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Guidelines for the pharmacological treatment of post traumatic stress disorder
Document name:
Post Traumatic Stress Disorder:
Guidelines for pharmacological
treatment
Portfolio
Document type:
Medicines Management
Guideline
Staff group to whom it
applies:
All prescribers, pharmacy and clinical
staff within the Trust
Distribution:
The whole Trust
How to access:
Intranet
Issue date:
Version 2
March 2012
Next review:
February 2015
Approved by:
Drug and Therapeutics Sub
Committee
Developed by:
Kate Dewhirst, Deputy Chief
Pharmacist
Director leads:
Medical Director
Contact for advice:
[email protected]
South West Yorkshire Partnership NHS Foundation Trust
Pharmacological guidelines for the Treatment of PTSD
1
Guidelines for the pharmacological treatment of post traumatic stress disorder
CONTENTS
Page
3
1.
Treatment algorithm …………………………………..………………………
2.
Introduction……………………………………………….……………………
4
3.
General principles………………………………………………………………
5
4.
Medication ………………………………………………………………………
6
5.
References and further reading………….……………………………………
7
Appendix 1: Antidepressant discontinuation/withdrawal symptoms
Appendix 2: Committee on Safety of Medicines (CSM) and Medicines and Healthcare
Regulatory Authority (MHRA) Advice
8
9
Author
Kate Dewhirst, Deputy Chief Pharmacist
Abbreviations
NICE
PTSD
SSRI
TCAs
CSM
MHRA
CBT
National Institute for Health and Clinical Excellence
Post Traumatic Stress Disorder
Selective serotonin re-uptake inhibitors
Tricyclic antidepressants
Committee on Safety of Medicines
Medicines and Healthcare Regulatory Authority
Cognitive behavioural therapy
South West Yorkshire Partnership NHS Foundation Trust
Pharmacological guidelines for the Treatment of PTSD
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Guidelines for the pharmacological treatment of post traumatic stress disorder
1.
TREATMENT ALGORITHM
Pharmacological Treatment of Post Traumatic Stress Disorder
Diagnosis of PTSD
Treatment of choice is traumafocused psychological therapy (e.g.
CBT)
Consider prescribing medication
 only in adults (children should be offered trauma-focused psychological treatment)
 if the individual prefers not to engage in trauma-focused psychological treatment
 if the individual cannot start psychological treatment because of the serious threat of further trauma
 if the individual has gained little or no benefit from a course of trauma-focused psychological treatment
 as an adjunct to psychological treatment where there is significant co-morbid depression or severe
hyperarousal that significantly affects the individual’s ability to benefit from psychological treatment
*Discuss
●Potential side effects
including transient anxiety
●Delay in onset of effect
●Length of treatment
●License implications
●Potential discontinuation
or withdrawal symptoms
Provide
●Written information
Prescribe low initial doses
and gradually increase
The largest evidence base
exists for paroxetine,
sertraline
See Appendix 2 -CSM
advice
Prescribe an SSRI*
Consider the short-term
prescription of a hypnotic
medication
Monitor
●One week after starting treatment in those with PTSD who are at risk of selfharm or suicide or are aged between 18 and 29 years
●Two weeks after starting treatment in others.
●See at regular and appropriate intervals thereafter throughout treatment
Assess response at 8 to 12 weeks
Partial response
Response
Continue treatment
for 12 months then
gradually withdraw.
See appendix 1
Little or no response
Consider gradual
increase in dose
within approved
limits
Monitor and
assess as above
South West Yorkshire Partnership NHS Foundation Trust
Pharmacological guidelines for the Treatment of PTSD
Switch to an antidepressant of a different
class
 Mirtazepine
 Amitriptyline or
 Phenelzeine
(NICE recommend specialist mental
health care supervision)
Monitor and assess as above
Adjunctive treatment with olanzapine
may be considered in refractory cases
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Guidelines for the pharmacological treatment of post traumatic stress disorder
2.
INTRODUCTION
NICE published clinical guidelines for the management of post traumatic stress disorder (PTSD) in
adults and children in primary and secondary care in March 2005.
This document will concentrate on the pharmacological treatment options. Recommended first line
treatment options are non-pharmacological and include psychological therapies such as trauma
focused cognitive behavioural therapy (CBT) and eye movement desensitisation and reprocessing.
Pharmacological treatments are recommended for adults only.
For information on psychological treatments refer to the NICE guideline or the local Psychological
Services Department
PTSD can affect anyone of any age who experiences, witnesses or is confronted with an event or
events that involved actual or threatened death or serious injury, or the threat to the physical
integrity of self or others.
Prevalence has been estimated between 1-9% and carries significant personal and social costs.
Many of those diagnosed have a co-morbid condition such as depression, generalised anxiety states
substance misuse. There is significant overlap of symptoms of depression and anxiety, such as
reduced concentration levels and sleep disturbances.
Symptoms may develop immediately after the traumatic event or less commonly have a delayed
onset and may include
Re-experiencing through flashbacks or nightmares
Avoidance of people or situations
Hyperarousal leading to sleep problems, irritability hypervigilance
Emotional numbing detachment from other people, amnesia
Depression
Alcohol or substance misuse
Anger
Somatic symptoms
Pharmacological treatment is based on the hypothesis that severe trauma can lead to long lasting
neurobiological changes particularly within the serotonin system.
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Pharmacological guidelines for the Treatment of PTSD
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Guidelines for the pharmacological treatment of post traumatic stress disorder
3.
GENERAL PRINCIPLES
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The choice of treatment should be shared between the service user and the healthcare
professionals. This improves concordance and clinical outcomes. Consider service
user preference, experience and outcomes of previous treatments.
Do not routinely prescribe medication for treatment of PTSD for children and
adolescents.
Be alert to co-morbidity, which is common (particularly anxiety, depression and
substance misuse).
It may be appropriate to treat any co-morbid substance misuse before beginning the
treatment for PTSD.
Consider NICE recommendations and licensed indications when choosing treatment
options.
Many of the trials assessed in NICE have statistically significant results but clinical
significance is inconclusive.
Personal history, any self-medication, cultural and individual characteristics are
important considerations in care.
Initial treatment and assessment should be offered in primary care.
Sufficient information written and verbal should be provided to the service user and
carer about treatment options.
In particular, for adults prescribed antidepressants, discuss the potential side effects and
discontinuation /withdrawal symptoms, especially for paroxetine (See appendix 1).
Where appropriate the Care Program Approach may be used and is particularly useful
where care is shared between primary and secondary care.
Start with low initial doses. Doses of SSRIs should be started low (e.g. paroxetine 10mg
per day) and increased gradually to reduce the risks of initial exacerbation of anxiety
symptoms.
Doses higher than those used in depression may be required to achieve full effect.
Increases should be gradual and within approved limits.
Increasing the dose in the presence of agitation or restlessness, particularly at the
beginning of treatment may be detrimental.
Response to treatment may take 8 to 12 weeks.
Treatment should be continued for at least 12 months after resolution of symptoms
followed by a gradual reduction.
If response to the first medication is poor a different class of antidepressant should be
used.
Apply the same monitoring precautions regarding increased risk of anxiety, suicidal
ideation and akathesia in the initial stages of treatment with antidepressants as those
recommended in depression and anxiety.
See service users one week after commencing treatment and thereafter at frequent,
regular and appropriate intervals throughout treatment.
South West Yorkshire Partnership NHS Foundation Trust
Pharmacological guidelines for the Treatment of PTSD
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Guidelines for the pharmacological treatment of post traumatic stress disorder
4.
MEDICATION
Drug
SSRIs
Paroxetine
Licensed for post traumatic
stress disorder
Sertraline
Licensed for post traumatic
stress disorder in adult females
Potential Advantages
Low toxicity in overdose
Less sedative than other
antidepressants
Less anticholinergic side
effects than TCA
Some supporting evidence for
paroxetine and sertraline
Tricyclic antidepressants
Amitriptyline
Imipramine
Delayed onset of effects
Exacerbation of symptoms
in early stages.
Withdrawal/discontinuation
symptoms (more reports
for paroxetine than other
SSRIs)
Evidence is often
inconclusive
SSRIs
Fluoxetine
Not licensed
Mirtazepine
Potential Disadvantages
Costs per 28 days
supply Drug Tariff
March 2012
Paroxetine 20mg once
a day £2.10
Sertraline 50mg once a
day £4.24
Fluoxetine 20mg once
a day £0.95
Higher doses may be
required e.g. fluoxetine
60mg per day
(£48.52if 60mg
capsules used)
Sedative, may help with
nightmares and sleep
disturbance
Limited supporting evidence
Not licensed
Sedative
Weight gain
Evidence is often
inconclusive
Mirtazepine 30mg
once a day £1.77
Some supporting evidence for
efficacy
Sedative
Not licensed
Evidence is often
inconclusive
Anticholinergic side effects
including constipation dry
mouth and blurred vision
Sedative
High doses up to 300mg
per day may be needed,
potential cardiac side
effects, ECG recommended
Cardiotoxic in overdose
Not licensed
Food and dietary
interactions with potential
hypertensive crisis
Long-term efficacy not
established.
Tolerance and dependence
if used long term
Not Licensed. No evidence
of efficacy, sedative and
high risk of side effects
compared to benefits
Amitriptyline 150mg a
day £2.81
(based on 50mg
tablets)
Phenelzine
Some supporting evidence
May help intrusive and
avoidance symptoms
Hypnotics
Short term sleep improvement
Antipsychotics
Limited supporting evidence
for olanzapine as adjunct to
SSRIs in those unresponsive to
SSRIs alone
South West Yorkshire Partnership NHS Foundation Trust
Pharmacological guidelines for the Treatment of PTSD
(BNF 62)
Imipramine 150mg a
day £7.26
(based on 25mg
tablets)
Phenelzine
15mg three times a day
£15.75
Olanzapine 10mg per
day
£8.81
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Guidelines for the pharmacological treatment of post traumatic stress disorder
5. REFERENCES AND FURTHER READING
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
NICE Clinical Guideline 26. The management of post-traumatic stress disorder in adults
and children in primary and secondary care. March 2005
Post Traumatic stress disorder. Clinical Evidence February 2010
www.clinicalevidence.bmj.com
Medicines and Healthcare Regulatory Authority/Committee on Safety of Medicines
www.mhra.gov.uk
Maudsley Prescribing Guidelines 2010
Psychotropic Drug Directory 2012
BNF www.bnf.org
Summaries of Product Characteristics www.medicines.org.uk
Phenelzine Shared Care Guideline, SWYPFT nww.swyt.nhs.uk
Paroxetine communication, SWYPFT nww.swyt.nhs.uk
Antidepressants in clinical practice: Guidelines for safe and effective use of
antidepressants in adults and older people (in line with NICE Clinical Guideline 90).
SWYPFT nww.swyt.nhs.uk
Stein DJ et al. Pharmacology for post traumatic stress disorder (PTSD) (Review). The
Cochrane Collaboration. 2009
The management of post traumatic stress disorder in adults. Clinical Resource Efficiency
Support Team Northern Ireland. June 2003
South West Yorkshire Partnership NHS Foundation Trust
Pharmacological guidelines for the Treatment of PTSD
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Guidelines for the pharmacological treatment of post traumatic stress disorder
APPENDIX 1
DISCONTINUATION /WITHDRAWAL SYMPTOMS ASSOCIATE WITH
ANTIDEPRESSANTS
Stopping antidepressants abruptly can cause discontinuation/withdrawal symptoms. To minimize
the risk of the dose should be reduced gradually over an extended period of time.
Symptoms are usually mild and self-limiting but can occasionally be severe especially if the
antidepressant is stopped abruptly.
Some commonly experience withdrawal symptoms
Flu-like symptoms (chills, aches, sweating)
Nausea and vomiting
Dizziness
Numbness and tingling (electric shock
sensations)
Irritability
Anxiety
Insomnia
Excessive (vivid) dreams
Not all symptoms are associated with every antidepressant and may one individual experience not
all. The perception of symptoms may be made worse if no prior warning is given.
Symptoms of discontinuation may be misinterpreted as relapse of the original illness or a new
physical illness. Onset is usually within 5 days of stopping, depending on the half-life of the
antidepressant.
If symptoms are mild, discussion of the reason for the symptoms and reassurance of the selflimiting nature are required. The service user should be monitored for resolution of the symptoms.
If symptoms are severe the re-introduction of the antidepressant should be considered followed by a
more gradual reduction. The use of another antidepressant from another class with a longer halflife may make reduction easier. Fluoxetine, having a longer plasma half-life, seems to be
associated with a lower incidence of discontinuation symptoms than other similar antidepressants.
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Pharmacological guidelines for the Treatment of PTSD
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Guidelines for the pharmacological treatment of post traumatic stress disorder
APPENDIX 2
Committee on Safety of Medicines (CSM) and Medicines and Healthcare Regulatory
Authority (MHRA) Advice

Hyponatraemia (usually in the elderly and possibly due to inappropriate secretion of
antidiuretic hormone) has been associated with all types of antidepressants however it
has been reported more frequently with SSRIs than with other antidepressants. The CSM
has advised that hyponatraemia should be considered in all patients who develop
drowsiness, confusion or convulsions while taking an antidepressant.

CSM advice (SSRIs for major depressive disorder in children and adolescents). Following a
review of the safety and efficacy of SSRIs for the treatment of depression in children and
adolescents the CSM has advised (December 2003) that the SSRIs citalopram, escitalopram,
paroxetine and sertraline and the related antidepressant venlafaxine are contra-indicated in
those under 18 years; fluvoxamine should also not be used to treat depression in these
individuals because there is insufficient information on safety and efficacy.

CSM advice (paroxetine dosage). The recommended dose for the treatment of depression,
social anxiety disorder, generalised anxiety disorder, and post-traumatic stress disorder is 20mg
and for obsessive-compulsive disorder and panic disorder it is 40mg daily. There is no
evidence that higher doses are more effective.
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Pharmacological guidelines for the Treatment of PTSD
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