Dobbs
Adjunctive
Risperidone
Treatment –
Multiple
Authors
Annette Boyle
PTSD
What does a veteran gain
with a PTSD diagnosis? One
would hope, of course, that
it grants access to effective
treatment and support.
This is not happening. In
civilian populations, two
thirds of PTSD patients
respond to treatment. But
as psychologist Christopher
Frueh, who researched and
treated PTSD for the VA
from the early 1990s until
2006, notes, “In the two
largest VA studies of
combat veterans, neither
showed a treatment effect.
Vets getting PTSD
treatment from the VA are
no more likely to get better
than they would on their
own.”
The reason, Frueh says, is
the collision of the PTSD
construct’s vagaries with
the VA’s disability system,
in which every benefit
seems structured to
discourage recovery.
Pharmaceutical Therapy
Medications aren’t
effective.
Financial benefits of
PTSD diagnosis end when
veteran lands a job.
R.A.B. suggests a
disability system more
like the system in
Australia.
SRI antidepressants are
the only accepted form
of drugs approved by
FDA. If the vet doesn’t
respond, Risperidone is
prescribed.
In this study, Risperidone
did not reduce PTSD
symptoms, produce
global improvement or
increase quality of life.
There is a real need to
better understand the
various medications
currently used to treat
PTSD.
A Memo by Army Chief of
Staff cautioned health-
Psychotherapy
care profivers from the
use of atypical
antipsychotics that raises
concerns of potential
adverse effects.
“While there is anecdotal
evidence [and] small
studies that support the
use of these drugs, there
aren’t large, wellcontrolled studies to
show whether they are
truly effective.”
“Hoge noted that, while
only traditional
antidepressants have “A”
level recommendations
for treatment of PTSD,
adjunctive use of other
drugs may be quite
effective for specific
patients. “One good
example is Minipress
[prazosin], a blood
pressure medication that
reduces the physiological
hyper-arousal associated
with nightmares. By
blocking the physiological
reaction, it can improve
sleep in patients with
PTSD”
Bergland
Two million Americans
have served in Iraq and
Afghanistan, and 20
percent of them are
estimated to have PTSD.
The Veterans Health
Administration has been
overwhelmed with PTSD
patients.
Two new treatments for
PTSD victims have
shown promising results
in recent studies. The
treatments are called
“Prolonged Exposure
Therapy” (PE) and
“Cognitive Processing
Therapy” (CPT).
“Prolonged Exposure
Therapy forces a patient
to vividly remember
every detail of a
traumatic experience
and verbalize the
memories… According
Congressional
Budget Office
Over 2 million service
members have deployed
overseas in the conflicts in
Iraq and Afghanistan since
2001. Of the service
members who deployed
overseas and treated by
the VA, 21 percent were
diagnosed with PTSD and
two percent were
diagnosed with TBI. An
additional 5 percent had
both TBI and PTSD.
As of September 2011,
mental health diagnosis
were the second largest
category of diagnosis at the
VHA (Veterans Health
Administration) of OCO
Veterans (Overseas
Contingency Operations,
Iraq and Afghanistan),
encompassing 52 percent
of patients.
to the VA, the three
main components of PE
are “Breathing, real
world in vivo exposure
and talking through the
trauma while listening
to the tapes.
Cognitive Processing
Therapy, according to
the VA, works well in
patients who feel as if
their lives are still held
in “the grip of war.”
This group therapy
encourages the
participant to let the
group know their story
and to face the fears
and emotions of reliving
memories together,
with the new comradery
found in the therapy
group.
VHA offers two new
forms of “evidence
based psychotherapy”.
These two therapies are
called cognitive
processing therapy and
prolonged exposure
therapy. The Institute
of Medicine has
concluded that these
two therapies, PE and
CPT, are the only types
of psychotherapy that
have been found to
effectively treat
veterans with PTSD.
The institute also noted
that these therapies are
more effective on
civilians than on
veterans.
VHA’s clinical research
has determines that
patients who undergo
therapy require at least
Upon Arrival to the VHA, a
patient undergoes a
screening for potential
medical conditions, known
as the Iraq and Afghanistan
Post-Deploy screening.
Veterans are asked specific
questions to determine if
symptoms of PTSD are
present, in which case a
referral to a mental health
professional would occur.
Diagnosis of PTSD is done
by clinical staff and is based
off of the Diagnostic and
Statistical Manual of
Mental Disorders (DSM),
which is the professionally
certified criteria for
diagnosing mental
disorders in the United
States.
Outcomes of
Prolonged
Exposure
Therapy –
multiple authors
nine treatment sessions
to produce positive
outcomes.
Prolonged Exposure
Therapy is a
behaviorally based
treatment whose
interventions include
education on
psychotherapies,
breathing retraining, in
vivo exposure and
recreation of the
memories of war.
Veterans who fully
participated in PE
Therapy in this study
showed a 41% decrease
in symptoms, including
depression. There was
also significant
improvements on the
participant’s quality of
life.
This study also
interestingly found that
participants who were
also prescribed
psychiatric medications
experienced less
reduction of PTSD
symptoms that those
participants that were
relying solely on PE
Therapy for treatment.
Alan Fontana
and Robert
Rosenheck
This study conducted a
very thorough and lengthy
research plan to find what
categories of stressors
contributed the most to
PTSD. Also, what were the
connections of these
stressors to each other and
how did they affect PTSD
symptoms in veterans
together.
As one might assume, the
Killing or injuring of others
had the strongest direct
effect on PTSD. This
stressor was found to be
the most substantial
reason for veterans to
develop PTSD.
This also greatly increased
the number of atrocities
service members
committed. The research
suggested that once the
“moral prohibition” of
killing others is destroyed,
the prohibitions against
lesser evils is weakened as
well.
Pharmaceutical Treatment:
Dobbs – Wired
The VA doesn’t really treat veterans with PTSD. Nothing the VA tries really works for them. The New
York Times reports in a study they did that about 20 percent of combat veterans develop lasting PTSD
symptoms and a fifth of those treated are prescribed anti-psychotic medicine. These drugs however,
are not at all effective and are often not taken in their entirety because they come with serious sideeffects including weight loss and fatigue.
Anti-psychotic medication is an unusual choice for treatment of PTSD because the medicine is aimed at
treating psychosis, not mood disorders. Furthermore, the financial benefits of being diagnosed with
PTSD, a disability check (that can be as much as $3,000 monthly), ends upon a veteran receiving a job,
though the symptoms might not end at all.
“Richard A. Bryant, an Australian PTSD re- searcher and clinician, suggests a disability system more like
that in place Down Under. An Australian soldier injured in combat receives a lifelong “noneconomic”
disability payment of $300 to $1,200 monthly. If the injury keeps him from working, he also gets an
“incapacity” payment, as well as job training and help finding work. Finally—a crucial feature—he
retains all these benefits for two years once he goes back to work. After that, incapacity payments taper
to zero over five years. But noneconomic payments—a kind of financial Purple Heart—continue forever.
And like all Australians, the soldier gets free lifetime health care. Australian vets come home to an
utterly different support system from ours: Theirs is a scaffold they can climb. Ours is a low-hanging
“safety net” liable to trap anyone who falls in.”
http://www.wired.com/2011/08/the-va-fails-at-ptsd-treatment-again/
Multiple Authors – Adjunctive Risperidone Treatment
A study was done by several doctors to determine the effectiveness of pharmaceuticals on PTSD
patients. Serotonin reuptake-inhibiting (SRI) antidepressants are the only form of pharmaceuticals
approved by the FDA to treat patients with PTSD. For veterans who do not respond to SRI treatment,
another treatment of a second generation antipsychotic, a drug called Risperidone, is commonly
prescribed, though, according to this study, there is little evidence to support this.
In this study, certain scores were used to rate PTSD severity (CAPS Score), overall global improvement
(CGI score), and a general level of quality of life. “In summary, Risperidone, the second most widely
prescribed [Second-generation antipsychotics] within VA for PTSD and the best data-supported
adjunctive pharmacotherapy for PTSD, did not reduce overall PTSD severity (CAPS total score), produce
global improvement (CGI score), or increase quality of life… in patients with chronic SRI-resistant
military-related PTSD symptoms. Overall, the data do not provide strong support for the current
widespread prescription of risperidone to patients with chronic SRI-resistant military-related PTSD
symptoms, and these findings should stimulate careful review of the benefits of these medications in
patients with chronic PTSD.”
http://jama.jamanetwork.com/article.aspx?articleid=1104803
Potential overuse of antipsychotic drugs for PTSD patients
Annette Boyle
“There is a real need to better understand the various medications currently being used off-label by
providers to treat combat-related PTSD,” Maj. Gary H. Wynn, research psychiatrist with the
Neurotrauma and Psychological Health Project Management Office at the U.S. Army Medical Materiel
Development Activity (USMMDA) told U.S. Medicine.”
“A memo from Army Chief of Staff Herbert A. Coley, however, cautioned health-care providers in April
that use of atypical antipsychotics raises “numerous concerns with potential long-term adverse health
effects (e.g., weight gain, glucose dysregulation, cardiac effects, extrapyramidal effects), and these
medications have shown disappointing results in clinical trials in the treatment of PTSD. Risperidone
specifically has been given a D-level recommendation in the VA/DoD CPG (harm outweighs benefits)
based on the results of a large multicenter VA cooperative study.””
““While there is anecdotal evidence [and] small studies that support the use of these drugs, there aren’t
large, well-controlled studies to show whether they are truly effective,” he said. The program initially
will evaluate trazodone, quetiapine and eszopiclone, all drugs frequently used to help PTSD patients
with sleep difficulties.”
“Hoge noted that, while only traditional antidepressants have “A” level recommendations for treatment
of PTSD, adjunctive use of other drugs may be quite effective for specific patients. “One good example
is Minipress [prazosin], a blood pressure medication that reduces the physiological hyper-arousal
associated with nightmares. By blocking the physiological reaction, it can improve sleep in patients with
PTSD,” he said.”
http://www.usmedicine.com/agencies/department-of-defense-dod/potential-overuse-of-antipsychoticdrugs-for-ptsd-patients-is-under-review/2/
Psychotherapy
Two New PTSD Treatments Offer Hope for Veterans – Bergland
Two new treatments for PTSD victims have shown promising results in recent studies. The treatments
are called “Prolonged Exposure Therapy” (PE) and “Cognitive Processing Therapy” (CPT). CBS’s 60
minutes went behind the scenes of the battle against PTSD in an episode titled “The War Within:
Treating PTSD” 60 minutes talked with 16 veterans about their reentry into society and the difficulties it
possessed. It also talked about these two new methods for treatment.
“Prolonged Exposure Therapy forces a patient to vividly remember every detail of a traumatic
experience and verbalize the memories… Dr. Kevin Reeder is the man behind the VA program. He
explains that the idea is to relive the story of the attack at least five times in a single session, and then
listen to your voice on tape re-telling the story. The belief is that hearing the traumatic memory
repeatedly will neutralize its power from bubbling up from your subconscious memory and catching you
off guard.” According to the VA, the three main components of PE are “Breathing, real world in vivo
exposure and talking through the trauma while listening to the tapes.
Cognitive Processing Therapy, according to the VA, works well in patients who feel as if their lives are
still held in “the grip of war.” This group therapy encourages the participant to let the group know their
story and to face the fears and emotions of reliving memories together, with the new comradery found
in the therapy group. Often times, the soldiers in VA treatments express that they would go back to
combat again just to experience the comradery they felt overseas and this therapy style tries to
reproduce that and allow for healing of memories and fears from PTSD. The main points of CPT include
learning about PTSD symptoms, becoming aware of thoughts and feelings, learning skills and
understanding changes in beliefs.
http://www.psychologytoday.com/blog/the-athletes-way/201311/two-new-ptsd-treatments-offerhope-veterans
Congressional Budget Office
VHA offers two new forms of “evidence based psychotherapy”. These two therapies are called cognitive
processing therapy and prolonged exposure therapy. The Institute of Medicine has concluded that
these two therapies, PE and CPT, are the only types of psychotherapy that have been found to
effectively treat veterans with PTSD. The institute also noted that these therapies are more effective on
civilians than on veterans.
VHA’s clinical research has determines that patients who undergo therapy require at least nine
treatment sessions to produce positive outcomes.
http://permanent.access.gpo.gov/gpo18872/02-09-PTSD.pdf
outcomes of prolonged exposure therapy for veterans with ptsd
multiple authors
Prolonged Exposure Therapy is a behaviorally based treatment whose interventions include education
on psychotherapies, breathing retraining, in vivo exposure and recreation of the memories of war.
Veterans who fully participated in PE Therapy in this study showed a 41% decrease in symptoms,
including depression. There was also significant improvements on the participant’s quality of life.
This study also interestingly found that participants who were also prescribed psychiatric medications
experienced less reduction of PTSD symptoms that those participants that were relying solely on PE
Therapy for treatment.
http://onlinelibrary.wiley.com.proxy.library.vcu.edu/doi/10.1002/jts.21830/pdf
PTSD
Congressional Budget Office
Over 2 million service members have deployed overseas in the conflicts in Iraq and Afghanistan since
2001. Of the service members who deployed overseas and treated by the VA, 21 percent were
diagnosed with PTSD and two percent were diagnosed with TBI. An additional 5 percent had both TBI
and PTSD.
As of September 2011, mental health diagnosis were the second largest category of diagnosis at the VHA
(Veterans Health Administration) of OCO Veterans (Overseas Contingency Operations, Iraq and
Afghanistan), encompassing 52 percent of patients.
Upon Arrival to the VHA, a patient undergoes a screening for potential medical conditions, known as the
Iraq and Afghanistan Post-Deploy screening. Veterans are asked specific questions to determine if
symptoms of PTSD are present, in which case a referral to a mental health professional would occur.
Diagnosis of PTSD is done by clinical staff and is based off of the Diagnostic and Statistical Manual of
Mental Disorders (DSM), which is the professionally certified criteria for diagnosing mental disorders in
the United States.
National Center for PTSD
Discusses moral injury of soldiers and how it occurs
Moral injury can occur from an individual’s actions, or inactions or bearing witness to human suffering
and violently disturbing images of battle. These types of events that an individual bears witness too can
lead to serious inner conflict because of the strikingly polarization between these events and the moral
and ethical beliefs of the soldier.
Moral injury is defined as “Perpetrating, failing to prevent, bearing witness to, or learning about acts
that transgress deeply held moral beliefs and expectations.”
The researchers at the National Center for PTSD found that being the target of killing or injuring in war
was associated with PTSD and being the agent of killing or failing to prevent death or injury was
associated with general psychological distress and suicide attempts. In a related study, and article in
1991 was cited to have found that combat guilt was the most significant predicating factor of both
suicide attempts and the veteran’s constant dwelling on suicide.
http://www.ptsd.va.gov/professional/newsletters/research-quarterly/v23n1.pdf
A Model of War Zone Stressors and Posttraumatic Stress Disorder
Alan Fontana and Robert Rosenheck
This study conducted a very thorough and lengthy research plan to find what categories of stressors
contributed the most to PTSD. Also, what were the connections of these stressors to each other and
how did they affect PTSD symptoms in veterans together.
As one might assume, the Killing or injuring of others had the strongest direct effect on PTSD. This
stressor was found to be the most substantial reason for veterans to develop PTSD.
This also greatly increased the number of atrocities service members committed. The research
suggested that once the “moral prohibition” of killing others is destroyed, the prohibitions against lesser
evils is weakened as well.
http://onlinelibrary.wiley.com.proxy.library.vcu.edu/doi/10.1023/A:1024750417154/pdf
Works Cited
Bergland, Christopher. "Two New PTSD Treatments Offer Hope for Veterans." Psychology Today: Health,
Help, Happiness. Psychology Today, 26 Nov. 2013. Web. 12 Oct. 2014.
Boyle, Annette M. "Potential Overuse of Antipsychotic Drugs for PTSD Patients Is Under Review." US
Medicine. US Medicine, Sept. 2012. Web. 12 Oct. 2014.
Dobbs, David. "The VA Fails at PTSD Treatment - Again | WIRED." Wired.com. Conde Nast Digital, 16
Aug. 0011. Web. 12 Oct. 2014.
Fontana, Alan, and Robert Rosenheck. "A Model of War Zone Stressors and Posttraumatic Stress
Disorder." VCU Libraries. Journal of Traumatic Stress, 1999. Web. 12 Oct. 2014.
Goodson, Jason T., Carin M. Lefkowitz, Amy W. Helstrom, and Michael J. Gawrysiak. "Outcomes of
Prolonged Exposure Therapy for Veterans with Posttraumatic Stress Disorder." VCU Libraries.
Journal of Traumatic Stress, 26 Aug. 2013. Web. 12 Oct.
2014.
Krystal, John H., Robert A. Rosenheck, Joyce A. Cramer, Jennifer C. Vessicchio, Karen M. Jones, Julia E.
Vertrees, Rebecca A. Horney, Grant D. Huang, and Christopher Stock. "Adjunctive Risperidone
Treatment for Antidepressant-Resistant Symptoms of Chronic Military Service–Related PTSD."
JAMA Network. The Journal of the American Medical Association, 03 Aug. 2011. Web. 12 Oct.
2014.
Maguen, Shira, and Brett Litz. "Moral Injury in Veterans of War." Moral Injury in Veterans of War 23.1
(2012): 1-6. National Center for PTSD. National Center for PTSD, 2012. Web. 12 Oct. 2014.
States, Congress Of The United, and Congressional Budget Office. "The Veterans Health Administration's
Treatment of PTSD and Traumatic Brain Injury Among Recent Combat Veterans." Congress of
the United States (2012): 1-52. Congressional Budget Office. Congress of the United States, Feb.
2012. Web. 12 Oct. 2014.