title: Treatment-refractory posttraumatic stress disorder (TRPTSD): a review and framework for the future.
abstract: Post-traumatic stress disorder (PTSD) is a serious psychiatric consequence of trauma that occurs in a proportion of individuals exposed to life-threatening events. Trauma-focused psychotherapy is often recommended as first choice for those who do not recover spontaneously. But many individuals require medications. In the US, only paroxetine (PRX) and sertraline (SRT) are FDA approved for PTSD. But response and remission rates with these medications are low, so numerous other pharmacologic interventions have been tried. To date, there has not been a systematic review of the data on what are the best next-step pharmacologic strategies for individuals who fail standard treatments. To that end, we review 168 published trials of medications other than PRX or SRT and provide a detailed analysis of the 88/168 studies that describe alternative pharmacologic interventions in patients refractory to other treatment. We also review clinical factors relevant to treatment-refractory PTSD; the neurobiology of extinction, as well as evidence-based psychotherapy and neuromodulation strategies for this condition.
authors: Mental Health Service, Sepulveda Ambulatory Care Center, VA Greater Los Angeles Healthcare System, North Hills, CA, USA; Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, Los Angeles, USA. Electronic address: rkoek@ucla.edu.
authors: Ralph J
authors: RJ
authors: Koek
authors: Mental Health Service, Sepulveda Ambulatory Care Center, VA Greater Los Angeles Healthcare System, North Hills, CA, USA. Electronic address: hollynschwartz@gmail.com.
authors: Holly N
authors: HN
authors: Schwartz
authors: Psychiatrist, US Navy, Naval Medical Center San Diego, San Diego, CA, USA. Electronic address: Stephenie.scully@gmail.com.
authors: Stephenie
authors: S
authors: Scully
authors: Neurosurgery Service, Greater LA VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Bldg 500 (10H2), 90073, USA; Department of Neurosurgery, David Geffen School of Medicine, Los Angeles, USA. Electronic address: Jean-philippe.langevin@va.gov.
authors: Jean-Philippe
authors: JP
authors: Langevin
authors: Mental Health Service, Sepulveda Ambulatory Care Center, VA Greater Los Angeles Healthcare System, North Hills, CA, USA; VA VITAL Program Director VA Campus Toolkit, USA. Electronic address: shana.spangler@va.gov.
authors: Shana
authors: S
authors: Spangler
authors: Mental Health Service, Sepulveda Ambulatory Care Center, VA Greater Los Angeles Healthcare System, North Hills, CA, USA; Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, Los Angeles, USA. Electronic address: arkady.korotinsky@va.gov.
authors: Arkady
authors: A
authors: Korotinsky
authors: Mental Health Service, Sepulveda Ambulatory Care Center, VA Greater Los Angeles Healthcare System, North Hills, CA, USA; Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, Los Angeles, USA. Electronic address: kevin.jou@va.gov.
authors: Kevin
authors: K
authors: Jou
authors: Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, Los Angeles, USA; Semel Institute for Neuroscience and Human behavior at UCLA, 760 Westwood Plaza, Los Angeles, CA 90024, USA.
authors: Andrew
authors: A
authors: Leuchter
mesh_terms: D000818:Animals; D004351:Drug Resistance / Q000502:physiology; D005108:Extinction, Psychological / Q000187:drug effects / Q000502:physiology; D006801:Humans; D013313:Stress Disorders, Post-Traumatic / Q000503:physiopathology / Q000628:therapy*
keywords: Extinction; Neuromodulation; Post-traumatic stress disorder; Psychopharmacology; Treatment-refractory