Bajor L, Ticlea A, Osser DN. The Psychopharmacology Algorithm Project at the Harvard South Shore Program: an update on posttraumatic stress disorder. Harv Rev Psychiatry 19: 240-58

Harvard Medical School, Harvard South Shore Psychiatry Residency Training Program, Brockton, MA 02301, USA.
Harvard Review of Psychiatry (Impact Factor: 1.73). 09/2011; 19(5):240-58. DOI: 10.3109/10673229.2011.614483
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This project aimed to provide an organized, sequential, and evidence-supported approach to the pharmacotherapy of posttraumatic stress disorder (PTSD), following the format of previous efforts of the Psychopharmacology Algorithm Project at the Harvard South Shore Program.
A comprehensive literature review was conducted to determine the best pharmacological choices for PTSD patients and to update the last published version (1999) of the algorithm. We focused on optimal pharmacological interventions to address the prominent symptoms of PTSD, with additional attention to the impact that common comorbidities have on treatment choices.
We found that SSRIs and SNRIs are not as effective as previously thought, and that awareness of their long-term side effects has increased. New evidence suggests that addressing fragmented sleep and nightmares can improve symptoms (in addition to insomnia) that are frequently seen with PTSD (e.g., hyperarousal, reexperiencing). Prazosin and trazodone are emphasized at this initial step; if significant PTSD symptoms remain, an antidepressant may be tried. For PTSD-related psychosis, an antipsychotic may be added. In resistant cases, two or three antidepressants may be used in sequence. Following that, or with partial improvement and residual symptomatology, augmentation may be tried; the best options are antipsychotics, clonidine, topiramate, and lamotrigine.
This heuristic may be helpful in producing faster symptom resolution, fewer side effects, and increased compliance.

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    • "In fact, various AAs have shown positive antidepressant and anti-anxiety effects in a number of small-scale open-label studies (OLSs) and randomized controlled clinical trials (RCTs) (Han et al., 2013; Pae et al., 2013; Pae and Patkar, 2013; Pae et al., 2008b); however, the most largest RCT for PTSD (Krystal et al., 2011) has also failed to separate the efficacy of risperidone from placebo. Although small RCTs and OLSs have demonstrated the potential beneficial effects of AAs for the treatment of PTSD, there is a lack of adequately powered RCTs investigating the efficacy of AAs for treatment of PTSD (Bajor et al., 2011; Pae et al., 2008a). The current meta-analysis cannot replace a well-designed adequately powered RCT but it can complement available knowledge by pooling data from various small RCTs conducted using a priori inclusion criteria. "
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