Biomedical approaches to treatment are based on the assumption that biological factors are involved in psychological disorders. A number of drugs are used to treat various disorders based on theories of the brain chemistry involved, but this does not mean that there is a full understanding of how neurotransmitters and symptoms are linked. Neither is it fully known why drugs work in some cases but not in others. The fact is that drugs are often used to alleviate symptoms to make other forms of therapy possible. Not all individuals respond in the same way to a drug and it is not known why. Clinicians must find an appropriate drug and dosage for each individual, and they must be prepared to replace the drug if the patient does not benefit from it.

SSRIs

Since PTSD is assumed to involve an imbalance in noradrenaline, anxiolytic medications are used to restore an appropriate chemical balance in the brain. In addition, since depression is often comorbid with PTSD - that is, patients have symptoms of both disorders - antidepressants called Selective Serotonin Reuptake Inhibitors (SSRIs) are often prescribed. SSRIs block the reuptake of serotonin from the synaptic gap into the terminal buttons.  This process then increases the level of serotonin in the gap, stabilizing mood.

Antidepressants are often prescribed because many PTSD patients suffer from depression; improvements in depression contribute to improvement in PTSD, regardless of how the PTSD itself is treated.  Medications are nearly always used in conjunction with therapy for PTSD because while medications may treat some of the symptoms commonly associated with the disorder, they will not relieve a person of the flashbacks or feelings associated with the original trauma.

Davidson et al. (2001) carried out a study of 208 patients with moderate to severe PTSD to test the effectiveness of Zoloft, an SSRI.  The study was a double-blind trial - meaning that neither the patients nor the researchers knew which treatment was given to which participants.  This is done to avoid researcher bias.  Participants were randomly allocated to receive Zoloft or a placebo.

After twelve weeks of treatment, the participants in the Zoloft group showed greater improvement than those that took the placebo. The self-reported improvement rates were 60% for the Zoloft group and 38% for the placebo group. However, there were negative side effects for the Zoloft group, including insomnia, diarrhea, nausea and decreased appetite.  9% of the Zoloft group also experienced withdrawal symptoms at the end of the study.

 Teacher only box

Knowing that sleep disturbances are common for people with PTSD, what do you suggest?  Is it ethical to continue to give PTSD patients these drugs?  If not, why do you think that doctors continue to prescribe them?

You may want to have students read the following article: Use of Benzodiazapines for PTSD in Veterans' Affairs

When discussing this with students, it is important to note that benzodiazapines are no longer recommended in the treatment of PTSD. Students may want to suggest some alternatives to helping people with sleep disturbance besides these drugs - e.g. meditation, melatonin, or other medications. As for the ethics - that is a discussion for students to have.  Why do doctors continue to prescribe them?  This is a good question. A lack of education of the modern standing of the drugs? Personal bias toward the drug based on perceived successes in the past? Influence of drug companies that influence the objectivity of psychiatrists?

More modern research has looked at a rather controversial drug in the potential treatment of PTSD - MDMA, more commonly known as Ecstasy.  Mithoefer et al. (2011) conducted a clinical trial of the drug MDMA with 20 patients with chronic PTSD persisting for an average of over 19 years. All of the participants had already undergone some form of drug treatment of psychotherapy but with no results. Participants were randomly allocated to either an MDMA group or a placebo group. Both groups also received psychotherapy. Participants treated with a combination of MDMA and psychotherapy saw statistically significant improvements in their PTSD -- over 80% of the trial group no longer met the diagnostic criteria for PTSD following the trial, compared to only 25% of the placebo group.

Evaluation of drug therapy

The key strength of drug therapy is that for many people who suffer from PTSD, it alleviates the symptoms that make day-to-day living difficult.

In spite of the strengths of drug treatments, there are also some rather serious limitations. One limitation is the problem of side-effects – negative effect of using the drug itself. For example, anti-depressants are known to have the following side effects in some patients: nausea, increased weight gain, loss of sexual desire, insomnia, blurred vision, constipation, dizziness, and anxiety. This was seen in the study by Davidson et al. (2001).

Another limitation of drug therapy is that clinicians are still not sure how these drugs alleviate symptoms of PTSD and why the treatment is not effective for all patients. Even though they boost levels of neurotransmitters in the brain within days or even hours of use, it usually takes several weeks of treatment before a therapeutic benefit results. And not all patients respond to them.  For example, the serotonin hypothesis has been challenged as an etiology to explain the origins of depression. So, although some may people may benefit from the increased level of serotonin, it may be that drugs like Prozac are simply alleviating a symptom of depression, but not actually addressing the root of the disorder. As depression is often comorbid with PTSD, it may not actually be very helpful in the treatment of the disorder.

Relying too heavily on drug treatments may lead to the neglect of important psychological or social factors that may play a significant role in the disorder. It can be argued that simply using a drug to treat PTSD is a reductionist approach. A drug may alleviate symptoms, but it does not address the actual etiology of the disorder.  The drug then only provides temporary relief from the symptoms and the chance of relapse is high.

Another limitation of drug treatment is the problem of developing a dependence on the drug. Anti-depressants and anti-anxiety drugs may lead to discontinuation syndrome – often known as “withdrawal symptoms.” In addition, if drug treatment is discontinued, the chance of relapse is high. Hollon et al. (2005) compared the discontinuation of anti-depressants after 16 weeks of treatment to discontinuation of Cognitive Behavioural Therapy. 76% of the patients who had received drug treatment relapsed following medication withdrawal, compared with only 31% of the patients who had been treated with therapy.  

 Teacher only box

The goal of this reflection is to get students to think about how they would make a decision about taking a drug.  All drugs have potential side effects, so this will always be an issue.  Many students will focus on some of the following points below:

• How important it is for you to improve your memory
• The actual effectiveness of the drug
• Looking at the incidence of the side effects
• The problem of discontinuation (withdrawal)
• The cost and whether such a drug could be covered by health insurance

Finally, drug therapy presents some ethical concerns. Unless treatment is regarded as an emergency – for example, the client is suicidal - it cannot be given without the client’s consent, except in cases where the client may not be capable of giving consent. This consent should be given on the basis of full information about the potential benefits and drawbacks of the drugs concerned, in which case it fulfills the ethical criterion of informed consent.

There is a major concern about the rise in prescriptions of drugs such as antidepressants and benzodiazepines because they can cause harm if they are not prescribed appropriately. There is an ongoing debate among clinicians about possible medical and psychological risks in prescribing so many of these drugs as well as whether they are effective long-term since most clinical trials only last around 6 or 8 weeks and only address whether patients report a reduction in symptoms.

Seeing the potential limitations of drug treatment, it becomes even more apparent that there is a sincere ethical concern about the way that diagnoses are made.   When drug treatment is seen as necessary in spite of the potential limitations, it is important the diagnosis has been made in a way that increases its validity.  Ideally, every client is diagnosed as needing drug treatment would have had more than one series of tests carried out by more than one psychiatrist.  However, this is rarely the case. Often these drugs are prescribed by a family doctor, not a psychiatrist.

Checking for understanding