May 2010

Borderline Personality Disorder: A Role for Medication?
Antipsychotics, including aripiprazole (Abilify) and olanzapine (Zyprexa), as well as mood stabilizers, such as topiramate (Topamax) and lamotrigine (Lamictal), alleviate some symptoms of borderline personality disorder, but the effects of antidepressants on this condition are variable.

Morphine to Prevent PTSD
Early treatment with morphine following an injury may reduce the risk of posttraumatic stress disorder (PTSD).

Risperidone-Induced Hyperprolactinemia Lowers BMD in Boys
Both risperidone (Risperdal and others), through its effects on prolactin concentrations, and selective serotonin reuptake inhibitors (SSRIs) can lower bone mineral density in boys.

Priapism with Antipsychotics
Antipsychotic medications with a high affinity for the α1-adrenal receptor, such as chlorpromazine (Thorazine), quetiapine (Seroquel), and ziprasidone (Geodon), may be more likely to cause priapism than those with a low affinity.

In Brief
Spouses of People with Dementia Have Higher Risk of Depression; Modafinil (Provigil) Effective for Treating Fatigue in HIV+ Patients

Citalopram and Escitalopram Overdoses
Overdoses with both citalopram (Celexa and others) and escitalopram (Lexapro) can cause serious toxicity.

Morphine to Prevent PTSD

May 2010

A pharmacologic strategy that could be administered after trauma to attenuate the risk of a patient developing posttraumatic stress disorder (PTSD) has long been a goal for clinicians and researchers. Results with benzodiazepines and beta-blockers have been mixed.

In a small sample of children with burn injuries, Saxe and associates found that morphine reduced the risk of PTSD.1 A subsequent study observed similar protective effects from morphine in adults.2 Other investigators have reported that higher pain intensity predicts a greater risk of PTSD. Now a large military study supports a role for morphine in reducing the likelihood of PTSD.

In an observational study, Holbrook and colleagues identified 696 US military personnel who were injured in Iraq (but did not suffer a serious brain injury).3 Of these, 243 were diagnosed with PTSD. Among PTSD patients, 61% had received morphine acutely. Of the 453 service members who did not develop PTSD, 76% had received morphine (P < .001). Even after adjustment for potential confounds such as age and clinical variables, the association of early morphine treatment with a reduced PTSD risk remained significant.

An observational study cannot prove cause and effect. But it is a step forward and consistent with a growing number of similar findings. It certainly sets the stage for randomized controlled trials, which should investigate dose-effect relationships.

Assuming prospective research confirms this role for morphine, the mechanism will be of great interest. Is pain relief the mediator? If so, might other analgesics play a similar role? Or does morphine have a direct effect on anxiety or suffering? What is the relevant neuropharmacology? The public-health implications of this science are enormous.

1Saxe G, Stoddard F, Courtney D, Cunningham K, Chawla N, Sheridan R, King D, King L: Relationship between acute morphine and the course of PTSD in children with burns. J Am Acad Child Adolesc Psychiatry 2001;40:915-921.

2Bryant RA, Creamer M, O'Donnell M, Silove D, McFarlane AC: A study of the protective function of acute morphine administration on subsequent posttraumatic stress disorder. Biol Psychiatry 2009;65:438-440.

3Holbrook TL, Galarneau MR, Dye JL, Quinn K, Dougherty AL: Morphine use after combat injury in Iraq and post-traumatic stress disorder. N Engl J Med 2010;362:110-117.