Nightmares a risk factor for suicide

Nightmares a risk factor for suicide

by Adrienne Franzese -

After reading the article titled "Trail of Prazosin for PTSD in Military Veterans" by Raskind et al. I must admit I was a bit disappointed with the findings. The study appeared to be very solid with few confounders to misinterpret the conclusion that Prazosin did not alleviate nightmares or improve sleep quality for military veterans compared to the placebo at either 10 weeks and/or 26 weeks of treatment. There are some earlier studies of Prazosin that have shown improvement but they were not as robust as this study. 

I have little experience in seeing patients distressing dreams improve with taking Prazosin but have heard directly from patients that they believe Prazosin has improved their nightmares who are already taking the medication or have in the past. Most of my experience is in psychiatric crisis therefore I rarely get to know the outcomes of medications I start with patients. Now that my role has transitioned to outpatient psychiatric care I had comfort in the idea that I had a tool (Prazosin) for treating patient's nightmares. This article made me re-think about the use of this tool in practice. 

I really appreciate Seth's guidance in exploring validity of research articles and studies in order to truly understand their significance. I hope he will post a check list of things to look at for critiquing future research articles. Hint Hint!

The follow up article titled "What role do nightmares play in suicide? A brief exploration" by Titus et al. demonstrated how significant nightmares are as potential risk factors for suicide. It noted that nightmares are not included in suicide screening even though the risk for repeated suicide was 4-fold for individuals suffering from frequent nightmares even after adjusting for other symptoms such as depression, anxiety, PTSD and substance abuse. 

I know I rarely ask about nightmares unless I am ruling out PTSD as a diagnosis. The article states that Prazosin is the most effective pharmacological intervention and Imagery Rehearsal (IRT) has the strongest empirical support for treatment. As of note this article was written originally in 2017 while the Raskind et al article was written 2/2018. 

Even though the Raskind article demonstrates Prazosin as having little efficacy for decreasing nightmares I think it is still worth screening and trying Prazosin on patients with a low risk profile for that particular medication in hopes of giving them some relief from disturb sleep and nightmares.

I am hopeful that more research will be done exploring Prazosin and other interventions for nightmares since this symptom clearly impairs patient’s wellbeing in many aspects (insomnia, suicidality, etc.) Interesting factors to explore in further studies would be the effects of Prazosin with civilians suffering from PTSD related nightmares and on women suffering from nightmares.

Thanks for a great discussion.

Raskind, M.A., Peskind, E.R., Chow, B., Harris, C., Davis-Karim, A., Holmes, H.A., Hart. K.L. et al, (2018) “Trail of Prazosin for PTSD in Military Veterans”, The New Englan Journal of Medicine. Vol 378(6) 507-517.

 

Titus, C. E., Speed, K. J., Cartwright, P. M., Drapeau, C. W., Heo, Y. & Nadorff, M. R. (2018) “What role do nightmares play in suicide? A brief exploration.” Current Opinion in Psychology. (22)

 

Re: Nightmares a risk factor for suicide

by Sarishma -

Hey Adrienne,

I too was shocked after reading the article for this week regarding that Prazosin did not help to reduce nightmares and improve sleep for combat war veterans (Raskind. et al, 2018). As everyone else who posted a response, I do not agree with this article, however, there is not that much information or research provided to conclude that Prazosin is ineffective. With all the research out there stating that it has been effective, and noticing improvement with patients who are currently taking the medication, leaves me to wonder why Prazosin isn't FDA approved for Nightmares related to PTSD (Stahl, & Muntner, 2014).

It is interesting to note, because all of the information and studies prove otherwise that Prazosin is effective in reducing nightmares, and sleep quality. Looking at UpToDate and other articles, it all reaches to the same conclusion, Prazosin is effective (Zak, & Karippot, 2017). I think during the discussion, Seth mentioned about the validity of the article and he brought up a good point. Because people may take this article by Raskind, and start taking their patients off Prazosin, despite previous research studies stating otherwise. I think we should look at the overall picture and see what is beneficial for them. Sometimes other medications like SSRIs/SNRIs may not help, so going outside the box might be necessary to help improve symptoms. 

UpToDate also suggests that other forms of treatment management should be used, such as psychotherapy (Zak, & Karippot, 2017). I think the article we read this week had a lot of limitations and exclusion criteria. They excluded patients who were using Trazodone and other medications prior to the start of the clinical trials, etc (Raskind. et al, 2018). That is something to note as well in retrospect of the validity. Also, there could be a number of reasons why the FDA still hasn't approved Prazosin for labeled use of nightmares for PTSD (Loughlin, & Generali, 2007). More research needs to be conducts, with larger groups sizes, and with diverse population. However, until then, we should do what is best for the patient and treat accordingly. 

This was an very interesting topic and discussion. Interesting to see what other articles we will discuss in the future.

Sarishma 

References:

Loughlin, K., & Generali, J. (2007). Prescription drugs: alternative uses, alternative cures. New York: Pocket Books.

Raskind, M.A., Peskind, E.R., Chow, B., Harris, C., Davis-Karim, A., Holmes, H.A., Hart. K.L. et al, (2018) “Trail of Prazosin for PTSD in Military Veterans”, The New Englan Journal of Medicine. Vol 378(6) 507-517.

Stahl, S. M., & Muntner, N. (2014). Stahls essential psychopharmacology: prescribers guide. New York: Cambridge University Press.

Zak, R., & Karippot, A. (2017). Nightmares and nightmare disorder in adults. Retrieved March 02, 2018, from https://www.uptodate.com/contents/nightmares-and-nightmare-disorder-in-adults?sectionName=Prazosin&anchor=H4261530858&source=see_link#H4261530858