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Expert Calls for New Approaches to Treating PTSD in Veterans
By Matt McMillen
WebMD Health News
Reviewed by Laura J. Martin, MD
Aug. 2, 2011 -- Risperdal, an antipsychotic medication commonly prescribed to veterans with posttraumatic stress disorder (PTSD) when antidepressants have failed to help, does not alleviate the symptoms of PTSD, according to a new study in the Journal of the American Medical Association.
"[T]hese findings should stimulate careful review of the benefits of these medications in patients with chronic PTSD," the authors conclude.
Two antidepressant medications, Zoloft and Paxil, are the only drugs that the FDA has approved to treat PTSD. Women are more likely to benefit from them than men, and neither drug is very effective at treating those with a chronic form of disorder.
The lack of approved options has led doctors who treat veterans with PTSD to prescribe antipsychotics on what's known as an off-label basis, which is when doctors prescribe the drug for a use unapproved by the FDA.
Within the Veterans Administration, 20%, or nearly 87,000, veterans diagnosed with PTSD took an antipsychotic in 2009. One of these antipsychotics, Risperdal, is part of a class of drugs known as second-generation antipsychotics. This class accounts for 93.6% of all antipsychotic prescriptions given to veterans with PTSD.
VA researchers recruited 296 veterans who had severe, long-standing PTSD related to their military service. Study participants previously could not tolerate or failed to respond to two or more antidepressants. The study was conducted at 23 VA medical centers around the country from 2007 to 2009, with a follow-up in February of 2010. Nearly three quarters of the veterans had served in Vietnam or earlier conflicts; the remaining participants served in Iraq or Afghanistan.
The veterans taking Risperdal showed no significant improvement in symptoms compared to those taking a placebo over the six month course of treatment. The rate of remission, for example, was 4% among the placebo group compared to 5% for those taking the medication. "Thus," the authors conclude, "it is unlikely that clinicians could detect the magnitude of the [Risperdal] effect over placebo that was observed in this study."
Innovation Is Needed
Finding effective forms of treatment is crucial, but it is not the only priority for veterans with PTSD. Changing the negative perceptions that many veterans have concerning mental health care is equally important to ensuring that they enter and complete treatment, according to an editorial published alongside the Risperdal study.
"Improving evidence-based treatments, therefore, must be paired with education in military cultural competency to help clinicians foster rapport and continued engagement with professional warriors," writes Charles W. Hoge, MD, of Walter Reed Army Medical Center in Silver Spring, Md. "This includes sensitivity and knowledge in attending to difficult topics, such as grief and survivor's guilt stemming from loss of team members, ethical dilemmas in combat, or situations associated with feelings of betrayal."
Hoge writes that the current dropout rate is quite high among veterans undergoing treatment for PTSD. He estimates that current treatment strategies will reach no more than 20% of veterans needing PTSD treatment. Reaching veterans who need care, he writes, requires research to identify useful and safe medications as well as other helpful forms of therapy.
"[S]ignificant improvements in population care for war veterans will require innovative approaches to increase treatment reach," Hoge concludes.