TRAUMATIZED TROOPS How to treat combat-related PTSD

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TRAUMATIZED TROOPS How to treat combat-related PTSD
Author(s)
Timothy W. Lineberry, MD Sriram Ramaswamy, MD
Michael J. Bostwick, MD
James R

Thousands of U.S. troops are seeking mental health care after being deployed in Iraq. Among 222,000 Army and Marine Iraq veterans, 35% sought treatment in the year after returning home—many for posttraumatic stress disorder (PTSD).In a related article, we discuss the diagnosis and treatment of military sexual trauma, a form of PTSD.

Persistent pathology

The greater the intensity of an Iraq/Afghanistan veteran’s combat experiences (“firefights”), the more likely the soldier is to develop PTSD.Traumatic brain injury: Choosing medications for neurobehavioral symptoms”). Sexual trauma also may cause or exacerbate PTSD.Military sexual trauma: How to identify and treat a unique form of PTSD”).

Table 1

3 domains of posttraumatic stress disorder symptoms

DomainSymptoms
Re-experiencing
  • Recurrent, intrusive, distressing recollections or dreams of traumatic event
  • Acting or feeling as if the event were recurring
  • Intense psychological distress or physiologic reactions when exposed to internal or external cues
Avoidance and numbing
  • Efforts to avoid thoughts, feelings, or conversations about the trauma or activities, places, or people that arouse recollections
  • Inability to recall an important aspect of the trauma
  • Markedly less interest or participation in significant activities
  • Feeling detached or estranged from others
  • Restricted range of affect
  • Sense of a foreshortened future
Increased arousal
  • Difficulty falling or staying asleep
  • Irritability or angry outbursts
  • Difficulty concentrating
  • Hypervigilance
  • Exaggerated startle response
Source: DSM-IV-TR

FigurePTSD screen for war veterans


Source: U.S. Department of Veterans Affairs. Afghan & Iraq Post-Deployment Screen, Attachment B. Screening for risk factors associated with development of post-traumatic stress disorder (PTSD)

Cognitive therapy

Psychotherapy is the cornerstone of PTSD treatment; skilled therapists may achieve greater efficacy and more-durable results than medications do. Evidence strongly supports cognitive behavioral therapy—including exposure therapy, anxiety management, and cognitive therapy.U.S. troops returning home: Are you prepared? Current Psychiatry 2006;5(1):12-22.

Drug brand names

  • Carbamazepine • Carbatrol
  • Fluoxetine • Prozac
  • Lamotrigine • Lamictal
  • Lithium • Lithobid, others
  • Mirtazapine • Remeron
  • Paroxetine • Paxil
  • Prazosin • Minipress
  • Sertraline • Zoloft
  • Trazodone • Desyrel
  • Temazepam • Restoril
  • Valproic acid • Divalproex, others
  • Venlafaxine • Effexor
  • Zolpidem • Ambien

Disclosures

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products. Drs. Lineberry, Bostwick, and Rundell served on active duty in the U.S. Air Force. Dr. Ramaswamy is staff psychiatrist, Omaha Veterans Administration. and Director of Psychopharmacology Research, Creighton University, Omaha, NE.

References

1. Hoge CW, Auchterlonie JL, Milliken CS. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. JAMA 2006;295(9):1023-32.

2. Hoge CW, Castro CA, Messer SC, et al. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004;351:13-22.

3. Schlenger WE, Kulka RA, Fairbank JA, et al. The prevalence of post-traumatic stress disorder in the Vietnam generation: a multimethod, multisource assessment of psychiatric disorder. J Trauma Stress 1992;5:333-63.

4. Prigerson HG, Maciejewski PK, Rosenheck RA. Combat trauma: trauma with highest risk of delayed onset and unresolved posttraumatic stress disorder symptoms, unemployment, and abuse among men. J Nerv Ment Dis 2001;189:99-108.

5. Prigerson HG, Maciejewski PK, Rosenheck RA. Population attributable fractions of psychiatric disorders and behavioral outcomes associated with combat exposures among U.S. men. Am J Public Health 2002;92(1):59-63.

6. Diagnostic and statistical manual of mental disorders (4th ed, text rev). Washington, DC: American Psychiatric Association; 2000.

7. Xydakis MS, Fravell MD, Nasser KE, Casler JD. Analysis of battlefield head and neck injuries in Iraq and Afghanistan. Otolaryngol Head Neck Surg 2005;133:497-504.

8. Okie S. Traumatic brain injury in the war zone. N Engl J Med 2005;352(20):2043-7.

9. Kang H, Dalager N, Mahan C, et al. The role of sexual assault on the risk of PTSD among Gulf War veterans. Ann Epidemiol 2005;15(3):191-5.

10. Bradley R, Greene J, Russ E, et al. A multidimensional metaanalysis of psychotherapy for posttraumatic stress disorder. Am J Psychiatry 2005;162:214-27.

11. Foa EB, Hembree EA, Cahill SP, et al. Randomized trial of prolonged exposure for posttraumatic stress disorder with and without cognitive restructuring: outcome at academic and community clinics. J Consult Clin Psychol 2005;73:953-64.

12. Schnurr PP, Lunney CA, Sengupta A. Risk factors for the development versus maintenance of post-traumatic stress disorder. J Trauma Stress 2004;17:85-95.

13. Friedman MJ, Donnelly CL, Mellman TA. Pharmacotherapy for PTSD. Psychiatric Annals 2003;33(8):57-62.

14. Asnis GM, Kohn SR, Henderson M, Brown NL. SSRIs versus non- SSRIs in posttraumatic stress disorder: an update with recommendations. Drugs 2004;6:383-404.

15. Simon GE, Savarino J, Operskalski B, et al. Suicide risk during antidepressant treatment. Am J Psychiatry 2006;163(1):41-7.

16. Oquendo M, Brent DA, Birmaher B, et al. Posttraumatic stress disorder comorbid with major depression: factors mediating the association with suicidal behavior. Am J Psychiatry 2005;162(3):560-6.

17. Schoenfeld FB, Marmar CR, Neylan TC. Current concepts in pharmacotherapy for posttraumatic stress disorder. Psychiatr Serv 2004;55:519-31.

18. Martenyi F, Brown EB, Zhang H, et al. Fluoxetine versus placebo in posttraumatic stress disorder. J Clin Psychiatry 2002;63:199-206.

19. Brady KT, Sonne SC, Roberts JM. Sertraline treatment of comorbid posttraumatic stress disorder and alcohol dependence J Clin Psychiatry 1995;56(11):502-5.

20. Davidson JR, Rothbaum BO, van der Kolk BA, et al. Multicenter, double-blind comparison of sertraline and placebo in the treatment of posttraumatic stress disorder. Arch Gen Psychiatry 2001;58(5):485-92.

21. Zohar J, Amital D, Miodownik C, et al. Double-blind placebocontrolled pilot study of sertraline in military veterans with posttraumatic stress disorder J Clin Psychopharmacol 2002;22(2):190-5.

22. Marshall RD, Beebe KL, Oldham M, et al. Efficacy and safety of paroxetine treatment for chronic PTSD: a fixed-dose, placebocontrolled study. Am J Psychiatr 2001;158(12):1982-8.

23. Tucker P, Zaninelli R, Yehuda R, et al. Paroxetine in the treatment of chronic posttraumatic stress disorder: results of a placebocontrolled, flexible-dosage trial. J Clin Psychiatry 2001;62(11):860-8.

24. Raskind MA, Peskind ER, Kanter ED, et al. Reduction of nightmares and other PTSD symptoms in combat veterans by prazosin: a placebo-controlled study. Am J Psychiatry 2003;160(2):371-3.

25. Hamner MB, Deitsch SE, Brodrick PS, et al. Quetiapine treatment in patients with posttraumatic stress disorder: an open trial of adjunctive therapy. J Clin Psychopharmacol 2003;23(1):15-20.

26. Villarreal G, Calais L, Pickard J, et al. Open-label aripiprazole monotherapy in the treatment of posttraumatic stress disorder. Poster presented at: annual meeting of the NIMH New Clinical Drug Evaluation Unit; June 6-9, 2005; Boca Raton FL.

27. Vieweg WVR, Julius DA, Fernandez A, et al. Posttraumatic stress disorder in male military veterans with comorbid overweight and obesity: Psychotropic, antihypertensive, and metabolic medications. Prim Care Companion J Clin Psychiatry 2006;8(1):

28. Stein MB, Kline NA, Matloff JL. Adjunctive olanzapine for SSRI-resistant combat-related PTSD: a double-blind, placebo-controlled study. Am J Psychiatry 2002;159(10):1777-9.

29. Kozaric-Kovacic D, Pivac N, Muck-Seler D, et al. Risperidone in psychotic combat-related posttraumatic stress disorder: an open trial. J Clin Psychiatry 2005;66(7):922-7.

30. Ahearn EP, Mussey M, Johnson C, et al. Quetiapine as an adjunctive treatment for post-traumatic stress disorder: an 8-week open-label study. Int Clin Psychopharmacol 2006;21(1):29-33.

31. Lambert MT. Aripiprazole in the management of post-traumatic stress disorder symptoms in returning Global War on Terrorism veterans. Int Clin Psychopharmacol 2006;21(3):185-7.

32. Warner MD, Dorn MR, Peabody CA. Survey on the usefulness of trazodone in patients with PTSD with insomnia or nightmares. Pharmacopsychiatry 2001;34(4):128-31.

33. Ocasio-Tascon ME, Alicea-Colon E, et al., Torres-Palacios A, et al. The veteran population: one at high risk for sleep-disordered breathing. Sleep Breath 2006 Feb 22;[Epub ahead of print].

34. Krakow B, Lowry C, Germain A, et al. A retrospective study on improvements in nightmares and post-traumatic stress disorder following treatment for co-morbid sleep-disordered breathing. J Psychosom Res 2000;49(5):291-8.

35. Forbes D, Creamer M, Hawthorne G, et al. Co-morbidity as a predictor of symptom changes after treatment in combat-related posttraumatic stress disorder. J Nerv Ment Dis 2003;191:93-9.

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Timothy W. Lineberry, MD
Assistant professor, Mayo Clinic, Rochester, MN
Sriram Ramaswamy, MD
Instructor, Creighton University, Omaha, NE, Staff Psychiatrist, Omaha VA Medical Center

Michael J. Bostwick, MD
Associate professor, Mayo Clinic

James R. Rundell, MD
Professor, Mayo Clinic

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Author(s)
Timothy W. Lineberry, MD Sriram Ramaswamy, MD
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James R
Author(s)
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Michael J. Bostwick, MD
James R
Author and Disclosure Information

Timothy W. Lineberry, MD
Assistant professor, Mayo Clinic, Rochester, MN
Sriram Ramaswamy, MD
Instructor, Creighton University, Omaha, NE, Staff Psychiatrist, Omaha VA Medical Center

Michael J. Bostwick, MD
Associate professor, Mayo Clinic

James R. Rundell, MD
Professor, Mayo Clinic

Author and Disclosure Information

Timothy W. Lineberry, MD
Assistant professor, Mayo Clinic, Rochester, MN
Sriram Ramaswamy, MD
Instructor, Creighton University, Omaha, NE, Staff Psychiatrist, Omaha VA Medical Center

Michael J. Bostwick, MD
Associate professor, Mayo Clinic

James R. Rundell, MD
Professor, Mayo Clinic

Article PDF
0505CP_Article1.pdf
Article PDF
0505CP_Article1.pdf

Thousands of U.S. troops are seeking mental health care after being deployed in Iraq. Among 222,000 Army and Marine Iraq veterans, 35% sought treatment in the year after returning home—many for posttraumatic stress disorder (PTSD).In a related article, we discuss the diagnosis and treatment of military sexual trauma, a form of PTSD.

Persistent pathology

The greater the intensity of an Iraq/Afghanistan veteran’s combat experiences (“firefights”), the more likely the soldier is to develop PTSD.Traumatic brain injury: Choosing medications for neurobehavioral symptoms”). Sexual trauma also may cause or exacerbate PTSD.Military sexual trauma: How to identify and treat a unique form of PTSD”).

Table 1

3 domains of posttraumatic stress disorder symptoms

DomainSymptoms
Re-experiencing
  • Recurrent, intrusive, distressing recollections or dreams of traumatic event
  • Acting or feeling as if the event were recurring
  • Intense psychological distress or physiologic reactions when exposed to internal or external cues
Avoidance and numbing
  • Efforts to avoid thoughts, feelings, or conversations about the trauma or activities, places, or people that arouse recollections
  • Inability to recall an important aspect of the trauma
  • Markedly less interest or participation in significant activities
  • Feeling detached or estranged from others
  • Restricted range of affect
  • Sense of a foreshortened future
Increased arousal
  • Difficulty falling or staying asleep
  • Irritability or angry outbursts
  • Difficulty concentrating
  • Hypervigilance
  • Exaggerated startle response
Source: DSM-IV-TR

FigurePTSD screen for war veterans


Source: U.S. Department of Veterans Affairs. Afghan & Iraq Post-Deployment Screen, Attachment B. Screening for risk factors associated with development of post-traumatic stress disorder (PTSD)

Cognitive therapy

Psychotherapy is the cornerstone of PTSD treatment; skilled therapists may achieve greater efficacy and more-durable results than medications do. Evidence strongly supports cognitive behavioral therapy—including exposure therapy, anxiety management, and cognitive therapy.U.S. troops returning home: Are you prepared? Current Psychiatry 2006;5(1):12-22.

Drug brand names

  • Carbamazepine • Carbatrol
  • Fluoxetine • Prozac
  • Lamotrigine • Lamictal
  • Lithium • Lithobid, others
  • Mirtazapine • Remeron
  • Paroxetine • Paxil
  • Prazosin • Minipress
  • Sertraline • Zoloft
  • Trazodone • Desyrel
  • Temazepam • Restoril
  • Valproic acid • Divalproex, others
  • Venlafaxine • Effexor
  • Zolpidem • Ambien

Disclosures

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products. Drs. Lineberry, Bostwick, and Rundell served on active duty in the U.S. Air Force. Dr. Ramaswamy is staff psychiatrist, Omaha Veterans Administration. and Director of Psychopharmacology Research, Creighton University, Omaha, NE.

Thousands of U.S. troops are seeking mental health care after being deployed in Iraq. Among 222,000 Army and Marine Iraq veterans, 35% sought treatment in the year after returning home—many for posttraumatic stress disorder (PTSD).In a related article, we discuss the diagnosis and treatment of military sexual trauma, a form of PTSD.

Persistent pathology

The greater the intensity of an Iraq/Afghanistan veteran’s combat experiences (“firefights”), the more likely the soldier is to develop PTSD.Traumatic brain injury: Choosing medications for neurobehavioral symptoms”). Sexual trauma also may cause or exacerbate PTSD.Military sexual trauma: How to identify and treat a unique form of PTSD”).

Table 1

3 domains of posttraumatic stress disorder symptoms

DomainSymptoms
Re-experiencing
  • Recurrent, intrusive, distressing recollections or dreams of traumatic event
  • Acting or feeling as if the event were recurring
  • Intense psychological distress or physiologic reactions when exposed to internal or external cues
Avoidance and numbing
  • Efforts to avoid thoughts, feelings, or conversations about the trauma or activities, places, or people that arouse recollections
  • Inability to recall an important aspect of the trauma
  • Markedly less interest or participation in significant activities
  • Feeling detached or estranged from others
  • Restricted range of affect
  • Sense of a foreshortened future
Increased arousal
  • Difficulty falling or staying asleep
  • Irritability or angry outbursts
  • Difficulty concentrating
  • Hypervigilance
  • Exaggerated startle response
Source: DSM-IV-TR

FigurePTSD screen for war veterans


Source: U.S. Department of Veterans Affairs. Afghan & Iraq Post-Deployment Screen, Attachment B. Screening for risk factors associated with development of post-traumatic stress disorder (PTSD)

Cognitive therapy

Psychotherapy is the cornerstone of PTSD treatment; skilled therapists may achieve greater efficacy and more-durable results than medications do. Evidence strongly supports cognitive behavioral therapy—including exposure therapy, anxiety management, and cognitive therapy.U.S. troops returning home: Are you prepared? Current Psychiatry 2006;5(1):12-22.

Drug brand names

  • Carbamazepine • Carbatrol
  • Fluoxetine • Prozac
  • Lamotrigine • Lamictal
  • Lithium • Lithobid, others
  • Mirtazapine • Remeron
  • Paroxetine • Paxil
  • Prazosin • Minipress
  • Sertraline • Zoloft
  • Trazodone • Desyrel
  • Temazepam • Restoril
  • Valproic acid • Divalproex, others
  • Venlafaxine • Effexor
  • Zolpidem • Ambien

Disclosures

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products. Drs. Lineberry, Bostwick, and Rundell served on active duty in the U.S. Air Force. Dr. Ramaswamy is staff psychiatrist, Omaha Veterans Administration. and Director of Psychopharmacology Research, Creighton University, Omaha, NE.

References

1. Hoge CW, Auchterlonie JL, Milliken CS. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. JAMA 2006;295(9):1023-32.

2. Hoge CW, Castro CA, Messer SC, et al. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004;351:13-22.

3. Schlenger WE, Kulka RA, Fairbank JA, et al. The prevalence of post-traumatic stress disorder in the Vietnam generation: a multimethod, multisource assessment of psychiatric disorder. J Trauma Stress 1992;5:333-63.

4. Prigerson HG, Maciejewski PK, Rosenheck RA. Combat trauma: trauma with highest risk of delayed onset and unresolved posttraumatic stress disorder symptoms, unemployment, and abuse among men. J Nerv Ment Dis 2001;189:99-108.

5. Prigerson HG, Maciejewski PK, Rosenheck RA. Population attributable fractions of psychiatric disorders and behavioral outcomes associated with combat exposures among U.S. men. Am J Public Health 2002;92(1):59-63.

6. Diagnostic and statistical manual of mental disorders (4th ed, text rev). Washington, DC: American Psychiatric Association; 2000.

7. Xydakis MS, Fravell MD, Nasser KE, Casler JD. Analysis of battlefield head and neck injuries in Iraq and Afghanistan. Otolaryngol Head Neck Surg 2005;133:497-504.

8. Okie S. Traumatic brain injury in the war zone. N Engl J Med 2005;352(20):2043-7.

9. Kang H, Dalager N, Mahan C, et al. The role of sexual assault on the risk of PTSD among Gulf War veterans. Ann Epidemiol 2005;15(3):191-5.

10. Bradley R, Greene J, Russ E, et al. A multidimensional metaanalysis of psychotherapy for posttraumatic stress disorder. Am J Psychiatry 2005;162:214-27.

11. Foa EB, Hembree EA, Cahill SP, et al. Randomized trial of prolonged exposure for posttraumatic stress disorder with and without cognitive restructuring: outcome at academic and community clinics. J Consult Clin Psychol 2005;73:953-64.

12. Schnurr PP, Lunney CA, Sengupta A. Risk factors for the development versus maintenance of post-traumatic stress disorder. J Trauma Stress 2004;17:85-95.

13. Friedman MJ, Donnelly CL, Mellman TA. Pharmacotherapy for PTSD. Psychiatric Annals 2003;33(8):57-62.

14. Asnis GM, Kohn SR, Henderson M, Brown NL. SSRIs versus non- SSRIs in posttraumatic stress disorder: an update with recommendations. Drugs 2004;6:383-404.

15. Simon GE, Savarino J, Operskalski B, et al. Suicide risk during antidepressant treatment. Am J Psychiatry 2006;163(1):41-7.

16. Oquendo M, Brent DA, Birmaher B, et al. Posttraumatic stress disorder comorbid with major depression: factors mediating the association with suicidal behavior. Am J Psychiatry 2005;162(3):560-6.

17. Schoenfeld FB, Marmar CR, Neylan TC. Current concepts in pharmacotherapy for posttraumatic stress disorder. Psychiatr Serv 2004;55:519-31.

18. Martenyi F, Brown EB, Zhang H, et al. Fluoxetine versus placebo in posttraumatic stress disorder. J Clin Psychiatry 2002;63:199-206.

19. Brady KT, Sonne SC, Roberts JM. Sertraline treatment of comorbid posttraumatic stress disorder and alcohol dependence J Clin Psychiatry 1995;56(11):502-5.

20. Davidson JR, Rothbaum BO, van der Kolk BA, et al. Multicenter, double-blind comparison of sertraline and placebo in the treatment of posttraumatic stress disorder. Arch Gen Psychiatry 2001;58(5):485-92.

21. Zohar J, Amital D, Miodownik C, et al. Double-blind placebocontrolled pilot study of sertraline in military veterans with posttraumatic stress disorder J Clin Psychopharmacol 2002;22(2):190-5.

22. Marshall RD, Beebe KL, Oldham M, et al. Efficacy and safety of paroxetine treatment for chronic PTSD: a fixed-dose, placebocontrolled study. Am J Psychiatr 2001;158(12):1982-8.

23. Tucker P, Zaninelli R, Yehuda R, et al. Paroxetine in the treatment of chronic posttraumatic stress disorder: results of a placebocontrolled, flexible-dosage trial. J Clin Psychiatry 2001;62(11):860-8.

24. Raskind MA, Peskind ER, Kanter ED, et al. Reduction of nightmares and other PTSD symptoms in combat veterans by prazosin: a placebo-controlled study. Am J Psychiatry 2003;160(2):371-3.

25. Hamner MB, Deitsch SE, Brodrick PS, et al. Quetiapine treatment in patients with posttraumatic stress disorder: an open trial of adjunctive therapy. J Clin Psychopharmacol 2003;23(1):15-20.

26. Villarreal G, Calais L, Pickard J, et al. Open-label aripiprazole monotherapy in the treatment of posttraumatic stress disorder. Poster presented at: annual meeting of the NIMH New Clinical Drug Evaluation Unit; June 6-9, 2005; Boca Raton FL.

27. Vieweg WVR, Julius DA, Fernandez A, et al. Posttraumatic stress disorder in male military veterans with comorbid overweight and obesity: Psychotropic, antihypertensive, and metabolic medications. Prim Care Companion J Clin Psychiatry 2006;8(1):

28. Stein MB, Kline NA, Matloff JL. Adjunctive olanzapine for SSRI-resistant combat-related PTSD: a double-blind, placebo-controlled study. Am J Psychiatry 2002;159(10):1777-9.

29. Kozaric-Kovacic D, Pivac N, Muck-Seler D, et al. Risperidone in psychotic combat-related posttraumatic stress disorder: an open trial. J Clin Psychiatry 2005;66(7):922-7.

30. Ahearn EP, Mussey M, Johnson C, et al. Quetiapine as an adjunctive treatment for post-traumatic stress disorder: an 8-week open-label study. Int Clin Psychopharmacol 2006;21(1):29-33.

31. Lambert MT. Aripiprazole in the management of post-traumatic stress disorder symptoms in returning Global War on Terrorism veterans. Int Clin Psychopharmacol 2006;21(3):185-7.

32. Warner MD, Dorn MR, Peabody CA. Survey on the usefulness of trazodone in patients with PTSD with insomnia or nightmares. Pharmacopsychiatry 2001;34(4):128-31.

33. Ocasio-Tascon ME, Alicea-Colon E, et al., Torres-Palacios A, et al. The veteran population: one at high risk for sleep-disordered breathing. Sleep Breath 2006 Feb 22;[Epub ahead of print].

34. Krakow B, Lowry C, Germain A, et al. A retrospective study on improvements in nightmares and post-traumatic stress disorder following treatment for co-morbid sleep-disordered breathing. J Psychosom Res 2000;49(5):291-8.

35. Forbes D, Creamer M, Hawthorne G, et al. Co-morbidity as a predictor of symptom changes after treatment in combat-related posttraumatic stress disorder. J Nerv Ment Dis 2003;191:93-9.

References

1. Hoge CW, Auchterlonie JL, Milliken CS. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. JAMA 2006;295(9):1023-32.

2. Hoge CW, Castro CA, Messer SC, et al. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004;351:13-22.

3. Schlenger WE, Kulka RA, Fairbank JA, et al. The prevalence of post-traumatic stress disorder in the Vietnam generation: a multimethod, multisource assessment of psychiatric disorder. J Trauma Stress 1992;5:333-63.

4. Prigerson HG, Maciejewski PK, Rosenheck RA. Combat trauma: trauma with highest risk of delayed onset and unresolved posttraumatic stress disorder symptoms, unemployment, and abuse among men. J Nerv Ment Dis 2001;189:99-108.

5. Prigerson HG, Maciejewski PK, Rosenheck RA. Population attributable fractions of psychiatric disorders and behavioral outcomes associated with combat exposures among U.S. men. Am J Public Health 2002;92(1):59-63.

6. Diagnostic and statistical manual of mental disorders (4th ed, text rev). Washington, DC: American Psychiatric Association; 2000.

7. Xydakis MS, Fravell MD, Nasser KE, Casler JD. Analysis of battlefield head and neck injuries in Iraq and Afghanistan. Otolaryngol Head Neck Surg 2005;133:497-504.

8. Okie S. Traumatic brain injury in the war zone. N Engl J Med 2005;352(20):2043-7.

9. Kang H, Dalager N, Mahan C, et al. The role of sexual assault on the risk of PTSD among Gulf War veterans. Ann Epidemiol 2005;15(3):191-5.

10. Bradley R, Greene J, Russ E, et al. A multidimensional metaanalysis of psychotherapy for posttraumatic stress disorder. Am J Psychiatry 2005;162:214-27.

11. Foa EB, Hembree EA, Cahill SP, et al. Randomized trial of prolonged exposure for posttraumatic stress disorder with and without cognitive restructuring: outcome at academic and community clinics. J Consult Clin Psychol 2005;73:953-64.

12. Schnurr PP, Lunney CA, Sengupta A. Risk factors for the development versus maintenance of post-traumatic stress disorder. J Trauma Stress 2004;17:85-95.

13. Friedman MJ, Donnelly CL, Mellman TA. Pharmacotherapy for PTSD. Psychiatric Annals 2003;33(8):57-62.

14. Asnis GM, Kohn SR, Henderson M, Brown NL. SSRIs versus non- SSRIs in posttraumatic stress disorder: an update with recommendations. Drugs 2004;6:383-404.

15. Simon GE, Savarino J, Operskalski B, et al. Suicide risk during antidepressant treatment. Am J Psychiatry 2006;163(1):41-7.

16. Oquendo M, Brent DA, Birmaher B, et al. Posttraumatic stress disorder comorbid with major depression: factors mediating the association with suicidal behavior. Am J Psychiatry 2005;162(3):560-6.

17. Schoenfeld FB, Marmar CR, Neylan TC. Current concepts in pharmacotherapy for posttraumatic stress disorder. Psychiatr Serv 2004;55:519-31.

18. Martenyi F, Brown EB, Zhang H, et al. Fluoxetine versus placebo in posttraumatic stress disorder. J Clin Psychiatry 2002;63:199-206.

19. Brady KT, Sonne SC, Roberts JM. Sertraline treatment of comorbid posttraumatic stress disorder and alcohol dependence J Clin Psychiatry 1995;56(11):502-5.

20. Davidson JR, Rothbaum BO, van der Kolk BA, et al. Multicenter, double-blind comparison of sertraline and placebo in the treatment of posttraumatic stress disorder. Arch Gen Psychiatry 2001;58(5):485-92.

21. Zohar J, Amital D, Miodownik C, et al. Double-blind placebocontrolled pilot study of sertraline in military veterans with posttraumatic stress disorder J Clin Psychopharmacol 2002;22(2):190-5.

22. Marshall RD, Beebe KL, Oldham M, et al. Efficacy and safety of paroxetine treatment for chronic PTSD: a fixed-dose, placebocontrolled study. Am J Psychiatr 2001;158(12):1982-8.

23. Tucker P, Zaninelli R, Yehuda R, et al. Paroxetine in the treatment of chronic posttraumatic stress disorder: results of a placebocontrolled, flexible-dosage trial. J Clin Psychiatry 2001;62(11):860-8.

24. Raskind MA, Peskind ER, Kanter ED, et al. Reduction of nightmares and other PTSD symptoms in combat veterans by prazosin: a placebo-controlled study. Am J Psychiatry 2003;160(2):371-3.

25. Hamner MB, Deitsch SE, Brodrick PS, et al. Quetiapine treatment in patients with posttraumatic stress disorder: an open trial of adjunctive therapy. J Clin Psychopharmacol 2003;23(1):15-20.

26. Villarreal G, Calais L, Pickard J, et al. Open-label aripiprazole monotherapy in the treatment of posttraumatic stress disorder. Poster presented at: annual meeting of the NIMH New Clinical Drug Evaluation Unit; June 6-9, 2005; Boca Raton FL.

27. Vieweg WVR, Julius DA, Fernandez A, et al. Posttraumatic stress disorder in male military veterans with comorbid overweight and obesity: Psychotropic, antihypertensive, and metabolic medications. Prim Care Companion J Clin Psychiatry 2006;8(1):

28. Stein MB, Kline NA, Matloff JL. Adjunctive olanzapine for SSRI-resistant combat-related PTSD: a double-blind, placebo-controlled study. Am J Psychiatry 2002;159(10):1777-9.

29. Kozaric-Kovacic D, Pivac N, Muck-Seler D, et al. Risperidone in psychotic combat-related posttraumatic stress disorder: an open trial. J Clin Psychiatry 2005;66(7):922-7.

30. Ahearn EP, Mussey M, Johnson C, et al. Quetiapine as an adjunctive treatment for post-traumatic stress disorder: an 8-week open-label study. Int Clin Psychopharmacol 2006;21(1):29-33.

31. Lambert MT. Aripiprazole in the management of post-traumatic stress disorder symptoms in returning Global War on Terrorism veterans. Int Clin Psychopharmacol 2006;21(3):185-7.

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Issue
Current Psychiatry - 05(05)
Issue
Current Psychiatry - 05(05)
Page Number
39-52
Page Number
39-52
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MDedge Psychiatry
Current Psychiatry
Publications
MDedge Psychiatry
Current Psychiatry
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TRAUMATIZED TROOPS How to treat combat-related PTSD
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TRAUMATIZED TROOPS How to treat combat-related PTSD
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