Discussion Forum for 2/22/18

Thanks so much for your thoughtful reply to this thread. I was also surprised to learn of this article's findings and wanted to understand more of the possible nuances behind such data. I found the articles and insight you shared to be extremely helpful. I was especially struck by the data that only 20% of veterans had been prescribed a sufficient dose for decreasing nightmares. This is concerning and helps elucidate the importance of strictly following dosing guidelines in order to support maximum efficacy for our patients' treatments.

I also conducted a literature search and found articles that had conflicting results from the article we reviewed during Journal Club. Most of the articles that I found showed resounding support for the use of Prazosin in veterans. Indeed, as you mentioned, this shows that we must be diligent in consulting literature and critique scientific literature closely before applying broad changes in our prescribing.

Works cited:

Breen, A., Blankley, K., & Fine, J. (2017). The efficacy of prazosin for the treatment of posttraumatic stress disorder nightmares in US military veterans. Journal of the American Association of Nurse Practitioners, 29(2), 65-69.

George, K. C., Kebejian, L., Ruth, L. J., Miller, C. W., & Himelhoch, S. (2016). Meta-analysis of the efficacy and safety of prazosin versus placebo for the treatment of nightmares and sleep disturbances in adults with posttraumatic stress disorder. Journal of Trauma & Dissociation, 17(4), 494-510.

Hi Melissa,

Thank you for your informative post. I too, did a Pubmed search and found a RCT study that discusses prazosin as ineffective for PTSD. However, looking closer at this particular article, the sample size was quite small, 32 male veterans from Iran-Iraq war with chronic PTSD. Exclusion criteria were all disorders besides PTSD and depression since they are generally concurrent (Khalzie, Nasouri, & Ghadami, 2016). The subjects were divided into randomized prasozin and placebo groups monitored for 8 weeks (Khalzie, Nasouri, & Ghadami, 2016).

Also, sleep was measured by an actigraph device, like a watch that records movements during sleep to assess sleep. The actigraph was used to measure sleep for two consecutive nights before prasozin administration and two consecutive nights after prazosin administration for 8 weeks (Khalzie, Nasouri, & Ghadami, 2016). After this brief experiment the author came to the conclusion that prazosin was ineffective, however acknowledged the limitations to this study.

The reason I mention this study and its methods are due to the fact, that there are studies like this one that have limitations and do not necessarily apply to the general population. As you mentioned previously, many times there needs to be further research or a landmark study to draw a definitive conclusion.

Khazaie, H., Nasouri, M., & Ghadami, M. R. (2016). Prazosin for Trauma Nightmares and Sleep Disturbances in Combat Veterans with Post-Traumatic Stress Disorder. Iranian Journal of Psychiatry and Behavioral Sciences, 10(3). doi.org.ucsf.idm.oclc.org/10.17795/ijpbs-2603

Thanks for providing additional articles for us to reference.  I am glad that this article was brought up for journal club discussion (though sadly I was not able to make it to the in person session).  What I really like about the articles chosen for us to discuss is how new they are.  After graduation, I hope to continue to try to stay up to date on the most recent evidence, but it does pose potential risks.  We as providers need to be able to look to the broader research in order to corroborate, and not take new evidence as the holy grail (as has been previously discussed).  And, at the end of the day, as important as evidence based practice is, clinical expertise in individual settings also must play a role in what we decide to do.  That is part of what our research classes and journal clubs teach us - the value of a critical eye in examining evidence.  As has been brought up multiple times in this forum, other confounding research exists - enough to make us stop and think about what this more research means in the broader picture.  Our job as NP's is to stay up to date, with the understanding that no single study can be taken to be an absolute.  

On another note, I too work with veterans and have seen Prazosin change people's lives and also seen it have no effect, and it really seems to depend on a variety of factors that I don't know have yet been studied in depth.  Regardless, I think it remains a very viable option, especially for veterans with PTSD and nightmares that are greatly impairing their sleep, while at the same time keeping in mind that there is the risk of it not being a solve.