Acupuncture is practiced as an accepted health care model in China, Korea and Japan. Traditionally, it involves the stimulation of specific points (acupoints) by inserting needles into the skin. Electro-acupuncture is similar in that the same points are stimulated with needles inserted on specific points along the body. It uses two needles attached to an electrical device that generates continuous electric pulses. These pass from one needle to the other with varying frequency and intensity dictated by the condition. Administration is usually for no more than 30 minutes at a time. Laser acupuncture is essentially the same except that a laser is used instead of needles. Moxibustion uses heat from burning a herb (artemisia vulgaris), or uses an electric source, to stimulate specific points or areas of the body.

One of the challenges in performing efficacy trials of acupuncture is that it is difficult to provide a control condition. Sham methods that have been used include needling the wrong points or with very superficial technique. Or using a simulation of laser acupuncture without full stimulation.

What is the evidence for the effectiveness of acupuncture in people with PTSD?

Moderate to low quality evidence found improvements in PTSD symptoms and some improvement in depression symptoms and functioning following needle acupuncture (30 to 60 minutes per session, 2 to 4 sessions per week over 3 to 12 weeks). There were no improvements in anxiety, sleep, or quality of life. Some participants experienced minor to moderate pain, superficial bleeding, and hematoma at needle insertion sites.

August 2021

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Scientific understanding of the neurobiological changes occurring during PTSD onset shows memory consolidation appears particularly vulnerable to disruption in the first six hours after trauma, making this a crucial period for intervention for prevention of PTSD. This technical commentary presents the evidence on pharmaceutical interventions administered during this period. Please also see the psychotherapy for prevention of PTSD topic.

What is the evidence on medications for the prevention of PTSD?

Hydrocortisone is a glucocorticoid, which attenuates heightened fear response through increased removal of fear-inducing memories. Moderate to low quality evidence found a medium to large, reduced risk of PTSD within 3-6 months post-trauma in people with severe physical illness or injury receiving hydrocortisone post-trauma. Risks were not assessed in these samples, so contraindications need checking.

There was no benefit of hydrocortisone over placebo after 6 months post-trauma. There were also no benefits of propranolol, oxytocin, gabapentin, fish oil, dexamethasone, escitalopram, imipramine, or chloral hydrate for preventing PTSD at any time frame. Studies are few and small.

August 2021

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Several beneficial treatments for PTSD are available, including pharmaceutical and psychological approaches. Treatment guidelines typically recommend psychological therapies as first-line PTSD treatment. However, some antidepressants in particular may also be used as first-line treatment. It remains uncertain whether benefit increases when combining pharmacological and psychological treatments. This topic presents the evidence for all pharmaceutical treatments compared to all psychosocial and combination therapies for PTSD.

What is the evidence on pharmaceutical versus psychological and combination interventions for PTSD?

Moderate to low quality evidence found large improvements in PTSD symptoms by last follow-up with psychotherapy and with psychotherapy + medication compared to medications alone. There were no differences between these three treatment options immediately following treatment, and no differences between combined and psychological therapies at last follow-up. There were no differences in drop-outs rates, indicating similar tolerability of all treatments.

Note that last follow-up time frames were not reported in the reviewed evidence, and treatments were not all necessarily maintained to last follow-up, so these results must be interpreted with caution.

August 2021

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Alpha blockers, such as prazosin, are medications that work as alpha-adrenergic receptor antagonists. They cross the blood-brain barrier, antagonise the alpha receptors in the central nervous system, and block the stress response. Higher than normal nocturnal central nervous system adrenergic activity that occurs in PTSD contributes to the disruption of normal rapid eye movement sleep. Prazosin reduces this adrenergic activity and therefore could be effective in treating posttraumatic arousal symptoms such as sleep disturbances and nightmares.

What is the evidence on prazosin for PTSD?

Moderate quality evidence found medium to large improvements in PTSD symptoms, nightmares, and sleep disturbances with prazosin than with placebo when compared at treatment endpoint. When comparing baseline to endpoint improvements over time, there was also a large reduction in nightmare frequency, and a trend, medium-sized improvement in PTSD symptoms with prazosin. However, there were no significant differences in sleep quality between prazosin and placebo, suggesting the placebo group may have had more sleep disturbances at baseline (the two reviews in this topic included mostly the same studies).

Prazosin resulted in more dry mouth than placebo, with no differences in dizziness, headache, nausea, lack of energy, muscle weakness or asthenia, drowsiness or somnolence, syncope, nasal congestion, or palpitations.

August 2021

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Anticonvulsants are primarily used to treat epilepsy, but may also be effective for some mental disorders. Anticonvulsant medications influence the actions of neurotransmitters including glutamate and GABA, leading to a decrease in brain cell (neuron) excitability. Anticonvulsant medications for PTSD symptoms assessed in this topic include topiramate, tiagabine, and divalproex.

What is the evidence on anticonvulsants for PTSD?

Moderate quality evidence found topiramate improved symptom response more than placebo. Tiagabine showed less symptom improvement than the antidepressant phenalzine, and divalproex showed less symptom improvement than the antidepressants phenelzine, paroxetine, and desipramine. There were more dropouts due to adverse events with topiramate than with the antidepressant brofaromine.

No other significant differences were found in response, symptom improvement or adverse effects between anticonvulsants and other pharmaceutical agents (antidepressants and antipsychotics).

August 2021

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Antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs), have been found to be efficacious in the treatment of depression and anxiety. PTSD was originally classed as an anxiety disorder. Antidepressants may work for PTSD by correcting imbalances in neurotransmitters thought to play a role in causing and/or maintaining symptoms.

What is the evidence on antidepressants for PTSD?

Moderate quality evidence found the antidepressants phenelzine (large effect), desipramine (medium-sized effect), paroxetine, venlafaxine, fluoxetine, and sertraline (all small effects) were more effective for PTSD symptoms than placebo. Phenelzine was more effective for PTSD symptoms than the antidepressants citalopram, bupropion, sertraline, and imipramine. Phenelzine was also more effective than the anticonvulsants divalproex and tiagabine, the alpha blocker prazosin, and the adrenergic receptor agonist guanfacine. Paroxetine and desipramine were more effective for PTSD symptoms than citalopram, divalproex, and prazosin. Venlafaxine and fluoxetine were more effective for PTSD symptoms than citalopram and prazosin. Citalopram was less effective for PTSD symptoms than the antidepressant mirtazapine and the antipsychotic olanzapine. There were fewer dropouts due to adverse events with the antidepressant brofaromine than with the antidepressants sertraline and paroxetine, and the anticonvulsant topiramate.

Moderate to low quality evidence found no differences between paroxetine or sertraline plus prolonged exposure vs. paroxetine, sertraline, or prolonged exposure alone. There were no differences in PTSD relapse rates after discontinuation of antidepressants or placebo. Moderate to high quality evidence found no influence of baseline PTSD symptom severity on efficacy of paroxetine and sertraline after 12 weeks of treatment.

August 2021

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While most pharmacological guidelines suggest first-line pharmacotherapy should include selective serotonin reuptake inhibitor (SSRI) antidepressants, some people with PTSD do not adequately respond to this treatment. There are also high prevalence rates of PTSD symptoms in people with psychosis, particularly in hospitalised patients. Antipsychotics are effective for the symptoms of psychosis and have also been investigated in people with a primary diagnosis of PTSD.

What is the evidence on antipsychotics for PTSD?

Moderate to high quality evidence found a small improvement in PTSD symptoms with risperidone or olanzapine than with placebo. Olanzapine was also more effective for symptom improvement than the antidepressant citalopram.

There were no significant differences between antipsychotics and placebo in treatment dropouts due to adverse events, however there was more weight gain with antipsychotics.

August 2021

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Benzodiazepines are implemented to treat insomnia, irritability, and anxiety, which are common symptoms in people with PTSD. While benzodiazepines may diminish these symptoms, they may worsen other features, such as promoting avoidance in the long term. They are also associated with well-established patterns of tolerance and dependence, so they are prescribed with caution.

What is the evidence on benzodiazepines for PTSD?

Moderate quality evidence found a small effect that benzodiazepines can have an adverse impact on the prevention and treatment of PTSD.

August 2021

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Biofeedback is a technique where information about the person’s body is fed back to them so that they can be trained to alter their body’s conditions. Physical therapists use biofeedback to help stroke victims regain movement in paralyzed muscles. Other specialists use biofeedback to help their patients cope with pain. It is also commonly used to reduce stress and anxiety, and to encourage relaxation.

Electromyographic biofeedback is used by psychologists to help anxious patients learn to relax. The electromyograph picks up electrical signals in the muscles and translates these signals into a flashing light or a beep every time muscles grow tense. If patients relax their tense muscles, they can slow down the flashing or beeping. Electroencephalographic biofeedback is used to teach self-regulation of brain function. It is usually provided using video or sound, with positive feedback for desirable brain activity and negative feedback for undesirable brain activity. Thermal biofeedback uses a temperature sensor to allow the patient to track his or her body temperature. During times of stress, the body will divert blood from the surface area of the body to the muscles and organs, allowing us to better respond to a nearby threat. When a patient is stressed, this will show as a drop-in temperature in the body’s surface areas. When a patient’s surface temperature is high, it typically means they are in a relaxed or sleepy state.

Dysregulation in autonomic nervous system activity is common in a variety of mental health disorders and presents targets for biofeedback. Hypoarousal patterns include slow, regular heart rate, increased heart rate variability, warm skin temperature, low sweat gland activity, and dominance of EEG frequencies in the theta to low alpha range (3.5–10 Hz). In contrast, hyperarousal is reflected by increased heart rate and decreased heart rate variability, high electrodermal activity, and higher frequency EEG bandwidth ranges in high-alpha or beta range (15–42 Hz).

What is the evidence for the effectiveness of biofeedback in people with PTSD?

The only review that met inclusion criteria assessed EEG neurofeedback. It contained moderate to low quality evidence and found a large improvement in PTSD symptoms with 4-12 weeks of neurofeedback compared to no treatment.

August 2021

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People with serious mental illnesses are more likely to be sedentary than the general population. This can lead to chronic medical conditions associated with inactivity. Physical activity reduces the risk of these medical conditions, and positive psychological effects have also been reported, including improved quality of life. Exercise also has the potential to alleviate secondary symptoms including depression, low self-esteem and social withdrawal.

What is the evidence for the effectiveness of exercise for people with PTSD?

Moderate to high quality evidence found a medium-sized effect of improved PTSD symptoms following physical activity (pre-post analysis). Compared to control conditions the effect was larger, but reduced over time (>1 month after the trial ended). The effect was largest in low quality studies, in military samples, with yoga rather than other exercise conditions, and when compared to passive rather than active control conditions.

August 2021

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