For many years, prazosin has been accepted as part of the prescribed treatment for post-traumatic stress disorder (PTSD). The drug works by blocking the alpha-1 receptors, and is commonly used to treat individuals with high blood pressure. In addition, the efficacy of prazosin in helping to reduce nightmares associated with PTSD – particularly among war veterans – has been shown in several cases.

However, recently published findings from a clinical trial seem to have stirred things up a little – further prompting questions revolving the efficacy of the drug.

Success observed in previous studies

The positive effects of prazosin have been demonstrated in several studies in the past. It has been described as a drug that is well-tolerated and a significant pharmacological treatment alternative for patients, who often experienced nightmares associated with PTSD. Often, in those studies, the nightmares returned rapidly when prazosin therapy was discontinued – and later resolved when the treatment was reintroduced to patients.

Although many studies involved war veterans, prazosin has also been associated with improvements in nightmares and sleep in youths diagnosed with PTSD. One study, for instance, evaluated prazosin-treated patients between the ages of five and 18, who had experienced various forms of trauma – e.g. sexual abuse, family violence and bullying. The researchers discovered that prazosin can be an intervention that is helpful in treating paediatric patients experiencing nightmares and sleep disturbances associated with PTSD.

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No better than a placebo?

Dr Murray Raskind, a psychiatrist based in Seattle Washington, along with several colleagues conducted a recent trial involving 304 participants. The study was also published in The New England Journal of Medicine (NEJM). The participants were veterans recruited from 13 Department of Veterans Affairs medical centres with chronic PTSD and reported frequent nightmares. A total of 152 participants were assigned to prazosin while the remaining 152 to placebo. The results were rather surprising – i.e. after 10 weeks, researchers noted no significant differences between the group given prazosin and the placebo group.

Raskind’s trial involving 304 war veterans found no significant differences between the group given prazosin and the placebo group.
Raskind’s trial involving 304 war veterans found no significant differences between the group given prazosin and the placebo group.

“Experts in PTSD familiar with the research have been shocked by the findings,” Raskind told Reuters Health in a telephone interview. He also said that the results “should discourage doctors from giving prazosin as a 'one-size-fits-all' therapy and encourage them to identify veterans who will find it effective.”

Perhaps for some, this recent finding might not have come as a very big astonishment. An earlier statement made by the US Department of Veterans Affairs (VA) and Department of Defense (DoD) regarding the treatment of PTSD had echoed the questionable effects of prazosin.

“For nightmares associated with PTSD, there is insufficient evidence to recommend for or against the use of prazosin as mono- or augmentation therapy,” it said. The VA/DoD statement in fact included the results from Raskind’s trial – which, at the time of their review, had yet been published.

What will the future look like for prazosin?

In a way, the recent controversy surrounding prazosin has brought psychotherapy into discussion, as well. Previous studies have supported the use of methods such as Exposure, Relaxation, and Rescripting Therapy (ERRT) and Image Rehearsal Therapy (IRT), as viable alternatives to address issues concerning sleep disturbances and other PTSD symptoms. Nonetheless, more clinical trials in different patient populations are definitely required before anyone can rule out the efficacy of prazosin in treating patients with PTSD.

More clinical trials are needed to investigate the efficacy of prazosin in different populations. Photo credit: Anxiety Clinic
More clinical trials are needed to investigate the efficacy of prazosin in different populations. Photo credit: Anxiety Clinic

Dr Charles Marmar, Chair of the Psychiatry Department at NYU Langone Health – who was not involved in the study – however, agreed that the negative results in Raskind’s trial may not necessarily mean that prazosin has lost its reputation in PTSD treatment. Newsweek reported Marmar as saying, “All combat trauma in America constitutes 15% of PTSD; 85% of all PTSD cases are civilian. And the data look pretty good on prazosin for civilians.” He also added that he “wouldn’t be at all discouraged from using this drug in a VA population."

The treatment of PTSD has been challenging, and coupled with the intricacy of the ways in which different individuals with different conditions respond to the treatment, drawing out a definite conclusion as to what treatment, or combination(s) of treatment that 'works best' is not an easy feat. The wealth of data regarding the different types of intervention to treat PTSD should encourage further investigations to enhance the current knowledge and understanding about the matter. MIMS


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Sources:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538493/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5700900/
http://www.nejm.org/doi/full/10.1056/NEJMoa1507598
https://www.reuters.com/article/us-health-ptsd-military/common-drug-for-ptsd-doesnt-stem-nightmares-sleep-problems-in-veterans-idUSKBN1FR3AD
https://www.healthquality.va.gov/guidelines/MH/ptsd/VADoDPTSDCPGFinal012418.pdf
http://www.newsweek.com/treating-veterans-ptsd-blood-pressure-medication-prazosin-not-always-work-800465