Efficacy of Intravenous Ketamine for Treatment of Chronic Posttraumatic Stress Disorder. A Randomized Clinical Trial
Importance Few pharmacotherapies have demonstrated sufficient efficacy in the treatment of posttraumatic stress disorder (PTSD), a chronic and disabling condition.
Objective To test the efficacy and safety of a single intravenous subanesthetic dose of ketamine for the treatment of PTSD and associated depressive symptoms in patients with chronic PTSD.
Design, Setting, and Participants Proof-of-concept, randomized, double-blind, crossover trial comparing ketamine with an active placebo control, midazolam, conducted at a single site (Icahn School of Medicine at Mount Sinai, New York, New York). Forty-one patients with chronic PTSD related to a range of trauma exposures were recruited via advertisements.
Interventions Intravenous infusion of ketamine hydrochloride (0.5 mg/kg) and midazolam (0.045 mg/kg).
Main Outcomes and Measures The primary outcome measure was change in PTSD symptom severity, measured using the Impact of Event Scale–Revised. Secondary outcome measures included the Montgomery-Asberg Depression Rating Scale, the Clinical Global Impression–Severity and –Improvement scales, and adverse effect measures, including the Clinician-Administered Dissociative States Scale, the Brief Psychiatric Rating Scale, and the Young Mania Rating Scale.
Results Ketamine infusion was associated with significant and rapid reduction in PTSD symptom severity, compared with midazolam, when assessed 24 hours after infusion (mean difference in Impact of Event Scale–Revised score, 12.7 [95% CI, 2.5-22.8]; P = .02). Greater reduction of PTSD symptoms following treatment with ketamine was evident in both crossover and first-period analyses, and remained significant after adjusting for baseline and 24-hour depressive symptom severity. Ketamine was also associated with reduction in comorbid depressive symptoms and with improvement in overall clinical presentation. Ketamine was generally well tolerated without clinically significant persistent dissociative symptoms.
Conclusions and Relevance This study provides the first evidence for rapid reduction in symptom severity following ketamine infusion in patients with chronic PTSD. If replicated, these findings may lead to novel approaches to the pharmacologic treatment of patients with this disabling condition.
PTSD in the armed forces: What have we learned from the recent cohort studies of Iraq/Afghanistan?
L'armée anglaise semblait préservée du PTSD dans son expérience irakienne: Pas plus de PTSD que dans les troupes non déployées (1). Les explications semblaient se situer au niveau d'une organisation différente (taux d'encadrement, soldats plus âgés, et mission plus courtes). Les choses ont bien changées et actuellement nos alliées sont confrontés aux même problème que nous (2). Il est constaté un taux de PTSD double chez les réservistes engagés (3), par ailleurs ces troubles apparaissent plus tôt et chez des combattants plus jeunes que dans les conflits précédents (4) Le travail présenté fait le point de l'expérience actuelle en la matière des psychiatres militaires anglais
In conclusion, the developments in military epidemiology have allowed cohort studies to confirm that combat experience is temporally related to PTSD. Yet, the majority of those who are deployed seem to be resilient. Across studies there are other common prospective vulnerability factors for PTSD, including psychiatric co-morbidity, alcohol misuse and lack of support. Whilst cross-sectional studies have found evidence to suggest that events outside of the military are important risks for PTSD, this needs to be investigated further in longitudinal research. Delayed-onset PTSD and other symptom trajectories which increase following deployment may be most important from a military perspective, but there is a need to further understand the reasons for the observed heterogeneity of PTSD trajectories.
Mental health following traumatic physical injury: An integrative literature review
A B S T R A C T
Aim: To investigate the state of knowledge on the relationship between physical trauma and mental health in patients admitted to hospital with traumatic physical injury.
Background: Adults who sustain traumatic physical injury can experience a range of mental health problems related to the injury and subsequent changes in physical health and function. However earlyscreening and identification of mental health problems after traumatic physical injury is inconsistent and not routine during the hospital admission process for the physically injured patient.
Integrative review methods were used. Data were sourced for the period 1995–2010 fromEMBASE, CINAHL, MEDLINE and PsycINFO and hand searching of key references. Abstracts were screened by 3 researchers against inclusion/exclusion criteria. Forty-one papers met the inclusion criteria. Data were retrieved, appraised for quality, analysed, and synthesised into 5 main categories.
Results: Forty-one primary research papers on the relationship between mental health and traumatic physical injury were reviewed. Studies showed that post-traumatic stress disorder, depression and anxiety were frequent sequelae associated with traumatic physical injury. However, these conditions were poorly identified and treated in the acute hospital phase despite their effect on physical health.
Conclusion: There is limited understanding of the experience of traumatic physical injury, particularly in relation to mental health. Greater translation of research findings to practice is needed in order to promote routine screening, early identification and referral to treatment for mental health problems in this patient group.
Invisible Wounds Psychological and Neurological Injuries. Confront a New Generation of Veterans
Morphine Use after Combat Injury in Iraq and Post-Traumatic Stress Disorder.
Post-traumatic stress disorder (PTSD) is a common adverse mental health outcome among seriously injured civilians and military personnel who are survivors of trauma. Pharmacotherapy in the aftermath of serious physical injury or exposure to traumatic events may be effective for the secondary prevention of PTSD.
We identified 696 injured U.S. military personnel without serious traumatic brain injury from the Navy–Marine Corps Combat Trauma Registry Expeditionary Medical Encounter Database. Complete data on medications administered were available for all personnel selected. The diagnosis of PTSD was obtained from the Career History Archival Medical and Personnel System and verified in a review of medical records.
Among the 696 patients studied, 243 received a diagnosis of PTSD and 453 did not. The use of morphine during early resuscitation and trauma care was significantly associated with a lower risk of PTSD after injury. Among the patients in whom PTSD developed, 61% received morphine; among those in whom PTSD did not develop, 76% received morphine (odds ratio, 0.47; P<0.001). This association remained significant after adjustment for injury severity, age, mechanism of injury, status with respect to amputation, and selected injury-related clinical factors.
Our findings suggest that the use of morphine during trauma care may reduce the risk of subsequent development of PTSD after serious injury.
The mental health of the UK Armed Forces is a topic much debated by healthcare professionals, politicians and the media.While the current operations in Afghanistan, and the recent conflict in Iraq, are relevant to this debate, much of what is known about the effects of war upon the psyche still derives from the two World Wars. This paper will examine the historical and contemporary evidence about why it is that some Service personnel suffer psychological injuries during their military service and others do not. The paper will also consider some of the strategies that today’s Armed Forces have put in place to mitigate the effects of sending military personnel into danger.