Anxiety And DepressionAnxiety And DepressionAnxiety And DepressionAnxiety And Depression

Dennis Mungall , Pharm.D.Director,Virtual Education, Non traditional Doctor of Pharmacy Program

Associate Professor , Pharmacy PracticeOhio State University/ College of Pharmacy

Learning ObjectivesLearning Objectives

1. Understand the various anxiety disorders , Depression and how each disorder presents

2. Understand the treatment strategies for each disorder

3. Understand the signs and symptoms of each disorder

4. Understand the consequences to the health care system of anxiety and depression

History of DepressionHistory of DepressionIt is thought that ancient man saw

mental illness as possession by supernatural forces. Ancient human skulls have been found with large holes in them, a process that has become known as trepanning. The accepted theory is that it was an attempt to let evil spirits out. We cannot be certain of this, but we do know that again and again human kind has returned to the idea of mental illness being caused by “evil forces”.

History of DepressionHistory of DepressionAnd yet in certain of these cases there is mere anger and grief and sad dejection of mind………those affected with melancholy are not every one of them affected according to one particular form but they are suspicious of poisoning or flee to the desert from misanthropy or turn superstitious or contract a hatred of life. Or if at any time a relaxation takes place, in most cases hilarity supervenes. The patients are dull or stern, dejected or unreasonably torpid……they also become peevish, dispirited and start up from a disturbed sleep.” Arateus (AD 150)

History of DepressionHistory of DepressionHippocrates (460-377 BC) lived at the time of

Hellenic enlightenment, when great advances were made in all areas of knowledge. He applied Empedocles’ theory to mental illness and was insistent that all illness or mental disorder must be explained on the basis of natural causes. Unpleasant dreams and anxiety were seen as being caused by a sudden flow of bile to the brain, melancholia was thought to be brought on by an excess of black bile4, and exaltation by a predominance of warmth and dampness in the brain. Temperament was thought to be choleric, phlegmatic, sanguine or melancholic depending on the dominating humor

History of DepressionHistory of DepressionBy the end of the fifteenth century psychological

problems were greatly entwined with legal and religious issues and were not seen alone. The devil was seen as the cause of all ills .Mental disorder was equated with sin. They also stated that where doctors could find no cause for a disease and where the disease did not respond to traditional treatment it was caused by the devil. A witch was stripped and her pubic hair was shaved before presentation to judges, so that the devil would have nowhere to hide. On being found guilty a witch would be burnt at the stake. Literally hundreds of thousands of women and children suffered this fate and probably many of the mentally ill.

History of DepressionHistory of Depression• Robert Burton’s anatomy of melancholy appeared for

the first time in 1621.2 He described in detail the psychological and social causes (such as poverty, fear and solitude) that were associated with melancholia and seemed to cause it

• In Early nineteenth century Heinroth believed that sin was the causal factor in mental illness. Not sin in the theological sense, but the offending of an individual’s morals by their own thoughts. He was referring to an internal conflict

• The man who exemplified the hard-nosed scientific feel of this era was the German psychiatrist Wilhelm Griesinger (1817-1868). For him mental diseases were somatic diseases6, and the cause of mental illness was always to be found in the brain. He firmly believed that psychiatry and neuropathology were one

History of DepressionHistory of Depression• Freud successfully realised was that

neurophysiological and psychological knowledge need not be contradictory.

• Psychoanalysis predominated until the 1970s, which was followed by renewed interest in genetic, biochemical and neuropathological causes of mental disorder which came to be known as biological psychiatry

IntroductionIntroduction

Lifetime Prevalence of Depression and Anxiety Disorders

Lifetime Prevalence of Depression and Anxiety Disorders

Comparision with Other Medical Conditions

Comparision with Other Medical Conditions

Sx Overlap of Anxiety and Depression

Sx Overlap of Anxiety and Depression

Sx Overlap ( cont.)Sx Overlap ( cont.)

Risk Of Psychiatric Disorder

PercentPercent

Kroenke et al. Kroenke et al. Arch Fam MedArch Fam Med. 1994;3:774.. 1994;3:774.

Physical Symptoms (#)Physical Symptoms (#)

Physical Symptoms

Kroenke et al. Kroenke et al. Arch Fam MedArch Fam Med. 1994;3:774.. 1994;3:774.

0 10 20 30 40 50 60 70

Fainting

Insomnia

Chest Pain

Abdominal Pain

Headache

Fatigue

Mood Disorder Anxiety Disorder

0 10 20 30 40 50 60 70

Fainting

Insomnia

Chest Pain

Abdominal Pain

Headache

Fatigue

Mood Disorder Anxiety Disorder

Somatic Symptoms In Mood And Anxiety Disorders

0123456789

10

Panic Agoraphobia SocialAnxiety

Disorder

OCD Any AnxietyDisorder

Rates

Control Alcohol-Dependent

0123456789

10

Panic Agoraphobia SocialAnxiety

Disorder

OCD Any AnxietyDisorder

Rates

Control Alcohol-Dependent

***

**

Lifetime Rates Of Anxiety Disorders InAlcohol-Dependence

Occurring Prior To Substance Dependence

Merikangas et al. Merikangas et al. Psychologic MedPsychologic Med. 1998;28:773.. 1998;28:773.

0

20

40

60

80

100

Mood Disorder Anxiety Disorder

0

20

40

60

80

100

Mood Disorder Anxiety Disorder

PercentPercent

Alcohol DependenceAlcohol Dependence Drug DependenceDrug Dependence

Mood/Anxiety Disorder

Primary Care Presentation Primary Care Presentation

Anxiety and Depression in Primary Care

Anxiety and Depression in Primary Care

Depression and GenderDepression and Gender

Days Lost from WorkDays Lost from Work

Costs of Depression in the United States

Costs of Depression in the United States

Costs of Depression in the United States  Cost Center Amount ($ billion) Direct costsInpatient care 8.3Outpatient care 2.8Partial care 0.1Pharmaceuticals 1.2 Total direct costs 12.4 Indirect costsAbsenteeism 11.7Decreased productivity 2.1Suicide 7.5 Total indirect costs 31.3

Recovery RatesRecovery Rates

Relapse RatesRelapse Rates

Utilizers of Medical CareUtilizers of Medical Care

DepressionDepression

Case StudyCase Study

Depression PrevalenceDepression Prevalence

Morbidity and MortalityMorbidity and Mortality

Morbidity and MortalityMorbidity and Mortality

SuicideSuicide

Depression : DSM IVDepression : DSM IV

Major Depressive Episode:CriteriaMajor Depressive Episode:Criteria

Criteria (cont.)Criteria (cont.)

Hamilton Rating Score for Depression

Hamilton Rating Score for Depression

Interview TechniquesInterview Techniques• Depressed or

Down• Restless• Fatigued• Guilty• Inability to

Concentrate

Associated FeaturesAssociated Features

Associated Features (cont.)Associated Features (cont.)

• Prior episodes

• Family history

• Prior suicide attempts

• Female gender

• Recent childbirth

• Medical comorbidity

• Alcohol or substance abuse

• Recent separation or bereavement

Depression Guideline Panel. Depression in Primary Care: Volume 1. Detection and Diagnosis.Depression Guideline Panel. Depression in Primary Care: Volume 1. Detection and Diagnosis.Clinical Practice Guideline, Number 5. Rockville, MD. U.S. Department of Health and Human Service,Clinical Practice Guideline, Number 5. Rockville, MD. U.S. Department of Health and Human Service,Public Health Service, Agency for Health Care Policy and Research. AHCPR Publication No. 93-0550. April 1993.Public Health Service, Agency for Health Care Policy and Research. AHCPR Publication No. 93-0550. April 1993.

Depression Risk Factors

• Inadequate treatment

• Poor medication compliance

• Frequent +/- multiple episodes

• Preexisting dysthymia

• Onset after age 60

• Long duration or severe index episode

• Seasonal pattern

• Familial mood disorders

• Comorbid anxiety or substance abuse disorder

Recurrent Depression Risk Factors

• Comorbid general medical/neurologic illness

• Cognitive decline

• Multiple losses/bereavement

Factors Complicating Diagnosis OfLate Life Depression

Disease ManagementDisease Management

The Five Rs

Kupfer. Kupfer. J Clin PsychiatryJ Clin Psychiatry. 1991;52(Suppl 5):28.. 1991;52(Suppl 5):28.

RemissionRemission

xx

xxxx

SymptomsSymptoms

SyndromeSyndrome

ResponseResponse

RelapseRelapseRecoveryRecovery

RecurrenceRecurrence

Treatment PhasesTreatment Phases

Acute 6-12Acute 6-12Weeks Weeks

ContinuationContinuation4-9 Months4-9 Months

MaintenanceMaintenance 1 Year1 Year

Depression Treatment Outcome

Response to TherapyResponse to Therapy

RelapseRelapse

ComplianceCompliance

GuidelinesGuidelines

• Accurate diagnosis

• Appropriate antidepressant

• Adequate dose/duration

Criteria For An Adequate Trial Of Antidepressant Treatment

Initial Approach to RXInitial Approach to RX

Initial Approach to RXInitial Approach to RX

Initial Approach to RXInitial Approach to RX

Choosing an AntidepressantChoosing an Antidepressant

Long Term Treatment StrategiesLong Term Treatment Strategies

Rules of DosingRules of Dosing

Serotonin Side EffectsSerotonin Side Effects

Pharmacokinetics of Antidepressants

Pharmacokinetics of Antidepressants

Drug InteractionsDrug Interactions

Treatment ChoicesTreatment Choices

Treatment Choices ( cont.)Treatment Choices ( cont.)

Treatment Choices ( cont.)Treatment Choices ( cont.)

Treatment SummaryTreatment Summary

• Maximize dose• Augmentation:

– Thyroid hormone (T3 > T4) – Lithium (levels 0.7 mEq/mL)

• Combination therapy: eg, SSRI/TCA

• Other: – MAOIs - venlafaxine

– ECT

Strategies In Treatment Resistant Depression

• Common, class effect

• Affects men and women

• Reduced libido

• Dysfunctional orgasm– delayed ejaculation

– inability to ejaculate

– anorgasmia

Keller-Ashton et al. Keller-Ashton et al. J Sex Marital TherJ Sex Marital Ther. . 1997;23:165.1997;23:165.Segraves. Segraves. J Clin PsychiatryJ Clin Psychiatry. 1998;59(Suppl 4):48.. 1998;59(Suppl 4):48.

SSRIs And Sexual Dysfunction

• Tolerate sexual dysfunction in favor of optimal therapeutic response

Dose (or consider drug holiday), but monitor for relapse

• Beneficial in case reports: bupropion, buspirone, amantadine, bromocriptine, methylphenidate, yohimbine, gingko biloba

• Consider alternate antidepressant

Keller-Ashton et al. Keller-Ashton et al. J Sex Marital TherJ Sex Marital Ther. 1997;23:165. Rothschild. . 1997;23:165. Rothschild. Am J PsychiatryAm J Psychiatry. 1995;152:1514.. 1995;152:1514.Segraves. Segraves. J Clin PsychiatryJ Clin Psychiatry. 1998;59(Suppl 4):48.. 1998;59(Suppl 4):48.

Potential Management Strategies

SSRI - Related Sexual Dysfunction

• Weight gain associated with TCAs, MAOIs, SSRIs, and newer antidepressants

Appetite, weight loss associated with depression; therapeutic response may increase weight to normal

• Weight gain during SSRI therapy has not been systematically studied

Antidepressants And Weight Gain

• Sedation

• Anticholinergic effects

• Orthostatic hypotension

• Cardiac toxicity

TCAs: Enhanced Side Effects In The Elderly

Anticancer Drugs Associated With DepressionAnticancer Drugs Associated With Depression

Massie et al. J Pain Symptom Manage. 1994;9:325.

• Corticosteroids

• Interferon

• Asparaginase

• Cyproterone

• Vinblastine

• Vincristine

• Procarbazine

• Tamoxifen

Risk Factors For Suicide In Cancer PatientsRisk Factors For Suicide In Cancer Patients

Massie et al. J Pain Symptom Manage. 1994;9:325.

• Current or prior suicidality• Depression• Psychosis/irrational

thinking• Substance abuse• Recent loss• Poor social support• Older male

• Uncontrolled pain• Advanced disease• Poor prognosis• Cancer site (head/neck,

lung, GI, urogenital,breast)

• Exhaustion/fatigue

Dysthymia: CriteriaDysthymia: Criteria

Treatment of DysthymiaTreatment of Dysthymia

Generalized Anxiety Disorder: Excessive Chronic

Anxiety and Worry

Generalized Anxiety Disorder: Excessive Chronic

Anxiety and Worry

DSM IV Classification DSM IV Classification

Case Studies : GADCase Studies : GAD

Acute Anxiety

Chronic Anxiety

Uncontrolled Anxiety

Roy-Byrne et al. Roy-Byrne et al. J Clin PsychiatryJ Clin Psychiatry. 1997;58(Suppl 3):34.. 1997;58(Suppl 3):34.

• InterestInterest• AppetiteAppetite• EsteemEsteem• SuicideSuicide

DepressionDepression

• AgitationAgitation• DysphoriaDysphoria• SleepSleep• FatigueFatigue• ConcentrationConcentration

• RestlessnessRestlessness• TensionTension• IrritabilityIrritability• WorryWorry

GADGAD

Symptom Overlap In GAD And Depression

CriteriaCriteria

GABAGABA

BenzodiazepinesBenzodiazepines

Rx of GADRx of GAD

TreatmentTreatment

Rx of GADRx of GAD

Social Phobia/Social Anxiety Disorder : Fear of Scrutiny

Social Phobia/Social Anxiety Disorder : Fear of Scrutiny

Case Study: Social AnxietyCase Study: Social Anxiety

• Fear/avoidance of social situations

• Feared situations avoided or endured with intense anxiety or distress

• Fear recognized as excessive or unreasonable

• Fear/avoidance interferes with work, social, family activities

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, American Psychiatric Association, 1994.American Psychiatric Association, 1994.

DSM-IV Social Anxiety Disorder

* Magee et al. * Magee et al. Arch Gen PsychiatryArch Gen Psychiatry. 1996;53:159.. 1996;53:159.**Weiller et al. **Weiller et al. Br J PsychiatryBr J Psychiatry. 1996;168:169.. 1996;168:169.

13.314.4

4.5 4.9

0

5

10

15

20

General Population* Primary Care**

Lifetime Prevalance One-month Prevalence

13.314.4

4.5 4.9

0

5

10

15

20

General Population* Primary Care**

Lifetime Prevalance One-month Prevalence

PrevalencePrevalence(%)(%)

Prevalence Of Social Anxiety Disorder

Beidel. Beidel. J Clin PsychiatryJ Clin Psychiatry. 1998;59(Suppl 17):27.. 1998;59(Suppl 17):27.

PalpitationsPalpitations

Trembling/Trembling/ShakingShaking

BlushingBlushingSweatingSweating

““Butterflies”Butterflies”

Common Somatic Complaints

Social Anxiety Disorder And AgoraphobiaSocial Anxiety Disorder And AgoraphobiaDifferential Diagnosis

SocialSocialAnxietyAnxietyDisorderDisorder

DisorderDisorder

Fear of negative Fear of negative evaluation or evaluation or humiliation in social or humiliation in social or performance situationsperformance situations

Common FearCommon Fear

Public scrutinyPublic scrutiny

Key ConcernsKey Concerns

Avoids speaking, Avoids speaking, eating, drinking, eating, drinking, writing, or using writing, or using restroomsrestroomsonly in publiconly in public

ExampleExample

Agora-Agora-phobiaphobia

Fear that help won’t Fear that help won’t be available or be available or escape won’t be escape won’t be possiblepossible

Being caught in Being caught in situation where situation where escape may be escape may be difficultdifficult

Avoids being alone Avoids being alone or away from or away from home; being in a home; being in a crowd; traveling in crowd; traveling in a car, bus or a car, bus or airplane; or being airplane; or being on a bridge or in an on a bridge or in an elevatorelevator

Social Anxiety Disorder And Panic DisorderSocial Anxiety Disorder And Panic DisorderDifferential Diagnosis

SocialSocialAnxietyAnxietyDisorderDisorder

DisorderDisorder

Fear of negative Fear of negative evaluation or evaluation or humiliation in social or humiliation in social or performance situationsperformance situations

Common FearCommon Fear

Public scrutinyPublic scrutiny

Key ConcernsKey Concerns

Avoids speaking, Avoids speaking, eating, drinking, eating, drinking, writing, or using writing, or using restroomsrestroomsonly in publiconly in public

ExampleExample

PanicPanicDisorderDisorder

Fear of having a Fear of having a heart attack, dying, heart attack, dying, or “going crazy”or “going crazy”

Sudden, Sudden, unexpected unexpected panic attacks panic attacks alone or in alone or in public; not public; not exclusively exclusively limited to social limited to social situationssituations

Discrete attacks Discrete attacks about 10 minutes, about 10 minutes, including chest including chest pain, fear of dying, pain, fear of dying, or smothering or smothering sensations/avoids sensations/avoids places where places where attacks have attacks have occurredoccurred

Social Anxiety Disorder And GADSocial Anxiety Disorder And GADDifferential Diagnosis

SocialSocialAnxietyAnxietyDisorderDisorder

DisorderDisorder

Fear of negative Fear of negative evaluation or evaluation or humiliation in social or humiliation in social or performance situationsperformance situations

Common FearCommon Fear

Public scrutinyPublic scrutiny

Key ConcernsKey Concerns

Avoids speaking, Avoids speaking, eating, drinking, eating, drinking, writing, or using writing, or using restroomsrestroomsonly in publiconly in public

ExampleExample

GeneralizedGeneralizedAnxietyAnxietyDisorderDisorder

Fear of everyday Fear of everyday routine, life routine, life circumstances, e.g. circumstances, e.g. job, finances, health, job, finances, health, or minor mattersor minor matters

Anxiety/worry Anxiety/worry shifting from shifting from one concern to one concern to another - no another - no fear of social fear of social situationssituations

Worries almost Worries almost constantly about constantly about routine, everyday routine, everyday mattersmatters

• Are you afraid of being scrutinized in public?

• Do you fear speaking to others?

• Do you avoid social situations or events?

Screening Questions For Social Anxiety Disorder In Primary Care

• Participating in small groups

• Eating, drinking, writing in public

• Talking to authority figures

• Performing or giving a talk

• Attending social events

• Working while being observed

• Meeting strangers or dating

• Using public bathroom

• Being center of attention

Common FearsSocial Anxiety Disorder

• Distinguishable from other anxiety disorders

• Very common, but undiagnosed, undertreated, costly

• Effectively treated with SSRIs +/- psychotherapy

• Easily screened with patient self-rated questionnaire

Social Anxiety Disorder

• Reduce anxiety/phobic avoidance

• Reduce disability

• Treat depression/other comorbidities

• Choose therapy that is tolerable over long-term

Davidson. Davidson. J Clin PsychiatryJ Clin Psychiatry. 1998;59(Suppl 17):47.. 1998;59(Suppl 17):47.

Social Anxiety Disorder Treatment Goals

TreatmentTreatment

• Can be effective• Potential problems in patients with

alcohol/substance abuse • Not effective for comorbid depression• Side effects

– disruption of cognitive function/sedation– tolerance/dependence/withdrawal

Benzodiazepine Treatment Of Social Anxiety Disorder

van Vliet et al.van Vliet et al. Psychopharmacology Psychopharmacology. 1994;115:128.. 1994;115:128.

Fluvoxamine Treatment Of Social Anxiety Disorder

50

7

0

10

20

30

40

50

60

Fluvoxamine Placebo

50

7

0

10

20

30

40

50

60

Fluvoxamine Placebo

RespondersResponders(%)(%)

Treatment Group (N = 30)Treatment Group (N = 30)

50

9

0

10

20

30

40

50

60

Sertraline Placebo

50

9

0

10

20

30

40

50

60

Sertraline Placebo

Katzelnick et al. Katzelnick et al. Am J PsychiatryAm J Psychiatry. 1995;152:1368.. 1995;152:1368.

Sertraline Treatment Of Social Anxiety Disorder

RespondersResponders(%)(%)

Treatment Group (N = 12)Treatment Group (N = 12)

* P<.001 † P=.03 ‡ P=.17* P<.001 † P=.03 ‡ P=.17Stein et al. Stein et al. JAMAJAMA. 1998;280:708.. 1998;280:708.

05

1015202530354045

Avoidance Fear/Anxiety

Social Life Work Family Life

05

1015202530354045

Avoidance Fear/Anxiety

Social Life Work Family Life

%%ImprovementImprovement

OverOverBaselineBaseline

Paroxetine (N=90)Paroxetine (N=90) Placebo (N=92)Placebo (N=92)

‡†

***

Paroxetine Treatment Of Social Anxiety Disorder

• Irreversible, nonselective– effective – poorly tolerated– hazardous

• Reversible, selective– moderate effectiveness– well tolerated– not available in US

Monoamine Oxidase Inhibitor Treatment OfSocial Anxiety Disorder

MAOI: DietMAOI: Diet

• Effective for mild, occasional performance anxiety

• Not effective in generalized social anxiety disorder

• Will not treat comorbid conditions

• Very limited role

-Blocker Treatment Of Social Anxiety Disorder

• Doubtful efficacy

• Poor side effect profile– sedation, tremor, dry mouth– effects on cognitive function– sexual dysfunction– weight gain– constipation

Tricyclic Antidepressant Treatment Of

Social Anxiety Disorder

• Frequently undiagnosed and untreated

• Presents as marked and persistent fear of social or performance situations or with physiologic symptoms

• Treatment options: psychosocial and pharmacologic– SSRIs show most promise

Conclusions: Social Anxiety Disorder

Panic Disorder: Spontaneous panic attacks

Panic Disorder: Spontaneous panic attacks

Case Study : PanicCase Study : Panic

Criteria For Panic AttacksCriteria For Panic Attacks

Other Causes of Panic SxOther Causes of Panic Sx

Other Causes of Panic SxOther Causes of Panic Sx

Rx: Panic DisorderRx: Panic Disorder

BenzodiazepinesBenzodiazepines

ClonazepamClonazepam

Benzodiazepines (cont.)Benzodiazepines (cont.)

AntidepressantsAntidepressants

Antidepressants (cont.)Antidepressants (cont.)

Post Traumatic Stress Disorder

Post Traumatic Stress Disorder

PTSD : Case StudyPTSD : Case Study

Prevalence Of PTSDPrevalence Of PTSD

0

2

4

6

8

10

12

15 - 24 25 - 34 35 - 44 45 - 54 Total

0

2

4

6

8

10

12

15 - 24 25 - 34 35 - 44 45 - 54 Total

Males Females

Core Features Of PTSD Core Features Of PTSD

• Intrusive symptoms• Avoidance behavior• Numbing• Hyperarousal

symptoms

TraumaTrauma

CriteriaCriteria

0

5

10

15

20

25

30

Rape Molestation PhysicalAttack

Accident PhysicalAbuse

0

5

10

15

20

25

30

Rape Molestation PhysicalAttack

Accident PhysicalAbuse

Non-Combat Related Trauma Associated With PTSDNon-Combat Related Trauma Associated With PTSD

Kessler et al. Kessler et al. Arch Gen PsychiatryArch Gen Psychiatry. . 1995;52:1048.1995;52:1048.

IncidenceIncidence(%)(%)

MalesMales FemalesFemales

• Must specifically ask about trauma

• Assess presence of core symptoms

• Patient self-rated scales (eg Impact of Event Scale, MINI)

• Assess comorbidity (depression, substance use disorders, anxiety disorders)

Diagnosis Of PTSD In Primary Care

• Education

• Support

• Anxiety management

– pharmacotherapy

– psychotherapy

• Lifestyle modification

Treatment Of PTSD

Non-Combat Related PTSD:Non-Combat Related PTSD:SSRI Treatment Studies

Van Der KolkVan Der Kolket al. 1994et al. 1994

AuthorAuthor

64*64*

NN

Flu vs. Pbo;Flu vs. Pbo;5 weeks5 weeks

RegimenRegimen

Significant Significant symptoms symptoms with Fluwith Flu

OutcomeOutcome

Davidson et al. Davidson et al. J Trauma StressJ Trauma Stress. 1991;4:419.. 1991;4:419.Marshall et al. Marshall et al. J Clin PsychopharmacolJ Clin Psychopharmacol. 1998;18:10.. 1998;18:10.

DavidsonDavidsonet al. 1991et al. 1991

55 Flu;Flu;8 - 32 weeks8 - 32 weeks

Intrusive and Intrusive and avoidant symptomsavoidant symptoms

RothbaumRothbaumet al. 1996et al. 1996

77 Ser;Ser;12 weeks12 weeks

Symptoms in 4/5 Symptoms in 4/5 respondersresponders

MarshallMarshallet al. 1998et al. 1998

1919 Par;Par;12 weeks12 weeks

Significant Significant all core all core symptomssymptoms

* Including 31 cases of combat related PTSD* Including 31 cases of combat related PTSD

Rothbaum et al. Rothbaum et al. J Trauma StressJ Trauma Stress. 1996;9:865.. 1996;9:865.Van Der Kolk et al. Van Der Kolk et al. J Clin PsychiatryJ Clin Psychiatry. 1994;55:517.. 1994;55:517.

TreatmentTreatment