**4. Conclusion**

60 Post Traumatic Stress Disorders in a Global Context

Vaiva et al., 2003) or in combination with antidepressants to treat excessive hyperarousal or

For significant symptoms of insomnia that persist with the use of therapeutic doses of antidepressants, a trial of low-dose mirtazepine (15 mg) or trazodone (50- 100 mg) may be helpful. Alternative non-benzodiazepine hypnotics include zopiclone and zaleplon. Zaleplon may be helpful for patients presenting with middle insomnia resulting from nightmares. Its rapid onset of action and very short half-life (approximately one hour) permits patients to take it in the middle of the night (Samuels, 2005). There is evidence demonstrating the benefits of using prazosin, an adrenergic inhibitors to reduce nightmares in combat veterans (Raskind et al., 2002, Raskind et al., 2003; Miller, 2008; Peterson et al.,

In clinical practice, despite limited empirical evidence, most veterans with PTSD receive psychotherapy in combination with pharmacotherapy either concurrently (at the same time) or sequentially (one modality after another) (Alderman et al., 2009). There is limited research using combination treatment for PTSD (Canadian Psychiatric Association, 2006, Marshall and Cloitre, 2000). A recent Cochrane systematic review of four clinical trials using SSRI with PE/CBT concluded that not enough evidence is available to support or refute the effectiveness of combined psychological & pharmacotherapy" (Hetrick et al., 2010). Many patients receive psychotherapy and pharmacotherapy either at the same time or one after another. Even though this is generally considered standard clinical practice in our specialty clinics, there is very limited research demonstrating the benefit of combination treatment. A recent Cochrane review published this year, found only four published trials of combination treatment and concluded that there was not sufficient evidence at this time to either support or refute the effectiveness of combined psychological and pharmacotherapy (Hetrick et al., 2010). One study demonstrated the benefits of psychotherapy augmentation in patients who

Medication compliance is crucial for treatment to be effective. Medication non-compliance may be related to the psychological meaning of taking medication (Fenton and McGlashan, 2000). Veterans may believe that taking medication means they are weak or defective, or they fear that they will become addicted to the medication, (National Institute for Clinical Excellence, 2005) that it will change their personality or lead to job loss. These false beliefs or fears about medications should be explored and confronted prior to starting medication. Providing a safe environment and a positive doctor-patient interaction will help develop trust and may make the veteran more accepting of treatment, improving medication compliance (Weiden and Rao, 2005, Kluft, 2002). Engaging and educating all care providers is essential so the veteran feels safe and comfortable with treatment. Peer social support programs, such as Operational Stress Injury Social Support Program (OSISS) in Canada, may play a valuable role in encouraging medication and treatment compliance. Family involvement may also assist treatment adherence, although this requires further study (Phillips et al., 2001). Education about the potential risk of increased suicidal thoughts

hyperactive symptoms (Friedman, 2006).

**3. Special treatment consideration** 

**3.1 Treatment adherence** 

**2.3.1 Combining psychotherapy and pharmacotherapy** 

have had a partial response to pharmacotherapy (Rothbaum et al., 2006).

2011).

The presentation of military-related PTSD is often complex. The primary care clinician should consider early referral for specialist military psychological and psychiatric care. Understanding military culture and the nature of military deployments helps the clinician appreciate the challenges veterans' face, which is essential to establishing a trusting therapeutic alliance. Treatment often involves a combination of medications making compliance more challenging. Although remission is not always possible, pharmacological interventions assist with symptom reduction and improve functioning and quality of life. Pharmacological interventions also assist with stabilization and facilitate psychotherapeutic interventions such as trauma-focused psychotherapy.

The treatment of veterans with PTSD often involves a multidisciplinary team of health professionals and it is important that the physician maintain a close interagency liaison with a view to 'shared care'.
