Pharmacotherapy for post traumatic stress disorder (PTSD)

 

Abstract

Background

Post traumatic stress disorder (PTSD) is a prevalent and disabling disorder. Evidence that PTSD is characterised by specific psychobiological dysfunctions has contributed to a growing interest in the use of medication in its treatment.

Objectives

To assess the effects of medication for post traumatic stress disorder.

Search methods

We searched the Cochrane Depression, Anxiety and Neurosis Group specialised register (CCDANCTR-Studies) on 18 August 2005, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library issue 4, 2004), MEDLINE (January 1966 to December 2004), PsycINFO (1966 to 2004), and the National PTSD Center Pilots database. Reference lists of retrieved articles were searched for additional studies.

Selection criteria

All randomised controlled trials (RCTs) of pharmacotherapy for PTSD.

Data collection and analysis

Two raters independently assessed RCTs for inclusion in the review, collated trial data, and assessed trial quality. Investigators were contacted to obtain missing data. Summary statistics were stratified by medication class, and by medication agent for the selective serotonin reuptake inhibitors (SSRIs). Dichotomous and continuous measures were calculated using a random effects model, heterogeneity was assessed, and subgroup/sensitivity analyses were undertaken.

Main results

35 short-term (14 weeks or less) RCTs were included in the analysis (4597 participants). Symptom severity for 17 trials was significantly reduced in the medication groups, relative to placebo (weighted mean difference -5.76, 95% confidence intervals (CI) -8.16 to -3.36, number of participants (N) = 2507). Similarly, summary statistics for responder status from 13 trials demonstrated overall superiority of a variety of medication agents to placebo (relative risk 1.49, 95% CI 1.28 to 1.73, number needed to treat = 4.85, 95% CI 3.85 to 6.25, N = 1272). Medication and placebo response occurred in 59.1% (N = 644) and 38.5% (628) of patients, respectively. Of the medication classes, evidence of treatment efficacy was most convincing for the SSRIs.

Medication was superior to placebo in reducing the severity of PTSD symptom clusters, comorbid depression and disability. Medication was also less well tolerated than placebo. A narrative review of 3 maintenance trials suggested that long term medication may be required in treating PTSD.

Authors' conclusions

Medication treatments can be effective in treating PTSD, acting to reduce its core symptoms, as well as associated depression and disability. The findings of this review support the status of SSRIs as first line agents in the pharmacotherapy of PTSD, as well as their value in long-term treatment. However, there remain important gaps in the evidence base, and a continued need for more effective agents in the management of PTSD.

 

Plain language summary

Medication for post traumatic stress disorder

Post traumatic stress disorder (PTSD) occurs after exposure to significant trauma and results in enormous personal and societal costs. Although traditionally treated with psychotherapy, there is increasing recognition of a theoretical basis for medication treatments. This was a systematic review of 35 short-term randomised controlled trials of pharmacotherapy for PTSD (4597 participants). A significantly larger proportion of patients responded to medication (59.1%) than to placebo (38.5%) (13 trials, 1272 participants). Symptom severity was significantly reduced in 17 trials (2507 participants). The largest trials showing efficacy were of the selective serotonin reuptake inhibitors, with long-term efficacy also observed for these medications.

 

摘要

背景

改善創傷壓力疾患(PTSD)的藥物治療

創傷後壓力疾患(PTSD)是一個常見且會造成失能的疾病，證據顯示創傷後壓力疾患是特殊的心理生理性功能異常，導致藥物治療的使用興趣逐漸增加。

目標

評估藥物治療創傷後壓力症候群的效果。

搜尋策略

我們在2005年8月18號搜尋Cochrane Depression, Anxiety and Neurosis Group specialised register(CCDANCTRStudies)、Cochrane Central Register of Controlled Trials(CENTRAL) (The Cochrane Library issue 4, 2004)、MEDLINE (1966年1月到2004年12月)、PsycINFO (1966年到2004年)、及National PTSD Center Pilots database。選到的文章的參考文獻也會做進一步搜尋來找到更多的研究。

選擇標準

所有針對創傷後壓力疾患藥物治療的隨機對照控制試驗。

資料收集與分析

兩位審查者獨立評估納入此回顧中的隨機對照控制試驗，整理試驗數據，並評估試驗品質。其中也聯絡試驗研究人員，以取得遺失的試驗資料。統計摘要依藥物種類以及不同的選擇性血清素再吸收抑製劑來分層處理,使用隨機效應模式(random effect model)來計算二元及連續變項,同時評估異質性(heterogeneity)以及做次群體(subgroup)/敏感度(sensitivity)分析。

主要結論

35個短期(少於或等於14週)的隨機對照控制試驗被納入分析(共有4597位參與個案)。在17個試驗中，藥物治療組在症狀嚴重度相對於安慰劑組明顯的減少(加權平均差異為−5.76，95%信賴區間(CI)為−8.16至−3.36，共2507位參與個案)。類似地，在13個試驗中，整體對於使用反應狀況的統計，顯示整體各種藥物的使用優於安慰劑組(relative risk 1.49, 95% CI 1.28 to 1.73, number needed to treat = 4.85, 95% CI 3.85 to 6.25, N = 1272)。藥物反應及安慰劑反應分別為59.1%(644位個案)及38.5%(628位個案)。在藥物治療中，治療的效果是最有說服力證據的為選擇性血清素再回收抑制劑(SSRI)。藥物治療在減少創傷後壓力症狀嚴重度、減少憂鬱症共病及減少造成失能上明顯優於安慰劑。藥物治療比安慰劑有較差的耐受性。在一篇含3個維持治療試驗的敘述性回顧中，認為創傷後壓力症候群是需要長期治療的疾病。

作者結論

對於創傷後壓力症候群,藥物治療是有效的，可以減少核心症狀，也可減少相關的憂鬱症狀及失能狀況。這篇回顧支持選擇性血清素回收抑制劑(SSRI)為第一線治療創傷後壓力症候群的藥物，且在長期治療上也有其價值。但是，在整個證據上仍存在著重大的缺口，因為還需要發現更多有效治療的藥物。

翻譯人

本摘要由彰化基督教醫院許文郁翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

創傷後壓力症候群(PTSD)會在面臨重大創傷後出現，並且造成極大的個人及社會損失。雖然傳統上會以心理治療為主，不過對於藥物治療也漸漸地找到了理論的基礎。本次的系統性回顧共包含35個短期的隨機對照試驗，研究以藥物治療創傷後壓力症候群(共有4597位參與個案)。比起安慰劑(39.5%),有明顯較大比率(59.1%)的患者對於藥物治療有反應(13個試驗，1272位試驗個案)。症狀嚴重度在17個試驗中有明顯的減少(2507位試驗個案)。最大的幾個試驗顯示選擇性血清素回收抑制劑有其效用，且在長期治療上也是如此。