Pharmacological Considerations in Treating Patients Exposed to Intimate Partner Violence
, Volume , Number ,
Patients who have been exposed to intimate partner violence (IPV) often develop significant psychiatric symptoms, most commonly insomnia, anxiety, and depression (Wuest J et al, Can J Public Health 2007,98(6):460–464; Stene L et al, Scand J Public Health 2010, 38(5 Suppl):88–95). Despite the fact that a majority of those exposed to IPV seek medical care and treatment (Wood S et al, J Midwifery Women’s Health 2008;53(6):538–546), they don’t tend to disclose their histories of abuse.
However, the behavior of a therapist can help patients open up about abuse. For example, women in group therapy for domestic violence reported that they were more likely to discuss IPV when they felt the clinician was “caring,… easy to talk to, had a protective manner, or if the clinician offered a follow-up visit” (McCauley J et al, J Gen Intern Med 1998;13(8):549–555).
Among patients seeking psychiatric treatment, the prevalence of IPV is alarmingly high. In a survey of 270 women and 158 men receiving services at a large psychiatric facility, rates of IPV were 63% and 32%, respectively. However, only 44% of patients were specifically screened by their clinicians for IPV; and women (55%) were screened more often than men (27%) (Chang J et al, Gen Hosp Psychiatry 2011;33(1):58–65). Because trauma can result in a wide range of psychiatric disorders, not only PTSD (Moreau C and Zisook S, Psychiatr Clin North Am 2002;25(4):775–790), a full psychiatric evaluation is a must when a therapist identifies IPV.
Let’s take a look at the most common symptoms associated with IPV and the medications you can prescribe to help treat them.
Insomnia. Females exposed to severe IPV showed decreased sleep, averaging just above 5.5 hours per night (Walker R et al, J Interpers Violence 2011;26(10):2004–2024). Recent research showed that women with IPV-related insomnia and nightmares had an eight-fold greater risk of depression, even when PTSD severity was controlled for (Pigeon W et al, J Womens Health 2011;20(12):1923–1929). Although off-label when prescribed for insomnia, trazodone (Desyrel, Oleptro) is often helpful in these patients, while prazosin (Minipress, Vasoflex) can be effective for nightmares related to PTSD (Bajor L et al, Harv Rev Psychiatry 2011;19(5):240–258).
Anxiety and PTSD. Traumas that can be a component of IPV, like rape and physical abuse, have the highest likelihood of leading to the development of PTSD (Kessler R et al, Arch Gen Psychiatry 1995;52(12):1048–1060). Studies have found patients exposed to IPV had PTSD rates of 31% to 75% (Stein M and Kennedy C, J Affect Disord 2001;66(2–3):133–138). From the standpoint of medication therapy, SSRIs are the mainstay of treatment for PTSD. Paroxetine (Paxil, Pexeva) and sertraline (Zoloft) are the only FDA-approved medications for PTSD and have the most empirical support (Stein D et al, Cochrane Database Syst Rev 2006; 25(1):CD002795). It is important to note that paroxetine is rated as category D for pregnancy in the US, which means that studies in pregnant women have demonstrated a risk to the human fetus, and therefore is not recommended for women of childbearing age. Although benzodiazepines have abuse potential and no clear protective or long-term benefit in PTSD, they help some patients, at least in the short-term.
Risperdone (Risperdal) has been shown to be helpful for PTSD-related psychosis (Seedat S et al, CNS Drugs 2005;19(5):411–427), and there is limited evidence that topiramate (Topamax, Topiragen) and lamotrigine (Lamictal) may also be helpful adjunctively in treating PTSD (Bajor L et al, Harv Rev Psychiatry 2011;19(5):240–258).
Depression. Many patients who have been exposed to IPV suffer depression. The rate of IPV-related major depressive disorder (MDD) ranges from 18% to 54% and it is highly comorbid when patients also suffer from PTSD, especially as the severity of symptoms increases. This comorbidity with PTSD was shown to be associated with more “maladaptive depressogenic cognitive styles” and increased disability (Stein M and Kennedy C, J Affect Disord 2001;66(2–3):133–138). This association means that we need to independently identify and address both disorders. It is noteworthy that the first-line agents for MDD include SSRIs, and adjunctive medications include atypical antipsychotics (American Psychiatric Association: Practice Guideline for the Treatment of Patients with Major Depressive Disorder, third edition, American Psychiatric Association, Arlington, Virginia;2010). This suggests that combined treatment for both disorders may be possible with the same group of agents.