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Prazosin may worsen insomnia, nightmares in suicidal PTSD

Patients with suicidal posttraumatic stress disorder who received nighttime-only prazosin demonstrated worse improvements in insomnia and nightmares and no reduction in suicide ideation, according to findings published in Journal of Clinical Psychopharmacology.

“Insomnia and nightmares have been reproducibly shown to be risk factors for suicidal ideation, suicidal behavior and suicide death,” William Vaughn McCall, MD, MS, executive vice dean for the Medical College of Georgia at Augusta University, and colleagues wrote. “Nightmares are a signature symptom of PTSD, and PTSD is associated with a high risk for suicide.”

McCall and colleagues conducted a randomized clinical trial to determine whether prazosin, a hypertension drug also used to treat nightmares, reduces suicidal ideation among 20 adult, suicidal PTSD patients vs. placebo. The researchers used the Clinician-Administered PTSD scale to confirm diagnosis of PTSD.

Participants were randomly assigned to receive escalating doses of prazosin or placebo at bedtime only for 8 weeks. All participants were simultaneously receiving their mood disorder medications.

Each week, the researchers measured changes in severity of suicidal ideation, nightmares, PTSD, insomnia and depression using longitudinal mixed-effects models and patient scores on the Columbia Suicide Severity Rating Scale, Disturbing Dreams and Nightmare Severity Index, PTSD Checklist-specific version, Insomnia Severity Index and Hamilton Rating Scale for Depression.

The researchers found that over the course of the study, all psychometric measures improved. However, patients receiving prazosin demonstrated significantly less improvement in nightmares and insomnia at nighttime.

No significant change was observed in daytime measures of suicidal ideation and daytime-only PTSD symptoms among patients in the prazosin group.

BP was not significantly affected. There were no suicide attempts or deaths, but two patients needed to be hospitalized for psychiatric reasons.

“The finding of worse nighttime-variable outcomes for the prazosin group was a surprise... The differences between our findings and those of prior [randomized controlled trials] of prazosin might be related to the high psychiatric and medical acuity of our sample and to the complexity of the psychotropic medication regimens,” McCall and colleagues concluded. – by Alaina Tedesco

Disclosures: McCall reports receiving royalties from Wolters Kluwer Health; support from MECTA and Merck; and being a scientific advisor for Sage Therapeutics. Please see study for all other authors’ relevant financial disclosures.