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Differential Diagnosis of PTSD: The Importance of Comorbidities David N. Osser, MD, Associate Professor of Psychiatry Harvard Medical School Brockton Division of the VA Boston Healthcare System

Specific comorbidities Substance Use Disorder Major Depression Bipolar Disorder Psychosis Impulse Control Disorder

Substance use disorders and PTSD Common Increased risk of abusing prescription medications Chilcoat HD, Breslau N. Posttraumatic stress disorder and drug disorders: testing causal pathways. Arch Gen Psychiatry 1998;55:913–7.

Substance use disorders and PTSD Recommendations Screen for SUD Avoid benzodiazepines

Substance use disorders and PTSD Recommendations Screen for SUD Avoid benzodiazepines

Substance use disorders and PTSD Algorithm reccomendations don’t apply: If the patient is actively abusing substances Osser DN, Renner JA, Bayog R. Algorithms for the pharmacotherapy of anxiety disorders in patients with chemical abuse and dependence. Psychiatr Ann 1999;29:285–301.

Substance use disorders and PTSD Specific medications Desipramine One positive study with this comorbidity (no effect otherwise) Topiramate 300 mg/day Small study of PTSD patients with alcohol use disorder Mason BJ, Kocsis JH, Ritvo EC, Cutler RB. A double-blind, placebo-controlled trial of desipramine for primary alcohol dependence stratified on the presence or absence of major depression. JAMA 1996;275:761–7

Substance use disorders and PTSD Specific medications Desipramine One positive study with this comorbidity (no effect otherwise) Topiramate 300 mg/day Small study of PTSD patients with alcohol use disorder Batki, SL., et al. Topiramate treatment of alcohol use disorder in veterans with posttraumatic stress disorder: a randomized controlled pilot trial." Alcoholism: Clinical and Experimental Research 38.8 (2014): 2169-2177.

Major depression and PTSD Increases the risk of developing PTSD Major depression You may want to know that patients with both diagnoses may not respond to antidepressants as well as those PTSD alone. Breslau N, Davis GC, Peterson EL, Schultz LR. A second look at comorbidity in victims of trauma: the posttraumatic stress disorder-major depression connection. Biol Psychiatry 2000;48:902–9.

Major depression and PTSD Increases the risk of developing PTSD Major depression Less responsive to antidepressants Patients with: depression + PTSD You may want to know that patients with both diagnoses may not respond to antidepressants as well as those PTSD alone. Brady KT, Clary CM. Affective and anxiety comorbidity in post-traumatic stress disorder treatment trials of sertraline. Compr Psychiatry 2003;44:360–9

Bipolar disorder and PTSD We recommend screening for bipolar disorder in PTSD patients Be very cautious about using antidepressant Consider skipping to other options

Bipolar disorder and PTSD We recommend screening for bipolar disorder in PTSD patients Be very cautious about using antidepressant Consider skipping to other options

Psychosis (e.g. schizophrenia) Psychosis and PTSD Psychosis (e.g. schizophrenia) PTSD symptoms

Psychosis and PTSD Psychosis PTSD Consider skipping initial sleep management Go straight to antidepressants followed by augmentation with antipsychotics Psychosis PTSD Kozaric-Kovacic D, Pivac N. Quetiapine treatment in an open trial in combat-related post-traumatic stress disorder with psychotic features. Int J Neuropsychopharmacol 2007;10:253–61.

Special considerations in pregnancy Women of childbearing potential Avoid paroxetine Risk of fetal septal defects Fluoxetine may have comparable risks If the patient is a woman of childbearing potential, avoid paroxetine due to the risk of fetal septal defects. A study published in 2015 by Reefhuis and colleagues also raises concerns about the use of fluoxetine, as it may have comparable risks to paroxetine. Reefhuis, J., Devine, O., Friedman, J. M., Louik, C., & Honein, M. A. (2015). Specific SSRIs and birth defects: bayesian analysis to interpret new data in the context of previous reports.