Treatment options for PTSD

Posttraumatic stress disorder (PTSD) is a condition that affects 8 million adults in the United States, and 8% of the population will suffer from some form of PTSD throughout their life. This disorder is characterized by consistent and often highly distressing memories that cue some aspect of a traumatic event in the past. Prevalence of PTSD is higher among women and combat veterans, with women are twice as likely as men to experience PTSD throughout their lifetime. This disorder is more impactful than simply having persistent uncomfortable flashbacks as most people might imagine. PTSD causes high degrees of disability in normal daily activities among those affected. These individuals are more likely to suffer from poor family relationships, and are associated with lower income, and less occupational success according to the DSM-5. Lastly, individuals diagnosed with PTSD are 80% more likely to suffer from another mental disorder.

            These data are supported in the article “Alcohol use and craving among Veterans with mental health disorders and mild traumatic brain injury” where Dr. Amy Herrold states that individuals suffering from PTSD or depression are 3 to 4 times more likely to suffer from alcohol use disorder (AUD). Dr. Herrold specializes in assessing potential treatments for cooccurring conditions which are common with PTSD. She points out that these cooccurring conditions such as a patient suffering from both PTSD and AUD makes it far more difficult for the patient to recover, and intensifies the symptoms of both disorder. Dr. Harold is investigating the use of transcranial magnetic stimulation (TMS) to treat cases of cooccurring disorders such as PTSD, AUD, and mild traumatic brain injury (mTBI). TMS has been shown to reduce symptoms of AUD in patients with these cooccurring conditions, which indicates that it could be a potential treatment option for these disorders.

While treatments aimed at modulating the neural activity of circuits involved in the symptoms of these disorders are becoming more popular, traditional methods of treating PTSD are pharmacological. The most common medications to treat PTSD are selective serotonin or serotonin-norepinephrine reuptake inhibitors (SSRIs/SNRIs) which are the go-to medication to treat depression and anxiety related disorders. This is evidenced by the fact that 13% of the population in the U.S. is on some sort of antidepressants. While these medications are effective in treating major symptoms for anxiety and depressive disorders, they are now being prescribed at lower rates due to concerns with major side effects that these medications often bring on. However, new experimental treatment options show promise, specifically as it relates to treating PTSD.

One of these new treatment options is ketamine, which has shown to reduce the negative symptoms of PTSD in a more targeted manner, and with greater effectiveness that traditional SSRIs. Ketamine was originally used as an anesthetic and works as an NDMA receptor antagonist. In normal conditions, this this receptor is activated by glutamate, and has a general effect of increasing the excitability of neurons. When ketamine acts to antagonize or reduce the excitatory effects of glutamate in the brain, the general result is a slowing down of these neural circuits. Understanding this mechanism is useful in the study of PTSD treatments, since a potential hypothesis is that ketamine treatment can disrupt fear conditioning in the hippocampus (the brain area most commonly associated with memory) which is dependent on the activity of the NMDA receptor to encode a situation that we perceive as harmful. In a human double-blind controlled study of 41 patients, researchers found that ketamine was more effective than a commonly prescribed benzodiazepine at reducing the severity of PTSD symptoms. Additionally, several specific case studies corroborate that ketamine treatment was effective in reducing PTSD symptoms when traditional SSRIs failed. One such example was from a 23-year old veteran with PTSD, who had previously been prescribed SSRIs, SNRIs, TCAs (tricyclic antidepressants), valproate, as well as numerous types of psychotherapies without a consistent positive result. After a brief ketamine treatment, he showed “an immediate drastic decrease in dysphoria that led to improved functioning.”

While this new experimental treatment shows promise, there are also areas of scrutiny, mainly being that the treatment itself can sometimes cause “transient dissociation.” While this has only been documented in rare cases, it is not a minor side effect, and more research should be conducted into the efficacy of the treatment, as well as the potential off-target effects such as dissociation events that have been reported. However, no experimental medication comes without its potential downsides. While ketamine might not be the treatment option best suited for a majority of patients, it is at the very least opening the door to exploring more potential options to treat this increasingly widespread mental health disorder.

References

Liriano, Felix, et al. “Ketamine as Treatment for Post-Traumatic Stress Disorder: a Review.” Drugs in Context, vol. 8, 2019, pp. 1–7., doi:10.7573/dic.212305.

Herrold, Amya, et al. “Transcranial Magnetic Stimulation: Potential Treatment for Co-Occurring Alcohol, Traumatic Brain Injury and Posttraumatic Stress Disorders.” Neural Regeneration Research, vol. 9, no. 19, 2014, p. 1712., doi:10.4103/1673-5374.143408.

Herrold, Amy A., et al. “Alcohol Use and Craving among Veterans with Mental Health Disorders and Mild Traumatic Brain Injury.” Journal of Rehabilitation Research and Development, vol. 51, no. 9, 2014, pp. 1397–1410., doi:10.1682/jrrd.2013.07.0170.