| Dr Jeremy Butler
Medication perse is unlikely to produce complete resolution of psychological symptoms in most refugees who have suffered or witnessed trauma. Symptoms tend to be protracted and the emigration to a new country is in itself a major stressor. Additionally, many have significant medical problems including malnutrition which can adversely affect their mental state.
The most common diagnoses are post traumatic stress disorder and major depression. These two conditions are synergistic and can often become chronic causes of morbidity impairing the person's capacity to learn English and integrate into Australian society. 0f the two, major depression is likely to be the most responsive to drugs and needs to be treated as a priority as psychological techniques have limited efficacy if the patient is significantly retarded by depression.
A suggested approach to the use of medication in people suffering from combinations of PTSD and depression is as follows:
(1) Start with one of the ssri's as they are efficacious and generally well tolerated. They have been demonstrated to be the most effective drugs in reducing the hyper arousal and flashback symptoms of PTSD. The dose should be at one half the usual recommended starting dose e.g. 25mg sertraline, l0 mg paroxetine. Subsequently it can be increased every seven days up to twice the usual therapeutic dose if required. Anxiety symptoms can take up to six weeks to respond so patience is required.
(2) If the ssri cannot be tolerated or is ineffective, a trial of moclobemide up to a dose of 900mg daily is indicated. It is less effective as an antidepressant but has been used in PTSD with some success. It is most important to allow a decent wash out period between an ssri and moclobemide as the potentially fatal sertonin syndrome can be precipitated if they are used in conjunction.
(3) A third option is to use either nefazadone up to 300mg twice daily or venlafaxine up to 225mg per day. Venlafaxine has not been used much in PTSD but it is a potent antidepressant although side effects affecting the GIT can be a major problem. It should be started at a daily dosage of 37.5mg and increased every few days.
(4) Mianserin up to 120mg per day is a useful antidepressant with sedative properties. It is usually well tolerated although some patients become over sedated. Due to the potential for causing agranulocytosis fbc needs to be checked periodically. It should be commenced at a dose of 20mg nocte.
(5) The tricyclic antidepressants are best avoided if possible due to the lack of safety in overdose and their side effect profile. However, if no other agent is tolerated, they can be used in dosages of up to 200mg daily. Preferentially, use either nortriptyline or dothiepin. Do not use tricyclic antidepressants in combination with ssri's due to unpredictable effects on liver enzymes.
Apart from short-term acute anxiolysis benzodiazepines should not be used. In addition to concerns about tolerance, they can retard the capacity of the brain to habituate to stress. Hence, psychological treatment can be impaired. Similarly, hypnotics such as temazepam should be used for periods of up to two weeks only.
Major tranquillisers such as chlorpomazine and haloperidol are useful as short-term sedatives. However, they have no proven efficacy in the treatment of PTSD and should not be used beyond a few weeks.
Dr Jeremy Butler mb, bs. FRANZCP, consultant psychiatrist
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