Introduction
Post-traumatic stress disorder (PTSD) can be described in the generality as the development of persistent and characteristics symptoms which leads to difficulties in normal functioning. This is usually due to an exposure to a life-threatening event or experience or an event that can be perceived by the individual as a life-threatening or causing serious injury (Alexander, 2012). These cases are widespread, and the range of events that exposes an individual to this disorder cannot be streamlined to any particular aspect of life. The behavioral responses to the events and the perceptions of the individual about the event have a significant impact on the acquiring of the PTSD as well as the recovery process. The clinician is thus required to understand the preceding and succeeding events at the time of the experience that caused the emergence of the presented symptoms (Jeffreys et al., 2012). Patients with this disorder usually present symptoms such as sleep difficulties or disturbances, fatigue, loss or difficulty of memory and concentration, night sweats and a withdrawn social life. PTSD can present as chronic or acute. In acute cases, the symptoms will last for a period of not less than one month bit not beyond three months since the occurrence of the traumatic event. In chronic cases, the symptoms will presents even after three months of the traumatic event.
The characteristic symptoms clusters for PTSD are categorized in three forms. These include avoidance of the stimuli connected with the traumatic event, re-experiencing of the traumatic event and hyper-arousal which is characterized by anger, irritability or hyper-vigilance (Jeffreys et al., 2012). Statistics indicates that of the total population of war veterans; 20% have been identified as experiencing PTSD or Traumatic Brain Injuries (TBI). Of these 20%, half of them do not seek medication or treatment for their condition. On the other hand, 7% of those who seek treatment do not receive the minimally required form of treatment that can help them overcome the PTSD or TBI. In the general population, PTSD cases are reported at the rate an average rate of 7% which is a clear indication that war veterans are a risk group for PTSD (The Congress of the United States: Congressional Budget Office, 2012). This is supported by the evidence of the traumatic and emotionally draining events that they have experienced either in the Vietnam, Iraq or the Afghan wars. PTSD treatment in the war veterans can be difficult to diagnose and treat and this is usually associated with the highly complicated clinical presentations resulting from other cormobid psychiatric issues in diagnosis such as major repressive disorders and substance abuse (Martenyi et al., 2002).
The treatment of PTSD has majorly relied on medications the antidepressants, anti-psychotics and beta-blockers with other options being the use of cognitive behavioral therapy (CBT). CBT is a non-medication technique used in the treatment of PTSD and encompasses a host of therapeutic activities such as exposure therapy that helps the victims to face and take control of the associated fear. It also involves cognitive restructuring whereby the patient is helped to make or draw sensible deductions of the bad memories. The third aspect of CBT is stress inoculation training that involves teaching the victims several approaches of overcoming the memories in a constructive way. Controversy has however been rife on the effectiveness of these modes of treatment both the mediation and the non-medication.
Studies have been employed to determine the comparative efficacy of the different antidepressants with others dwelling on the efficacy of treatment options as compared to cases where no treatment is rendered. Despite these controversies and the lack of common ground on the efficacy of treatment or lack of it for veterans of PTSD, antidepressants have substantially been associated with positive outcomes (Alexander, 2012). This indicates that the use of antidepressants for treatment of PTSD cases on veterans using antidepressants is still the most viable as compared to avoidance of treatment as long as the patients are helped to adhere to the complete treatment plan.
Discussion
Brady et al. (2000) acknowledges the fact that post traumatic stress disorder is a problem affecting many people in the society. Traditionally, the disorder was usually associated with war veterans and soldiers but it is now a reality affecting even the civilians. The disorder disrupts the normal life routines of the patient and renders them unable to regain control of their lives. PTSD symptoms can range from mild to severe, and degree of psychological destruction/disruption is proportional to the level of severity. Conventionally, the therapeutic approaches for patients with PTSD have not managed fully to control the symptoms that characterize the disorder. Moreover, the approaches were accompanied with unbearable side effects such as diarrhea and sweating that led to high attrition rates. Therefore, a proper treatment approach for PTSD should manage to balance or moderate the symptoms and the side effects. In a study undertaken by Brady et al. (2000) it was established that antidepressants are rather safer and moderated than other forms of treatment including placebo.
The study incorporated a total sample size of 187 outpatients with a confirmed case of mental disorder (PTSD). The majority of the sample size (73%) was women who had reportedly experienced instances of physical and sexual abuse. In the 12-week study, participants were assessed for PTSD-related symptoms such as insomnia, flashbacks and nightmares. The participants were put under Sertraline (antidepressant) for the 12 weeks, and a placebo was used as control. CAPS-2 and CGI-S scales were used to assess the baseline-to-end-point changes during the 12-week clinical trial. Statistical comparisons between placebo (control) and Sertraline showed comparative effectiveness of Sertraline.
In three out of the four outcomes measured Sertraline showed a significant efficacy. The responder rates for Sertraline hydrochloride were significantly higher than the placebo, (53 % and 32% respectively).Responder rates were defined as the degree of baseline-to-end-point. Among the efficacy points of the antidepressant-based treatment include tolerated symptoms, safety and hence low attrition cases.However, the drug was comparatively ineffective in terms of reducing insomnia. Therefore, the study by Brady et al. (2000) recommends the use of antidepressants in the treatment of PTSD due to the comparative advantages associated with the drug in comparison to placebo or no treatment.
Although past literature shows that pharmacological approaches to PTSD for veterans were not effective, a study conducted by Martenyi et al. (2002) disputes this earlier finding. According to the research-based article, there was great evidence on the effectiveness of the pharmacological approach, precisely, the use of antidepressants. Unlike the traditional placebo-based treatments, use of pharmacological approaches such as the use of fluoxetine was pretty promising in terms of controlling PTSD symptoms and comorbidities. In a study conducted by Martenyi et al. (2002) that involved 75 participants from Europe, South Africa and Israel showed comparative efficacy of fluoxetine in the treatment of PTSD and subsequently reducing the lifetime symptoms associated with the disorder. The study majored in these three countries in areas that were predominantly affected by war. As such, many of the participants (48%) had experienced a combat-related trauma. In the 12 weeks study that used the mean baseline change (using the TOP-8 scale) as the primary outcome showed major statistical advantages of fluoxetine in as early as the 6th week of the trial. On the other hand, the study used secondary assessment to assess secondary outcomes. The CAPS, CGI-I, CGI-S, HAM-A, the Hopkins 90-item symptom revised checklist among others were used to assess the secondary outcomes. In overall, the results of the study showed significant improved outcomes for the participants. Although mild dosages of the fluoxetine showed no significant difference in terms of safety, upper normal dosages for patients with PTSD showed commendable and satisfactory outcomes.
Amidst the widespread recommendation of psychotherapy as the treatment for PTSD, there is overwhelming evidence that suggests the benefits of using pharmacological interventions. Use of pharmacological interventions as a recommendation comes in the awakening of increased patient preference and the apparent costs and unavailability of psychotherapy programs (Jeffreys et al., 2012). Moreover, with the availability of psychotherapy programs use of pharmacological interventions is pretty advantageous as a supplementary approach. As much as evidence-based practice recommends the use of psychotherapy as a treatment of trauma-based disorders as a first-line therapy, the use of antidepressants play a great role in improving patients’ response to psychotherapy programs (Jeffreys et al., 2012).The comparative advantages of antidepressants such as SSRIs is that they secure the patient from the enduring symptomatic comorbidities that are associated with PTSD. Another advantage point of using antidepressants is that they offer a wide spectrum of preferences and options for patients. For patients who cannot bear with the first-line treatment, antidepressants offer a second-line treatment options that are less strenuous that the first-line medications. For instance, mirtazapine provides a strong second-line medication for patients who cannot bear with the first-line medications. According to Jeffreys et al. (2012), antidepressants are better in terms of safety, tolerance and suppression of symptoms. However, Jeffreys et al. (2012), assert that CPG guidelines for PTSD should be appropriately consulted and complied with for successful use of antidepressants. CPG provides invaluable clinical guidelines on the use of both first-line and second-line antidepressants.
English et al. (2006) identifies PTSD as a mental illness that usually exhibits the impairment of occupational and psychosocial function. The application of serotonin uptake inhibitors (SRIs) as a treatment for PTSD has long been proved an effective and promising method of overcoming PTSD. The study by English et al. (2006) focuses on the use of citalopram that is essentially a SIR in treating PTSD in veterans. In the study, a total of eighteen veterans with PTSD were subjected to citalopram treatment in an open-trial for a period of eight weeks. The results were based on the patients who were able to complete at least four weeks of the open trial. Those who quit after the fourth week were recorded as participants with intent-to-treatment while those that completed the eight weeks of the open-trial were labeled as the completer-only group. However, all results were analyzed as lastly observed at the quit time. The results indicated that the use of citalopram had moderate improvements hyper-arousal (p < 0.009) and re-experiencing (p < 0.001) while also showing significant reduction in anxiety and depression occurrences (p < 0.001).
The results had variation in individual participants, and this could have been attributed to the behavioral techniques of adapting to the post-combat PTSD such as drug and substance abuse and issues of social avoidance. These have been associated with higher comorbidity and the response to the treatment is usually impacted negatively by such issues. In essence, there is slow response due to the two-pronged fight one against PTSD and the other against drug and substance addiction. Apart from the primary effects of the citolopram, the SRI has also proved to be tolerable for the veteran groups showing a high level of tolerance with little or no side effects. The major objections for other SRIs have been associated with the intolerable bit where the side effects increasingly overwhelm the expected positive outcomes. Some of the side effects usually associated with the use of SRIs include somnolence, sexual dysfunction, and nausea and in some instances the presentation of drug-to-drug interactions. Due to the increased tolerability of citalopram, the researchers initiated an incremental administering of the SRI of 20 mg on a weekly basis depending on the patients response to the treatment. The maximum was however retained at below 60 mg. This is essentially the maximum level to which citalopram can be administered safely.
The major advantage with this incremental mode of administering the SRI is that the dosages can be customized to suit the specific response of the patient that limits that side effects associated with small or large dosages. Despite the fact that the study population was small for effective generalization of the results, as well as the limitation to the combat-induced PTSD, the use of citalopram has proved to be a consistently effective mode of chronic PTSD treatment. However, the researchers indicate that there is a need for further research with application of larger sample populations as well as eliminating the limitation to combat-related PTSD so that the effects of the citalopram can be determined against a placebo-controlled trial.
In a similar approach, Davidson et al. (2001) focused on research to determine the effects of Sertraline in treating outpatients with PTSD against the effects of a placebo administered to the same population. The sample population for the sertraline was set at 100 PTSD patients while the placebo was administered to a total of 108 patients. The sertraline was administered at flexible doses of between 50 to 200 mg for the 12 weeks of the double-blind comparison study. The flexibility of the dosages of sertraline was based on the relative clinical response as well as tolerability of the participants to sertraline. The study sought to analyze the efficacy and safety of the sertraline with all measurements compared to the baseline results of both the rates and intensity of PTSD symptoms as indicated on the Impact of Event Scale (IES).
The study by Davidson et al. (2001) noted that there were no significant comparative differences in the issues of safety for either the sertraline or the placebo. However, there were significant differences in the efficacy with sertraline showing reduced intensity and rate of PTSD symptoms as compared to the placebo. In terms of tolerability, neither sertraline nor placebo showed any significant clinical changes in heart rates or blood pressures that were considered the vital signs of checking tolerability. These results then pointed out to the fact that sertraline is a significantly effective mode of PTSD treatment showing high levels of tolerability and safety as well as reduced frequency and intensity of symptoms associated with PTSD.
Patient characteristics prior to the study were analyzed to provide baseline data for determining how behavioral influences such as drug and substance use and social avoidance would impact on the treatment. The rate of quitting among participants with several behavioral cases of drug and substance abuse or social avoidance pointed to the idea that this population required higher specialized care that integrated cognitive behavior therapy and the treatment. This would help alleviate cases of relapse of addiction and enable seamless integration into a significantly helpful social circle (Davidson et al., 2001).
Conclusion
As demystified by the studies above, it is true that antidepressants are clinically reliable in the treatment of PTSD. The primary objective of treating post-traumatic stress disorders is to free the patient from the devastating and frustrating symptoms of PTSD such as nightmares, flashbacks and re-experiences and securing the patient from the symptomatic comorbidities that accompany PTSD. While other interventions may free veterans from these symptoms, they seemingly do not secure their health completely (Jeffreys et al., 2012). Therefore, as an evidence-based practice, clinical practice should embrace the use of antidepressants. Although the use of antidepressants are not without the side-effects such as excessive sweating and insomnia, it is logical to experience these symptoms for a short while and satisfactorily secure the patient’s health, going to the future. Moreover, it is believable that the side-effects of the antidepressants present comparatively bearable effects than the PTSD symptoms.
War veterans have been noted as a risk group for PTSD. Most of the PTSD cases in this group go unreported while where reported, there are no individualized care plans for the patients. This explains the high levels of poor response to clinical treatment for these patients. The lack of follow-up procedures to ensure adherence to the treatment plans as well as monitoring the response to medication has been poor. This has impacted negatively on the ongoing treatment as patients may not be well versed with the need for realignment of dosages to response. However, the major controversy as earlier noted has been the issue of efficacy of medication or treatment as compared to avoidance of the same. This has been propelled by confirmed cases where placebo-based interventions have been applied in PTSD cases showing improved results in terms of reduction of intensity and frequency of PTSD symptoms (Brady et al., 2000). On the other hand, medications have been blamed with increased cases of side effects for these patients such as somnolence, nausea and sexual dysfunction which could have been avoided if treatment were foregone. However, the comparative studies conducted and documented above show that this general perception is wrong for a wide range of antidepressants. High tolerability and safety have been monitored from baseline showing positive outcomes.
The cost of treating PTSD in veterans has significantly increased over the years with the 2002 to 2010 costs of treatment rising to beyond the cumulative total of 6 billion as indicated by the Veterans Health Administration (The Congress of the United States: Congressional Budget Office, 2012). This then implies that cheaper and safer methods of treatment for this population are important especially considering the advanced age and the economic strain placed on these patients and their families. The use of antidepressants has been ascertained as being relatively cheap especially when adopted at early stages of development of PTSD. While the use of antidepressants already proves significant positive outcomes, it is critical that the clinicians dealing with the veterans provide channels for modifying behaviors. This would help the patients cope with the cases of social avoidance and drug and substance abuse (Jeffreys et al., 2012).
References
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