner provides the best outcome.  

 

Introduction

Panic disorder is a prevalent and disabling condition, affecting 3% to 8% of the world’s population.1 The hallmark of the disorder is recurrent panic attacks, which are sudden episodes of acute apprehension or intense fear that occur without any apparent cause. During the panic attack, any of the symptoms listed in Table 1 can occur. These intense attacks usually last no more than a few minutes, but, in rare instances, can return in waves for up to 2 hours. In order to meet  Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)2 criteria for panic disorder, an individual must experience panic attacks as well as at least 1 month of persistent fear of having an additional attack, worry about the implications of the attack, or have a significant change in behavior as a result of the attacks.

Panic disorder often affects individuals in early to mid adulthood. The median onset is 24 years of age, although most do not seek treatment until their mid 30s.3,4 However, panic attacks can also begin in late adolescence. Twice as many women as men suffer from panic disorder.5 The course is typically chronic, although often waxing and waning.2

Agoraphobia is a common complication and consequence that occurs in approximately 50% of people with panic disorder. In the United States, an estimated 5.3% of the population, mostly women, suffer from agoraphobia.6 Patients suffering from agoraphobia are afraid of being in situations from which escape might be difficult, or in which help might be unavailable or embarrassing if they suddenly had a panic attack.2 In addition to the fear of experiencing a panic attack, many agoraphobics are afraid of what others will think of them after witnessing them having an attack. It is common for the agoraphobic to avoid crowded public places such as grocery stores, department stores, or restaurants. Enclosed or confined places, such as tunnels, bridges, or the hairdresser’s chair, may also be avoided. Individuals may feel trapped when using public transportation, such as trains, buses, subways, and planes, and may therefore avoid them. Individuals with panic and agoraphobia may also fear being at home alone in case a panic attack occurs and they will need help. The fears usually result in travel restrictions, the need to be accompanied by others when leaving home or staying at home, and being partially or completely house bound.

Panic disorder is associated with high comorbidity. Common comorbid conditions are major depressive episodes, specific phobias, obsessive-compulsive disorder (OCD), social anxiety disorder (SAD), generalized anxiety disorder, and posttraumatic stress disorder (PTSD).5,7 There are also high rates of substance use disorders, including alcohol, drugs, and both prescribed and non-prescribed medication. Panic disorder co-occurring with major depressive disorder (MDD), alcohol/substance abuse, and personality disorder, considerably increases the probability of a suicide attempt.5,7

Panic disorder often results in a diminished capacity for employment, especially for those with agoraphobia.8 Those who are financially dependent and those who receive either welfare or disability benefits constitute 27% of all panic disorder patients.9 Clearly, panic disorder is a relatively common psychiatric disorder that, especially when accompanied by agoraphobia, can result in considerable suffering and loss of productivity. Fortunately, in the past few decades there have been advances in the recognition and diagnosis of panic disorder as well as development of effective pharmacotherapy and psychotherapy.

 

Assessment

A comprehensive assessment is important in evaluating panic disorder and distinguishing it from other conditions, as panic attacks can occur in other psychiatric and medical disorders. The conditions that most likely need to be considered in assessing patients with panic disorder are listed in Table 2. A thorough medical history as well as a physical exam, laboratory tests, and an electrocardiogram if appropriate can help rule out any causative or concurrent medical problems related to the panic attacks.10 Certain medical problems that may cause panic-like symptoms or trigger panic attacks include, but are not limited to, complex partial seizures, hyperthyroidism, hyperparathyroidism, arrhythmias, asthma, withdrawal from drugs or alcohol, or use of psychostimulants, including caffeine. It is important to assess the presence of medications used for the treatment of medical illnesses as some of them (ie, antiasthmatics) may provoke panic. Assessment of medical status of panic patients who may undergo behavior therapy is specifically important for patients with cardiovascular problems. Collaborative work with the patient’s primary care physician is highly recommended.

 

Other psychiatric conditions are also part of the differential diagnosis, including MDD, bipolar disorder, SAD, specific phobias, OCD, and PTSD. Panic attacks can occur as symptoms of these disorders, or the disorders may exist as comorbidities. Panic attacks that seem to occur spontaneously or in the middle of the night as opposed to being triggered by specific situations or thoughts (such as with a traumatic reminder in someone with PTSD or fearing humiliation in SAD) can help distinguish panic disorder from its counterparts. Another distinguishing feature of panic disorder is fear of internal symptoms rather than fear of an external threat.

 

Theoretical Framework for Treatment

Cognitive-behavioral and biomedical theories have attempted to describe the mechanisms of panic and panic disorder.11,12 A brief synthesis of these theories reveals that panic disorder is likely a combination of an increase in alarm reaction, error in information processing (catastrophic thinking), and abnormal coping strategies to relieve anxiety and provide a sense of security (safety rituals and avoidance). The disorder represents a sequential process where the symptoms start with panic attacks and progress through the stages of abnormal thinking, rituals, and avoidance. These symptom clusters may be “wired” through different neuronal circuits and respond preferentially to different treatments.

Neuroanatomical areas of the brain responsible for alarm reactivity receive an abundance of projections from neurons having their origins in noradrenergic and serotonergic nuclei. Medications that affect serotonergic and noradrenergic systems are likely to influence the structures that are responsible for the alarm reactions and primitive defensive responses (ie, periaqueductal gray, septal areas, amygdala, and parts of orbital frontal cortex). Medications that affect serotonergic and dopaminergic pathways are capable of influencing systems involved in information processing of dangerous stimuli. These include the rostral cingulum and the basal ganglia, and their interaction with limbic areas. γ-aminobutyric acid (GABA)-receptor agonist medications are capable of slowing general reactivity of neurons. However, they can negatively affect information processing and cortical and hippocampal information retention that is necessary for forming new noncatastrophic memories important for deconditioning and desensitization.

Unfortunately, there are currently no Food and Drug Administration-approved medications that directly affect formation of new coping behaviors. It is highly unlikely that the current medications could directly affect complex behaviors such as safety rituals and avoidance. Rather, current medications influence alarm reactivity directly, and these effects over time may indirectly improve patient coping. Conversely, cognitive-behavioral therapy (CBT) directly affects coping strategies and modifies negative thinking. CBT is also capable of influencing alarm reactivity.

Pharmacotherapy and CBT, rationally applied in combination and taking into account their direct and indirect effects, should be more effective than either treatment alone. However, this theoretical framework is incomplete. The intricacy of the neuronal circuits and neurotransmitters and their relation to complex behaviors is not yet fully understood.

 

Pharmacotherapy

Selective serotonin reuptake inhibitors (SSRIs) are considered first-line treatment for panic disorder based on their efficacy, tolerability, ability to treat common comorbid depression and anxiety disorders, and lack of abuse potential. Sertraline, fluoxetine, and paroxetine all have FDA indications for the treatment of panic disorder, but fluvoxamine, citalopram, and escitalopram are considered equally effective.   

Several meta-analyses have demonstrated that SSRIs are generally as or more effective than other pharmacotherapies.13 Boyer14 analyzed 27 randomized, placebo-controlled studies and found that SSRIs were superior to imipramine and alprazolam. Otto and colleagues13 performed an effect-size analysis of 12 placebo-controlled trials of SSRIs for the treatment of panic and compared it to a meta-analysis on non-SSRI antidepressants. They found that SSRIs were as effective as other antidepressants (both with effect sizes of 0.55), and dropout rates were similar. Another meta-analysis examined 43 randomized and open, nonrandomized trials and compared effect sizes between SSRIs and tricyclic antidepressants (TCAs). Effect sizes were similar but dropout rates were lower for SSRIs (18%) versus TCAs (31%).15 TCAs and clomipramine have been demonstrated to be efficacious in panic patients but are generally less tolerated than SSRIs.16,17

Benzodiazepines have the longest history of proven efficacy in panic disorder. In several controlled trials, alprazolam, lorazepam, and clonazepam were effective for panic disorder.18-21 Meta-analyses show benefits of benzodiazepines.22-27 Most studies, with the exception of a study by van Balkom and colleagues,25 showed similar effect sizes as the antidepressants. However, outcome measures were not consistent across studies. The benefits of the benzodiazepines are that they have a rapid onset of action and generally favorable side-effect profile. They can be used in maintenance, regular dosing, or on an as-needed basis. The downsides are the propensity for development of physiological dependence, tolerance, and cognitive side effects at higher doses. Compared to the antidepressants, they are not able to treat common comorbid depressive disorders.

Several older controlled studies have shown monoamine oxidase inhibitors (MAOIs) to be efficacious for panic disorder treatment.28,29 Sheehan and colleagues,29 in a placebo-controlled, double-blind study, found that phenelzine and imipramine groups showed significant improvement, with phenelzine superior to imipramine on some measures. MOAIs, however, are often problematic due to a heavy burden of side effects and dietary restrictions. The reversible monoamine oxidase inhibitors (RIMAs) such as moclobemide and brofaromine, do not require dietary restriction, and have been demonstrated in some (but not all30) controlled studies to be beneficial in panic disorder.31-34 Neither are currently available in the US.

Other pharmacologic agents may also be effective in panic disorder, although they have not yet been studied as extensively. Two small, controlled trials showed benefits in treatment with mirtazapine.35,36 GABA-ergic anticonvulsants, such as valproic acid37,38 and gabapentin,39 have shown promise in small trials, although gabapentin was more effective than placebo only for more severely ill patients.

 

Medication Treatment Considerations

Clinical trial data assist in understanding which group of medications are effective for panic disorder, and serve as a starting point for which medication is likely to benefit a particular patient. Selection of specific medications frequently depends on whether patients have received prior pharmacotherapy for the treatment of a mood and anxiety disorder, on previous reaction to medication, and on severity and acuity of their illness state.

SSRIs are currently the treatment of choice for patients who have never received prior pharmacotherapy and have at least moderate severity of illness. In addition to treating anxiety, SSRIs treat the frequently present comorbid MDD and lower the risk of future MDD. All SSRIs are thought to be effective in treating panic disorder and differ only in subtle side-effect profile and in their effects on the cytochrome P450 liver enzyme systems. In general, selection among antidepressants should be based on the patient’s anxiety symptom profile (one should avoid medications with side effects similar to their anxiety symptoms) and history of prior medication side effects. For example, paroxetine, fluvoxamine, or citalopram are more sedating medications and would be preferable SSRIs for patients with prominent activation. In the patient with severe insomnia one might select a sedating tricyclic antidepressant, such as nortriptyline or mirtazapine. Use of a dual-acting medication, such as venlafaxine, may be considered in the early stages of the treatment; however, at present there is no strong evidence from clinical research to support their early use. The clinical experience of the authors of this article is that treatment of uncomplicated panic may be started with small doses and increased to higher doses in patients with more obsessive thought patterns and avoidance.

Patients with panic disorder are often fearful of medication side effects or medications in general. They also have a tendency to have heightened side effects and reactions to side effects.10 This can be particularly problematic with the SSRIs, which often cause transient increases in anxiety, jitteriness, or exacerbation of panic attacks at initiation of treatment. For these reasons, and to minimize the likelihood of patients discontinuing the medications early, it can be helpful to start at very low doses and titrate upwards slowly. If needed, liquid formulations of most SSRIs are available to facilitate starting at very low doses, (eg, as low as fluoxetine 1 mg). However, the patient will at some point most likely need to achieve a dose in the range of what is required for the treatment of MDD.15

Benzodiazepines are not the first choice of treatment for panic disorder because of tolerance, dependency potential, and possible interference with CBT (especially with as-needed use). Therefore, these medications should be reserved for the “emergency” situations (eg, initial panic attacks) or for the reduction of anxiety in extreme or infrequent phobic situations (eg, airplanes, elevators) when the patient has not yet begun CBT. Finally, benzodiazepines can be used for maintenance of the chronic patients with refractory anxiety. If used chronically, these agents should be prescribed using a pharmacokinetically appropriate schedule in order to minimize daily withdrawal or interdose anxiety. Prior history of alcohol and drug abuse should be assessed before beginning treatment, as this may preclude their use.

Benzodiazepines can be initiated concurrently with an antidepressant. This strategy is particularly useful for patients with a history of increased anxiety with initiation of antidepressants or for acute anxiety in need of rapid relief. The benzodiazepine can be initiated with a planned treatment duration of approximately 4 weeks (to allow the antidepressant to take effect), followed by a flexible taper of the benzodiazepine over several weeks. This strategy was tested by Goddard and colleagues,40 who found that the combination of clonazepam and sertraline for 4 weeks followed by a 3-week taper of the clonazepam resulted in more responders than with sertraline and placebo by the first and third week. However, by the end of the 12-week trial there were no differences in the number of responders, and the dropout rates were similar.

 

Psychotherapy

Of the psychotherapeutic modalities, CBT has received the most widespread empirical and theoretical support in controlled studies for panic disorder.12,41-43 CBT is associated with low dropout rates, maintained long-term improvements, and the largest within-group and between-group effect sizes relative to all other comparison conditions.44,45

A recent long-term follow-up found treatment gains were maintained when reassessed at 6–8 years.46

CBT for panic disorder with and without agoraphobia has been described in manuals which have both patient and therapist guide versions.47 The goal of the treatment is to change catastrophic thinking that results when patients misinterpret internal bodily sensations as dangerous. First, the patient is guided through a psychoeducational process of understanding the panic process and the self-regulating nature of the physiology of anxiety. The patient is instructed on breathing and muscle relaxation techniques, which must be practiced at home between sessions. Next, the patient is engaged in monitoring his or her thinking, toward identifying and reappraising anxiety and panic-generating thoughts (cognitive restructuring). Finally, the patient is exposed, both in session and out of session, to bodily sensations that have become conditioned to fear. Through repeated exposure the patient habituates to the feared bodily sensations, thereby unlearning the fear response. The patient learns to confront possible agoraphobic avoidance of situations associated with previous panic attacks and anxiety.

Although considerable and growing research continues to demonstrate that CBT is well tolerated, cost effective, and efficacious in the short and long term, some patients do not benefit from it and there is still a need to improve the treatment.48 Efforts have been made to make CBT more efficient and to dismantle and identify its efficacious treatment components.

Data on utilization of healthcare services and medication have shown significant reductions in costs following CBT for panic disorder.49 CBT for panic disorder has been effectively and efficiently transported to the primary care setting. In a randomized, controlled study, mid-level behavioral health specialists trained to deliver CBT and pharmacotherapy were significantly more effective in treating primary care panic disorder than treatment as usual.50

Recent research has been conducted to increase self-directed therapy, reduce therapy frequency, and further streamline CBT delivery in innovative ways. Forty patients with panic disorder with agoraphobia were randomly assigned to either a traditional 12-session CBT group or a 4-session traditional treatment group plus a virtual reality component.51 Both groups were equally effective at treatment end, although the virtual reality group was less effective at 6-month follow-up. Using a manualized treatment program, panic disorder patients received either four sessions of group CBT or one meeting with a therapist plus three telephone contacts.52 Although the authors suggested that certain comorbid conditions negatively impacted self-directed treatment outcomes, the findings of the study (ie, higher end-state functioning in telephone condition) add to the viability of self-directed treatment options. An international multicenter trial reported that CBT delivered by brief computer-augmentation was as effective as extended therapist-delivered CBT, providing some support for the use of computers as an adjunct to effective CBT.53

A final emerging area in the evolution of CBT are mindfulness-based approaches. Mindfulness- or acceptance-based approaches are being hailed as the third wave in CBT54 (the first wave was strict behavioral approaches; the second wave was cognitive approaches). Mindfulness is a type of meditation that has been adapted from Buddhist psychology. One definition of mindfulness is “awareness of present experience with acceptance.”55 Mindfulness-based CBT has been applied to the treatment of panic disorder and other anxiety disorders,56 but it requires further carefully controlled research.57

CBT currently provides well-established treatments for panic disorder. It continues to be developed and evaluated, spawning innovating treatments that await further evaluation.

 

Combining Treatment Modalities

Several studies have been conducted to understand the importance of combined medication and CBT, versus either alone. A meta-analysis found combination treatments of CBT and medication, including benzodiazepines and/or antidepressants, superior to control groups, while exposure was not effective alone.25 In addition, the combined behavioral therapy and antidepressant group was superior to medications alone or psychotherapeutic interventions alone for agoraphobic avoidance. In another meta-analysis, Gould and colleagues24 showed that pharmacologic and CBT treatments were superior to control conditions, but that CBT had the largest effect sizes and the lowest attrition rates. A 1-year follow-up study, employing a time-series design, found that 89% of the participants were symptom free after receiving CBT, and that they also reduced their use of benzodiazepines. A study comparing CBT and pharmacologic treatment found all treatments effective, but the CBT group treatment was the most cost effective.58

In a clinic where CBT was accepted as the basic treatment for panic disorder with agoraphobia, it was suggested that psychiatrists appeared to rationally choose whether to add a benzodiazepine or antidepressant, either alone or in combination with each other and the CBT. Psychiatrists generally used combination treatments for more severe disorders, while CBT alone was often chosen when cognitive components were more pronounced than other symptoms. Benzodiazepines were often chosen for more somatically oriented patients with prominent panic attacks. Those choices resulted in substantial clinical improvements.59

If both CBT and medication are being used, coordination between the treatments is crucial. Completely blocking anxiety may prevent patients from receiving benefits from therapy and does not promote development of new ways of coping. Gradual reduction and stopping of medication can be attempted after 2–3 months of complete resolution of symptoms.

 

Treatment Algorithm

The treatment of panic disorder can proceed in a stepwise process, starting with treatments of proven efficacy and low rates of adverse events. Full response should be defined as not only a resolution of panic attacks, but also a resolution of the fear of panic and avoidant behaviors. The steps of the treatment are listed in the suggested (but not empirically tested) Algorithm.

 

Step 1

Education is the important first step in treatment, whether the treatment is pharmacotherapy, CBT, or the combination. At the most basic level, this involves explanations that the panic attacks do not signify that something is wrong with the body, and that the panic attacks are not dangerous. As primary care providers and the public are currently more aware of panic attacks, patients may already know that what they are experiencing is anxiety rather than a life-threatening condition such as a heart attack or stroke. The education should include explanations of how the cycle of panic attacks and fear of panic operates, and what kinds of behaviors reinforce the fear of the attacks. The clinician can also educate the patient on expectations regarding medication treatment; panic attacks may resolve, but the avoidance behavior may not change unless addressed directly with the help of a CBT therapist. Useful resources are available on the Internet and information in the form of pamphlets can be ordered from the Anxiety Disorders Association of America (www.adaa.org) and the National Institute of Mental Health (www.nih.nimh.gov). Involving the family can be helpful, especially when avoidance behavior is prominent and/or a family member misinterprets and is fearful of the patient’s panic attacks.

 

Step 2

Step 2 begins with a first-line of medication (SSRI) or CBT. The treatment choice is made during the initial patient session with the physician, in which the patient’s preference for either medication or psychotherapy is taken into consideration, along with the acuity of their current condition and availability of CBT. Patients who have very severe panic disorder accompanied by depression or other anxiety disorders are often less able to initially engage in CBT, and need to be started on antidepressants early. When availability or cost of CBT for the individual patient is problematic, medication treatment may be the only option.

 

Step 3

Step 3 begins after two trials of an SSRI are deemed to be unsuccessful. This step should start with a discussion with the patient about their preferences for switching to another medication or another treatment modality (eg, CBT) or augmenting the current modality by adding another medication or CBT. If the patient has had nonresponse or side effects to two prior SSRIs, the next choice is between other antidepressants (eg, venlafaxine, mirtazapine, or a TCA). A GABA-ergic strategy, such as benzodiazepines or gabapentin, can be used as augmentation if there is a partial response. Alternatively, a sedating atypical antipsychotic, such as olanzapine or quetiapine, can be used concomitantly. These medications are not ordinarily first-line treatments for anxiety disorders. If the patient continues to be treatment refractory, MAOIs may also be tried. MAOIs require dietary restrictions as well as first tapering off other antidepressants.

 

Step 4

Step 4 involves treatments with more intensive CBT or with medications or combinations of treatments that have not yet been tried. An expert consultation is usually recommended. Treatments with less established evidence could be attempted at this step. Combining an intensive CBT program (several times a week) with medication augmentation strategies may also result in a desired effect. Electroconvulsive therapy may be helpful for comorbid panic and depression but not for panic alone.60 Other strategies are under development for the treatment-resistant population, but they have yet to move past early experimental stages.

 

Long-Term Management

While in some patients panic attacks remit in the course of a few months, panic disorder is usually a chronic, waxing and waning condition. However, some patients can achieve complete remission. As per expert consensus guidelines, after 12–24 months of remission (defined as absence of panic attacks, fear of panic, and avoidance, as well as overall well being and lack of disability) the clinician may discuss with the patient the risks and benefits of continuing versus tapering off the medication.61 The risk of relapse may be reduced if the patient has undergone CBT.62 If a course of CBT has been successful, the individual may benefit from once monthly sessions for 3–6 months and “booster” CBT sessions as needed thereafter. Other patients may be left with the symptoms of other disorders, initially masked by the panic attacks. Approximately 20% of patients will not respond to any treatment and need to be maintained in the most comfortable state with medication, therapy, or their combination.63

 

Conclusion

Panic disorder (and the often accompanying agoraphobia) is a relatively common condition that can significantly disrupt the patient’s life in many ways. Knowledge of neuroanatomy and neuropharmacology of these conditions can assist us in better understanding current treatments of these disorders and in selecting the appropriate treatment choices. However, knowledge of neuropharmacology is not enough in selecting treatment for a particular patient. A thorough assessment and understanding of the interplay of multiple psychological and biological factors together with a deep knowledge of evidence from contemporary clinical research can assist the effective management of an individual patient. For the best possible results, psychotherapy (CBT) and pharmacologic treatment may need to be used individually or in a rationally chosen combination for the best possible results.  PP

 

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Journal CMEs

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Post-Deployment Violence and Antisocial Behavior: The Influence of Pre-Deployment Factors, Warzone Experience, and Posttraumatic Stress Disorder

David M. Benedek, MD, DFAPA, and Thomas A. Grieger, MD, DFAPA

Needs Assessment: In combat veterans, violent or aggressive behavior emerging as an adaptive response on the battlefield often persists upon homecoming. Clinical and empirical studies of combat veterans from Vietnam demonstrate that post-deployment antisocial behavior correlates with a number of pre-military experiences, certain aspects of warzone exposure, and the development of posttraumatic stress disorder. The lessons learned from these studies, as well as an understanding of the limitations of these studies, will help in assessing and mitigating violence and antisocial behavior in returning service members.

 

Learning Objectives:

 
  • Discuss major study findings of the effects of combat deployment on post-deployment violence and antisocial behavior.
 
  • Identify the limitations of these studies concerning post-deployment behavior of service members returning from combat operations.
 
  • Recognize the relative contributions of pre-deployment behavior, warzone experiences, and posttraumatic stress disorder to the emergence of violence and antisocial behavior.
 


Target Audience:
Primary care physicians and psychiatrists.

 

Accreditation Statement: Mount Sinai School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

 

Mount Sinai School of Medicine designates this educational activity for a maximum of 3.0 Category 1 credit(s) toward the AMA Physician’s Recognition Award. Each physician should claim only those credits that he/she actually spent in the educational activity.

 

It is the policy of Mount Sinai School of Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. Presenters must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved drugs or devices.

 

To receive credit for this activity: Read this article and the two CME-designated accompanying articles, reflect on the information presented, and then complete the CME quiz. To obtain credits, you should score 70% or better. Termination date: March 31, 2008. The estimated time to complete all three articles and the quiz is 3 hours.

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Primary Psychiatry. 2006;13(3):51-56

 

Drs. Benedek and Grieger are associate professors and assistant chairmen in the Department of Psychiatry at the Uniformed Services University in Bethesda, Maryland.

 

Disclosure: Drs. Benedek and Grieger report no affiliation with or financial interest in any organization that may pose a conflict of interest.

 

Please direct all correspondence to: David M. Benedek, MD, DFAPA, Department of Psychiatry, Uniformed Services University, 4301 Jones Bridge Rd, Bethesda, MD 20814; Tel: 301-319-4944; Fax: 301-295-1536; E-mail: Dbenedek@usuhs.mil.


 

 
 

Abstract

 

The United States has historically been concerned with successful reintegration of returning combat veterans into civilian society. Apprehensions are based on the recognition that traumatic warzone exposures may have negative emotional and behavioral consequences, and that violent and aggressive behavior demonstrated in the combat zone may persist upon homecoming. The majority of clinical and empirical data on post-deployment violence and antisocial behavior in US combat veterans comes from studies of returnees from the Vietnam War. These studies have demonstrated correlations between warzone exposures, posttraumatic stress disorder, and post-deployment violence in subpopulations of Vietnam veterans; however, there are methodologic limitations to the generalizability of these findings. Study results regarding post-deployment violence and antisocial behavior in Vietnam veterans can inform efforts to mitigate violence and antisocial behavior in service members returning from combat related to the global war on terrorism as well as future research.

 

Introduction

 

The United States has long held concerns about its military service members returning from war.1,2 Apprehension surrounding the prospects for soldiers’ successful reintegration into society has stemmed from concerns about the persistence of aggressive behavior (that may be adaptive on the battlefield) and from concerns related to the potential behavioral and emotional consequences of traumatic battlefield exposures. A variety of clinical and empirical studies have examined the relationships between battlefield exposures and the development of mental disorders such as posttraumatic stress disorder (PTSD) and depression. Other studies have examined the effects of warzone experience on the development of post-deployment violence, aggression, and other antisocial behavior. Recent statistical analyses have attempted to model the extent to which PTSD itself may mediate the development of post-deployment antisocial behavior in the aftermath of deployment.

 

The prevalence and management considerations for combat-related PTSD have been described elsewhere in this issue.3 This article reviews the literature surrounding efforts to identify predictors of violence and antisocial behavior in returning war veterans with and without PTSD. Literature describing the relationship between PTSD and post-deployment violence, aggression, and antisocial behavior is summarized as well. Finally, studies attempting to delineate the effects of pre-deployment behavior, combat exposure, and PTSD as mediators of post-deployment antisocial behavior are reviewed.

 

Antisocial Behavior in Veteran Populations

Studies of postwar adjustment of Vietnam veterans have provided the vast majority of information concerning violence and antisocial behavior in returning soldiers. Yesavage4 collected data on 70 consecutive Vietnam era schizophrenic male patients admitted to the psychiatric intensive care unit of the Veterans Administration (VA) Medical Center in Palo Alto, California. Nineteen of the 27 subjects in Vietnam saw combat. Measuring incidents of assault and assault-related behavior during admission, the study made correlations to self-report of combat exposure and criminal behavior before and after military service. When examined independently as a risk for inpatient assaultive behavior, significant correlations were found between pre-service criminal behavior, combat experience, and post-service criminal behavior. Multiple regression analyses demonstrated that while pre-military antisocial behavior predicted post-military antisocial behavior, violent tendencies in Vietnam era veterans were better explained by their war experience than by premorbid criminal behavior. The study suggested that anger and violence was better viewed as “reaction stress rather than as simply another outburst of a notoriously sociopathic population.”4 The generalizability of these conclusions is limited because the sample size was small, all study participants had schizophrenia, and substance abuse was not controlled for in the analysis.

 

Resnick and colleagues5 reviewed assessment data from 118 Vietnam era veterans seeking services at two Los Angeles VA hospitals to examine the relationships between the number of pre-adult and adult antisocial behaviors (as defined by the Diagnostic and Statistical Manual of Mental Disorders, Third Edition [DSM-III]6 criteria for antisocial personality disorder), level of combat exposure, and development of combat-related PTSD symptoms. The Structured Diagnostic Interview for Vietnam Veterans was used to obtain a thorough pre-military, military, and post-military history and to determine objective scores of pre-adult antisocial behavior, adult antisocial behavior, combat exposure, and PTSD symptom intensity.7 Hierarchical regression analyses indicated that combat exposure was significantly associated with PTSD severity (P<.005), and that the number of adult antisocial behaviors was predicted by the number of pre-adult antisocial behaviors (P<.05) and by combat exposure (P<.005). No interaction effect was observed for the pre-adult behavior and combat exposure. Resnick and colleagues5 concluded that the degree of combat exposure exerts independent effects on the development of PTSD symptoms as well as on post-combat antisocial behavior. The authors noted limitations based on data derived from retrospective interviews. Antisocial behavior scores were determined by behavior that included interpersonal violence, but this was only one of four determinants of overall score. Since other studies demonstrated an association between combat exposure and antisocial behavior, including non-violent arrests,8,9 the extent to which this study demonstrates combat exposure as a predictor of violence is less clear. Finally, the fact that subjects were drawn from clinical populations limits the generalizability to non-clinical populations. In a sample of 114 Vietnam veterans, Wilson and Zigelbaum10 noted a relationship between interpersonal assault, combat experience, and PTSD symptoms as well, but also failed to control for other variables associated with violent behavior.

 

PSTD as a Predictor of Post-Military Violence and Aggression

 

While the aformentioned studies examined combat exposure, violence, and antisocial behavior, they did not specifically explore the diagnosis of PTSD as a risk factor for these outcomes. Other studies of Vietnam veterans have examined this association in depth.

 

In the National Vietnam Veterans Readjustment Study (NVVRS), Kulka and colleagues11 found that male Vietnam veterans with PTSD reported an average of 13.3 acts of violence in the preceding year, in contrast to 3.5 acts of violence reported by Vietnam veterans who did not receive a PTSD diagnosis. However, in the original sample, veterans with PTSD had been exposed to greater levels of combat and had higher levels of post-Vietnam substance abuse. These variables were associated with increased violence and were not controlled for in the analysis, thus confounding interpretation of the association between PTSD per se, and violent acts.

 

Lasko and colleagues12 measured self-reported aggression using a number of previously validated instruments. Their sample included 27 male Vietnam veterans who met DSM-III-R13 Structural Clinical Interview criteria for PTSD,14 and 15 non-PTSD Vietnam veteran controls. Significant differences on nearly all psychometric measures of aggression were found with higher levels observed in the PTSD group. These differences were not explained by either level of combat exposure or history of substance abuse.

 

Mcfall and colleagues15 compared male Vietnam veterans seeking inpatient treatment for PTSD (N=228), to male psychiatric inpatients without PTSD (N=64), and to a community sample of Vietnam veterans with PTSD not undergoing inpatient treatment for violent behavior (N=273). Violent behavior included property destruction, physical fighting, and threats with and without weapons. After controlling for warzone variables, patients seeking inpatient treatment for PTSD were significantly more likely than psychiatric inpatients without PTSD to have engaged in one or more violent acts in the 4 months preceding hospitalization (P<.001). The PTSD inpatient group was more likely to endorse physical fighting (P<.01), threats of violence without a weapon (P<.01), or threats of violence with a weapon (P<.001), than the community sample. However, the small number of subjects without PTSD in the community sample precluded drawing distinctions between those patients with PTSD compared to those without PTSD. When considered in conjunction with the findings of Lasko and colleagues,12 the study provides supporting evidence of a relationship between PTSD and violent aggression independent of level of combat exposure. However, as in previously cited studies, the findings were essentially limited to males with combat-related PTSD.

 

Collins and Bailey16 examined a sample of 1,327 incarcerated male felons in the North Carolina prison system. No patients in the study developed PTSD from combat-related experience. Information from the Diagnostic Interview Schedule, Version III, was added to specific questions about demographics and criminal history in individual interviews and through a comprehensive review of State Department of Corrections and Bureau of Investigations records on each participant. Presence or absence of PTSD was recorded, as well as the temporal relationship between first PTSD symptom and six indicators of violence. The indicators of violence included history of multiple fights since 18 years of age, current incarceration or former arrests for rape or assault, and current incarceration or lifetime arrest for robbery. Of 1,140 subjects who agreed to participate and on whom sufficient data was available for analysis, 2.3% satisfied DSM-III criteria for PTSD. After controlling for demographic factors, race, antisocial personality, and problem drinking, the authors found that those who received a diagnosis of PTSD were significantly more likely to be currently incarcerated for homicide, rape, or assault (P<.001), or to have an arrest history for a violent offense in the year before incarceration (P<.001). The authors noted that among subjects who reported at least one PTSD symptom and at least one arrest for homicide, rape, or assault, 85% reported that their first PTSD symptom occurred in the same year of, or in the previous year to, their arrest. Despite the limited number of subjects who met criteria for PTSD, the authors noted that the stability of model results and the level of statistical significance suggested that PTSD—even when antisocial personality disorder was controlled for and when symptoms were unrelated to combat experience—was associated with subsequent violence.

 

A number of studies have sought to define the relationship of pre-military experience to warzone abusive violence (eg, participation in atrocities) and to subsequent development of PTSD. Laufer and colleagues17 examined data on 336 Vietnam combat veterans and found that combatants that participated in abusive violence or atrocities during the war were more likely to have enlisted rather than have been drafted, had higher rates of juvenile delinquency, and had dropped out of high school more frequently. In another NVVRS study, Kulka and colleagues18 examined childhood abuse, childhood problem behaviors, and antisocial personality before 18 years of age as potential predictors of later warzone violence. Self-report of pre-military difficulties were recorded on a Lichert scale and compared to six types of warzone abusive violence, which included torturing, wounding, or killing prisoners of war; terrorizing, wounding, or killing civilians; and mutilating of bodies. These types of violence were ultimately combined into a single magnitude variable. No significant correlations were found.

 

When Fontana and Rosenheck19 re-examined the NVVRS data for a relationship between being a prior victim of sexual abuse and warzone violence, no correlation was found. However, sexual abuse criteria were defined very broadly as “physical assault, torture, rape, mugging, or similar assault (not war related).” This diminished any understanding of the potential contribution of each component in the study (eg, individuals with a history of being mugged but not raped may have endorsed this abuse item). However, a second study of outpatient Vietnam veterans using the same database more carefully discriminated between childhood physical and sexual abuse items.19 When either was affirmed, frequency was measured on a Lichert scale. As in the first study, no correlations were found between abuse and violence in the warzone.

 

Finally, Hiley-Young and colleagues20 examined data on 207 consecutively admitted Vietnam veterans and assessed pre-military, warzone, and post-military experience. Complete data were available on 177 participants. High rates of childhood victimization, warzone violence, and post-military violence were found in the PTSD sample, as measured by the Minnesota Multiphasic Personality Inventory for PTSD subscale scores.21 Here, level of combat exposure predicted PTSD severity. Rates of childhood abuse were similar to those reported in previous epidemiologic studies of veterans with PTSD, but neither childhood abuse nor other childhood factors predicted warzone violence. Of the six measures of warzone abusive violence, only participation in mutilation was related to the development of PTSD (P<.01), and only participation in killing prisoners of war or civilians predicted post-military violence toward a spouse (P<.05) or others (P<.001). Participation in abusive violence did not predict post-military drug abuse, alcohol abuse, or criminality. The authors noted methodologic limitations due to the inadequacy of instruments available for measurement of PTSD, the use of single items to measure complex childhood variables, and ambiguities associated with subjective historical reports of violence related to enemy combatants versus civilians. Again, the fact that study subjects were all adult, male psychiatric inpatients with extensive combat exposure limits the generalizability to larger or mixed gender veteran populations.

 

Taken as a whole, these studies suggest that both pre-military antisocial behavior and, to some extent, combat exposure during wartime contribute to post-military antisocial behavior. The studies suggest that pre-military childhood experiences are not strong predictors of wartime abusive violence. However, small and selective samples, absence of control for substance abuse or previous antisocial behavior, and overly inclusive definitions of both causal factors and outcome measures limit both the generalizability of conclusions and the definitiveness with which they may be drawn.

 

Warzone Experience and Intimate Partner Violence

 

More recently, several studies have looked specifically at the relationship between battlefield deployment and subsequent spousal aggression and violence. Using structural equation modeling, Orcutt and colleagues22 examined the effects of warzone stressors and PTSD symptom severity on partner reports of male-perpetrated intimate partner violence in 376 Vietnam veteran couples. Investigators noted that perceived battlefield threat (not actual combat exposure), severity of PTSD symptoms, and a number of premilitary adverse experiences demonstrated direct relationships with subsequent intimate partner violence. Interestingly, after controlling for PTSD, a direct negative correlation between combat exposure and partner violence was demonstrated. This result suggested that battlefield exposures themselves may not contribute to interpersonal violence, absent the mediating effect of PTSD. However, certain warzone experiences (eg, participation in battlefield atrocities and killing) have been demonstrated to predict post-deployment spousal violence.20,23 McCarroll and colleagues24 compared deployed to non-deployed male soldiers and found that when age, race, and previous violence were controlled for, deployment to a non-combat environment did not predict domestic violence upon return home. As with the more general studies of post-deployment violence and antisocial behaviors, these studies suggest a considerable contribution of pre-military variables, direct effects of certain specific (but not all) warzone combat experiences, and an indirect contribution of these and other variables mediated through the development of PTSD.25

 

Relationship Between Warzone Trauma, PTSD, and Antisocial Behavior

An analysis of the extensive literature demonstrating that adverse childhood experiences predict subsequent development of PTSD (in military and civilian populations) and that these experiences correlate with a wide variety of antisocial and violent behavior is beyond the scope of this article. However, a recent examination of the potential mediating role that battlefield-specific PTSD (and not childhood experience) plays in the subsequent development of post-military antisocial behavior should be noted.

 

In an effort to examine the question of the etiology of post-military antisocial behavior through structural equation modeling, Fontana and Rosenheck26 recently reanalyzed data from the NVVRS in a manner that addresses several of the methodologic limitations of previous studies. With this approach, the total effects can be partitioned into those that are direct or unmediated by another variable, and those that are indirect or mediated by one or more other variables. All causal interpretations to be made of data are specified in advance and evaluated as a set. Such modeling cannot alter limitations of the associational data, but can provide an indication of how well a set of causal propositions fits the empirical associations within the data.27

 

In this study,26 a sample of 1,198 male Vietnam veterans were divided into two random subsamples of 599 patients each. The subsamples did not differ on demographics or on pre-determined causal variables, which included premilitary risk factors, traumatic exposure and disciplinary actions in the military, homecoming reception, PTSD and post-military substance abuse, and antisocial behavior. Each of the postulated causal variables was measured using summations of a variety of indicators within the NVVRS database. For example, substance abuse was derived from the Diagnostic Interview Schedule of alcohol abuse/dependence and drug abuse/dependence during the preceding 6 months, and homecoming reception was measured using the sum of three questions concerning the extent to which the American people made the veteran feel “at home again, respected . . . and proud,” and two scales of family support developed for the study.

 

By ordering the five causal variables according to their historic occurrence, pathways leading to antisocial behavior were generated in the two subsamples using an initial model (omitting PTSD and substance abuse) and an expanded model (including PTSD and substance abuse with the other causal variables). Amount of variance in antisocial behavior accounted for in the initial and expanded models differed by only 1%, but in the expanded model 55% of the total effects were attributed to the causal variables, and 30% of the total effect was attributed to PTSD and substance abuse. Both warzone exposure and homecoming reception contributed significantly to the development of PTSD in the causal model analysis. The investigators concluded that post-military antisocial behavior represented manifestations of a lifetime history of antisocial behavior far more than it reflected the after-effect of warzone experience. However, warzone trauma and homecoming reception, which contributed to the development of PTSD, contributed significantly to the variance in antisocial behavior observed. The authors acknowledged the limitations of the retrospective nature of historic data and reporting bias, particularly as they may affect models based on temporal occurrence and symptom self-reports of symptom severity and frequency.27 Although concerns related to overly inclusive definitions of variables are applicable here, the significant contribution of homecoming reception on the development of PTSD has also been replicated in other studies.28-30 The explanation of a mediating role for PTSD on antisocial behavior was consistent with the findings of Orcutt and colleagues22 in their study of PTSD and intimate partner violence.

 

Conclusion

 

Differences in the nature of deployment, combat, and warzone experiences of military service members currently deploying to Southwest Asia and eventually returning home may contribute to differences in the incidence and prevalence of PTSD and the course and progression of illness. Preliminary studies of the prevalence, severity, and natural history of PTSD in these veterans appear to support this observation.3 One such study of soldiers engaged in heavy combat in Iraq suggests that the rate of severe intimate partner violence reported 1 year after homecoming is considerably higher than the baseline rate of such violence in the non-deployed military population.31 As deployments and homecomings are ongoing, any analyses of the extent to which this generation of returning members of the armed forces engage in violent or otherwise antisocial behavior are now only preliminary. Anecdotal reports of interpersonal violence and substance abuse have garnered considerable media attention, but systemic analyses have been limited to comparisons of pre- and post-war rates of mood, anxiety disorders, suicide, and substance abuse. The extent to which the studies of post-deployment violence can be generalized to the current population of returning volunteer force veterans (including larger percentages of women, reservists, and national guardsman) is unclear. However, these studies suggest that, particularly in the population of veterans either actively seeking treatment or otherwise coming to clinical attention, antisocial behavior (including aggression, hostility, and interpersonal violence) will be an issue of concern. Interventions directed at identifying and treating individuals at risk should include treatment for PTSD. However, existing models of the relationship between combat experience, PTSD, and post-deployment antisocial behavior suggest that successful identification and treatment of veterans with PTSD from their battlefield experiences will not effectively engage the larger veteran population for whom post-deployment violence or antisocial behavior may also be a difficulty. PP

 

References

 

1. Leventman S. Epilogue: Social and Historical Perspectives on the Vietnam Veteran. In: Figley CR, ed. Stress Disorders Among Vietnam Veterans: Theory, Research and Treatment. New York, NY: Brunner/Mazel; 1978:291-295.

 

2. Wecter D. When Johnny Comes Marching Home. Cambridge, MA: Houghton Mifflin; 1944.

 

3. Grieger A, Benedek DM. Psychiatric disorders following return from combat duty during the twenty-first century. Primary Psychiatry. 2006;13(3):45-50.

 

4. Yesavage JA. Differential effects of Vietnam combat experiences vs. criminality on dangerous behavior by Vietnam veterans with schizophrenia. J Nerv Ment Dis. 1983;171(6):382-384.

 

5. Resnick HS, Foy DW, Donahoe CP, Miller EN. Antisocial behavior and post-traumatic stress disorder in Vietnam veterans. J Clin Psychol. 1989;45(6):860-866.

 

6. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. Washington, DC: American Psychiatric Association; 1980.

 

7. Foy DW, Sipprelle RC, Rueger DB, Carroll EM. Etiology of posttraumatic stress disorder in veterans: analysis of premilitary, military, and combat exposure influences. J Consult Clin Psychol. 1984;52(1):79-87.

 

8. Wilson JP, Zigelbaum SD. Post-traumatic stress disorder and the disposition to criminal behavior. In: Figley CR, ed. Trauma and Its Wake: Traumatic Stress Theory, Research, and Intervention. Volume II. New York, NY: Brunner/Mazel; 1986:305-321.

 

9. Beckham JC, Feldman ME, Kirby AC, Hertzberg MA, Moore SD. Interpersonal violence and its correlates in Vietnam veterans with chronic posttraumatic stress disorder. J Clin Psychol. 1997;53(8):859-869.

 

10. Wilson JP, Zigelbaum SD. The Vietnam veteran on trial: the relation of post-traumatic stress disorder to criminal behavior. Behav Sci Law. 1983;(3):69-83.

 

11. Kulka RA, Schlenger WE, Fairbank JA, et al. Trauma and the Vietnam War Generation: Report of Findings from the National Vietnam Readjustment Study. New York, NY: Brunner/Mazel; 1990.

 

12. Lasko NB, Gurvits TV, Kuhne AA, Orr SP, Pitman RK. Aggression and its correlates in Vietnam veterans with and without chronic posttraumatic stress disorder. Compr Psychiatry. 1994;35(5):373-381.

 

13. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed rev. Washington, DC: American Psychiatric Association; 1987.

 

14. Spitzer RL, Williams JB. Structured Clinical Interview for DSM-III-R Non-Patient Version (Modified for Vietnam Veterans Readjustment Study 4/1/87). New York, NY: Biometric Research Department, New York State Psychiatric Institute; 1986.

 

15. McFall M, Fontana A, Raskind M, Rosenheck R. Analysis of violent behavior in Vietnam combat veteran psychiatric inpatients with posttraumatic stress disorder. J Trauma Stress. 1999;12(3):501-517.

 

16. Collins JJ, Bailey SL. Traumatic stress disorder and violent behavior. J Trauma Stress. 1990;3(2):203-220.

 

17. Laufer RS, Gallops MS, Frey-Wouters E. War stress and trauma: the Vietnam experience. J Health Soc Behav. 1984;25(1):65-85.

 

18. Kulka RA, Schlenger WE, Fairbank JA, et al. Contractual Report of Findings From the National Vietnam Veterans Readjustment Study. Research Triangle Park, NC: Research Triangle Institute; 1988.

 

19. Fontana A, Rosenheck R. Posttraumatic stress disorder among Vietnam Theater Veterans. A causal model of etiology in a community sample. J Nerv Ment Dis. 1994;182(12):677-684.

 

20. Hiley-Young B, Blake DD, Abueg FR, Rozynko V, Gusman FD. Warzone violence in Vietnam: an examination of premilitary, military, and postmilitary factors in PTSD in-patients. J Trauma Stress. 1995;8(1):125-141.

 

21. Hathaway SR. Minnesota Multiphasic Personality Inventory. San Antonio, TX: Psychological Corporation; 1967.

 

22. Orcutt HK, King LA, King DW. Male-perpetrated violence among Vietnam veteran couples: relationships with veteran’s early life characteristics, trauma history, and PTSD symptomatology. J Trauma Stress. 2003;16(4):381-390.

 

23. Taft CT, Pless AP, Stalans LJ, Koenen KC, King LA, King DW. Risk factors for partner violence among a national sample of combat veterans. J Consult Clin Psychol. 2005;73(1):151-159.

 

24. McCarroll JE, Ursano RJ, Liu X, et al. Deployment and the probability of spousal aggression by U.S. Army soldiers. Mil Med. 2000;165(1):41-44.

 

25. Marshall AD, Panuzio J, Taft CT. Intimate partner violence among military veterans and active duty servicemen. Clin Psychol Rev. 2005;25(7):862-876.

 

26. Fontana A, Rosenheck R. The role of war-zone trauma and PTSD in the etiology of antisocial behavior. J Nerv Ment Dis. 2005;193(9):203-209.

 

27. James LR, Mulaik SA, Brett J. Causal Analysis: Assumptions, Models, and Data. Beverly Hills, CA: Sage Publications; 1982.

 

28. Bolton EE, Litz BT, Glenn DM, Orsillo SM, Roemer L. The impact of homecoming reception on the adaptation of peacekeepers following deployment. Mil Psychol. 2002;14(3): 241-251.

 

29. Johnson DR, Lubin H, Rosenheck R, Fontana A, Southwick S, Charney D. The impact of homecoming reception on the development of posttraumatic stress disorder. The West Haven Homecoming Stress Scale (WHHSS). J Trauma Stress. 1997;10(2):269-277.

 

30. Solomon Z, Oppenheimer B. Social network variables and stress reaction lessons from the 1973 Yom-Kippur War. Mil Med. 1986;151(1):12-15.

 

31. Hoge C. The psychological aftermath of war: the land combat study at one year. Symposium presentation at: Annual Meeting of the International Society for Traumatic Stress Studies; November 3, 2005; Toronto, Ontario, Canada.

 

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Journal CMEs

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Virtual Reality and Other Experiential Therapies for Combat-Related Posttraumatic Stress Disorder

James L. Spira, PhD, MPH, Jeffrey M. Pyne, MD, Brenda Wiederhold, PhD, Mark Wiederhold, MD, Ken Graap, MEd, and Albert Rizzo, PhD

Needs Assessment: Posttraumatic stress disorder (PTSD) is a common mental health problem among combat veterans. Given the current conflicts in Iraq and Afghanistan, the prevalence of combat-related PTSD is expected to increase. Various psychotherapies have been used to treat PTSD. The most effect psychotherapies appear to be cognitive behavioral and exposure therapies. Virtual-reality–assisted exposure therapy for combat-related PTSD is a new method for delivering exposure therapy and is currently being tested by the Department of Defense.

 

Learning Objectives:

 
  • List the three core symptom clusters of PTSD.
 
  • Identify the most effective psychotherapies for PTSD treatment.
 
  • Describe the use of virtual reality as an exposure therapy for PTSD.
 


Target Audience:
Primary care physicians and psychiatrists.

 

Accreditation Statement: Mount Sinai School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

 

Mount Sinai School of Medicine designates this educational activity for a maximum of 3.0 Category 1 credit(s) toward the AMA Physician’s Recognition Award. Each physician should claim only those credits that he/she actually spent in the educational activity.

 

It is the policy of Mount Sinai School of Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. Presenters must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved drugs or devices.

 

To receive credit for this activity: Read this article and the two CME-designated accompanying articles, reflect on the information presented, and then complete the CME quiz. To obtain credits, you should score 70% or better. Termination date: March 31, 2008. The estimated time to complete all three articles and the quiz is 3 hours.

 

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Primary Psychiatry. 2006;13(3):58-64

 

Dr. Spira is clinical professor in the Department of Psychiatry at the University of California in San Diego and clinical director of the Casa Palmera Residential Treatment Program in Del Mar, California. Dr. Pyne is research health scientist at the Central Arkansas Veterans Healthcare System in North Little Rock. Dr. B. Wiederhold is executive director and Dr. M. Wiederhold is president of the Virtual Reality Medical Center in San Diego. Mr. Graap is president and CEO of Virtually Better, Inc., in Decatur, Georgia. Dr. Rizzo is research scientist and research assistant professor at the University of Southern California in Los Angeles.

 

Disclosure: Drs. Spira and Rizzo report no affiliation with or financial interest in any organization that may pose a conflict of interest. Dr. Pyne has received research support from the Department of Veterans Affairs Health Services Research and Development Service. Drs. B. and M. Wiederhold, and Dr. Graap have received research support from the Office of Naval Research.

 

Please direct all correspondence to: James L. Spira, PhD, MPH, 817 Mola Vista Way, Solana Beach, CA 92075; Tel: 619-807-4953; Fax: 858-792-7356; E-mail: JimSpira@aol.com.


 

 

Abstract

 

Numerous experiences can lead to acute stress disorder or posttraumatic stress disorder (PTSD) in military personnel. Unfortunately, PTSD is a relatively common outcome of combat exposure. The primary focus of this article is the role of experiential psychotherapy treatments which teach skill development to better cope with combat-related PTSD. The article focuses largely on virtual-reality–assisted exposure therapies.

 

Introduction

 

Numerous experiences can lead to acute stress disorder or posttraumatic stress disorder (PTSD) in military personnel. Combat-related experiences that can lead to PTSD include witnessing another service member being killed or wounded, feeling responsible for the death of a military member, being ambushed, a near death experience, and witnessing the death or wounding of civilians, including children. Each of these experiences is outside the range of what is considered normal human experience. In addition, PTSD appears to be more severe and longer lasting when the event is caused by human means and design, such as warfare.1

 

Combat-related PTSD may be a condition that existed from the start of humankind. The written history of PTSD dates back to the account of Achilles in The Iliad by Homer (800 B.C.). More recently in the United States, symptoms of PTSD have been described as “soldier’s heart” during the Civil War, “shell shock” during World War I, “combat fatigue” or “war neurosis” during World War II, and PTSD after the Vietnam War. The Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III),2 published the first diagnostic criteria for PTSD.

 

In a study of Vietnam veterans, 31% of men and 27% of women suffered from PTSD at some point since their return from the war.3 A few months after returning from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF), 12.2% to 19.9% of Marine Corps personnel and 6.2% to 11.5% of Army personnel met diagnostic criteria for PTSD.4 The numbers of OIF and OEF service members with PTSD is expected to increase over time because delayed PTSD symptom onset has been shown in connection with other recent military conflict.5 This heightened rate of PTSD ia also due to the duration of conflict, the repeated and longer deployments, the unknown duration of deployment, the unconventional type of warfare, the increased use of reservists, and the increased risks for all military occupations.

 

According to the Veterans Healthcare Administration, the British National Health Service National Institute for Clinical Excellence, the American Psychiatric Association (APA), and recent expert panels,6-9 the current treatment recommendations for PTSD include the use of medication and psychotherapy. Each of these sources recommends selective serotonin reuptake inhibitors (SSRIs) as the first-line medication treatment for PTSD. However, the remission rates for combat-related PTSD remain low (20% to 30%) with the use of SSRIs.10 Despite the commonality of combination therapy in clinical practice, there are no published controlled trials comparing the efficacy of combination medication and psychotherapy to medication or psychotherapy alone.

 

This article briefly reviews the PTSD symptom clusters and medication treatments for PTSD. The primary focus is a review of psychotherapies for PTSD. The use of virtual reality (VR)-assisted exposure therapy for the treatment of combat-related PTSD will also be discussed.

 

PTSD Symptom Clusters

 

After experiencing a traumatic event, the three core PTSD symptom clusters include re-experiencing, avoidance/numbing, and hyperarousal. The re-experiencing symptoms include recurrent and intrusive distressing recollections of the event, recurrent distressing dreams of the event, flashbacks, intense psychologic distress when reminded of the event, and physiologic reactivity when reminded of the event. The avoidance/numbing symptoms include efforts to avoid thoughts, feelings, or conversations associated with the event; efforts to avoid activities, places, or people that are reminders of the event; inability to recall important aspects of the event; decreased interest in significant activities; feeling detachment from others; decreased range of affect; and sense of foreshortened future. The hyperarousal symptoms include problems sleeping, increased irritability, difficulty concentrating, hypervigilance, and exaggerated startle response.

 

Medication Treatments for PTSD by Symptom Cluster

 

The APA recommends SSRIs as the first-line medication treatment for all three PTSD symptom clusters.9 The evidence supporting the use of other classes of medications by PTSD symptom cluster was also summarized in a recent article.11 For example, tricyclic antidepressants were found generally effective except in relieving symptoms in the avoidance/numbing cluster. While monoamine oxidase inhibitors (MAOIs) were found generally effective, there is limited evidence about the effectiveness of the more tolerable reversible MAOIs. Benzodiazepines were generally ineffective for core PTSD symptom clusters, but may improve sleep. Anticonvulsants appeared more helpful for re-experiencing symptoms. Second-generation antipsychotics appeared helpful for all core PTSD symptom clusters. Adrenergic inhibitors may be useful as an early intervention to prevent the development of PTSD following a traumatic event, to decrease re-experiencing symptoms, or as an adjunctive treatment. However, in a recent meta-analysis, the overall effectiveness of medication management was found to be half as effective as psychotherapy and had twice the drop-out rate.12

 

Psychotherapy Treatments for PTSD

 

The psychotherapy options include preventive and treatment strategies. The psychotherapeutic preventive strategies following traumatic exposure include one-session critical incident stress debriefing (CISD) and cognitive-behavioral therapy (CBT). Two recent meta-analyses found no evidence to support the use of CISD to decrease psychologic distress or prevent the onset of PTSD.13,14 A limited number of well-designed studies demonstrate some success in preventing PTSD using a few sessions of CBT starting 2–3 weeks after the traumatic event.15,16

 

Psychotherapeutic treatment strategies extend along the continuum from therapies where the focus is more reflective, to therapies where the focus is more experiential and skill-based. Each of the therapies outlined below include reflective and experiential elements. More reflective therapies include interpersonal and psychodynamic therapies. Combination reflective and experiential therapies include CBT and dialectical behavioral therapy. More experiential and skill-based therapies include somatic (relaxation training and biofeedback), attentional (meditation), and exposure (flooding, graded exposure, eye movement desensitization reprocessing [EMDR], and hypnosis) therapies.

 

Reflective Psychotherapies

 

The well-structured interpersonal psychotherapy (IPT) was developed to address the interpersonal and social problems stemming from the development of a patient’s personality and is influenced by social interactions.17 Interpersonal and social problems often lead a patient with PTSD to seek treatment, and they often influence the symptom course. A pilot study of group-based IPT demonstrated improvement in social functioning but had limited effect on more PTSD-specific symptoms.18 Therefore, there is minimal evidence to support the use of IPT for the treatment of PTSD.19

 

Psychodynamic psychotherapy is less structured and has a long tradition in mental health treatment. A broad exploration of a patient’s underlying personality structure offers clarity to his or her response to life events, particularly to traumatic events. Psychodynamic formulations enhance understanding of the traumatic stress associated with PTSD, and are often incorporated into other treatment strategies used for the treatment of PTSD. In one controlled trial comparing brief psychodynamic psychotherapy, hypnotherapy, desensitization, and a wait-list control, all active treatment groups resulted in significant symptom improvement.20 Therefore, minimal evidence supports the use of psychodynamic psychotherapy in the treatment of PTSD.19

 

Combination Reflective and Experiential Psychotherapies

 

CBT targets the patient’s distorted threat appraisal assumptions in order to reverse dysfunctional thinking patterns that are associated with and perpetuate the PTSD symptom clusters. Through reflective dialogue, therapists help patients identify distorted automatic cognitive, affective, physiologic, and behavioral responses to current events, and focus instead on more rational responses appropriate to a given situation. Experiential homework is given to assist the patient in implementing what was discussed in therapy sessions. Proponents of CBT sometimes incorporate other therapeutic modalities, including aspects of the more experientially oriented therapies discussed below. Similar to psychodynamic and interpersonal approaches, therapists using a CBT approach often examine underlying factors that may influence current responses to traumatic events, such as core beliefs about oneself or the world. In the case of PTSD, many CBT therapists also have the patient describe the traumatizing event while utilizing relaxation techniques; this can be considered a mild form of exposure therapy. CBT can be conducted in group or individual formats. However, there are fewer group CBT studies than individual ones, and no studies comparing group and individual CBT.21 The evidence base for PTSD CBT is supported by a number of controlled studies.19

 

Dialectical behavioral therapy (DBT) is a structured psychotherapy specifically developed for the treatment of borderline personality disorder. The combination of borderline personality disorder and PTSD is referred to as complex PTSD. Borderline personality disorder often develops within the context of childhood abuse or neglect and is a known risk factor for developing PTSD related to a traumatizing event later in life. DBT combines reflective cognitive and experientially-based skill development by focusing on affect regulation, distress tolerance, and principles of mindfulness meditation to address distressing symptoms and behavior. While DBT has been used clinically in PTSD patients, the evidence base is limited to only case reports at this time.19

 

Experiential Psychotherapies

 

Experiential psychotherapies use non-reflective methods within a reflective psychotherapeutic context (usually CBT-based). These therapies focus on developing attentional control and autonomic regulation, in an attempt to gain mastery over troublesome symptoms. The more experiential therapies can be divided into somatic (eg, autonomic regulation through relaxation training and biofeedback), attentional (eg, meditation, developing control over cognitive processing), and exposure (eg, flooding, graded exposure, EMDR, hypnosis). As is true of all the psychotherapies, there is considerable overlap across the reflective-to-experiential continuum, and there is also considerable overlap among the components of the more experientially oriented therapies.

 

Many popular treatments for PTSD include a skill-based somatic component. Relaxation exercises have a physical (autonomic) emphasis. Typically, patients are trained to reduce the sympathetic arousal associated with PTSD symptoms and enhance parasympathetic recuperation using progressive muscle relaxation and slow abdominal breathing with or without biofeedback. There is no evidence to support relaxation training as an independent intervention, but it is often incorporated as an aspect of CBT, exposure therapy, or attentional interventions.

 

Biofeedback can be useful as a method of self-regulation. Practiced for more than 40 years, there are a variety of approaches to biofeedback. Using the oldest forms, the patient watches a monitor or listens to a tone that reflects autonomic arousal as measured by skin temperature, skin conductance, muscle tension, respiratory rate, and/or heart rate. Patients are told to manipulate the monitor (sound or graphic) by any means they can (eg, recall or imagining a pleasant scene or slow abdominal breathing). Rather than simply instructing the patient to “make the tone go up” any way possible, modern-day biofeedback practitioners continually monitor the physiologic data and suggest attentional and somatic exercises for the patient’s use. In this way, the relaxation approach is tailored to each patient. Such physiologic monitoring and feedback is a useful tool in conjunction with other interventions (including VR-graded exposure therapy, described below) to continually monitor objective arousal in patients with PTSD and assist patients in regaining a sense of mastery over their symptoms.22 No evidence supports the use of biofeedback interventions alone in the treatment of PTSD.

 

Attentional therapies employ various meditative traditions, which emphasize different aspects of attention. For example, Zen meditation emphasizes signal enhancement, ie, attending to and becoming absorbed in what one sees, hears, feels, and smells at each moment. When thoughts arise, practitioners note that “noise,” let it go, and returns to the sensations (“signal”) at hand. Vipassana (mindfulness) meditation emphasizes noise reduction. In other words, a person should notice what thoughts and feelings arise, but should not react to it or judge it. A person should simply notice what arises, passively attend to it until it dissipates, and then return to the moment at hand (such as feeling the breath flow in and out, or continuing with one’s work activity). These practices are complementary, merely emphasizing different aspects of the same principle.

 

Meditative traditions share with CBT the belief that cognitive processes drive affective, physiologic, and behavioral reactivity. However, while CBT focuses on underlying belief systems as the cause of current dysfunction, meditative traditions emphasize mastery over fundamental cognitive processes or attentional retraining (eg, whatever one attends to, one enhances). Indeed, when patients attend to a distressing thought or feeling, their sympathetic arousal is significantly increased. By contrast, when engaged in Zen meditation (attending to what they see, hear, and feel), patients significantly reduce their sympathetic arousal, even without controlling their breathing or otherwise consciously manipulating their physiology.23,24 While research on the effectiveness of meditation alone for PTSD is lacking, clinically it appears to be helpful when used in combination with other approaches.

 

Exposure-based therapy helps patients decrease fear response to internal and external cues that would otherwise cause symptom intensification. Exposure therapy is based on emotional processing theory (EMT). Applying EMT to PTSD, fear memories are stored as a “fear structure” and include psychologic and physiologic information about stimuli, meaning, and responses.25 Once accessed and emotionally engaged, the fear structure is then open to modification and, if treated appropriately, over time will result in habituation and extinction of the fear response. Common approaches to exposure therapy include flooding, graded exposure, EMDR, tolerating narrative report of the traumatic event, and hypnosis.

 

Flooding exposure therapies present the patient with as much stimulation as possible, and have the patient sustain attention to that stimulation until it begins to extinguish, (usually in approximately 20 minutes). Several theories support the use of flooding-type exposure. Classical conditioning is the original theoretical basis of this approach, where the conditioned stimulus (loud sound, internal memory) is no longer paired with a conditioned response (fear arousal), and therefore the conditioned response extinguishes over time. Case studies using flooding exposure therapy have reported mixed results.26-28 Therefore, the evidence base for flooding therapy lacks strength at this time.

 

Graded exposure therapy attempts to elicit arousal at the level the patient can tolerate and then increase exposure gradually over time as the patient learns skills to modulate arousal. This approach is most often coupled with a skill-based de-arousal method, such as relaxation training (progressive muscle relaxation, biofeedback), distancing (hypnosis, visual imagery), and/or attentional retraining (Zen or Vipassana meditation). Graded exposure can include imaginal, in vivo, or VR exposure techniques. To date, the most commonly used graded exposure technique used for PTSD treatment is imaginal exposure. VR-graded exposure is discussed in more detail below.

 

EMDR most typically involves the patient focusing on a disturbing memory while the therapist initiates saccadic eye movements by asking the patient to track the horizontal motion of the therapist’s rapidly moving finger. Following the therapist’s finger movement is thought to disassociate memories from associated emotions. In studies with and without the saccadic eye movements, it is unclear that the eye movements are necessary for treatment efficacy.29 A meta-analysis of EMDR and other exposure techniques found no significant differences in outcomes.30 At this time, the evidence base for EMDR treatment of PTSD shows it to be at least equivalent to CBT and in some cases to other exposure therapies.19

 

Hypnotherapy using light or deep trance techniques has been used clinically for decades to treat combat-related stress disorders.31 Typically, the patient is induced into a comfortable, relaxed mental and physical state while simultaneously reviewing and distancing from the traumatic episode. Thus, the patient learns to dissociate the traumatic event from arousing sequelae. However, results from controlled studies are unavailable at this time.32 Therefore, there is minimal evidence to support the use of hypnotherapy for the treatment of PTSD.

 

In summary, exposure-based therapies (including CBT with exposure) have been found to be the most effective form of treating PTSD.33 van Etten and Taylor12 analyzed 61 treatment trials that included pharmacotherapy and modalities such as behavior therapy (particularly exposure therapy), EMDR, relaxation training, hypnotherapy, and dynamic psychotherapy. Specifically, the effect size for all types of psychotherapy interventions was 1.17 compared with 0.69 for medication, and the mean dropout rate in medication trials was 32% compared with 14% in psychotherapy trials. Additionally, this meta-analysis found that exposure therapy was more efficacious than any other type of treatment for PTSD according to clinician-rated measures.

 

Virtual Reality-Assisted Exposure Therapy

 

VR can be used to deliver graded exposure or flooding exposure therapies. Graded exposure therapy has been used clinically for a variety of anxiety disorders.34,35 There are advantages of VR exposure over imaginal exposure. Therapist control over the exposure presented and VR exposure does not rely upon individual imagery ability or even the ability of the patient to verbalize his or her experiences (although the ability to talk about the traumatic event(s) can be utilized within a VR environment to increase personal relevancy and increase arousal). Many patients are unwilling or unable to effectively visualize the traumatic event. In fact, avoidance of reminders of the trauma is inherent in PTSD and is one of the defining symptoms of the disorder.36 One disadvantage of the use of VR exposure for PTSD is that the VR environment is content specific and must be developed for a particular context. The evidence base for use in combat-related PTSD treatment at this time is limited to case studies,37,38 but will be expanding with treatment trials described below that are currently underway and supported by the Department of Defense.

 

A VR environment can be used to present both general and specific stimuli to patients in order to assist them in reducing reactivity to the traumatic event. A general VR environment (eg, Iraqi village) is often sufficient to elicit a general reminder of the arousal experienced during deployment. Additionally, if the VR environment allows for operator control over a repertoire of various optional stimuli, then a graded exposure of relevant arousing stimuli can be individually tailored to allow for an arousal hierarchy to be developed and presented to each patient. For example, a Marine who conducted night operations may not get sufficiently aroused in a daytime environment. Similarly, a Navy Construction Battalion (Sea Bee) driver may require a convoy scenario to elicit arousal. Since the goal is to teach mastery over cognitive, affective, and physiologic arousal, the ability to generate arousal is critical for successful treatment. An optimal VR environment would therefore contain a general reminder of the deployment and have a range of options that the therapist can employ to bring out an arousal more specific to each patient’s unique experience.

 

Other aspects of VR environments important to treatment include realism, immersion, and interaction. Although technology has been steadily improving with regard to video graphics and VR in particular, it is unnecessary that the environment be completely “realistic.” Various VR studies have shown that exact reproductions are unnecessary to elicit anxiety.39 If the VR environments are similar enough to the index traumatic events, then it should be possible to trigger emotional responses similar to those which may have occurred originally, thereby providing access to the memories of the trauma. In the future, degree of realism (eg, the addition of vibration, scent, and other stimuli to the VR) will likely enhance the options available to clinicians and provide greater coverage of traumatic situations.

 

Immersion appears to be related to the degree of arousal that can be achieved with a given exposure. Using a head mount with the greatest clarity, viewing range, and comfort, along with the patient’s ability to see the environment move along with head or body movements, allows the patient greater immersion and perhaps greater arousal. Sounds presented through headphones are also a critical element for improved immersion. It is also possible to enhance immersion by placing a vibration platform underneath the patient (eg, to vibrate with helicopters going overhead, rockets exploding), matching climate (eg, dry heat blowing on the patient), or even using a machine to present smells to the patient (eg, burning rubber, gun powder). In theory, the more sensory modalities stimulated, the greater the immersion.

 

Another factor that effects immersion is the degree to which a patient can interact with the VR environment. Usually, the patient will use a joystick or computer mouse to navigate through the environment and move his or her head to change the visual field. The level of patient interaction with the VR environment is another aspect of exposure that the therapist can utilize to influence arousal.

 

Two Department of Defense-funded studies are underway to examine the use of VR therapies for combat-related PTSD. One study will utilize a graded exposure approach in a randomized controlled design, and the other will utilize a flooding approach in a case series design. In both studies (as described below), the primary outcomes will be symptom severity, physiologic reactivity to a test VR environment, and health-related quality of life.

 

Eighteen marine and navy personnel recently diagnosed with combat-related PTSD and receiving outpatient mental health treatment were interviewed by the authors of this article in order to develop the general and specific content for the VR environments. Specifically, patients were asked about the precise sights, sounds, smells, and feelings associated with the recurring intrusive thoughts they experienced upon returning from their combat tours. This information was then used to create VR environments for use with medical and Marine Corps personnel. Some relevant specific stimuli that can be turned on or off as needed include voices of Iraqi civilians, Arabic prayer, sounds of gunfire, rocket’s fired and exploding, helicopters flying overhead or landing, terrorists running and firing guns, comrades being wounded by gunfire, buildings and vehicles burning, and driving through dangerous areas.

 

In the flooding VR exposure study, the therapist will ask the patient to relate his or her narrative of the sentinel traumatic event or sequence of events and then presents the patient with VR stimuli sufficient to maintain a high level of arousal for at least 20 minutes. All patients will also be treated with an SSRI prescribed by their mental health provider. It is critical to not over-arouse the patient to the extent of cognitive dissociation, emotional shutdown, or being overwhelmed during or after the session. The therapist will also record the patient narrative and the sounds of the VR environment during the VR session so that the patient can continue to listen to the recording daily in between sessions, in order to facilitate the extinguishing of arousal. In a small, single-group design study of Vietnam veterans with chronic combat-related PTSD, the use of a similar protocol twice a week for 6 weeks proved beneficial in reducing PTSD symptoms.38

 

In the graded exposure VR study, the authors of this article will determine the relative value of 10 weekly sessions of VR graded exposure plus SSRI treatment compared to 10 weekly group CBT sessions plus SSRI treatment. The VR graded exposure therapy will incorporate Zen absorption techniques to focus comfortably into the moment (attentional retraining) and Vipassana internal noise reduction techniques to distance arousing thoughts and feelings. The graded exposure VR intervention will also incorporate biofeedback to monitor physiologic response so that the therapist can both better determine when a patient is becoming aroused, and train the patient to modulate these responses. Over the past 5 years, heart rate variability (HRV) has become the indicator of choice for many biofeedback therapists and those who wish to monitor physiologic reactivity in their patients or research subjects.24 In particular, the very low frequency (VLF)/low frequency (LF) ratio (part of the HRV spectral analysis) is the best single indicator of when a patient is focused comfortably in the moment without significant cognitive/affective/physiologic arousal. Simply, when VLF is >50% the LF, the therapist should instruct the patient to relax and focus in the moment. If this is impossible for the patient, the therapist should reduce the intensity of the VR stimulus. When the VLF is <50% the LF, the patient is calmer and more relaxed, and the VR stimuli can be increased so that the patient has more opportunity to practice experiential methods of self-regulation. As the patient becomes more skilled at modulating physiologic response to the VR environment, the patient will gain a sense of mastery over arousal, develop confidence to be able to handle even more arousal, and re-establish the calm and relaxed state as his or her natural baseline. As with other exposure therapies, the goal is to generalize these skills into everyday activities. At this time, it is unknown which patients will be more likely to benefit from VR-assisted exposure therapies or how best to integrate VR therapies with other existing treatments for PTSD.

 

Conclusion

 

Existing medications and psychotherapies are helpful in the treatment of PTSD. However, there is still a need to improve the outcomes for patients with PTSD, including combat-related PTSD. Experiential psychotherapies utilized within a therapeutic framework are promising additions to existing approaches. Ongoing studies testing VR-assisted interventions will help define the role of novel VR interventions in the treatment of combat-related PTSD. PP

 

References

 

1. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.

 

2. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. Washington, DC: American Psychiatric Association; 1980.

 

3. Schlenger WE, Kulka RA, Fairbank JA, Hough RL, Jordan BK, Marmar CR. The prevalence of post-traumatic stress disorder in the Vietnam generation: A multimethod, multisource assessment of psychiatric disorder. J Trauma Stress. 1992;5(3):333-363.

 

4. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Eng J Med. 2004;351(1):13-22.

 

5. Gray MJ, Bolton EE, Litz BT. A longitudinal analysis of PTSD symptom course: delayed-onset PTSD in Somalia peacekeepers. J Consult Clin Psychol. 2004; 72(5):909-913.

 

6. VHA/DoD Clinical Practice Guideline for Management of Major Depressive Disorder in Adults. Available at: www.oqp.med.va.gov/cpg/MDD/MDD_GOL.htm. Accessed January 30, 2006.

 

7. The expert consensus guideline series. Treatment of posttraumatic stress disorder. The expert consensus panels for PTSD. J Clin Psychiatry. 1999;60(suppl 16):3-76.

 

8. Foa EB, Keane TM, Friedman MJ. Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies. New York, NY: The Guilford Press; 2000.

 

9. Ursano RJ, Bell C, Eth S, et al. Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Am J Psychiatry. 2004;161(11 suppl):3-31.

 

10. Stein MB, Kline NA, Matloff JL. Adjunctive olanzapine for SSRI-resistant combat-related PTSD: a double-blind, placebo-controlled study. Am J Psychiatry. 2002;159(10):1777-1779.

 

11. Schoenfeld FB, Marmar CR, Neylan TC. Current concepts in pharmacotherapy for posttraumatic stress disorder. Psychiatr Serv. 2004;55(5):519-531.

 

12. van Etten ML, Taylor S. Comparative efficacy of treatments for posttraumatic stress disorder: a meta-analysis. Clin Psych and Psychotherapy. 1998;5:126-144.

 

13. van Emmerik AA, Kamphuis JH, Hulsbosch AM, Emmelkamp PM. Single session debriefing after psychological trauma: a meta-analysis. Lancet. 2002;360(9335):766-771.

 

14. Rose S, Bisson J, Churchill R, Wessely S. Psychological debriefing for preventing post traumatic stress disorder (PTSD). Cochrane Database Syst Rev. 2001;(3):CD000560.

 

15. Bryant RA, Sackville T, Dang ST, Moulds M, Guthrie R. Treating acute stress disorder: an evaluation of cognitive behavior therapy and supportive counseling techniques. Am J Psychiatry. 1999;156(11):1780-1786.

 

16. Bryant RA, Moulds ML, Nixon RV. Cognitive behaviour therapy of acute stress disorder: a four-year follow-up. Behav Res Ther. 2003;41(4):489-494.

 

17. Klerman GL, Weissman MM, Rounsaville BJ, Chevron ES. The interpersonal approach to understanding depression. In: Klerman GL, Rounsaville BJ, eds. Interpersonal Psychotherapy of Depression. New York, NY: Basic Books; 1984:51-69.

 

18. Robertson M, Rushton PJ, Bartrum D, Ray R. Group-based interpersonal psychotherapy for posttraumatic stress disorder: theoretical and clinical aspects. Int J Group Psychother. 2004;54(2):145-175.

 

19. Robertson M, Humphreys L, Ray R. Psychological treatments for posttraumatic stress disorder: recommendations for the clinician based on a review of the literature. J Psychiatr Pract. 2004;10(2):106-118.

 

20. Brom D, Kleber RJ, Defares PB. Brief psychotherapy for posttraumatic stress disorders. J Consult Clin Psychol. 1989;57(5):607-612.

 

21. Ruzek JI, Young BH, Walser RD. Group treatment of posttraumatic stress disorder and other trauma-related problems. Primary Psychiatry. 2003;10(8):53-57.

 

22. Wiederhold BK, Jang DP, Kim SI, Wiederhold MD. Physiological monitoring as an objective tool in virtual reality therapy. Cyberpsychol Behav. 2002;5(1):77-82.

 

23. Spira J. Using meditation and hypnosis to modify eeg and heart rate variability. Paper presented at: 35th Annual Meeting of the American Association of Biofeedback and Psychophysiology; April 1-4, 2004; Colorado Springs, CO.

 

24. Spira J, Kotay A. Influence of relaxation and stress on very low frequency heart rate variability. Paper presented at: 35th Annual Meeting of the American Association of Biofeedback and Psychophysiology; April 1-4, 2004; Colorado Springs, CO.

 

25. Foa EB, Kozak MJ. Emotional processing of fear: exposure to corrective information. Psychol Bull. 1986;99(1):20-35.

 

26. Keane TM, Kaloupek DG. Imaginal flooding in the treatment of a posttraumatic stress disorder. J Consult Clin Psychol. 1982;50(1):138-140.

 

27. Keane TM, Fairbank JA, Caddell JM, Zimering RT. Implosive (flooding) therapy reduced symptoms of PTSD in Vietnam combat veterans. Behav Therapy. 1989;20(2):245-260.

 

28. Pitman RK, Orr SP, Altman B, et al. Emotional processing and outcome of imaginal flooding therapy in Vietnam veterans with chronic posttraumatic stress disorder. Compr Psychiatry. 1996;37(6):409-418.

 

29. Cahill SP, Carrigan MH, Frueh BC. Does EMDR work? And if so, why?: a critical review of controlled outcome and dismantling research. J Anxiety Disord. 1999;13(1-2):5-33.

 

30. Davidson PR, Parker KC. Eye movement desensitization and reprocessing (EMDR): a meta-analysis. J Consult Clin Psychol. 2001;69(2):305-316.

 

31. Watkins JG. The psychodynamic treatment of combat neuroses (PTSD) with hypnosis during World War II. Int J Clin Exp Hypn. 2000;48(3):324-335.

 

32. Cardena E. Hypnosis in the treatment of trauma: a promising, but not fully supported, efficacious intervention. Int J Clin Exp Hypn. 2000;48(2):225-238.

 

33. Foa EB. Psychosocial treatment of posttraumatic stress disorder. J Clin Psychiatry. 2000;61(suppl 5):43-48.

 

34. Wiederhold BK, Gevirtz R, Spira J. Virtual reality exposure therapy vs. imagery desensitization therapy in the treatment of flying phobia. In: Riva G, Galimberti C, eds. Towards CyberPsychology: Mind, Cognition, and Society in the Internet Age. Amsterdam: IOS Press; 2001:254-272.

 

35. Moore K, Wiederhold BK, Wiederhold MD, Riva G. Panic and agoraphobia in a virtual world. Cyberpsychol Behav. 2002;5(3):197-202.

 

36. Difede J, Hoffman HG. Virtual reality exposure therapy for World Trade Center post-traumatic stress disorder: a case report. Cyberpsychol Behav. 2002;5(6):529-535.

 

37. Rothbaum BO, Foa EB. Exposure Therapy for PTSD. National Center for PTSD Newsletter. 1999;10(2).

 

38. Rothbaum BO, Hodges LF, Ready D, Graap K, Alarcon RD. Virtual reality exposure therapy for Vietnam veterans with posttraumatic stress disorder. J Clin Psychiatry. 2001;62(8):617-622.

 

39. Hodges LF, Rothbaum BO, Alarcon RD, et al. A virtual environment for the treatment of chronic combat-related post-traumatic stress disorder. Cyberpsychol Behav. 1999;2(1):7-14.

 

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Computer Physician Order Entry: To Implement or Not?

John S. Luo, MD

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Primary Psychiatry. 2006;13(3):19-21

 

Dr. Luo is assistant clinical professor in the Department of Psychiatry and Biobehavioral Sciences at the University of California in Los Angeles; past president of the American Association for Technology in Psychiatry (AATP) in New York City; and Gores Informatics Advocacy chair at the AATP.


 

 

An Institute of Medicine report1 in 2000 cited two large studies indicating an average of 3% medical error incidences in New York, Utah, and Colorado. In Utah and Colorado, 6.6% of these adverse events led to death, compared to 13.6% of adverse events in New York. The economics of preventable medical errors is staggering, ranging from $17–$29 billion due to loss of income and household production, disability, and healthcare costs. The Leapfrog Group,2 which includes organizations that leverage their healthcare purchasing power to encourage patient safety, quality, and customer value, uses computer physician order entry (CPOE) as an important measure toward patient safety in hospitals. Given that illegible handwriting might be open to misinterpretation, hospital systems see CPOE as a viable solution to reduce errors in prescriptions and medical orders. However, implementation of CPOE is not necessarily quick or easy. Cedars Sinai Hospital in Los Angeles abandoned their CPOE program in January 2003 when 400 physicians complained that it was difficult, time-consuming, and posed risks to patient safety. The hospital has no plans to try to implement a new CPOE program until sometime after 2006.3 CPOE is a conceptually good idea, but it is difficult to implement. A more than cursory assessment of CPOE will clarify whether your organization is ready.

 

What is CPOE?

 

CPOE is difficult to implement. Although most healthcare systems utilize computerized medication or laboratory orders in some form, the goal of using physicians for order entry is not to add to their administrative burden, nor is it to reduce costs by decreasing the number of inpatient ward clerks. Basic CPOE ensures standardized, legible, and complete orders by only accepting typed orders in a standard format. CPOE systems are implemented with varying degrees of an integrated clinical decision support system (CDSS) that alerts the physician of a medication dosing error or potential drug interaction.4 Basic clinical decision support may include suggestions or default values for drug doses, routes, and frequencies. A more sophisticated CDSS can perform drug allergy checks, drug-laboratory value checks, and drug-drug interaction checks, and can provide reminders about corollary orders such as prompting the user to order lithium levels after ordering lithium.5 Traditional inpatient wards also utilize nursing staff who often scrutinize medication and laboratory orders for clarification when their clinical judgment and experience tells them that something appears amiss. In teaching hospitals, this role to check and validate orders is often crucial when resident physicians are clinically inexperienced with medication dosing strategies.

 

Benefits and Limitations of CPOE

 

CPOE systems are challenging to implement, but the projected benefits are real. CPOE has been demonstrably effective in improving both efficiency and accuracy of orders.6

 

Bates and colleagues,7 and Cullen and colleagues,8 in their reviews of CPOE and CDSS on medication errors, established that these systems can reduce serious medication errors by 55%. Additionally, there was a 17% decrease in adverse drug events, and as the study progressed, the frequency decreased. Jha and colleagues,9 in 1998 reported that CPOE identified more adverse drug events, but not at a statistically significant difference. Ozdas and colleagues10 demonstrated that CPOE-based initial order sets which implement standardized acute coronary syndrome recommendations for acute myocardial infraction significantly increased the number of patients who received aspirin.

 

In contrast to the popular opinion that CPOE has benefits for reduction of adverse drug events, Berger and Kichak11 challenge the Institute of Medicine1 report on rates of adverse events, as well as the conclusions of the Bates studies.6,7 The authors11 indicate that the rates of adverse events based on studies in the 1980s was flawed due to lack of control groups, and that there were other methodologic flaws. King and colleagues12 demonstrated that CPOE generated a 40% decrease in medication error rates, but no actual difference in morbidity or mortality was shown. Berger and Kichak11 also highlighted conflict of interest in the Leapfrog Group, where 10% of the companies are involved in sales of software or hardware to healthcare organizations. In a review of the literature in 2003, Oren and colleagues13 noted that despite the published evidence on the effects of CPOE and other technologies such as automated dispensing machines, bar coding, and computerized medication administration records, the literature supporting the impact of these technologies in the reduction of medication errors and adverse drug events was limited because many of these systems could not be generalized to other systems. King and colleagues,12 in a cohort retrospective study of CPOE use on a pediatric inpatient ward, found a 40% reduction in medication error rate, but not in improved adverse drug events.

 

Significant Barriers

 

Implementation of a CPOE system evokes strong emotion, as identified in a qualitative study by Sittig and colleagues.14 In this study, a secondary analysis was done on previously collected qualitative data sets from interviews and observations of individuals where CPOE was implemented. The authors note that negative emotional responses were the most prevalent of the observations, and the number of positive emotions was quite small. An interesting conclusion from this study was that most of the negative emotions were based on how the system provided negative feedback, such as a failure to complete a task or erroneous actions. The authors surmise that a positive feedback system, which provides education and congratulatory messages, may help physicians react differently to the system by recognizing how CPOE helps them to achieve their own objectives of quality care. In a survey of 143 Johns Hopkins School of Medicine students, Knight and colleagues15 demonstrated that 95% of medical students thought that CPOE would help them learn what types of tests and treatments their patients needed. However, limitations were due to housestaff and faculty not wanting students to enter orders, because it would require extra time spent training and reviewing the orders.

 

A more distressing issue is how new errors arise with information technology in healthcare. Based on qualitative study of CPOE in four hospital systems, Ash and colleagues16 highlight two types of errors—those which occur in the process of entering and retrieving information, and errors in the communication and coordination process. The authors note that many computer systems are not well designed. Thus, providers are required to direct and isolate their attention in order to avoid juxtaposition errors. Such errors are often due to choosing a selection on the screen that is close to the correct, desired selection. In addition, the highly structured data needs of CPOE systems do not fit into the “flow” of human thinking, which is geared more toward free text. Therefore, such shifts to check all of the boxes on the screen may create a loss of perspective on the patient and fragment the focus on care. In terms of communication and coordination, some problems are inherent in the way that a CPOE system is often inflexible, forcing physicians to work in a linear and structured fashion. Urgency in such a structured system could prevent nurses from executing stat orders to be charted later. Feedback via communication with other healthcare professionals is often critical, and a CPOE may falsely limit the discussion among professionals because it was assumed that everyone saw it in the system. These new errors are not the result of poor computer programming, but are rather due to poor design or poor implementation of a CPOE system (Table).

 

Implementation Issues

 

The decision to implement a CPOE system is not simply a matter of deciding that it is a good idea for improving quality of care and patient safety. Ash and colleagues,17 members of the Oregon Health & Science University’s Physician Order Entry Team, interviewed thirteen experts from around the globe for the purpose of developing recommendations for CPOE implementation.

 

Clearly, successful implementation requires more than administration approval, as evidenced by Cedar Sinai’s experience of CPOE termination without physician buy-in. Multiple factors, including workflow, cost, change-management principles, vendor readiness, long-term support, continued evaluation and education, and integration into work flow must be addressed and constantly monitored.18

 

Conclusion

 

CPOE, using computers to enter orders directly, appears to be a simple solution for reducing errors. However, converting from paper to computer is not a simple matter. An underlying system of checks and balances exists with other care providers such as nursing and pharmacists who play a significant role in the oversight process. Clinical decision support systems are necessary to make CPOE more successful in catching errors and changing behavior to implement guidelines. Addressing human factors and emotional response to change are crucial in the successful adoption of the CPOE system. Seamless integration into the workflow process is necessary to reduce resistance. CPOE at the present time appears to be a great idea, but it is a complex process. With improved mobile computer technology, secure wireless communication, and standardized information exchange between various healthcare computer systems, CPOE may find its way into medical practice on a standard basis. PP

 

References

 

1. Corrigan JM, Kohn LT, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 2000.

 

2. The Leapfrog Group. Available at: http://www.leapfroggroup.org. Accessed February 9, 2006.

 

3. Morrissey J. Harmonic divergence. Cedars-Sinai joins others in holding off on CPOE. Mod Healthc. 2004;34(8):16.

 

4. Osheroff JA, Pifer EA, Teich JM, Sittig DF, Jenders RA. Improving Outcomes with Clinical Decision Support: An Implementer’s Guide. Chicago, IL: Health Information Management and Systems Society; 2005.

 

5. Kaushal R, Bates DW. Computerized physician order entry (CPOE) with clinical decision support systems (CDSSs). In: Wachter RM. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment no. 43l. Agency for Healthcare Research and Quality. Contract No. 290-97-0013; 2001. Available at: http://www.ahrq.gov/clinic/ptsafety/chap6.htm. Accessed February 9, 2006.

 

6. Bates DW, Leape LL, Cullen DJ, et al. Effect of a computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA. 1998;280(15):1311-1316.

 

7. Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA. 1995;274(1):29-34.

 

8. Cullen DJ, Sweitzer BJ, Bates DW, Burdick E, Edmondson A, Leape LL. Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units. Crit Care Med. 1997;25(8):1289-1297.

 

9. Jha AK, Kuperman GJ, Teich JM, et al. Identifying adverse drug events: development of a computer-based monitor and comparison with chart review and stimulated voluntary report. J Am Med Inform Assoc. 1998;5(3):305-314.

 

10. Ozdas A, Speroff T, Waitman LR, Ozbolt J, Butler J, Miller RA. Integrating best of care protocols into clinicians’ workflow via care provider order entry: impact on quality of care indicators for acute myocardial infarction. J Am Med Inform Assoc. 2005. Available at: http://www.jamia.org/cgi/reprint/M1656v1. Accessed February 9, 2006.

 

11. Berger RG, Kichak JP. Computerized physician order entry: helpful or harmful? J Am Med Inform Assoc. 2004;11(2):100-103.

 

12. King WJ, Paice N, Rangrej J, Forestell GJ, Swartz R. The effect of computerized physician order entry on medication errors and adverse drug events in pediatric inpatients. Pediatrics. 2003;112(3 Pt 1):506-509.

 

13. Oren E, Shaffer ER, Guglielmo BJ. Impact of emerging technologies on medication errors and adverse drug events. Am J Health Syst Pharm. 2003;60(14):1447-1458.

 

14. Sittig DF, Krall M, Kaalaas-Sittig J, Ash JS. Emotional aspects of computer-based provider order entry: a qualitative study. J Am Med Inform Assoc. 2005;12(5):561-567.

 

15. Knight AM, Kravet SJ, Harper GM, Leff B. The effect of computerized provider order entry on medical student clerkship experiences. J Am Med Inform Assoc. 2005;12(5):554-560.

 

16. Ash JS, Berg M, Coiera E. Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. J Am Med Inform Assoc. 2004;11(2):104-112.

 

17. Computerized Physician/Provider Order Entry Team. Available at: http://www.ohsu.edu/dmice/research/cpoe/index.shtml. Accessed February 9, 2006.

 

18. Ash J. Considerations concerning computerized physician order entry implementation: The 2001 menucha conference list. Available at: http://www.ohsu.edu/dmice/research/cpoe/research/menucha_2001.pdf. Accessed February 9, 2006.

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Journal CMEs

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Psychiatric Disorders Following Return from Combat Duty During the Twenty-First Century

Thomas A. Grieger, MD, DFAPA, and David M. Benedek, MD, DFAPA

Needs Assessment: The current protracted warfare in Afghanistan and Iraq is exposing hundreds of thousands of American men and women to psychologic and physical trauma. These exposures may be severe and repetitive. Early studies of returning troops show patterns of illness onset and course of illness that differ from those seen in earlier wars. Awareness of the nature of post-deployment psychiatric problems and the nature of current effective treatment will assist clinicians in their assessment and treatment of post-deployment psychiatric disorders.

 

Learning Objectives:

 
  • Describe the differences in modern warfare and how changes in deployment and deployment exposures may alter risk for post-deployment psychiatric problems.
 
  • Examine the rates of psychiatric illness in prior wars compared to the rates seen following recent deployments.
 
  • Identify components of assessment of posttraumatic stress disorder (PTSD).
 
  • Identify the primary pharmacologic and psychotherapeutic treatment modalities for PTSD.
 


Target Audience:
Primary care physicians and psychiatrists.

 

Accreditation Statement: Mount Sinai School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

 

Mount Sinai School of Medicine designates this educational activity for a maximum of 3.0 Category 1 credit(s) toward the AMA Physician’s Recognition Award. Each physician should claim only those credits that he/she actually spent in the educational activity.

 

It is the policy of Mount Sinai School of Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. Presenters must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved drugs or devices.

 

To receive credit for this activity: Read this article and the two CME-designated accompanying articles, reflect on the information presented, and then complete the CME quiz. To obtain credits, you should score 70% or better. Termination date: March 31, 2008. The estimated time to complete all three articles and the quiz is 3 hours.

 

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Primary Psychiatry. 2006;13(3):45-50

 

Drs. Grieger and Benedek are associate professors and assistant chairmen in the Department of Psychiatry at the Uniformed Services University in Bethesda, Maryland.

 

Disclosure: Drs. Grieger and Benedek report no affiliation with or financial interest in any organization that may pose a conflict of interest.

 

Please direct all correspondence to: Thomas A. Grieger, MD, DFAPA, Department of Psychiatry, Uniformed Services University, 4301 Jones Bridge Rd, Bethesda, MD 20814; Tel: 301-295-9888; Fax: 301-295-1536; E-mail: tgrieger@usuhs.mil.


 

 

Abstract

 

Knowledge of the psychiatric consequences of combat deployment expanded rapidly during the late 20th century as large numbers of Vietnam veterans experienced substantial difficulties with readjustment upon return from deployment. Current warfare in Afghanistan and Iraq has resulted in the longest period of sustained combat exposure for United States forces since Vietnam. This article compares the nature of conflict, composition of deployed forces, combat exposures, and injuries in these deployment settings compared to late 20th century conflicts. It also reviews early findings on rates of psychiatric disorders among returning troops and compares these findings with those of studies of troops returning from prior conflicts. Evaluation and treatment approaches to posttraumatic stress disorder in combat veterans are then provided. Preliminary findings suggest that early assessment of veterans may not represent the long-term psychiatric needs of returning veterans and that ongoing surveillance and availability of psychiatric care will be needed for this population.

 

Introduction

 

Psychiatrists and other physicians have long recognized that the trauma of war results in psychologic changes in those who return; yet, the field of psychiatry struggled for decades to develop a clear description of the etiology, symptoms, and course of post-war psychiatric disorders. As recently as 1968, during the height of the war in Vietnam, the Diagnostic and Statistical Manual of Mental Disorders, Second Edition (DSM-II),1 subsumed war reactions under the category of transient situational disturbances.2 The concept of post-combat symptoms as a transient response to exposure led psychiatrists to focus on principles of restoration of function with the belief that symptoms would resolve without lasting morbidity.3 Medical and public policy interest in the long-term effects of combat on returning soldiers became heightened during the 1970s. It became apparent to clinicians that large numbers of soldiers returning from Vietnam were experiencing protracted difficulties with readjustment into civilian society. During this period, clinicians and researchers began to develop criteria to describe the psychiatric symptoms that later came to define posttraumatic stress disorder (PTSD), first recognized in the DSM-III.4

 

Early epidemiologic studies of PTSD included primarily civilians, but also a small percentage of Vietnam veterans. These studies found a 4% lifetime rate of PTSD in non-wounded veterans and 20% lifetime prevalence of PTSD in veterans wounded in combat.5 The most extensive study of veterans, the National Vietnam Veterans Readjustment Study (NVVRS), interviewed veterans using sophisticated sampling techniques and adjusted for demographic factors.6 The study found that 15.2% of male veterans who had been deployed to the combat theater had active PTSD at the time of interview, and that 11.1% had symptoms consistent with partial PTSD at the time of interview. Male theater veterans had a 30.9% lifetime prevalence of PTSD and a 22.5% lifetime prevalence of partial PTSD. Thus, >50% of theater veterans had experienced significant traumatic stress-related symptoms at some point following return from war. The NVVRS also found a 50% lifetime rate of alcohol abuse and a 10% lifetime prevalence of depression among those who experienced intense combat. Among male veterans with PTSD, there was an 80% lifetime prevalence of alcohol abuse and a 30% lifetime prevalence of depression. Since the study was epidemiologic in design, it did not address the causal association between the disorders, but did demonstrate high rates of comorbidity. Of note, the NVVRS found substantially higher rates of PTSD among soldiers who had been seriously injured (ie, received a Purple Heart), with up to one-third reporting symptoms consistent with PTSD at the time of the interview.

 

These earlier studies could not accurately address the onset and early course of psychiatric illness in combat veterans because they were conducted many years after the combat exposure and were subject to inaccuracies in recollection. Other studies have shown that recall of specific combat exposures changes over time, and that reporting an increased number of exposures during later evaluations is correlated with worsening health perception.7 Since symptoms of PTSD and reported exposures associated with those symptoms both change over time, there is reason to question the accuracy of reported exposure severity and its association with subsequent symptom severity when there has been an extended passage of time from the original traumatic event.8

 

Studies following Operation Desert Shield/Desert Storm (DS/DS) found that among the 15,000 troops surveyed upon return from combat deployment, 12.1% met criteria for PTSD. Among those with high levels of combat-related exposures, 22.6% met criteria for PTSD.9 This study was conducted approximately 4 years following return from deployment, so recall of exposures may have been subject to bias. The study was also limited in that it used a well-validated checklist, but did not include a clinical interview. Operation DS/DS was also unique in that it was a short-lived conflict with very few casualties among United States forces. The majority of US casualties resulted from non-combat injuries, such as motor vehicle accidents. Deployed troops returned to a hero’s welcome. Other late 20th century conflicts were also either short in duration (Somalia) or low intensity with regard to danger to US forces (Bosnia, Croatia, Kosovo).

 

The current major active US conflicts, Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), differ significantly in many respects from the wars of the late 1900s. The nature of combat, the characteristics of the service members deployed, the characteristics of traumatic exposure during deployment, the nature of injuries sustained, and the survival rate from injuries have all changed. Early studies of returning deployed combat and support troops provide some insight into the early onset and course of psychiatric illness. As with most early studies of newly identified populations at risk, these studies also identify questions regarding the longer term prognosis, need for surveillance, barriers to access and utilization of mental health resources during and after deployment, and optimal approaches to treatment.

 

Nature of Conflict

 

The conflicts in OEF and OIF have each evolved over time. Early in conflict, the advancement of US forces was swift, successful, and resulted in relatively few US deaths compared to those of opposition forces. Many believed these conflicts would end shortly after the initial invasions. The formerly oppressed citizens of Afghanistan and Iraq initially greeted US forces as liberators. The general tone of the US public at large was optimistic and supportive of the military efforts. In the months that have ensued there has been a rising level and sophistication of insurgent activity, increasing distrust of the US presence in those countries, a continuously rising US death toll, and declining popular support of the campaigns within the US and abroad.

 

Nature of Deployed Forces

 

Unlike Vietnam, OEF and OIF troops represent an all-volunteer force (regular active and reserves), and many have been seasoned by prior operations in DS/DS, Somalia, Bosnia, Kosovo, and Haiti. In OIF and OEF, the use of reserve forces has been more extensive than in earlier 20th century campaigns, and longer and repeated deployments have disrupted the day-to-day lives of these “citizen soldiers” and their families. Stresses include loss of income and extended family separation. It is unclear how these changes in level of prior combat experience as well as changes in deployment cycle frequency and duration will affect resilience or vulnerability to post-deployment problems.

 

Nature of Exposures

 

Longer and more frequent deployments increase the risk of exposure to traumatic events. The nature and range of the potential traumatic events are also more diverse. Potential risk in past conflicts was generally from predictable sources, such as small arms fire or rocket-propelled grenades. The extensive use of improvised explosive devices, mortar fire, car bombs, and suicide bombers during OEF and OIF has created an environment where living quarters, dining facilities, and routine day-to-day travel are all subject to attack. The effect of constant vigilance and arousal in such an environment on post-deployment psychiatric illness is unclear.

 

Nature of Injuries

 

Improvements in body armor have drastically reduced the number of life-threatening chest and abdominal injuries.10 Advancements in treatment have also reduced the number of deaths among injured soldiers who reach medical care.11 Consequently, many seriously injured soldiers (who would have died in previous conflicts) now survive. Examining the rate of post-deployment psychiatric illness in injured soldiers compared to that of non-injured combat troops is an area for investigation, since physical injury is a known risk factor for PTSD and depression.

 

Acute Rates of Probable PTSD and Depression in Non-injured Combat Soldiers

 

Hoge and colleagues12 examined >3,000 combat troops returning from OEF and OIF. These troops reported high levels of combat exposure. More than 80% of the survey population returning from Iraq reported having received incoming small arms and rocket or mortar fire. Using broad and strict definitions of PTSD and depression (the strict measures requiring high levels of distress in addition to the presence of symptoms), 12.2% to 19.9% of troops returning from Iraq met criteria for PTSD, and 7.1% to 15.2% met criteria for depression approximately 4 months after return from deployment. In troops returning from Afghanistan (where combat was generally less intense), 6.2% to 11.5% met criteria for PTSD and between 6.9% and 14.2% met criteria for depression. Between 24% and 35% of these returning troops also endorsed one or more alcohol misuse-related behaviors or symptoms. The most concerning finding in the Hoge study was that the majority of those who met criteria for illness and who acknowledged that their symptoms were causing problems had not sought care. Cited reasons for not seeking care often centered on the perception that doing so would damage one’s career, or fear that others would think less of them. The potential public health impact of these findings is substantial. Assuming that 15% of returning veterans experience either PTSD or depression, there are roughly 60,000 OEF and OIF veterans with active psychiatric illness.

 

Changes in Rates of Probable PTSD and Depression Across Time

 

Studies of civilian victims of trauma generally show a decline in PTSD symptoms over time, although some studies show a waxing and waning course.13,14 Studies from DS/DS demonstrate two general courses of PTSD symptoms in veterans over time.15 Those with relatively low levels of symptoms initially following deployment have a relatively small change in symptoms at later evaluation. In contrast, those with higher levels of initial symptoms report a greater increase in symptoms with the passage of time. Another DS/DS study found a 3% rate of probable PTSD in veterans within 5 days of return from deployment, and an 8% rate of probable PTSD in the same group when sampled 18–24 months later.16 A third study of DS/DS veterans also found increasing rates of PTSD and severity of PTSD symptoms at 2 years following deployment compared to 1 month following deployment.17 These findings contrast those of civilian survivors of motor vehicle accidents, where very few individuals develop PTSD after the first month and the overall rates of PTSD decline consistently during the following year.13 These differences suggest that there is a different mechanism for the development and sustainment of PTSD in soldiers who experience repeated trauma during combat than for civilians who are exposed to a discrete traumatic event.

 

Onset and Course of PTSD and Depression in Battle-Injured Soldiers

 

One study of soldiers seriously injured in combat found surprisingly low rates of PTSD and depression in the first month following injury.18 When re-evaluated 3 and 6 months later, the rates of PTSD and depression had both risen and were similar to those of non-injured combat soldiers.12 Of note, approximately 50% of those who initially met criteria for PTSD or depression no longer met criteria at 6 months, and nearly 80% of those who met criteria at 6 months had screened negative for both disorders at the initial evaluation. It was somewhat surprising that rates of PTSD and depression were not higher in injured soldiers, since earlier studies of terrorism survivors have found that injury during the attack was associated with a three-fold greater rate of PTSD and depression 2 years later compared to those not injured during the attack.19 However, this sample of injured soldiers was somewhat unique in that all injured soldiers received an extensive psychiatric evaluation and ongoing psychiatric treatment as indicated throughout the course of hospitalization for their injuries. Early psychiatric intervention may have delayed or reduced the onset or severity of PTSD in this group.

 

Later onset of PTSD and depression in this group demonstrates the need for ongoing surveillance and availability of mental health services following return from deployment. Reserve and National Guard forces traditionally have difficulty accessing mental health care once they are demobilized. Since many of the troops returning from deployment are entering this demobilized status, this poses an additional public health challenge.

 

Rates of PTSD and Depression in Deployed Healthcare Workers

 

A recent study of deployed and non-deployed healthcare providers from one military treatment center found a 7.5% rate of probable PTSD in those who deployed compared to a 1% rate of PTSD in those who did not deploy.20 An association was found with degree of exposure to life threatening events, such as receiving incoming fire, but not with exposure to injured or dead soldiers and civilians. This finding contrasts earlier findings from non-medical terrorism survivors where exposure to injured and the dead was associated with higher levels of PTSD and depression 2 years after the attack.19 These findings suggest that exposures to traumatic events may have different psychologic effects based on an individual’s professional experience and prior life experiences.

 

Recent PTSD Research

 

Epidemiologic studies of PTSD vary widely in sample selection, timing of the assessment, setting for the assessment, and criteria for defining the presence of illness. The studies from the current conflicts were all conducted shortly after return from deployment in contrast to prior studies involving assessment years following combat exposure. While the three cited studies12,18,20 all used the PTSD checklist to determine the presence of PTSD, the Hoge12 study involved anonymous paper surveys administered in a work setting, the Kolkow20 study involved an Internet-based anonymous survey, and the Grieger18 study involved use of the instrument in conjunction with ongoing psychiatric treatment in a clinical setting. The presence of PTSD symptoms are common among all returning personnel. Persistence of symptoms across time, issues of reunion or return to a work setting other than combat, interpersonal difficulties arising in response to PTSD symptoms, substance use, and the development of comorbid disorders all contribute to conditions where the high levels of distress or functional impairment required for the diagnosis of PTSD are more clearly evident. It would be premature to believe that the early reported rates of PTSD from the recent studies will reflect the eventual rates of PTSD and other psychiatric disorders in returning veterans.

 

Treatment Considerations

 

Deployment and deployment traumas are different for each war and different for each individual exposed to deployment and combat. As outlined in the American Psychiatric Association Practice Guidelines,21 any treatment program for patients with PTSD must begin with a detailed assessment of the patient. Practice guidelines provide both general and specific elements of evaluation. Components of the general assessment are outlined in Table 1. Some of the components of a military-specific evaluation are outlined in Table 2.

 

Multiple studies have found that the selective serotonin reuptake inhibitor (SSRI) class of antidepressants are effective in reducing the severity of intrusion, avoidance/numbing, and arousal symptoms in patients with PTSD.22-26 Many of the patients in these trials were experiencing chronic rather than acute PTSD, so the response to medication is very promising. Moreover, these trials demonstrated improved quality of life and continued effectiveness during continuation treatment.27,28 Most patients were female and only a small percentage had PTSD stemming from combat experiences. Response rates in predominantly male combat troops have been less promising. One international study29 included predominantly combat veterans. The response to medication was much less robust, but the study did demonstrate improvement with the use of fluoxetine at relatively high doses (mean=57 mg/day). This contrasts earlier studies that showed improvement in PTSD symptoms in non-combat veterans, but little improvement in Veterans Administration patients with PTSD.30 These studies suggest that in addition to difference in onset and course of PTSD resulting from combat compared to PTSD resulting from individual civilian trauma, there may also be a different response to treatment. Schoenfeld and colleagues31 and Friedman32 provide comprehensive reviews of the evidence supporting the use of medications other than SSRIs for the treatment of PTSD, including the use of other classes of antidepressants, antiadrenergic agents, anticonvulsants, lithium, benzodiazepines, and antipsychotic agents. It should be noted that many of the studies included in the reviews were of open-label design or involved small numbers of subjects, and therefore do not substantiate changes in the standard of practice.

 

Cognitive-behavioral therapy (CBT) and specifically prolonged exposure therapy have been demonstrated as effective treatments for acute stress disorder, PTSD, and depression.33 Most studies of psychotherapy for PTSD have been with victims of non-combat–related traumas, but there is also evidence of efficacy of these treatments for combat veterans with both acute and chronic PTSD. Unfortunately, many mental health professionals have not received formal training in CBT techniques and are not comfortable in performing this evidence-based treatment. Other unique variants of CBT, including virtual reality exposure and eye movement desensitization techniques, are also under investigation or have demonstrated some benefit to patients with PTSD. To date, there is no evidence that they demonstrate greater effectiveness than more traditional CBT approaches. Rauch and Cahill34 review data supporting the use of exposure therapy, stress-inoculation training, cognitive therapy, eye-movement desensitization, and CBT in the treatment of PTSD. Similarly, Ruzek and colleagues35 discuss at length the techniques and advantages of various forms of group psychotherapy for patients with PTSD.

 

Perhaps most important in the evaluation is a determination of what symptoms and functional impairments are most troubling to the individual veteran. This approach will greatly assist in the establishment of rapport and building a therapeutic alliance. It will also guide in the appropriate selection of pharmacologic and psychologic interventions. Rather than focusing primarily on PTSD symptoms, the returning veteran may be more concerned over issues of his or her substance use patterns, anger control, reintegration with family, reintegration with civilian employment, or dealing with injuries or changes in professional status or roles.

 

Conclusion

 

Warfare in the 21st century has markedly different characteristics compared to prior warfare environments. The nature of war exposures, nature of soldiers engaged in warfare, and duration and frequencies of deployment to the combat theater have resulted in different presentations of post-deployment psychiatric sequelae. Early sampling of service members returning from deployment shows a tendency of resilience for most. As past wars and some recent studies have demonstrated, the short-term findings may not accurately predict the long-term outcome for these service members. Ongoing surveillance will be vital to ensuring that appropriate mental health services are made available to those returning from deployment over time. A comprehensive assessment, followed by proper selection of pharmacologic and psychotherapeutic treatments, can optimize clinical outcome for those experiencing difficulties upon return from deployment. PP

 

References

 

1. Diagnostic and Statistical Manual of Mental Disorders. 2nd ed. Washington, DC: American Psychiatric Association; 1968.

 

2. Boulanger G. Post-traumatic stress disorder: an old problem with a new name. In: Sonnenberg SM, Sonnenberg SM, Blank AS, Talbott JA, eds. The Trauma of War: Stress and Recovery in Vietnam Veterans. Washington, DC: American Psychiatric Press; 1985:13-30.

 

3. Jones FD. Psychiatric lessons of war. In: Jones FD, Sparacino LR, Wilcox VL, Rothberg JM, Stokes JW, eds. War Psychiatry. Washington, DC: Borden Institute; 1995:1-34.

 

4. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. Washington, DC: American Psychiatric Association; 1980.

 

5. Helzer JE, Robins LN, McEvoy L. Post-traumatic stress disorder in the general population. Findings of the epidemiologic catchment area survey. N Engl J Med. 1987;317(26):1630-1634.

 

6. Kulka RA, Schlenger WE, Fairbank J, et al. Evidence of post-traumatic stress disorder. In: Kulka RA, Schlenger WE, Fairbank J, et al. Trauma and the Vietnam War Generation: Report of Findings from the National Vietnam Veterans Readjustment Study. New York, NY: Brunner/Mazel; 1990:50-72.

 

7. Wessely S, Unwin C, Hotopf M, et al. Stability of recall of military hazards over time. Evidence from the Persian Gulf War of 1991. Br J Psychiatry. 2003;183:314-322.

 

8. Southwick SM, Morgan CA 3rd, Nicolaou AL, Charney DS. Consistency of memory for combat-related traumatic events in veterans of Operation Desert Storm. Am J Psychiatry. 1997;154(2):173-177.

 

9. Kang HK, Natelson BH, Mahan CM, Lee KY, Murphy FM. Post-traumatic stress disorder and chronic fatigue syndrome-like illness among Gulf War veterans: a population-based survey of 30,000 veterans. Am J Epidemiol. 2003;157(2):141-148.

 

10. Patel TH, Wenner KA, Price SA, Weber MA, Leveridge A, McAtee SJ. A U.S. Army Forward Surgical Team’s experience in Operation Iraqi Freedom. J Trauma. 2004;57(2):201-207.

 

11. Gawande A. Casualties of war—military care for the wounded from Iraq and Afghanistan. N Engl J Med. 2004;351(24):2471-2475.

 

12. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med. 2004;351(1):13-22.

 

13. Ursano RJ, Fullerton CS, Epstein RS, et al. Acute and chronic posttraumatic stress disorder in motor vehicle accident victims. Am J Psychiatry. 1999;156(4):589-595.

 

14. O’Donnell ML, Creamer M, Pattison P. Posttraumatic stress disorder and depression following trauma: understanding comorbidity. Am J Psychiatry. 2004;161(8):1390-1396.

 

15. Orcutt HK, Erickson DJ, Wolfe J. The course of PTSD symptoms among Gulf War veterans: a growth mixture modeling approach. J Trauma Stress. 2004;17(3):195-202.

 

16. Wolfe J, Erickson DJ, Sharkansky EJ, King DW, King LA. Course and predictors of posttraumatic stress disorder among Gulf War veterans: a prospective analysis. J Consult Clin Psychol. 1999;67(4):520-528.

 

17. Southwick SM, Morgan CA 3rd, Darnell A, et al. Trauma-related symptoms in veterans of Operation Desert Storm: a 2-year follow-up. Am J Psychiatry. 1995;152(8):1150-1155.

 

18. Grieger TA, Cozza S, Engel CC, et al. NR 604 Course of PTSD and depression in battle-injured soldiers. Presented at: 158th Annual Meeting of the American Psychiatric Association; May 21-26, 2005; Atlanta, GA.

 

19. Grieger TA, Waldrep DA, Ursano RJ, Lovasz M. The enduring imact of terrorism: follow up of Pentagon employees two years following the attack. Psychiatr Serv. 2005;56(11):1374-1378.

 

20. Kolkow TT, Grieger TA, Morse JS, Spira J. Post-deployment distress in medical personnel following deployment. Poster presented at: 158th Annual Meeting of the American Psychiatric Association; May 21-26, 2005; Atlanta, Georgia.

 

21. American Psychiatric Association Practice Guidelines. Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Posttraumatic Stress Disorder. Available at: http://www.psych.org/psych_pract/treatg/pg/PTSD-PG-PartsA-B-C-New.pdf. Accessed February 1, 2006.

 

22. Tucker P, Zaninelli R, Yehuda R, Ruggiero L, Dillingham K, Pitts CD. Paroxetine in the treatment of chronic posttraumatic stress disorder: results of a placebo-controlled, flexible-dosage trial. J Clin Psychiatry. 2001;62(11):860-868.

 

23. Londborg PD, Hegel MT, Goldstein S, et al. Sertraline treatment of posttraumatic stress disorder: results of 24 weeks of open-label continuation treatment. J Clin Psychiatry. 2001;62(5):325-331.

 

24. Davidson JR, Rothbaum BO, van der Kolk BA, Sikes CR, Farfel GM. Multicenter, double-blind comparison of sertraline and placebo in the treatment of posttraumatic stress disorder. Arch Gen Psychiatry. 2001;58(5):485-492.

 

25. Brady K, Pearlstein T, Asnis GM, et al. Efficacy and safety of sertraline treatment of posttraumatic stress disorder: a randomized controlled trial. JAMA. 2000;283(14):1837-1844.

 

26. Marshall RD, Beebe KL, Oldham M, Zaninelli R. Efficacy and safety of paroxetine treatment for chronic PTSD: a fixed-dose, placebo-controlled study. Am J Psychiatry. 2001;158(12):1982-1988.

 

27. Davidson J, Pearlstein T, Londborg P, et al. Efficacy of sertraline in preventing relapse of posttraumatic stress disorder: results of a 28-week double-blind, placebo-controlled study. Am J Psychiatry. 2001;158(12):1974-1981.

 

28. Rapaport MH, Endicott J, Clary CM. Posttraumatic stress disorder and quality of life: results across 64 weeks of sertraline treatment. J Clin Psychiatry. 2002;63(1):59-65.

 

29. Martenyi F, Brown EB, Zhang H, Prakash A, Koke SC. Fluoxetine versus placebo in posttraumatic stress disorder. J Clin Psychiatry. 2002;63(3):199-206.

 

30. van der Kolk BA, Dreyfuss D, Michaels M, et al. Fluoxetine in posttraumatic stress disorder. J Clin Psychiatry. 1994;55(12):517-522.

 

31. Schoenfeld FB, Marmar CR, Neylan TC. Current concepts in pharmacotherapy for posttraumatic stress disorder. Psychiatr Serv. 2004;55(5):519-531.

 

32. Friedman MJ. Pharmacologic management of posttraumatic stress disorder. Primary Psychiatry. 2003;10(8):66-73.

 

33. Foa EB, Meadows EA. Psychosocial treatments for posttraumatic stress disorder. In: Yehuda R, ed. Psychological Trauma (Review of Psychiatry). Vol 17. Washington, DC: American Psychiatric Press; 1998:179-204.

 

34. Rauch SM, Cahill SP. Treatment and prevention of posttraumatic stress disorder. Primary Psychiatry. 2003;10(8):60-65.

 

35. Ruzek JI, Young BH, Walser RD. Group treatment of posttraumatic stress disorder and other trauma-related problems. Primary Psychiatry. 2003;10(8):53-57.

 

Return

Dr. McMeekin is a psychiatrist in private practice at Piedmont Psychiatric Associates in Rock Hill, SC.

Acknowledgments: Dr. McMeekin is a regional speaker for Novartis Pharmaceuticals. The author reports no financial, academic, or other support of this particular work.


 

Abstract

A case of bipolar illness is presented demonstrating the varied presentations of the illness longitudinally, the effects that hormonal events and therapy can produce in bipolar patients, and how adequate mood stabilization can modify those events.

Introduction

Most gender-related studies and those that examine the impact of hormones on the onset of emotional illness have focused on major and minor depression. It is only recently that the effects of hormones and reproductive-related events have been studied in larger bipolar populations. The results have shown significant hormonal sensitivity in bipolar women.1 The more subtle and comorbid presentations of bipolar illness are often difficult to diagnose. This can delay accurate treatment and lead to significant psychosocial morbidity. Treatment based solely on current symptoms can be misleading, and a detailed longitudinal history accompanied by input from family members is often necessary for accurate diagnosis.2 Described here is a longitudinal case history illustrating the variability of symptoms and hormonal sensitivity in a female bipolar patient.
 

Case

A 45-year-old white woman was referred for treatment of chronic depression not responsive to, or even worsened by, most antidepressant medications.
 

During her initial interview she presented as poised and organized. However, this changed as she spoke; she became more disorganized in her thinking and speech, as she would become distracted by a thought or an outside diversion (such as a noise or a movement) and “block,” forgetting her line of thought. When questioned about this, she replied that she had often wondered if she had attention-deficit/hyperactivity disorder. Her main symptoms were compatible with mixed bipolar depression and included racing thoughts, insomnia, blunting of emotions with decreased ability to feel pleasure and intimacy, and marked anxiety with periods of panic, depressed mood, irritability, decreased energy, and a sense of boredom. There was a marked obsessive quality to her depression, as she was constantly ruminating about her “mistakes” and whether she should change jobs or marry her current boyfriend. She denied suicidal thoughts or psychotic thinking. Her memory was good. She sat rigidly and appeared tense, with little spontaneous movement other than her leg, which shook constantly. When she did move, her gestures were quick and hesitant.
 

In retrospect, she had first noted mild depression at the age of 9 years. She experienced her first hypomanic period at age 18 years, where she enjoyed an elevated mood, decreased need for sleep, increased energy, increased sexual drive, and an increased sense of well-being. This lasted for several months before she returned to her usual mildly depressed state. This pattern continued throughout her life, worsening with time. By age 35 years, her illness had progressed so that she felt “addicted to men.” She would “fall in love” and engage in “whirlwind romances,” which often involved activities such as sky diving, jaunts to foreign countries, and other exotic and sometimes dangerous activities. Her mood would then shift to an anxious, agitated depression and she would begin to worry about whether “she was making the wrong choice.” She broke numerous engagements while depressed and would ruminate about her career and lifestyle choices until her mood shifted into mania, after which she would begin the process anew. Some years she experienced four complete cycles. She would make impulsive decisions during her excited manic periods, changing jobs and residences often. This pattern shifted after she was diagnosed with Crohn’s disease at age 39 years and began treatment with prednisone.
 

With prednisone her mood shifted into a sustained period of mild mania that continued as long as she was given the medication. When the medication was stopped, she would shift into a chronic mixed depression. This pattern repeated each time prednisone was used to control an exacerbation of her Crohn’s disease. Control of her emotional state was complicated by her becoming perimenopausal and requiring hormonal replacement with 0.2 mg estrogen patches and 5 mg of progesterone for 10 days every 3 months to induce menses. She reported that the estrogen had no effect on her mood, but that she became “depressed” during and for a time following the progesterone therapy. She had not responded to or become irritable and hyperactive on clomipramine, sertraline, paroxetine, and bupropion. She reportedly had not responded to a trial of lithium or valproate, but tolerated and had a partial response to venlafaxine 225 mg/day that decreased with time. Her medications, when first evaluated, included venlafaxine 37.5 mg sustained release tablets, alprazolam 0.125–0.25 mg three to four times per day as needed for anxiety, and zolpidem 5–10 mg for sleep. Her other medications included the previously mentioned estrogen and progesterone, and mercaptopurine 25–50 mg/day for her Crohn’s disease.
 

Family, Medical, and Social History

There was a family history of depression and bipolar disorder. Her birth and early development were without difficulties. She had her menarche at age 9 years and gradually developed severe premenstrual symptoms, including racing thoughts, irritability, sensory hypersensitivity, and difficulty sleeping prior to each menstrual period. She had no allergies, accidents, or severe reactions to medications.
 

She was a high school and college graduate. She never married and had never been pregnant. She was extremely successful in her chosen profession. She had no police record, had never been in serious financial problems, and had never used illegal drugs or abused alcohol.
 

Treatment

The patient’s treatment was typified by disappointing responses to medications. She was continued on venlafaxine, alprazolam, and zolpidem. To this regimen was first added quetiapine 25 mg/day (discontinued due to sedation) and then lamotrigine 25 mg/day (discontinued due to agitation). She  responded to 7.5 mg of olanzapine with less anxiety and a stabilization of her mood cycles. Topiramate 50 mg was added for further mood stabilization and to prevent weight gain. Her mood improved and stabilized, her concentration improved, and she became less obsessive. She then decompensated, with her thoughts becoming disjointed and speeded, her sleep becoming broken, and her irritability and depression worsening. Her symptoms then began to decrease and she restabilized on olanzapine and topiramate.

After several months of increased stability and decreasing need for the olanzapine, she decompensated again. This time it was noted that it occurred after she had taken progesterone 5 mg for 10 days. Further discussions confirmed this pattern of deterioration coinciding with her course of progesterone. Her gynecologist prescribed norethindrone 0.35 mg in place of the progesterone, with the same increase in symptoms resulting. Her gynecologist then stopped her hormones and prescribed an injection of 3.75 mg leuprolide. The patient gradually began to feel more agitated and pressured, her anxiety and depression worsened, and her sleep deteriorated. This state lasted approximately 6 weeks. The leuprolide was determined to be the cause and no further injections were given. Hysterectomy was discussed and rejected by the patient.
 

The patient was able to tolerate a maximum of olanzapine 10 mg/day due to sedation, and topiramate 50 mg/day due to agitation. Neither was sufficient to fully control her symptoms while using the progesterone and norethindrone, or after taking the leuprolide. When taking estrogen alone she stabilized with olanzapine 1.25 mg, topiramate 25 mg, and venlafaxine 25 mg/day. She continued taking mercaptopurine 25 mg/day and promethazine 12.5 mg as needed for nausea caused by the mercaptopurine.
 

In an attempt to find a medication that the patient could tolerate at higher doses, she was given a trial of oxcarbazepine, and topiramate was stopped. The result was a complete remission of symptoms at 1,200 mg/day. The patient was able to concentrate and her distractibility ceased. Her movements were smoother and her facial expressions became more fluid, better following and reflecting her inner emotions and thoughts. Her obsessions stopped and she was able to make decisions without difficulty.
 

Unfortunately, side effects of nausea and stomach pain caused by the oxcarbazepine forced a decrease in the dose to 150 mg BID. Her side effects stopped, but her baseline depression, obsessions, and racing thoughts returned. When she returned 1 month later, she had gone through a course of progesterone and had an exacerbation of her symptoms. She decided to increase her oxcarbazepine by adding “micro” doses as tolerated. By her return she was taking 1,200 mg/day and was back in remission.
 

When she returned in 3 months she was taking olanzapine 1.25 mg, venlafaxine 25 mg, and oxcarbazepine 600 mg BID. Several events had occurred: First, she had gone through a progesterone-induced period with minimal effect. She also reported that she became irritable “the last 4 days,” but that this irritability remitted shortly after the progesterone was stopped. There was no evidence of bipolar illness on her return. She appeared confident; spoke clearly and to the point; and her movements, affect, and speech reflected the emotional stability she now felt.
 

One year later, her symptoms remain in remission except for some mild anxiety following her use of progesterone. Her Crohn’s disease is also in remission and she has stopped the mercaptopurine.
 

Discussion

This case demonstrates the overlapping and sometimes confusing effects of steroids and neuropeptides on mood and behavior in many patients with bipolar disorder. The suspected reason for variability is the probability that no single gene is responsible for the disease, but rather multiple genes interact to determine severity, symptoms produced, and treatment response.3
 

One area of increasing interest in mood disorders is the hypothalamic-pituitary-adrenal (HPA) axis. Patients with major depression have been shown to have enlargement of the pituitary and adrenal glands. This is believed to reflect an increased production of corticotropin-releasing hormone (CRH), which has been shown, in animals, to produce behavior resembling depression, increased vigilance, anxiety, and dysregulation of sleep. Normally, glucocorticoid receptors regulate the activity of the HPA axis and the production of CRH, adrenocorticotrophic hormone, and, ultimately, cortisol. Inability of a standard test dose of the steroid dexamethasone to suppress HPA axis overactivity is the basis of the dexamethasone suppression test (DST).
 

Evidence of continued HPA axis hyperactivity, even with symptomatic improvement with treatment, is a predictor of relapse. DST nonsuppression has been a consistent finding in major depression and a frequent (but not consistent) finding in mixed bipolar states (a combination of irritable-anxious mania and depression), but has not been found in euphoric mania.4,5
 

Regulation of female reproductive hormones is controlled by the hypothalamic-pituitary-ovarian (HPO) axis. The hypothalamus secretes gonadotropin-releasing hormone (GnRH) in a pulsatile fashion that stimulates follicle stimulating hormone (FSH) and luteinizing hormone (LH). Of these, the matching LH pulse frequency is most critical. LH pulse frequencies that are too rapid (as in polycystic ovary disease) or too slow (as in hypothalamic amenorrhea) lead to anovulation.6 Leuprolide is a potent GnRH agonist which initially overstimulates and then “down regulates” the receptor, causing an initial rise then a reversible suppression of the synthesis and release of LH and FSH.
 

The GnRH agonists have been used effectively in premenstrual dysphoric disorder, precocious puberty, carcinoma of the prostate, endometriosis, uterine fibroids, and polycystic ovarian disease. The frequency of psychiatric symptoms incurred by the use of GnRH agonists appears to be underappreciated. These symptoms include anxiety states, delirium, mania, depression, and psychosis associated with paranoia and auditory hallucinations. Sertraline has been reported to correct these symptoms even when the leuprolide injections are continued.7
 

Stress activates the HPA axis and may inhibit the HPO axis and reproductive functioning in women with depression. There have been findings of mean plasma estradiol levels being 30% less in women with major depression compared to matched controls. Estradiol has effects on brain levels of serotonin and norepinephrine. Estradiol also has anxiolytic effects6 and, when used with a transdermal delivery system, 17-β-estradiol has been shown to have antidepressant effects in perimenopausal women.8 Bipolar patients report a 20% increase in psychiatric problems during the perimenopausal/ menopausal phase of life. Seventy percent report depressive syndromes, 20% report anxiety and agitation, and 20% have manic episodes (some for the first time).1
 

Progesterone’s role in producing psychiatric symptoms in the general population has been studied by examining users of depot-medroxyprogesterone acetate in a health maintenance organization. Depressive symptoms were found in 40% of users and 60% of those discontinuing its use.9 The effects of estrogen or estrogen plus progesterone have been studied in postmenopausal women without psychiatric histories. No change in mood was found with estrogen alone; a slight but statistically significant increase in daily anxiety was noted when progesterone was added.10 There is more evidence for exacerbation if a prior psychiatric illness is present. If women with a prior history of postpartum depression are first given leuprolide to induce a hypogonadal state for 1 month, are then given supraphysiologic levels of estradiol and progesterone for 8 weeks to mimic pregnancy, and are then abruptly withdrawn from those hormones to mimic delivery, 62.5% will develop significant mood symptoms, with some showing mania.11
 

There is evidence of a hormonal effect in bipolar I women. In a survey, 45.3% reported severe psychiatric symptoms either during pregnancy or within 1 month after childbirth, with 86% of these women reporting depression as their major symptom. A small percentage reported “increased mood cycling or shifts from manic to depressed mood after delivery.” Also, 66% reported mood changes either prior to or during their menstrual cycles, with the majority (75%) reporting anger and mood lability as their primary symptoms. As noted previously, approximately 20% of bipolar women describe an increase in psychiatric symptoms during the perimenopausal and postmenopausal phase of their reproductive life.1
 

Leuprolide-induced sustained mania and mania followed by depression have been reported previously.12,13 The patient noted here had a prior history of documented bipolar disorder with a moderate but stable response to treatment that was destabilized by leuprolide, norethindrone, and progesterone. With the use of these drugs, a mixed anxious and depressed state resulted that was similar to that seen during her depressive episodes, but with greater intensity. To my knowledge, this is the first evidence of leuprolide-exacerbated mixed bipolar disorder to be reported in the literature.
 

In reporting her symptoms during an initial evaluation, she emphasized their depressive and anxious qualities. It was only on direct questioning that she recounted her racing thoughts, her nonstop intrusive and obsessive negative thinking, and her marked distractibility and sensory hypersensitivity to repetitive noises and noxious stimuli, suggesting a dysphoric manic diagnosis. It was only after some improvement that she was able to recount earlier euphoric manic episodes. No evidence of euphoric mania was seen during her period of treatment.
 

Conclusion

The patient’s symptoms show the myriad ways that steroids affect patients with bipolar spectrum disorder, and the beneficial effects that adequate mood stabilization can produce. Problematically, most of these patients present in a depressed or anxious and irritable state, and are often treated with antidepressants. While antidepressants as monotherapy in bipolar patients may be helpful,14 they may (as occurred in this patient) have no effect or have an initial response with decay. Antidepressants remain an important and effective therapeutic tool, but there is increasing awareness of their limitations in controlling symptoms and preventing suicide in bipolar patients,15 and of the need for adequate mood stabilization with drugs such as lithium or anticonvulsants as the cornerstone of therapy.16   PP
 

References

1.    Blehar MC, Depaulo JR Jr, Gershon ES, Reicht T, Simpson SG, Nurnberger J. Women with bipolar disorder: findings from the NIMH genetics initiative sample. Psychopharmacol Bull. 1998;34(3):239-243.
2.    Bowden CL. Update on bipolar disorder: epidemiology, etiology, diagnosis, and prognosis. Medscape Mental Health. 1997;2:1-9.
3.    Souery D, Rivelli SK, Mendlewicz J. Molecular genetic and family studies in affective disorders: state of the art. J Affect Disord. 2001: 62:45-55.
4.    Pariante CM, Miller AH. Glucocortcoid receptors in major depression: relevance to pathophysiology and treatment. Biol Psychiatry. 2001;49(5):391-404.
5.    Risby E, Hartline K, Owens MJ, Nemeroff CB. Neuropeptides in bipolar disorder. In: Young T, Joffe R, eds. Bipolar Disorder: Neurobiology and Clinical Applications. New York, NY: Marcelle Decker; 1996.
6.    Young E, Midgley A, Carlson N, Brown M. Alteration in the hypothalamic-pituitary-ovarian axis in depressed women. Arch Gen Psychiatry. 2000;57:1157-1162.
7.    Warnock JK, Bundren JC. Anxiety and mood disorders associated with gonadotropin-releasing hormone agonist therapy. Psychopharmacol Bull. 1997;33(2):311-316.
8.    Soares C, Almedida Op, Joffe H, Cohen LS. Efficacy of estradiol for the treatment of depressive disorders in perimenopausal women. Arch Gen Psychiatry. 2001;58:529-534.
9.    Civic D, Scholes D, Ichikawa L, LaCroix AZ, Yoshida CK. Depressive symptoms in users and non users of depo-medroxyprogesterone acetate. Contraception. 2000;61(6):385-390.
10.    Girder SS, O’Briant C, Steege J, Grewen K, Light KC. A comparison of the effect of estrogen with or without progesterone on mood and physical symptoms in postmenopausal women. J Womens Health Gend Based Med. 1999;8(5):637-646.
11.    Bloch M, Schmidt PJ, Danaceau M, Murphy J, Nieman L, Rubinow DR. Effects of gonadal steroids in women with a history of postpartum depression. Am J Psychiatry. 2000;157(6):924-930.
12.    Rachman M, Garfield DA, Rachman I, Cohen R. Lupron-induced mania. Biol Psychiatry. 1999;45(2):243-244.
13.    Sussman N. Leuprolide-induced mania: gonadotropin-releasing hormone agonist-associated mood disorder. Primary Psychiatry. 2000;7(4):26-31.
14.    Haykal RF, Akiskal HS. The long-term outcome of dysthymia in private practice: clinical features, temperament, and the art of management. J Clin Psychiatry. 1999;60(8):508-518.
15.    Baldessarini RJ, Tondo L, Hennen J. Effects of lithium treatment and its discontinuation on suicidal behavior in bipolar manic depressive disorders. J Clin Psychiatry. 1999;60(suppl 2):77-84.
16.    Frye MA, Ketter TA, Leverich GS, et al. The increasing use of polypharmacotherapy for refractory mood disorders: 22 years of study. J Clin Psychiatry. 2000;61(1)9-15.

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e-mail: ns@mblcommunications.com

 

Dr. Sussman is editor of Primary Psychiatry as well as professor of psychiatry and interim chairman in the Department of Psychiatry at the New York University School of Medicine in New York City.

Dr. Sussman reports no affiliation with or financial interest in any organization that may pose a conflict of interest.


 

For decades, clinicians have been bombarded with the results of clinical trials and meta-analyses that purport to show differences—or lack thereof—between therapeutic agents. Sorting through the evidence can be daunting, especially for someone not well versed in statistics and study design. If new funding has its intended impact, this situation may soon change. The following news item, which appeared in the New York Times on February 15, 2009,1 provides the background for this impending shift in the way drugs and other therapies are evaluated and compared:

WASHINGTON — The $787 billion economic stimulus bill approved by Congress will, for the first time, provide substantial amounts of money for the federal government to compare the effectiveness of different treatments for the same illness.

Under the legislation, researchers will receive $1.1 billion to compare drugs, medical devices, surgery and other ways of treating specific conditions. The bill creates a council of up to 15 federal employees to coordinate the research and to advise President Obama and Congress on how to spend the money.

The program responds to a growing concern that doctors have little or no solid evidence of the value of many treatments. Supporters of the research hope it will eventually save money by discouraging the use of costly, ineffective treatments…

The money will be immediately available to the Health and Human Services Department but can be spent over several years. Some money will be used for systematic reviews of published scientific studies, and some will be used for clinical trials making head-to-head comparisons of different treatments.1

The stimulus bill, which creates the Federal Coordinating Council for Comparative Effectiveness Research, is a top priority for President Obama’s administration in its mission to provide more care and better quality care, and to make health care more cost effective. Predictably, reactions to passage of the bill have been mixed.

Those who prescribe psychotropic medications recognize that prediction of treatment response is virtually impossible. Among the most widely used types of these medications, the antidepressants and antipsychotics, the overall likelihood of a patient being helped by any drug in a therapeutic class is about the same. No one can predict which drug is best for a patient until they have actually been tried on medication. One size does not fit all, so having many options is helpful. Currently, the option of finding the right drug for the right patient is taken for granted. However, this may change under the new system.

As would be expected, pharmaceutical companies and device makers are concerned about the impact of a comparative effectiveness board. Although not mandated, one goal of the new board will be cost control. The government could theoretically establish price controls through Medicare and Medicaid programs. A widely expressed concern is that the government, which foots the bill for most medication, might wind up being more concerned with cost than with minor differences in treatment effects.

At the moment, the pharmaceutical and device industries find themselves in an awkward position. Almost daily disclosures of buried studies and manipulation of physicians has engendered mistrust among clinicians and the public. These practices have made many physicians question the validity of any data that show an advantage for one psychotropic treatment over another. In that respect, one of the best aspects of the funding for this program is that it will not only facilitate analysis of the existing evidence but will also result in sponsorship of trials that industry will not support.

There is a British National Health Service version of the comparative effectiveness board. The National Institute for Health and Clinical Excellence (NICE) controls the available choice of treatment availability, just as a formulary committee would. NICE is a national organization that evaluates data on how well treatments work and what they cost. There has been considerable controversy when NICE has declined to pay for experimental treatments for life-threatening diseases. The same has occurred in the United States when insurance companies refuse to cover a treatment or procedure.

Overall, if it is done correctly, a comparative effectiveness board could provide accurate guidance for clinicians making treatment decisions. There are several pitfalls that will need to be addressed. One has to do with the fact that there are marked differences between individuals in terms of how they respond to the therapeutic effects of a treatment and how they absorb and metabolize medication. These differences may be gender based or based on ethnic factors. What probably will get worse is the paperwork needed to override a denial of treatment that cites the board’s findings as justification for that rejection. However, if there is just one national policy on which drugs can be prescribed—at least as initial therapy—it might mean that clinicians do not have to deal with the multiple pharmacy benefit managers that currently send their “prior approval” letters.

On balance, I wish the current system worked better. I wish there were no constraints when I make a treatment decision. Nevertheless, it is obvious that we all could benefit from objective evidence about the benefits, risks, and costs of these treatments. Unless an alternative strategy is devised, the intervention of the federal government may represent the only option we have. It is important that there be complete transparency, as well as policing of potential conflicts of interest. If comparative effectiveness research facilitates improved treatment decisions, it should be welcomed. PP

Reference

1.    Pear R. “U.S. to Compare Medical Treatments.” New York Times. February 16, 2009: A1. Available at: www.nytimes.com/2009/02/16/health/policy/16health.html?_r=1. Accessed March 23, 2009.

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Dr. Corcoran is director of the Center of Prevention and Evaluation Clinic at the New York State Psychiatric Institute in New York City.

Disclosure: Dr. Corcoran receives research support from the Irving Scholar Award to support clinical research (Endowment from Herbert and Florence Irving) and the National Institute of Mental Health.

Please direct all correspondence to: Cheryl Corcoran, MD, Director, Center of Prevention and Evaluation Clinic, New York State Psychiatric Institute, 1051 Riverside Dr, Rm 4804, New York, NY 10032; Tel: 212-543-6177; Fax: 212-543-6176; E-mail: cc788@columbia.edu.


 

This issue of Primary Psychiatry examines a hot topic—the relationship of cannabis use to psychosis—from some novel perspectives, including that of the busy clinician treating patients with intractable dual diagnosis, and spanning prodromal research, challenge studies with drugs of abuse, and electronic tools for examining a “slice of life” in the experience of a young person with beginning substance use and emerging psychotic symptoms. Throughout, each article considers the evidence for the premise of a causal relationship of cannabis use to psychosis and then examines the implications of this for psychotic disorders—their course and prognosis, what may be safe and efficacious treatment, and a consideration of the biologic basis for an association of cannabis use and psychosis in a developmental context.

The first article is by Wilfrid N. Raby, MD, PhD, who has decades of clinical experience treating individuals comorbid for both psychotic disorders and substance misuse. Dr. Raby demonstrates that marijuana is not benign, especially for those with psychotic disorders who have less adherence to treatment; greater relapse rates; and higher levels of risk for violence, victimization, and self-harm. He focuses on the need for integrated treatment, including cognitive-behavioral therapy and motivational interviewing, with a reliance on long-term residential treatment for particularly intractable comorbid illness. He concludes with an impressive case for clozapine for “dually diagnosed” schizophrenia, which leads to a reduction of drug use in ~70% of cases and decreases in relapse risk as well.

Michael T. Compton, MD, MPH, and Claire E. Ramsay,  MPH, provide a conceptual framework for considering the co-evolution of cannabis misuse and psychotic symptoms in adolescence, specifically the stress-diathesis model in which vulnerability interacts with exposures to lead to symptoms. They make a strong case for the premise that cannabis use hastens the inevitable onset of psychosis in vulnerable individuals, which is not negligible in import given how strongly associated earlier onset of psychosis is to poor course and outcome in schizophrenia and related disorders. They carefully examine how cannabis use and prodromal symptoms may influence one another among vulnerable teens, agnostic as to any conclusions about causality. They enumerate the several caveats to keep in mind in considering any causal association, including multiple drug use, consideration of potential confounders and moderators (eg, gender and family history), and methodologic concerns, specifically with retrospective assessments.

David Kimhy, PhD, and colleagues tackle this very concern raised by Ramsay and Compton, namely the limitations of retrospective assessments in examining the relationship of cannabis use to psychotic symptoms and disorders. They enumerate the many problems with retrospective assessments (identified as problematic also by the Food and Drug Administration), which include problems with accuracy due to memory impairments and biases in recall due to affective states and cognitive reframing. These problems may be particularly salient for phenomena such as thoughts and feelings in the context of normal and altered states, which can be transitory. They describe a methodology which obviates many of these problems seen with retrospective assessments in the laboratory, specifically Computerized Experience Sampling Methodology (ESM), which involves the use of Palm pilots outside of the laboratory, electronic devices which prompt study participants several times per day (with a beep) to answer screen queries as to  feelings, thoughts, stresses, and drug use. Such frequency of sampling in ESM enables the use of time-lag analyses to examine the presence of temporal sequence, a condition for causality. Namely, does cannabis use precede psychotic-like symptoms? Do psychotic-like symptoms precede cannabis use? Further, as Palm Pilots are carried outside the laboratory, data are collected in real time in the real world, and are “ecologically valid.” ESM enables the examination of motivations for drug use as well as the social contexts in which drug use occurs. The use of ESM has proven feasible in youths both who use drugs and who are vulnerable to psychosis, and can be used as a clinical tool which improves the efficacy of cognitive-behavioral therapy (CBT) through its use in “homework.” The hope is that ESM and CBT together might reduce cannabis use in vulnerable teens, such that psychosis onset is forestalled and outcome improved.

Nehal P. Vadhan, PhD, and colleagues address the thorny issue of causation through reviewing studies in the experimental manipulation of drug exposure, specifically cannabis challenge in the laboratory. Challenge studies eliminate confounds and permit the evaluation of biologic correlates of drug effects. A leading theory of pathophysiology in schizophrenia and its related disorders highlights the importance of working memory deficits in mediating the various symptoms of the illness. Outside of the realm of research on psychotic disorders, it has been observed that the active ingredient of cannabis, specifically Delta 9-tetrahydrocannabinol, when administered in the laboratory, can induce transient working memory deficits in otherwise healthy individuals. In a sense, cannabis challenge is a transient functional lesion study of the normal brain and its cognitive function. Whereas a few studies have examined symptoms and affective sequellae of cannabis challenge in individuals with psychosis vulnerability, it remains to be learned whether these effects are mediated by perturbation of working memory.

The question of a causal association between cannabis use and psychosis carries great import as cannabis use may be a uniquely modifiable risk factor for psychosis. Data suggest that for vulnerable young people, cannabis use can precipitate psychosis and have lifelong consequences in terms of subsequent illness. For individuals with psychosis, continued use of cannabis is related to a heightened risk of injury and harm, as well as poor outcome. With methodologies outside of traditional clinical interview, such as experience sampling and laboratory challenge, we may respectively develop a better understanding of the motivation and context of use, and the biologic underpinnings of its effects, such that more efficacious interventions can be developed. PP

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This interview took place on February 3, 2009 and was conducted by Norman Sussman, MD.

 

This interview is also available as an audio PsychCastTM at http://psychcast.mblcommunications.com.

Disclosure: Dr. Dubovsky receives research support from Esai, Pfizer, and Sumitomo Pharma.

 

Dr. Dubovsky is professor and chair of the Department of Psychiatry at the University of Buffalo in New York State and adjoint professor of Psychiatry and Medicine at the University of Colorado in Boulder. His research focuses on intracellular signaling in mood disorders, the pathophysiology of psychiatric illness, development of new treatments, and interactions between medical and psychiatric illnesses. Dr. Dubovsky maintains an active clinical practice devoted to mood disorders; complex and difficult clinical problems; and consultation to psychiatrists, other physicians, and other mental health professionals.

 

What is the most appropriate name to describe the newest generation of atypical antipsychotics?

The most appropriate name would be third-generation antipsychotics. The first-generation antipsychotics were the phenothiazines; the second generation was everything else (ie, butyrophenones, thioxanthenes, etc); and the most recent would be the third generation. They are a diverse group but are different enough from the neuroleptics—the first- and second-generation antipsychotics—to warrant their own category.

Are the newer atypical antipsychotics mechanistically different than the older ones?

All antipsychotics act on dopamine (D)2 receptors and have some level of D2 receptor antagonism. They all have a certain amount of serotonin (5-HT)2 blockade as well. The 5-HT2 receptor is linked to a D2 receptor such that when it is stimulated, it makes D2 receptors more sensitive to blockade, and if the D2 receptor is blocked, it mitigates some of the effects of blocking the D2 receptors, especially in the basal ganglia. The older neuroleptics are all 5-HT2 antagonists and D2 antagonists. They have relatively more D2 antagonism than 5-HT2 antagonism. With the newer atypical antipsychotics, the amount of D2 blockade has been turned down and the amount of 5-HT2 blockade turned up.

The major selling point of these newer antipsychotics is that they are more effective in treating negative symptoms than the conventional neuroleptics. Has this been supported by ongoing research?

This observation has not been supported by research. With the exception of clozapine, all of the newer antipsychotics have been studied in industry-sponsored randomized trials where they are compared with a placebo and an active comparator—haloperidol. Haloperidol is very potent in D2 blockade. Blocking this receptor results in many deficits in the ability to generate and coordinate behavior, whether motor behavior, emotional behavior, or thought. Thus, patients taking haloperidol have more bradykinesia and blunted affect. When compared with relatively less D2 blockade, there seem to be fewer negative symptoms from an antipsychotic. Futher, very drug-naive patients enter these randomized trials. Most of these patients have been on a neuroleptic. When switched to one of the third-generation atypical antipsychotics, they get less D2 blockade and less blunting; they seem to brighten up a little bit and their negative symptoms seem to improve. This is because the drug itself is not producing as many negative symptoms.

There are two major flaws in these comparisons. First, they are using higher doses of haloperidol and, therefore, getting more side effects. Thus, the drug being studied is always going to look better than a higher dose of haloperidol. Second, they are not addressing the haloperidol level by blood vessel to see whether it is even the right dose to treat the disorder.

Are the newer antipsychotics more effective in symptom control for schizophrenia?

Of the newer drugs in schizophrenia, the one drug that seems to be more effective than any other for negative cognitive symptoms is clozapine. The newer drugs have less D2 blockade and produce less cognitive Parkinsonism. In comparison to haloperidol, there is less blunting of thought and cognitive functioning is better.

The core cognitive deficit of schizophrenia is a defect in sensory gating (ie, the inability to shut off irrelevant information and to tell the difference between relevant and irrelevant sensory input). Clozapine is the only antipsychotic that is to some extent effective in correcting that deficit. The other thing that corrects the gating deficit is smoking. The defect in sensory gating is due to a malfunctioning gene for a type of acetylcholine receptor called the alpha-7 nicotinic receptor, which nicotine acts on. Thus, acute-inhaled nicotine will correct the gating deficit in schizophrenia. Some research1 suggests that clozapine works better in heavy smokers and that people who respond to clozapine are more likely to stop smoking. This is because clozapine, unlike other antipsychotics, corrects that gating deficit.

Research2 suggests that olanzapine and quetiapine may somewhat help the gating deficit, but they do not benefit as much as clozapine.

Are the newer antipsychotics more effective in symptom control for mood disorders?

All antipsychotics are effective for mania. In equivalent sedative doses, the newer ones are not more effective for mania than the older ones. Benzodiazepines, and before that barbiturates, used to be the mainstay of the treatment of mania years ago. Anything with sedatives, and especially antipsychotic properties, will work acutely for mania.

It is more difficult to determine the effectiveness of maintenance treatment for mood disorders. One must observe how the drug companies have designed their studies. Unlike with schizophrenia, there is no analog of the Clinical Antipsychotic Trials in Intervention Effectiveness (CATIE) study for bipolar disorder. The studies are entirely industry sponsored studies.

In the pivotal trial3 for olanzapine monotherapy, slightly <550 patients with bipolar I were treated openly with olanzapine plus lithium. Of that group, ~120 patients over 6 weeks could not stay in the study and were kicked out. The remaining ~430 were felt to be remitted, meaning they had a Young Mania Rating Scale score ≤12 and a Hamilton Rating Scale for Depression score ≤8. Thus, remitted meant 33% to 50% were as symptomatic as they were when they started. Those patients were randomized to ~20 mg olanzapine in decent doses or lithium in a therapeutic dose for 1 year. Investigators found that more olanzapine than lithium patients completed the study (~47% of the olanzapine patients and ~33% of the lithium patients), and there were fewer relapses to mania in the olanzapine study. However, rates of relapse into any affective episode or relapse into a depressive episode were about the same with both drugs.

As with all industry-sponsored studies of bipolar disorder, the sample was enriched: patients who were anticipated to respond in the first place were treated openly, anyone who did not respond openly was kicked out, and the ones who did seem to respond were placed into the randomized trial. At the end of the study, these patients were not well on monotherapy with any of the drugs. They were less symptomatic and had fewer acute episodes, but they were still ill. None of these kinds of studies conduct any measures of functioning or quality of life.

It is also important to note that such studies always exclude patients who are suicidal, are active substance abusers, or have any meaningful comorbidity. However, 80% of people with bipolar disorder are substance abusers. Thus, one cannot extrapolate to real life from these studies.

The same study method is used for the drugs that have now some labeling for maintenance of mood disorders (olanzapine and quetiapine). Quetiapine just had an add-on maintenance study4 published last year. It is the same method with all the studies conducted. The study conductors take patients who respond well acutely, randomize them, and get about the same results with lithium or sometimes divalproex sodium. In an add-on study, they add one of these drugs or a placebo onto lithium or divalproex sodium, and they get less relapse. However, is this the antipsychotic effect of the drug? These are sedating drugs. Is it the fact that patients sleep better and once they sleep better, their moods are better?—or is it that the rating scale scores emphasize insomnia, talking a lot, and agitation, and all of those are going to be better with a sedating drug?

I would like to see a study using diazepam, lorazepam, or clonazepam as a control—the latter two were at one time a mainstay of the treatment of bipolar disorder—and see whether or not there are better results with the antipsychotics.

Is the long-term risk of tardive dyskinesia lower with the new-generation antipsychotics?

First-generation antipsychotics were introduced in the 1950s and tardive dyskinesia was not identified until the late 1970s. Tardive dyskinesia has been reported with all of the atypical antipsychotics, including the newer ones. Though there have been fewer reports with the newer antipsychotics so far, it is yet unclear what long-term experience will show.

Are there any good data on compliance rates other than the CATIE study?

The only other data are in the industry-sponsored studies. There is a relatively low dropout rate with patients on these new-generation antipsychotics compared to historic experience with the neuroleptics or sometimes compared to the comparison neuroleptic. It is hard to know what to make of this because in any of the industry-sponsored studies, there is much effort into keeping patients in those studies and it is nothing like actual clinical practice. The compliance rate is expected to be better in any clinical trial.

The CATIE trial had worse results because they were not putting the massive effort into keeping the patients in the studies that investigators do in these multicenter trials. The reason for it is that investigators do not get paid as much if the patient leaves the study. While the investigators do not get paid for a certain result, they certainly get paid for recruiting and keeping patients in the study.

What drives your choice to prescribe one antipsychotic over another?

Though it is never a first choice, I use clozapine for very refractory schizophrenia. It is difficult to take, but it works better than the other antipsychotics. Most schizophrenic patients who are given clozapine are in a clozapine group, and so there is more effort put into other forms of therapy in addition to the medication that may explain some of the benefit. However, I have seen people who did very poorly on everything except for clozapine.

There were studies5 a number of years ago showing that the combination of a neuroleptic and an antidepressant worked very well for negative symptoms of schizophrenia in schizophrenic patients who were not depressed but who had a family history of depression. This suggested that depression in the family is somehow a marker of response to antidepressants in a patient with negative symptoms but with no real depressive symptoms. Thus, at times I combine an antidepressant with a drug like clozapine.

I also use clozapine for very intractable and severe ultradian cycling in bipolar patients. However, bipolar patients do not tolerate clozapine nearly as well as schizophrenic patients. They have much less patience themselves for the problems taking this medication, and so they are less likely to agree to it. Still, it works well when they need it.

I use molindone hydrochloride tablets in a low dose for patients who should not or do not want to gain weight. It is certainly as good as risperidone and some of the other atypical antipsychotics that have more D2 blockade. There is not a tremendous amount of difference between the amount of D2 blockade or extrapyramidal side effects between risperidone and a drug like molindone hydrochloride, but the latter is much less likely to cause weight gain than risperidone is. I use molindone hydrochloride and loxapine for psychotic depression. I have used all of the newer-generation antipsychotics for psychotic depression as well, almost always in combination with an antidepressant.

I use aripiprazole for some very refractory depression, with or without psychosis, and I find it to be unpredictable. Sometimes I have had very good results with it, but it is very hard to find the right dose. There is a lot of akathisia with it and a lot of blunting if the dose is raised too high. It is very hard to find the right dose with depressed patients, but it is less likely to cause weight gain than some of the others. I use ziprasidone for some severely depressed patients, but it is also unpredictable. Even though it causes less weight gain, it makes a lot of people very jittery and it cannot be combined with other serotonergic drugs easily because it is a selective serotonin reuptake inhibitor. PP

References

1.    McEvoy JP, Freudenreich O, Wilson WH. Smoking and therapeutic response to clozapine in patients with schizophrenia. Biol Psychiatry. 1999;46(1):125-129.
2.    Powell SB, Young JW,Ong JC, Caron MG, Geyer MA. Atypical antipsychotics clozapine and quetiapine attenuate prepulse inhibition deficits in dopamine transporter knockout mice. Behav Pharmacol. 2008;19(5-6):562-565.
3.    Tohen M, Calabrese JR, Sachs GS, et al. Randomized, placebo-controlled trial of olanzapine as maintenance therapy in patients with bipolar I disorder responding to acute treatment with olanzapine. Am J Psychiatry. 2006;163(2):247-256.
4.    Vieta E, Suppes T, Eggens I, Persson I, Paulsson B, Brecher M. Efficacy and safety of quetiapine in combination with lithium or divalproex for maintenance of patients with bipolar I disorder (international trial 126). J Affect Disord. 2008;109(3):251-263.
5.    Rummel C, Kissling W, Leucht S. Antidepressants for the negative symptoms of schizophrenia. Cochrane Database Syst Rev. 2006 Jul 19;3:CD005581.

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