Savvy Psychopharmacology

PTSD nightmares: Prazosin and atypical antipsychotics

Current Psychiatry. 2012 June;11(6):59-67

References

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Table 4

RCTs of prazosin for trauma-related nightmares

Study	Design	Patients	Results
Raskind et al, 2003²⁰	20-week, double-blind, placebo-controlled, crossover study (mean dose 9.5 mg/d at bedtime)	10 Vietnam veterans with chronic PTSD and severe trauma-related nightmares	Prazosin was superior to placebo on scores on the recurrent distressing dreams item and difficulty falling/staying asleep item of the CAPS and change in PTSD severity and functional status on the CGI-C
Raskind et al, 2007²¹	8-week, placebo-controlled, parallel study (mean dose 13.3 ± 3 mg/d in the evening)	40 veterans with chronic PTSD, distressing trauma nightmares, and sleep disturbance	Prazosin was superior to placebo in reducing trauma nightmares and improving sleep quality and global clinical status; prazosin also shifted dream characteristics of trauma-related nightmares to those typical of normal dreams
Taylor et al, 2008²²	7-week, randomized, placebo-controlled, crossover trial (mean dose 3.1 ± 1.3 mg)	13 outpatients with chronic civilian trauma PTSD, frequent nightmares, and sleep disturbance	Prazosin significantly increased total sleep time and REM sleep time; reduced trauma-related nightmares, distressed awakenings, and total PCL-C scores; improved CGI-I scores; and changed PDRS scores toward normal dreaming
CAPS: Clinician-Administered PTSD Scale; CGI-C: Clinical Global Impression of Change; CGI-I: Clinical Global Impression of Improvement; PCL-C: PTSD Checklist-Civilian; PDRS: PTSD Dream Rating Scale; PTSD: posttraumatic stress disorder; RCTs: randomized controlled trials; REM: rapid eye movement

Atypical antipsychotics

Atypical antipsychotics have been used to reduce nightmares in PTSD; however, most of the evidence from studies evaluated in the AASM’s Best Practice Guide were considered to be low quality.¹¹ Quetiapine and ziprasidone were not included in the AASM review. See (Table 5) for a review of the evidence for atypical antipsychotics for treating PTSD nightmares.

Table 5

Combat-related nightmares: Evidence for atypical antipsychotics

Study	Design	Patients/dosage	Results
Aripiprazole
Lambert, 2006 ^a	Case report	4 veterans with combat-related PTSD (3 male, 1 female; age 22 to 24); dose: 15 to 30 mg; concurrent treatment sertraline or CBT	Decreased frequency of weekly nightmares and agitated sleep by at least 50%
Olanzapine
Stein et al, 2002 ^b	8-week, double-blind, placebo-controlled study	19 male veterans with combat-related PTSD (olanzapine group mean age: 55.2 ± 6.6; placebo group 51.1 ± 8.1); mean dose: 15 mg/d	Significantly greater reduction in sleep disturbances (PSQI: -3.29 vs 1.57; P = .01); significantly higher weight gain (13.2 lbs vs -3 lbs; P = .001)
Jakovljevic et al, 2003 ^c	Case reports	5 veterans with combat-related PTSD for 6 to 7 years (age: 28 to 50); dose: 10 to 20 mg; adjunct treatment	Decreased frequency of nightmares within 3 days
Labbate et al, 2000 ^d	Case report	1 male veteran (age: 58) with a 20-year history of combat-related PTSD; dose: 5 mg at bedtime; concurrent treatment with sertraline (200 mg/d), bupropion (150 mg/d), and diazepam (15 mg/d)	Eliminated nightmares after 1 week and improved sleep quality
Quetiapine
Ahearn et al, 2006 ^e	8-week, open-label trial	15 PTSD patients (8 male; 7 female; 5 with combat-related PTSD; mean age: 49); mean dose: 216 mg/d (100 to 400 mg/d)	Significantly improved re-experiencing (CAPS: 10 vs 23; P = .0012) and sleep (PSQI: 17.5 vs 30; P = .0044) at 8 weeks compared with baseline
Robert et al, 2005 ^f	6-week, open-label trial	19 combat veterans; mean dose: 100 ± 70 mg/d (25 to 300 mg/d); adjunct treatment	Significantly improved sleep quality (PSQI: 1.67 vs 2.41; P = .006), latency (PSQI: 1.5 vs 2.65; P = .002), duration (PSQI: 1.31 vs 2.71; P < .001), and sleep disturbances (PSQI: 1.22 vs 1.71; P = .034) and decreased terror episodes (PSQI-A: 0.73 vs 0.91; P = .040) and acting out dreams (PSQI-A: 1.07 vs 1.35; P = .013); however, no difference in nightmares caused by trauma (PSQI-A: 1.53 vs 2.06)
Sokolski et al, 2003 ^g	Retrospective chart review	68 male Vietnam War combat veterans (mean age: 55 ± 3.5); mean dose: 155 ± 130 mg (25 to 700 mg); adjunct treatment	Improved sleep disturbances in 62% and nightmares in 25% of patients
Ahearn et al, 2003 ^h	Case report	2 male patients with combat-related PTSD (age 53, 72); dose: 25 to 50 mg; adjunct to SSRI therapy	Decreased frequency of nightmares with increased sleep duration
Risperidone
David et al, 2006 ⁱ	6-week, open-label trial	17 male veterans with combat-related PTSD (mean age: 53.7 ± 3.8); mean maximum dose: 2.3 ± 0.6 mg (range: 1 to 3 mg)	Improved recurrent distressing dreams (CAPS B-2: 3.8 vs 5.4; P = .04), but not with the PSQI subscale (PSQI bad dreams: 2.5 vs 2.7; NS). Decreased nighttime awakenings (1.9 vs 2.8; P = .003) and trauma dreams (19% vs 38%; P = .04)
Leyba et al, 1998 ^j	Case reports	3 male patients (age 43 to 46); dose: 1 to 3 mg; adjunct therapy	Decreased occurrence of nightmares
Ziprasidone
Siddiqui et al, 2005 ^k	Case report	1 male veteran with chronic combat-related PTSD (age 55); dose: 80 to 120 mg/d; adjunct with trazodone (100 mg) and topiramate	Improved occurrence of nightmares up to 4 months
CAPS: Clinician-Administered PTSD Scale; CAPS B-2: Clinician-Administered PTSD Scale B-2 (recurrent distressing dreams of the event); CBT: cognitive-behavioral therapy; PSQI: Pittsburgh Sleep Quality Index; PSQI-A: Pittsburgh Sleep Quality Index Addendum for PTSD; NS: not significant; PTSD: posttraumatic stress disorder; SSRI: selective serotonin reuptake inhibitor References Lambert MT. Aripiprazole in the management of post-traumatic stress disorder symptoms in returning Global War on Terrorism veterans. Int Clin Psychopharmacol. 2006;21(3):185-187. Stein MB, Kline NA, Matloff JL. Adjunctive olanzapine for SSRI-resistant combat-related PTSD: a double-blind, placebo-controlled study. Am J Psychiatry. 2002;159(10):1777-1779. Jakovljevic M, Sagud M, Mihaljevic-Peles A. Olanzapine in the treatment-resistant, combat-related PTSD—a series of case reports. Acta Psychiatr Scand. 2003;107(5):394-396. Labbate LA, Douglas S. Olanzapine for nightmares and sleep disturbance in posttraumatic stress disorder (PTSD). Can J Psychiatry. 2000;45(7):667-668. Ahearn EP, Mussey M, Johnson C, et al. Quetiapine as an adjunctive treatment for post-traumatic stress disorder: an 8-week open-label study. Int Clin Psychopharmacol. 2006;21(1):29-33. Robert S, Hamner MB, Kose S, et al. Quetiapine improves sleep disturbances in combat veterans with PTSD: sleep data from a prospective, open-label study. J Clin Psychopharmacol. 2005;25(4):387-388. Sokolski KN, Denson TF, Lee RT, et al. Quetiapine for treatment of refractory symptoms of combat-related post-traumatic stress disorder. Mil Med. 2003;168(6):486-489. Ahearn EP, Winston E, Mussey M, et al. Atypical antipsychotics, improved intrusive symptoms in patients with posttraumatic stress disorder. Mil Med. 2003;168(9):x-xi. David D, De Faria L, Mellman TA. Adjunctive risperidone treatment and sleep symptoms in combat veterans with chronic PTSD. Depress Anxiety. 2006;23(8):489-491. Leyba CM, Wampler TP. Risperidone in PTSD. Psychiatr Serv. 1998;49(2):245-246. Siddiqui Z, Marcil WA, Bhatia SC, et al. Ziprasidone therapy for post-traumatic stress disorder. J Psychiatry Neurosci. 2005;30(6):430-431.