Ranney Rachel, Maguen Shira, Woods Anne, Seal Karen H, Neylan Thomas C, Bernardy Nancy, Wiechers Ilse, Ryder Annie, Cohen Beth E
Veterans Affairs San Francisco Health Care System, San Francisco, California, USA.
Department of Psychiatry and Behavioral Sciences, San Francisco School of Medicine, University of California, San Francisco, California, USA.
J Eval Clin Pract. 2023 Feb;29(1):191-202. doi: 10.1111/jep.13726. Epub 2022 Jun 16.
Posttraumatic stress disorder (PTSD) is highly prevalent among veterans. Many veterans with PTSD respond well to serotonin reuptake inhibitors (SRIs). Nonresponders may be prescribed augmenting medications, which are not as well-studied in PTSD.
We used Veterans Health Administration electronic records to compare mental health outcomes (PTSD symptoms and rates of mental health hospitalizations and psychiatric emergency room visits) in patients with PTSD who were prescribed four different groups of augmenting medications (atypical antipsychotics, mirtazapine, prazosin or tricyclic antidepressants) in addition to SRIs-from the year before to the year after the start of the augmenting medication.
We included data from 169,982 patients with a diagnosis of PTSD (excluding patients with comorbid bipolar or psychotic disorders) seen in Veterans Affairs care from 2007 to 2015 who were taking an SRI and filled a new prescription for one of the four augmenting medications for at least 60 days.
Patients evidenced minimal (<2%) reduction in PTSD symptoms and a larger reduction in psychiatric hospitalizations and psychiatric emergency room visits after receiving augmenting medications; this effect was largely similar across the four medication groups. Initiating augmenting medications was preceded by increases in PTSD symptoms, psychiatric hospitalizations and psychiatric emergency room visits. After initiating an augmenting medication, PTSD symptoms/hospitalizations/emergency room visits returned to baseline levels (before the start of the augmenting medication), but generally did not improve beyond baseline.
Importantly, these effects could be explained by regression to the mean, additional interventions or confounding. These findings should be further explored with placebo controlled randomized clinical trials.
创伤后应激障碍（PTSD）在退伍军人中极为普遍。许多患有创伤后应激障碍的退伍军人对5-羟色胺再摄取抑制剂（SRIs）反应良好。无反应者可能会被开用增效药物，但这些药物在创伤后应激障碍中的研究并不充分。
我们利用退伍军人健康管理局的电子记录，比较了在服用SRIs的同时还被开用四种不同增效药物组（非典型抗精神病药物、米氮平、哌唑嗪或三环类抗抑郁药）的创伤后应激障碍患者，从增效药物开始使用前一年到使用后一年的心理健康结果（创伤后应激障碍症状、心理健康住院率和精神科急诊就诊率）。
我们纳入了2007年至2015年在退伍军人事务部接受治疗的169982例诊断为创伤后应激障碍的患者的数据（不包括患有双相或精神障碍合并症的患者），这些患者正在服用SRIs并开具了四种增效药物之一的新处方，且用药至少60天。
患者在接受增效药物后，创伤后应激障碍症状减少极少（<2%），精神科住院和精神科急诊就诊次数减少较多；这一效果在四个药物组中大致相似。在开始使用增效药物之前，创伤后应激障碍症状、精神科住院和精神科急诊就诊次数有所增加。开始使用增效药物后，创伤后应激障碍症状/住院/急诊就诊次数恢复到基线水平（在增效药物开始使用前），但一般未改善至基线以上。
重要的是，这些效应可以用均值回归、额外干预或混杂因素来解释。这些发现应通过安慰剂对照的随机临床试验进一步探索。
