Raskind (2018) article on prazosin for nightmares

Raskind (2018) article on prazosin for nightmares

by Diane Kim -

I really enjoyed reading and discussing Raskind’s (2018) article that stated that prazosin was not effective in treating nightmares for veterans. My initial reaction was a bit of shock, as I had always associated prazosin with being effective for nightmares. To be honest, I considered it to be a staple in clinical practice, although this was not rooted in my own research on the topic.

What struck me most about our discussion was the importance of reading and dissecting literature with a critical eye. One might read this article, published in the highly esteemed New England Journal of Medicine, and re-think his or her own clinical practice due to the results and findings that prazosin is not efficacious in treating nightmares within PTSD, compared to placebo. However, it is crucial to remember that the study only studied military veterans, thereby limiting the external validity of the study to all people with PTSD. Secondly, the study used predominantly male participants, also limiting the generalizability of the study to female veterans (let alone, females with PTSD). Thus, it was an important lesson in being very critical of the study design (in this case, who is being studied) and assessing if the results of the study are generalizable to your population of interest.

 

 

Raskind, M. A., Peskind, E. R., Chow, B., Harris, C., Davis-Karim, A., Holmes, H. A., ... & Romesser, J. (2018). Trial of Prazosin for Post-Traumatic Stress Disorder in Military Veterans. New England Journal of Medicine, 378(6), 507-517.


Re: Raskind (2018) article on prazosin for nightmares

by Lauren -

 Diane, 

Your post resonates with me quite a bit. I too considered prazosin to be an effective treatment modality, and one that I had appreciated as being particularly effective for nightmares. To be fair, I came to this conclusion by observing others’ prescriptive recommendations during clinical rotations, and had not evaluated the literature on my own. That said, you make a really valid critique on the article, specifically around generalizing the results to the greater population with PTSD (beyond military veterans), as well as critique of the study design. Your post is a good reminder to evaluate all aspects of an article before making changes to one's practice. 

Looking at other literature evaluating the efficacy of prazosin specifically for military veterans and combat-related nightmares, a systematic review (Breen, Blankley, & Fine, 2016) concluded that prazosin is an effective adjunctive treatment for addressing nightmares and associated poor-quality sleep, and has increased efficacy in those with more severe symptomology and suffering specifically from trauma-related nightmares. Importantly, those with mild symptoms are not recommended prazosin as it could delay the initiation of other therapeutic approaches to address the trauma. Essentially, it seems as though evaluating the severity of the symptoms and providing therapy is equally as important as provided medication support.
References
Breen, A., Blankley, K., & Fine, J. (2016). The efficacy of prazosin for the treatment of posttraumatic stress disorder nightmares in U.S. military veterans. Journal

Raskind, M.A., Peskind, E.R., Chow, B., Harris, C., Davis-Karim, A., Homes, H.A….& Romesser, J. (2018). Trial of prazosin for post-traumatic stress disorder in military veterans. New England Journal of Medicine, 378(6), 507-517.