Clinical Case Series: The Use of Prazosin for Combat-Related Recurrent Nightmares among Operation Iraqi Freedom Combat Veterans

Military Medicine, Jun 2005 by Daly, Christine Maura, Doyle, Michael E, Radkind, Murray, Raskind, Elaine, Daniels, Colin

Treatment emphasis was on stress symptom reduction and enhancement of ability to continue military duty performance. This approach is consistent with principals of "combat stress control" directed at normalization of stress disorder symptoms. Therefore, target symptom identification was emphasized and a formal diagnosis of a psychiatric disorder was generally avoided. This approach also respected soldiers' frequent concerns that a formal psychiatric disorder diagnosis might compromise future success in their military careers. However, combat-related nightmares and sleep disruptions in most cases were clearly accompanied by other symptoms that, taken together, fulfilled Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnostic criteria for PTSD.

Low-dose Prazosin therapy was begun at 1 mg before bedtime. Patients generally were monitored weekly. If nightmares persisted, then the Prazosin dose was increased in increments of 1 mg per week. The highest dose associated with nightmare reduction was 5 mg at bedtime. Records were reviewed for demographic information, combat history, presenting complaints, concomitant psychotropic medications, and any psychiatric history. Responses with respect to combat trauma-related nightmares were rated with the Clinical Global Impression of Change.15 This 7-point scale ranges from markedly improved to markedly worse. Marked improvement was defined operationally as complete resolution of nightmares. Moderate improvement was defined as a subjectively meaningful reduction in nightmare frequency and/or intensity.

Long-term (>3-month) psychiatric follow-up monitoring was rarely possible for these patients. Many of the soldiers who were treated were Reserve or National Guard soldiers processed through MAMS, who then returned to their home units.

Results

Of the 28 patients prescribed Prazosin, the effects of Prazosin could not be assessed for 5 because of an absence of follow-up evaluation or incomplete medical records. Of the remaining 23 patients, 20 were rated on the Clinical Global Impression of Change as markedly improved, 2 as moderately improved, and 1 as unchanged (even after Prazosin dose increases of 1 mg in weekly increments had achieved a total dose of 6 mg at bedtime). Sixteen patients' nightmares were markedly or moderately improved with only 1 mg at night. However, one patient required 5 mg at night before his nightmares resolved. Three representative cases are presented to illustrate the types of combat trauma encountered, the major presenting symptoms, and the responses to Prazosin.

Case 1

A 37-year-old National Guardsman originally presented to the BHC complaining of recurrent distressing nightmares related to a combat event that had occurred 4 months earlier, in which the patient killed an enemy at close range. When the patient was screened for the presence of additional psychiatric symptoms, he reported insomnia and low energy. However, he identified these additional symptoms as being primarily caused by his nightmares. Prazosin (1 mg at bedtime) therapy was initiated for the treatment of nightmares. No other psychotropic medications were started.