A new era of psychopharmacology combined with two wars in Asia has created its own surge in treating combat stress with prescription drugs. For tough cases doctors have even prescribed antipsychotics. But all drugs are not created equal, and a new study claims that one class of antipsychotic is no better than a placebo for treating post-traumatic stress.
The study underlines that there is no drug for PTSD symptoms. The researchers concentrated on one medication, Risperdal, but the results may apply to a whole class of antipsychotics that work on neurotransmission in the brain.
"It definitely calls into question the use of anti-psychotics in general for PTSD," Charles Hoge, a senior scientist at the Walter Reed Army Institute of Research, told The New York Times.
Antipsychotics like Risperdal target the way brain cells handle neurotransmitters like serotonin and dopamine. In that sense they're similar to antidepressants. They ease a symptom that might correspond to PTSD, but recent research indicates that combat stress can cause physical damage to the brain. The cells themselves may have changed shape or started to work in a different way.
Basically, antipsychotics may affect the brain on too shallow a level to help. But there might be hope for drugs that try to fix cells on a level closer to a person's genes.
"We don't understand the disorder well enough. All we have are puzzle pieces," says Dr. Ulrike Schmidt, a PTSD expert at the Max Planck Institute for Psychiatry in Munich. "But I can imagine that with more high-throughput experiments we will identify target genes, or the proteins they produce, which we can then try to steer with pharmaceuticals."
Her opinion is that the right genes or proteins might be found roughly "in the household of stress hormones," like cortisol.
Schmidt's research has shown that PTSD causes semi-permanent damage not only to parts of the brain, but also to the epigenome, the complex of molecules that surrounds a person's DNA and influences which genes are expressed. It's like a blow to a person's firmware — damage to a system that tells the body what to do. It's not irreversible, though a predisposition for it could be passed on to another generation.
Antipsychotics — widely prescribed as they are — may seem off the mark because psychosis itself is not a typical outcome of post-traumatic stress (the way depression is). But symptoms of psychosis and PTSD can overlap. And doctors have been prescribing antipsychotics "based almost entirely on their experience with them and how they expect them to work," according to the Times.
The big caveat is that PTSD isn't well understood. And some vets may have been prone to certain psychoses to start with. The current study didn't select for them.
This research into molecules and brain behavior may wind up emphasizing that PTSD is too fine-grained and changeable to be treated entirely with drugs. As a disorder it seems to straddle the mysterious boundary between the mind and the brain. The simplest treatment — for most people — may still be sports, like surfing or biking, combined with talk therapy.
Schmidt helps run a clinic in Munich for people with severe post-traumatic stress, where the treatment involves drugs as well as therapy. "We have psychotherapy that includes depth psychology, gestalt therapy and behavioral-therapy elements. We never say, 'Only behavioral therapy is good' — we combine them. And we try to ease certain symptoms with medication. For example, a patient with severe sleeping problems might receive medication for that. ... But the big goal is to lighten the therapy, or speed it up, with a PTSD-specific medication."
One other non-pharmacological treatment, of course, would be to fight fewer wars.