Sertraline treatment of comorbid posttraumatic stress disorder and alcohol dependence
Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston 29425, USA. The Journal of Clinical Psychiatry
(Impact Factor: 5.5).
Posttraumatic stress disorder (PTSD) often co-occurs with alcohol dependence, yet little is known about treatment of this comorbidity. The serotonin selective reuptake inhibitors have been shown preliminarily to be effective in decreasing symptoms of PTSD but have not been studied in individuals with comorbid alcohol dependence. This is of particular interest as the SSRIs also have a modest effect in decreasing alcohol consumption.
In this preliminary trial, nine subjects with comorbid PTSD and alcohol dependence were treated in an open-label trial with sertraline for a 12-week period. Symptoms of PTSD and depression were monitored monthly with the Impact of Event Scale and the Hamilton Rating Scale for Depression (HAM-D). Alcohol consumption was monitored by a self-report instrument (Time-Line Follow-Back).
There were significant decreases in all three symptom clusters of PTSD measured by overall PTSD symptom scores (p < or = .001) and in HAM-D scores (p < or = .001) during the follow-up period. Days of abstinence increased and average number of drinks decreased during the follow-up period. Four subjects claimed total abstinence during the follow-up period.
While limited by small sample size and the open-label, nonblinded study design, this study suggests that sertraline may be useful in the treatment of PTSD complicated by alcoholism. The medication was well tolerated and subjects showed improvement in PTSD symptoms as well as decreased alcohol consumption. A controlled trial of sertraline in this population would be of interest.
Available from: Kirsten C Morley
- "However, this superiority of integrated CBT versus a single-focused intervention was not subsequently observed in a pooled meta-analysis of community and clinic samples (Riper et al., 2014). With regards to comorbid anxiety disorders, while reductions in alcohol consumption have been observed to mediate PTSD responsiveness (Brady et al., 2005), early improvements in PTSD symptoms appear to have a greater impact on recovery in alcohol dependence than the reciprocal relationship, thus prompting recommendations for integrated treatment (Back et al., 2006). Sannibale et al. (2013) investigated the extent to which combining existing cognitive behavioural therapies for alcohol use disorder and PTSD (integrated therapy with exposure) would produce better outcomes than treating alcohol use disorder only (alcohol-support). "
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To assess the effectiveness of a 12 week specialized, integrated intervention for alcohol dependence with comorbid anxiety and/or mood disorder using a randomized design in an outpatient hospital setting.
Out of 86 patients meeting the inclusion criteria for alcohol dependence with suspicion of comorbid anxiety and/or depressive disorder, 57 completed a 3-week stabilization period (abstinence or significantly reduced consumption). Of these patients, 37 (65%) met a formal diagnostic assessment of an anxiety and/or depressive disorder and were randomized to either (a) integrated intervention (cognitive behavioural therapy) for alcohol, anxiety and/or depression, or (b) usual counselling care for alcohol problems.
Intention-to-treat analyses revealed a beneficial treatment effect of integrated treatment relative to usual counselling care for the number of days to relapse (χ(2) = 6.42, P < 0.05) and lapse (χ(2) = 10.73, P < 0.01). In addition, there was a significant interaction effect of treatment and time for percentage days of abstinence (P < 0.05). For heavy drinking days, the treatment effect was mediated by changes in DASS anxiety (P < 0.05). There were no significant treatment interaction effects for DASS depression or anxiety symptoms.
These results provide support for integrated care in improving drinking outcomes for patients with alcohol dependence and comorbid depression/anxiety disorder.
ClinicalTrials.gov Identifier: NCT01941693.
Available from: Sudie E Back
- "Sertraline, a serotoninspecific reuptake inhibitor, has been investigated in patients with comorbid alcohol dependence and PTSD. The first study was a small (n = 9) open-label, 12-week trial, which demonstrated significant pre–post decreases in alcohol use severity (e.g., number of drinking days, number of drinks per day), as well as PTSD symptoms of re-experiencing the trauma, avoidance, and hyperarousal (Brady et al. 1995). A second study examined the efficacy of 12 weeks of sertraline compared with placebo in 94 patients with alcohol dependence and PTSD (Brady et al. 2005). "
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ABSTRACT: Early-childhood trauma is strongly associated with developing mental health problems, including alcohol dependence, later in life. People with early-life trauma may use alcohol to help cope with trauma-related symptoms. This article reviews the prevalence of early-childhood trauma and its robust association with the development of alcohol use disorders and posttraumatic stress disorder. It also examines the potential biological mechanisms by which early adverse experiences can result in long-lasting changes in neurobiology underlying this vulnerability, as well as pharmacological and behavioral interventions. Recent investigations highlight the importance of assessing trauma among patients with alcohol use disorders and the positive benefits associated with the application of integrative psychosocial interventions that target both trauma-related symptoms and alcohol dependence.
Available from: ncbi.nlm.nih.gov
- "The efficacy of these medications may be more robust in non-veteran and predominately female patient populations (Hertzberg et al, 1999; Smajkic et al, 2001), including a negative clinical trial in predominately male veterans (Friedman et al, 2007). Although an openlabel study suggested that sertraline reduced PTSD symptoms and alcohol consumption (Brady et al, 1995), a larger randomized, placebo controlled study (n ¼ 94) showed no significant overall effect of sertraline on symptoms of PTSD or alcohol consumption (Brady and Sinha, 2005). "
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ABSTRACT: The wars in Iraq and Afghanistan are associated with high rates of post-traumatic stress disorder (PTSD) and comorbid alcohol use disorders. The pharmacotherapy of these comorbid conditions has received relatively little study. The current study compared the serotonin uptake inhibitor, paroxetine, to the norepinephrine uptake inhibitor, desipramine. It also evaluated the adjunctive efficacy of the Food and Drug Administration (FDA)-approved alcoholism pharmacotherapy, naltrexone, relative to placebo. Four groups of predominately male veterans (n=88) meeting current diagnostic criteria for both alcohol dependence (AD) and PTSD were randomly assigned under double-blind conditions to one of four groups: paroxetine+naltrexone; paroxetine+placebo; desipramine+naltrexone; desipramine+placebo. Main outcome measures included standardized scales that assessed symptoms of PTSD and alcohol consumption. Paroxetine did not show statistical superiority to desipramine for the treatment of PTSD symptoms. However, desipramine was superior to paroxetine with respect to study retention and alcohol use outcomes. Naltrexone reduced alcohol craving relative to placebo, but it conferred no advantage on drinking use outcomes. Although the serotonin uptake inhibitors are the only FDA-approved medications for the treatment of PTSD, the current study suggests that norepinephrine uptake inhibitors may present clinical advantages when treating male veterans with PTSD and AD. However, naltrexone did not show evidence of efficacy in this population. This study was registered with ClinicalTrials.gov, registration number NCT00338962 and URL: http://clinicaltrials.gov/ct2/show/NCT00338962?term=desipramine+AND+alcohol+dependence+AND+depression&recr=Closed&rank=1.Keywords: alcohol and alcoholism; psychopharmacology; PTSD; naltrexone; veterans; comorbidity
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