慢性、抗抑郁药难治性、与军事服役相关的创伤后应激障碍药物治疗无改善的相关因素：来自退伍军人事务部合作研究第504号的见解

Correlates of Nonimprovement to Pharmacotherapy for Chronic, Antidepressant-Resistant, Military Service-Related Posttraumatic Stress Disorder: Insights From the Veterans Affairs Cooperative Study No. 504.

作者信息

Byrne Simon P, Krystal John H, Rosenheck Robert A, Vessicchio Jennier, Pietrzak Robert H

机构信息

From the *Yale Child Study Center, Yale University School of Medicine, New Haven; †Clinical Neurosciences Division, Department of Veterans Affairs National Center for PTSD, and ‡Psychiatry Service, VA Connecticut Healthcare System, West Haven; and §Department of Psychiatry, Yale University School of Medicine; ∥Department of Neurobiology, Yale University School of Medicine; and ¶Psychiatry Services, Yale-New Haven Hospital, New Haven, CT.

出版信息

J Clin Psychopharmacol. 2017 Dec;37(6):717-721. doi: 10.1097/JCP.0000000000000777.

DOI:10.1097/JCP.0000000000000777

PMID:28945664

Abstract

BACKGROUND

Posttraumatic stress disorder (PTSD) is a chronic and often difficult-to-treat condition that is prevalent among military veterans. First-line pharmacotherapy for this population typically involves antidepressants; however, veterans who do not improve are sometimes prescribed antipsychotics such as risperidone. A 2011 randomized controlled trial of adjunctive risperidone versus placebo for veterans with chronic, antidepressant-resistant, military service-related PTSD revealed no difference between groups. Hence, there is a need to examine predictors of nonimprovement for chronic, treatment-resistant PTSD.

METHODS

We examined correlates of nonimprovement and delayed improvement (ie, ≥12 weeks) using data from 267 veterans with chronic, antidepressant-resistant PTSD who were prescribed adjunctive risperidone or a placebo. Veterans received 1 to 4 mg adjunctive risperidone (n = 133; mean dose, 2.74 mg) or a placebo daily (n = 134) in addition to their original treatment regimen over the 24-week trial.

RESULTS

Greater severity of PTSD symptoms at baseline, specifically reexperiencing (ie, nightmares) and emotional numbing (ie, sense of foreshortened future), was independently associated with nonimprovement. Of the 194 veterans (72.7%) who did improve, 95 (49.0%) showed delayed improvement, taking 12 weeks or longer to demonstrate a 10-point reduction in Clinician-Administered PTSD Scale scores. Emotional difficulties affecting role functioning, as assessed using the Veterans RAND 36-item Health Survey, independently predicted nonimprovement.

CONCLUSIONS

While results are indicative of nonspecific pharmacotherapeutic effects, they suggest that specific PTSD symptom clusters and impairment are associated with variable improvement in veterans with antidepressant-resistant PTSD. They underscore the importance of developing more effective and targeted pharmacotherapies for specific symptom clusters in this population.

摘要

背景

创伤后应激障碍（PTSD）是一种慢性且通常难以治疗的疾病，在退伍军人中很常见。该人群的一线药物治疗通常包括使用抗抑郁药；然而，对治疗无反应的退伍军人有时会被开处方使用抗精神病药物，如利培酮。2011年一项针对患有慢性、抗抑郁药耐药性、与军事服役相关PTSD的退伍军人进行的关于辅助使用利培酮与安慰剂的随机对照试验显示，两组之间没有差异。因此，有必要研究慢性、难治性PTSD治疗无反应的预测因素。

方法

我们使用来自267名患有慢性、抗抑郁药耐药性PTSD且被开处方辅助使用利培酮或安慰剂的退伍军人的数据，研究了治疗无反应和延迟改善（即≥12周）的相关因素。在为期24周的试验中，退伍军人除了接受原来的治疗方案外，每天还接受1至4毫克辅助利培酮（n = 133；平均剂量，2.74毫克）或安慰剂（n = 134）。

结果

基线时PTSD症状的严重程度更高，特别是再次体验（即噩梦）和情感麻木（即对未来的缩短感），与治疗无反应独立相关。在194名（72.7%）病情有所改善的退伍军人中，95名（49.0%）出现延迟改善，需要12周或更长时间才能使临床医生管理的PTSD量表得分降低10分。使用退伍军人兰德36项健康调查评估的影响角色功能的情感困难独立预测了治疗无反应。