The International Society for Traumatic Stress Studies New Guidelines for the Prevention and Treatment of Posttraumatic Stress Disorder: Methodology and Development Process. Benzodiazepine use in posttraumatic stress disorder among veterans with substance abuse. Pregnant women with posttraumatic stress disorder and risk of preterm birth. Eszopiclone for the treatment of posttraumatic stress disorder and associated insomnia: a randomized, double-blind, placebo-controlled trial. A Systematic Review of the Efficacy of Creative Arts Therapies in the Treatment of Adults With PTSD Do benzodiazepines reduce the effectiveness of exposure therapy for posttraumatic stress disorder? The use of benzodiazepine monotherapy for major depression before and after implementation of guidelines for benzodiazepine use. Factors Associated With Benzodiazepine Dependence Among Community-Dwelling Seniors Treatment of recent trauma survivors with benzodiazepines: a prospective study. A sham controlled study of repetitive transcranial magnetic stimulation for posttraumatic stress disorder Randomized controlled trial of Internet-delivered cognitive behavioral therapy for posttraumatic stress disorder. 5-Hz Transcranial Magnetic Stimulation for Comorbid Posttraumatic Stress Disorder and Major Depression.
Over the last two decades , treatment guidelines have become major aids in the delivery of evidence -based care and improvement of clinical outcomes . The International Society for Traumatic Stress Studies ( ISTSS ) produced the first guidelines for the prevention and treatment of posttraumatic stress disorder ( PTSD ) in 2000 and published its latest recommendations , along with position papers on complex PTSD ( CPTSD ) , in November 2018 . A rigorous methodology was developed and followed ; scoping questions were posed , systematic review s were undertaken , and 361 r and omized controlled trials were included according to the a priori agreed inclusion criteria . In total , 208 meta-analyses were conducted and used to generate 125 recommendations ( 101 for adults and 24 for children and adolescents ) for specific prevention and treatment interventions , using an agreed definition of clinical importance and recommendation setting algorithm . There were eight strong , eight st and ard , five low effect , 26 emerging evidence , and 78 insufficient evidence to recommend recommendations . The inclusion of separate scoping questions on treatments for complex presentations of PTSD was considered but decided against due to definitional issues and the virtual absence of studies specifically design ed to clearly answer possible scoping questions in this area . Narrative review s were undertaken and position papers prepared ( one for adults and one for children and adolescents ) to consider the current issues around CPTSD and make recommendations to facilitate further research . This paper describes the methodology and results of the ISTSS Guideline process and considers the interpretation and implementation of the recommendations Veterans with posttraumatic stress disorder ( PTSD ) and substance abuse may abuse benzodiazepines and develop violent dyscontrol when using them . A total of 370 veterans were compared by substance abuse diagnosis ( 50 % ) , benzodiazepine use ( 36 % ) , and their interaction on 1-year outcomes after inpatient discharge . Substance abusers were less likely to be prescribed benzodiazepines ( 26 % vs. 45 % ) . No outcome showed a differential worsening by substance abuse or benzodiazepines , although some baseline differences were noted . Outpatient health care utilization was lower in benzodiazepine users ( 47 vs. 33 visits ) . Among PTSD patients with comorbid substance abuse , benzodiazepine treatment was not associated with adverse effects on outcome , but it may reduce health care utilization IMPORTANCE Posttraumatic stress disorder ( PTSD ) occurs in about 8 % of pregnant women . Stressful conditions , including PTSD , are inconsistently linked to preterm birth .  Psychotropic treatment has been frequently associated with preterm birth . Identifying whether the psychiatric illness or its treatment is independently associated with preterm birth may help clinicians and patients when making management decisions . OBJECTIVE To determine whether a likely diagnosis of PTSD or antidepressant and benzodiazepine treatment during pregnancy is associated with risk of preterm birth . We hypothesized that pregnant women who likely had PTSD and women receiving antidepressant or anxiolytic treatment  would be more likely to experience preterm birth . DESIGN , SETTING , AND PARTICIPANTS Longitudinal , prospect i ve cohort study of 2654 women who were recruited before 17 completed weeks of pregnancy from 137 obstetrical practice s in Connecticut and Western Massachusetts . EXPOSURES Posttraumatic stress disorder , major depressive episode , and use of antidepressant and benzodiazepine medications . MAIN OUTCOMES AND MEASURES Preterm birth , operationalized as delivery prior to 37 completed weeks of pregnancy . Likely psychiatric diagnoses were generated through administration of the Composite International Diagnostic Interview and the Modified PTSD Symptom Scale . Data on medication use were gathered at each participant interview . RESULTS Recursive partitioning analysis showed elevated rates of preterm birth among women with PTSD . A further split of the PTSD node showed high rates for women who met criteria for a major depressive episode , which suggests an interaction between these 2 exposures . Logistic regression analysis confirmed risk for women who likely had both conditions ( odds ratio [ OR ] , 4.08 [ 95 % CI , 1.27 - 13.15 ] ) . For each point increase on the Modified PTSD Symptom Scale ( range , 0 - 110 ) , the risk of preterm birth increased by 1 % to 2 % . The odds of preterm birth are high for women who used a serotonin reuptake inhibitor ( OR , 1.55 [ 95 % CI , 1.02 - 2.36 ] ) and women who used a benzodiazepine medication ( OR , 1.99 [ 95 % CI , 0.98 - 4.03 ] ) . CONCLUSIONS AND RELEVANCE Women with likely diagnoses of both PTSD and a major depressive episode are at a 4-fold increased risk of preterm birth ; this risk is greater than , and independent of , antidepressant and benzodiazepine use and is not simply a function of mood or anxiety symptoms OBJECTIVE The development of novel strategies for the treatment of posttraumatic stress disorder ( PTSD ) represents a critical public health need . We present the first prospect i ve , r and omized , double-blind , placebo-controlled trial of a non-benzodiazepine hypnotic agent for the treatment of PTSD and associated insomnia . METHOD Twenty-four patients with PTSD by DSM-IV criteria and sleep disturbance were treated in a r and omized , double-blind , placebo-controlled crossover study of 3 weeks of eszopiclone 3 mg at bedtime compared to placebo . The primary outcome measures were changes in scores on the Short PTSD Rating Interview ( SPRINT ) and the Pittsburgh Sleep Quality Index ( PSQI ) . The data were collected from April 2006 to June 2008 . RESULTS Three weeks of eszopiclone pharmacotherapy was associated with significantly greater improvement than placebo on PTSD symptom measures including the SPRINT ( P = .032 ) and the Clinician-Administered PTSD Scale ( P = .003 ) , as well as on measures of sleep including the PSQI ( P = .011 ) and sleep latency ( P = .044 ) . Greater improvement with eszopiclone on PTSD measures was present even when specific sleep-related items were excluded . Adverse events were consistent with the known profile of the drug . CONCLUSIONS This study provides initial evidence that pharmacotherapy with eszopiclone may be associated with short-term improvement in overall PTSD severity as well as associated sleep disturbance . Longer , more definitive study of eszopiclone in PTSD is warranted . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00120250 Objective : There is a growing body of literature supporting the use of creative arts therapies ; however , the efficacy of creative arts therapies in the treatment of  posttraumatic stress disorder ( PTSD )  has not been systematic ally evaluated . The aim of this systematic review was to examine the efficacy of creative arts therapy including music therapy , art therapy , dance/movement therapy , and drama therapy , in the treatment of PTSD . Method : Ten data bases were search ed for peer- review ed literature published from inception to December 2016 . Studies were included in the review if they used a r and omized controlled trial ( RCT ) , a pseudo RCT , or a controlled study design ; tested the efficacy of one of the creative arts therapies described above ; and reported changes to PTSD diagnosis or symptomatology . Results : From an initial yield of 1,918 records , 1,653 records were screened on title and abstract and 125 were screened at full-text . Seven studies met the inclusion criteria for review , with four studies investigating art therapy , two studies investigating music therapy , and a final study investigating drama therapy . Individual studies were initially rated on a st and ardized quality and bias checklist , and then GRADE was used to rate the overall evidence for each intervention . The evidence for music therapy , art therapy , and drama therapy  was ranked as low to very low , with no studies found for dance/movement therapy . Generally , the quality of the trials was very poor . Future directions for this field of research are to improve the scientific quality of the research trials in this area OBJECTIVE Benzodiazepines , other anxiolytics , or sedative hypnotics are prescribed for 30%-50 % of posttraumatic stress disorder ( PTSD ) patients . Prior data and theory suggest that these medications may inhibit response to exposure therapy , one of the most effective PTSD treatments . The present post hoc study reanalyzed results from a psychotherapy trial to assess whether benzodiazepine use was associated with reduced response to exposure therapy . METHOD Between August 2002 and October 2005 , 283 female veterans and soldiers meeting DSM-IV criteria for PTSD were r and omly assigned to 10 weekly 90-minute sessions of either prolonged exposure ( n = 140 ) or present-centered psychotherapy ( n = 143 ) . Benzodiazepine use ( n = 57 ) or non-use ( n = 226 ) at intake was not r and omly assigned . Multilevel modeling was used to assess the effects of benzodiazepine status , psychotherapy condition , and their interaction on changes on the Clinician-Administered PTSD Scale and the PTSD Checklist during the treatment and 6-month follow-up periods . RESULTS Consistent with prior reports from these data , prolonged exposure psychotherapy produced greater reductions per week in PTSD symptoms than did present-centered psychotherapy ( b = -0.48 , P = .02 ) . Patients prescribed benzodiazepines did not have weaker response to prolonged exposure , but demonstrated poorer posttreatment maintenance of gains from present-centered psychotherapy ( b = -0.78 , P < .001 ) . CONCLUSIONS Prolonged exposure is a sufficiently robust treatment that patients who are taking benzodiazepines  can benefit from it . It is unclear whether benzodiazepine use or other patient factors accounted for benzodiazepine recipients ' poorer maintenance of gains in  present-centered psychotherapy .  TRIAL REGISTRATION Clinical Trials.gov identifier : NCT00032617 WHAT IS KNOWN AND OBJECTIVE The Department of Health ( DOH ) in Taiwan issued the ' Guidelines for Benzodiazepine Use in Sedation and Hypnosis ' in March 2004 , which clearly stated that benzodiazepines ( BZDs ) should not be used alone for the treatment of depression . However , the extent to which clinicians comply with the BZD guidelines was not known . This study aim ed to evaluate whether sole prescribing of BZDs  for major depression decreased after the implementation of the BZD guidelines . METHODS This was a retrospective longitudinal trend analysis by analyzing the Longitudinal Health Insurance Data base ( LHID ) from September 2002 to September 2005 . The LHID contains all cl aims data from a r and om sample of 1,000,000 beneficiaries of the universal National Health Insurance programme in Taiwan . The 3-year study period was divided equally into six periods , before and after the implementation of the guidelines respectively . For each period , the proportion of patients with major depression ( ICD-9-CM code 296.2x , 296.3x ) treated with BZDs without any concomitant antidepressant was calculated in order to conduct a trend analysis . RESULTS AND DISCUSSION A total of 5463 prescriptions of BZDs solely used for major depression were observed in the entire study period . In more than 80 % of the BZD prescriptions in which BZDs were used alone for major depression , they were prescribed at doses higher than one prescribed daily dose/defined daily dose and were supplied for more than 7 days . The number of out patients with major depression  ranged from 2137 to 3326 during the 12 periods . The proportion of depressed patients treated with BZDs alone per 3 months ( i.e. , the non-compliance rate ) fluctuated from 6·7 % to 9·4 % before implementation of the guidelines , and from 8·0 % to 9·4 % after implementation , in outpatient setting s. In addition , the guideline non-adherence rates in inpatient setting s varied from 7·0 % to 11·8 % and from 7·8 % to 12·6 % before and after the implementation of the BZD guidelines respectively . Further trend analyses indicated that the implementation of the guidelines was not associated with a reduced rate of sole prescribing of BZDs for major depression in either inpatient ( P = 0·083 ) or outpatient setting s ( P = 0·925 ) . WHAT IS NEW AND CONCLUSION The formulation and implementation of the BZD guidelines appear not to be associated with a reduced rate of sole prescribing of BZDs for major depression , and more comprehensive efforts are required Background : Benzodiazepine ( BZD ) dependence among seniors is an understudied problem . Objective : Identify the factors associated with BZD dependence . Method : Face-to-face computer-assisted interviews were conducted in the homes of 2,785 persons aged 65 years or older , r and omly selected . Results : Nine- and -a-half percent of BZD users met DSM-IV-TR criteria for BZD dependence . Factors associated with BZD dependence are being a woman , and having cognitive impairment , panic disorders , suicidal ideations , and a degree of embarrassment in obtaining help for emotional problem . Discussion : Nurses should be better positioned to identify those elderly users of BZDs who are more likely to be dependent and to address the problem through BZD withdrawal program BACKGROUND Most types of psychotropic drugs have been tried in the treatment of chronic posttraumatic stress disorder ( PTSD ) , but have yielded limited results . Theory and retrospective research predict that early treatment may be more efficacious . Specifically , high-potency benzodiazepines have been recommended for the treatment of acute responses to trauma and for prevention of PTSD . This study prospect ively evaluates the effect of early administration of benzodiazepines on the course of PTSD and PTSD symptoms . METHOD Thirteen trauma survivors ( the benzodiazepine group ) were treated within 6.7 + /- 5.8 days after the trauma ( range , 2 - 18 ) with either clonazepam ( N = 10 , 2.7 + /- 0.8 mg/day ) or alprazolam ( N = 3 , 2.5 mg/day ) . Thirteen other trauma survivors , pair-matched with subjects in the active treatment group for gender and symptom severity in the first week after the trauma , constitute the control group . Both groups were reevaluated 1 and 6 months after the trauma for PTSD symptoms ( Horowitz Impact of Event Scale ; Mississippi Rating Scale for Combat-Related PTSD-civilian trauma version ) , PTSD status ( Clinician Administered PTSD Scale ) , state anxiety , depression , and resting heart rate . RESULTS Subjects in the benzodiazepine group did not differ from controls in 1-month and 6-month PTSD and anxiety scores . Repeated measures ANOVA showed no group or group-by-time effect on psychometric measures . A trend toward group-by-time interaction in resting heart rate was noted ( progressive decrease in the benzodiazepine group ) . Nine benzodiazepine subjects and 3 controls met PTSD diagnostic criteria 6 months after the trauma . CONCLUSION Contrary to expectations , the early administration of benzodiazepines to trauma survivors with high levels of initial distress did not have a salient beneficial effect on the course of their illness , while reducing physiologic expression of arousal BACKGROUND Posttraumatic stress disorder ( PTSD ) is a commonly occurring and often debilitating psychiatric condition . There currently is not definitive information regarding the efficacy of repetitive transcranial magnetic stimulation ( rTMS ) for PTSD . OBJECTIVE This study seeks to examine the efficacy of rTMS for PTSD . METHODS Twenty subjects with PTSD were r and omly assigned to receive either 10 rTMS sessions delivered at 1 Hz to the right dorsolateral prefrontal cortex ( DLPRC ) or 10 sham rTMS sessions to the same area . A blinded rater assessed PTSD , depressive , anxiety , and neurocognitive symptoms before treatment , after the treatment series , and during a 2-month follow-up period . RESULTS Trancranial magnetic stimulation delivered at 1 Hz to the right DLPRC result ed in statistically and clinical ly significant improvements in core PTSD symptoms and depressive symptoms compared with sham treatments . The effectiveness showed some degradation during the 2 months after treatments were stopped . CONCLUSIONS This blinded sham controlled trial supports the efficacy of 10 sessions of right DLPRC rTMS delivered at 1 Hz for the treatment of PTSD symptoms BACKGROUND Posttraumatic stress disorder ( PTSD ) is a severe and disabling condition and few receive appropriate care . Internet-based treatment of PTSD shows promise in reducing barriers to care and preliminary evidence suggests it is efficacious in treating symptoms of PTSD . METHODOLOGY Forty-two individuals with a diagnosis of PTSD confirmed by clinician interview completed a r and omized controlled comparison of Internet-based cognitive behavioral therapy ( CBT ) with a waitlist control condition . PRINCIPLE FINDINGS Large pre- to posttreatment effect sizes ( ESs ) were found for the Treatment group on measures of PTSD symptoms , depression , anxiety , and disability . A small between-group ES was found for PTSD symptoms and moderate between-group ESs were found for depression , anxiety , and disability . CONCLUSIONS Results provide preliminary support for Internet-based CBT as an efficacious treatment for individuals with a confirmed primary diagnosis of PTSD Current treatment options for posttraumatic stress disorder ( PTSD ) offer modest benefits , underscoring the need for new treatments . Repetitive transcranial magnetic stimulation ( rTMS ) depolarizes neurons in a targeted brain region with magnetic fields typically pulsed at low ( 1 Hz ) or high ( 10 Hz ) frequency to relieve major depressive disorder ( MDD ) . Prior work suggests an intermediate pulse frequency , 5 Hz , is also efficacious for treating comorbid depressive and anxiety symptoms . In this chart review study , we systematic ally examined the clinical and safety outcomes in 10 patients with comorbid MDD and PTSD syndromes who received 5-Hz rTMS therapy at the Providence VA Medical Center Neuromodulation Clinic . Self-report scales measured illness severity prior to treatment , after every 5 treatments , and upon completion of treatment . Results showed significant reduction in symptoms of PTSD ( p = .003 , effect size = 1.12 , 8/10 with reliable change ) and MDD ( p = .005 , effect size = 1.09 , 6/10 with reliable change ) . Stimulation was well tolerated and there were no serious adverse events . These data indicate 5-Hz rTMS may be a useful option to treat these comorbid disorders . Larger , controlled trials are needed to confirm the benefits of 5-Hz protocol s observed in this pilot study
RESULTS BZDs are ineffective for PTSD treatment and prevention , and risks associated with their use tend to outweigh potential short-term benefits .
In addition to adverse effects in general population s , BZDs are associated with specific problems in patients with PTSD : worse overall severity , significantly increased risk of developing PTSD with use after recent trauma , worse psychotherapy outcomes , aggression , depression , and substance use .
The results of this systematic review suggest that BZDs should be considered relatively contraindicated for patients with PTSD or recent trauma .
OBJECTIVE Although benzodiazepines ( BZDs ) are commonly used in the treatment of posttraumatic stress disorder ( PTSD ) , no systematic review or meta- analysis has specifically examined this treatment .
The goal of this study was to analyze and summarize evidence concerning the efficacy of BZDs in treating PTSD .