Psychopharmacology and post-traumatic stress disorder

Psychopharmacology and post-traumatic stress disorder

Psychopharmacology involves the study of drugs that are employed to produce an effect on the mood, sensation and thinking of an individual (Meyer and Quenzer, 2004). This field of medicine is important because it provides substantial knowledge and innovations regarding the medicines needed for the treatment of disorders and diseases which are psychological in nature. Through this field of medicine, there are already medications and drugs which help in the modification and improvement of behavior of the persons with mental problems and disorders.  Psychopharmacology involves a vast research on psychoactive drugs which confer net effects on the nervous system. Psychoactive drugs, when targeted to the specific parts of the body, create a change in the functions of several organs in both physiological and psychological manners.

            The use of drugs is no doubt a very essential tool in maintaining one’s physical, emotional and even mental health. Medications provide an essential role in increasing the chances of living a longer and healthier life without complications brought about by diseases and threats to a healthy lifestyle.  There are drugs, however, which are widely used yet still unproven of its efficacy. In this light, the duo of psychopharmacology and mental/psychological disorders, more specifically post-traumatic stress disorder (PTSD), is given the attention. These two aspects are complementary with regards to the treatment, nature, efficacy or lack of it.  PTSD and psychopharmacology has been considered as a famous duo with regards to the study of psychology and the course of treatments that would be taken into consideration. These two topics correlate with each other in many perspectives- the reason why this paper would put greater emphasis on both topics.

            More importantly, PTSD is a very concerning phenomenon because many individuals are expected to experience it in the course of their lifetime. People should be sufficiently educated on this topic because we are all potential victims of this disorder.  Anyone could experience it and suffer its long term complications.

POST TRAUMATIC STRESS DISORDER (PTSD)

            PTSD is one of the most common cases which arise when a highly-traumatic event is experienced by an individual and in turn, generates some psychological consequences (Satcher et al., 1999). Events which would result in a big impact on a person’s mental condition may be exemplified by a serious injury or accident, death of a close relative or friend, or even just a peril in one’s identify.  The disorder is named as such to emphasize the fact that the disorder appears immediately after a very traumatic incident in a person’s life. This would make a distinction to a notion that the disorder is caused by pre-existing mental disorders and problems.

            PTSD occurs when a person fails to cope with his life after a stressful and horrible experience.  When a person’s psychological defenses fail to lessen the impact of a situation, he is very likely to suffer from PTSD.  The disorder is relative to each individual because of the factors to consider. Firstly, the impact and intensity of the stressful event is different in each individual.  Obviously, situations which are more complicated are those which are hard to get over with normally.  When a situation is not severely complicated, its effects on an individual may subside after a short period of time.  Secondly, the duration of the impact should also be considered in patients with PTSD.  In most cases, a situation which tends to become chronic has also a direct relation to its personal impact.  And lastly, the patient’s personality and attitude should also be considered in PTSD. Each patient follows different values, principles and culture regarding specific situations in life.  There are some individuals that remain passive after a major change in their lives, while there are others who are active after a difficult situation.  In conditions wherein an individual shows weakness or dependence to another person, thing or situation, he is most likely to suffer from PTSD than the individual who faces the situation in a cool and relaxed manner.  As mentioned earlier, PTSD is relative in each individual. A person may feel stress after a traumatic situation without experiencing PTSD.  Likewise, a person may also experience traumatic situations and experiences without succumbing to PTSD.

            It has been estimated that most Americans will experience a traumatic event at least once in their lifetime.  Of these persons who will have at least one traumatic experience, approximately 8% will most likely manifest the signs and symptoms of PTSD.  Solomon (1997) stated that the over-all prevalence of PTSD in the United States is between 1 to 12 % of the population.  As for the population at risk, it ranges from 0.2 % in postpartum women to 18 % in professional firefighters, 34 % in adolescent survivors of motor vehicle crashes, 48 % in female rape victims and 67 % in prisoners of war (Kluznik, et al., 1998).  Because of its relatively high risk to most people, especially those psychologically and emotionally dependent and challenged persons, there is a dire need for the health sectors to provide more information regarding the disorder at hand.

PHARMACOLOGICAL TREATMENT OF PTSD

            There have been extensive studies on psychopharmacological drugs and medications most especially aligned with its efficacy in treating PTSD and also selective serotonin reuptake inhibitors (SSRIs). Although there are already many cases wherein each of the sub-types of psychopharmacological treatments shows some improvements in the state of a patient’s mind, there are also poor cases and results on the other hand. This is why there are still inconvenient situations especially for medical professionals and health care providers since the results of using psychopharmacologic drugs are based on a case-to-case basis.

            Publications about how psychopharmacology performs in the medical arena are rampant. Most of these published reports either compare and contrast or support and discourage the use of these medications.  And coincidentally, many of these studies indicate almost the same results, as well as recommendations as to what should be done in order to make a final stand about the efficacy of psychopharmacological treatments.

Antidepressant drugs are the core for the treatment of depression, usually given together with supportive psychotherapy.  However, there is growing evidence that the combination of antidepressant treatment and psychotherapy may generate far better results than either treatment alone, especially for more severe and recurrent depression.  Over the past decade, tricyclic antidepressants such as imipramine or desipramine have been replaced by serotonin selective reuptake inhibitor (SSRI) antidepressants as immediate medications, generally because of these are more tolerable and safer than the older drugs.  Several theories have been proposed to explain the mechanism behind the 6-week time lag for the onset of the therapeutic effect of antidepressants on a patient diagnosed with depression.  It is thus interesting to note that the adverse side-effects of a medication appear first before the actual pharmacological effects of the drug are observed in a patient. The side-effects generally arise as the effects of antidepressants on early synapsis and the therapeutic effects eventually result from adaptive mechanisms such as desensitization and down-regulation of certain receptors.

Alternative novel theories that attempt to explain the mechanism of action of antidepressants focus on the level of gene expression (Thome et al., 2000).  However, these theories are not mutually exclusive.  The effects of antidepressants on neurotransmitter receptors are important for these drugs to affect gene expression.  Historical studies on tricyclic antidepressants and MAOIs effectively show that serotonin and norepinephrine provide an essential role in the activity of antidepressants (Schildkraut 1975).  At the same time, researchers have conducted animal studies on the nerve cells in the brain that produce and secrete serotonin and norepinephrine.  All neurons that produce norepinephrine are positioned either in the coeruleus or in the lateral ventral tegmental areas of the brain.  More importantly, a negative correlation has been reported between noradrenergic neurons of the coeruleus and serotonergic neurons of the raphe nucleus and this is mainly based on the projections among neurons (Pickel et al., 1977).  Somatodendritic autoreceptors inhibit the name and speed of the initiation of action potentials, while presynaptic autoreceptors control the secretion and circulation of serotonin. The presynaptic α2-adrenergic heteroreceptors, when initiated by norepinephrine, inhibit the production of serotonin.  On the other hand, the somatodendritic α1-adrenergic heteroreceptors activate this nerve cell work with norepinephrine.  During short-term treatment using an SSRI, the increase in the amount of serotonin in the corresponding site is enough to generate a reaction, generally that is based on the negative feedback loops that control the excessive levels of serotonin (Briley and Moret, 1993).  On the other hand, extensive introduction of an SSRI generates changes such as desensitization and down-regulation.  These changes, in turn, result in a higher rate of stimulation of the neurons, as well as a higher level of synthesis of serotonin in the pre-synaptic autoreceptors and a higher level of secretion of serotonin.

The model of presynaptic 5-HT1A autoreceptors that are associated in the negative feedback of serotonergic neurons has controlled the clinical approach of antagonists of this receptor, together with antidepressants.  Such combination is designed to improve the effectivity and efficiency of this drug (Artigas et al., 1996).  Research studies have used pindolol, which is a compound that decreases the action of serotonergic and adrenergic receptors.  Different results were reported, mostly due to the very low concentrations introduced (2.5 mg three times daily) that a significant amount of brain serotonin receptors may not be traced during image analysis of the brain using positron emission tomography (PET) (Berman et al., 1999).  It may also be possible that the amount of 5-HT1A autoreceptors have been significantly lowered among patients diagnosed with depression.

            Most antidepressants negatively control the transport of neurotransmitters into the cells from which they were generated from.  These proteins are more potent in blocking transport of serotonin than in delivering norepinephrine (Tatsumi et al., 1997).  Second-generation antidepressants such as SSRIs are generally more specific in terms of their targets and are more potent than the first-generation medications.  More so, specific antidepressants such as mirtazapine weakly control the transport of norepinephrine, serotonin, and dopamine.  Reboxetine, on the other hand, is designed to specifically counteract norepinephrine.  Bupropion, or Zyban, is a highly specific psychopharmaceutical that specifically stops the delivery of dopamine.  Bupropion may be more noradrenergic in effect than dopaminergic because of the influence of a cellular compound that is circulating in the body at much greater amounts than the earlier compound (Ascher et al., 1995).  Paroxetine is a very effective drug that inhibits the transfer of serotonin while citalopram a very selective compound.  It should be noted that the selective capability in a drug is not the same as the degree of effectivity of the medication.  In addition, pharmaceutical compounds carry different levels of selectivity in preventing the transfer of serotonin.  For example, citalopram is 10 times more effective in selectivity than paroxetine.  Sertraline is the most effective antidepressant with regards to blocking dopamine delivery, the same as the action of methylphenidate.

            Experimental evidence suggests that venlafaxine is a serotonin and norepinephrine reuptake inhibitor, yet even weaker in effect among humans.  It is thus catergorized as an SSRI, because their results are much better than the initial compounds.  At the α1-adrenoceptor, the strongest drugs are probably to have clinical effects on these receptors.  Mirtazapine is the sole psychopharmaceutical that is successful in binding to the α2-adrenoceptor. Another drug is demethylated derivative of the neuroleptic loxapine, which is also weak in terms of its influence on decreasing the activity dopamine D2 receptors.  The most efficient interplay of antidepressants is within the histamine H1 receptor. Histamine has been suggested as a neurotransmitter because it has been reported to generate effects such as interacting with 3 classes of receptors, histamine H1, H2, and H3.  The histamine receptor H3 influences the presynaptic secretion and delivery of histamine and other neurotransmitters.  Histamine H2 receptors are found in the brain these structures are linked with gastric acid production.  Outside the nervous system, histamine H1 receptors are also involved with hypersensitivity reactions.  Muscarinic acetylcholine receptors are general cholinergic receptors that are essential in memory and cognition.  These receptors are related to the pathophysiology of neurological disorders. Antidepressants have a wide coverage of affinity to human brain muscarinic receptors. Amitriptyline is the most active medication, while paroxetine is the most efficient of the new psychopharmaceuticals that show profound antimuscarinic effects.

            Serotonergic agents/ selective serotonin reuptake inhibitors (SSRIs) have also been used widely in the clinical treatment of PTSD. The disorder is composed of three classes of symptoms, namely hypervigilance, reexperiencing and avoidance. Through the employment of serotonergic agents, these classes have been observed to augment symptoms of PTSD (Brady et al., 1995).  Tricyclic anti-depressants (TADs) were commonly employed initially because studies validated that the use of these TADs shows less results than during the use of SSRIs.

            Another psychological drug being administered is the monoamine oxidase inhibitor (MAO).  MAO has been effective as anti-depressant, yet its use has been restricted because of also results in hypertension, especially to those following dietary regimen containing tyramine. MAOs have been efficient in the treatment of avoidance and reexperiencing symptoms regardless of its ineffectivity in situations with hyperarousal.  Anti-adrenergic agents are employed in pharmacotherapy because they are helpful in lessening nightmares, hypervigilance and startled responses to stimuli.  The administration of this drug also affects the blood pressure of a patient.

            Mood stabilizers and anti-convulsants are becoming widely used in treating PTSD.  Based on clinical studies, most patients responded well to the PTSD scale after taking this course of treatment. It was observed that these mood stabilizers and anti-convulsants such as Lamotrigine, treats the numbing sensations of PTSD patients and also their hyper-arousal and experiencing of nightmares.

            Another pharmacological drug that is employed in the treatment of PTSD is benzodiazepine. This drug has been widely used though no further studies have proven its range of efficacy. But based on the use of patients, benzodiazepine has been identified as effective, most especially in treating patients with anxiety, insomnia and irritability. Great caution, however, should be considered in using benzodiazepines because of the high risk of abuse and dependency a PTSD patient might suffer from. There is a high frequency of substance dependency which often leads to difficult withdrawal process and addiction. The patients should be fully apprised about the use of his medication especially in the course of discontinuation.

            After the use of medications and psychopharmacological drugs, psychotherapy should take place because during this time, the patient is already aware of himself, thus making psychotherapy more effective and serious. The aim of psychotherapy is to target and let the patient get over the feeling of self-defeat and helplessness. This may be done through reexamining the traumatic situation, educating the patient about the disorder he is having and improving the patient’s ability to cope with what is happening through several techniques which have been proven by extensive studies.

EFFICACY OF PSYCHOPHARMACOLOGICAL TREATMENTS

            The efficacy of using psychopharmacological treatments and medications is still far from being proved to be true in all or even most cases. There are still many things to consider before concluding that this branch of pharmacology is most effective in dealing with psychological dysfunctions and/or disorders. As stated earlier, there are many courses of psychopharmacological treatments. Each has its own strengths while there are still corresponding detriments and adverse effects. These medications may be of great help but still, the medical professionals should also aim to do no harm to the patient in all courses of treatment.

            There are many factors to consider in determining the efficacy of psychopharmacological treatments.  The pharmacokinetics of a certain drug is determined and/or affected and influenced mostly by his or her gender.  First of all, there are differences between men and women in their absorption rate, metabolism, and distribution of medication throughout the body and to the concerned areas and lastly the elimination of these medications.

            PTSD could lead to destructive effects not just in a person’s individuality but even to his or her familial and social relationships. The front act that a medical professional or a health care provider must do is to educate a group of PTSD patients and inform them of the cause, effect and course of treatment that they should undergo. The presence of a relative is also important during this process so that the patient could fully comprehend and voice out his or her concerns. Endorsements to mental health care providers and professionals are also essential since PTSD should be treated immediately so as to avoid its chronic effects and complications.

CONCLUSION

            Psychopharmacology is an effective treatment of psychologically related diseases. It is obvious that there are still many issues that professionals and researchers of this field should clarify, especially to those concerned with the described drugs. Great care should be exerted in the use of these treatments and one should be critical enough so as to do no harm to the patient.  PTSD is a destructive phenomenon an individual may experience. Everyone has fair chances of having this disorder. The most prone are those who are not educated well about the disease and those who have less empowerment and independence in life. Through relevant education and awareness, the susceptibility to develop PTSD would reduce into a lower rate.

            There have been no concrete studies which support the efficacy of pharmacological drugs in alleviating PTSD but based on the short term studies and by the statistics, PTSD patients can cope up with the help of psychopharmacologic medications. However, we still have to consider that all individuals are different. Each person has his distinct way of dealing with medications inside his system- adverse or amicable it may be. Treatment should not be carelessly made just because the treatment is good for others.

            Again, a great skill in decision making and critical thinking is of great need in dealing with these cases. As always, genuine knowledge about the course of treatment, disease and the patient’s history and individuality is important for us to maintain their safety and wellness. With these factors in mind, treating patients with PTSD would lessen its detrimental effects and may even bring the patient to a state of health and wellness and ultimately, his or her recovery.

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Foa EB, Heast-Ikeda D, Perry KJ (1995):  Evaluation of a brief cognitive-behavioral program for the prevention of chronic PTSD in recent assault victims. J. Consult. Clin. Psychol.  63:948-55.

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