Randomized Placebo-Controlled Trial of Methylphenidate for the Treatment of Post-Traumatic Stress Disorder with Associated Neurocognitive Complaints

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Background: Posttraumatic stress disorder (PTSD) is a chronic psychiatric illness that is associated with significant suffering and disability in Veterans. Current treatment options are not fully effective for all Veterans, and even when they are effective in lowering total symptom burden, many Veterans continue to experience significant symptom burden and associated functional impairment. Total symptom burden and associated functional impairment is often particularly high for those with comorbid mild traumatic brain injury (mTBI). Methylphenidate (MPH) is a widely available psychostimulant medication with a long track record of safety, which has been used to improve cognitive functioning in attention deficit hyperactivity disorder (ADHD) and has also shown benefit for mood and cognitive functioning in studies of moderate or severe TBI and as augmentation in treatment-resistant major depressive disorder. In a small pilot study of the efficacy of MPH for subjective cognitive impairment associated with PTSD and/or mTBI, members of our research team found that MPH resulted in not only a significant improvement in subjective and objective measures of cognitive functioning, but also a significant decrease in symptoms of both depression and PTSD. Methods: Here, we propose to follow up this promising initial finding with an aggregated N-of-1 randomized placebo-controlled trial of MPH versus placebo (PBO) for PTSD and cognitive symptoms in Veterans with PTSD, with or without comorbid TBI. N=70 Veterans across two sites will each receive sequential 4-week periods of MPH and PBO, in randomized order and separated by a 1-week washout, for a total of 20 weeks. During this time, they will complete weekly or biweekly assessments. This trial design, which is particularly well-optimized for conditions in which a heterogeneous response to treatment is expected, will let us achieve a number of specific aims. First, we will assess the efficacy of MPH compared to PBO for reducing PTSD and depression symptoms in Veterans with PTSD and neurocognitive complaints. Second, we will assess the impact of MPH compared to PBO on neurocognitive functioning in this same population. And third, we characterize the baseline predictors of treatment response to MPH in this population, including whether Veterans with a history of mTBI show greater average treatment response to MPH versus PBO. Finally, this trial design will also allow a systematic assessment of risks in this population, including the risk of discontinuation effects or loss of efficacy over time. Significance: MPH represents a well-tolerated medication with a novel mechanism of action compared to the currently recommended and often ineffective pharmacologic treatments for PTSD and mTBI with associated cognitive complaints. If the results of this study support the use of MPH to decrease PTSD and neurocognitive symptoms in Veterans, it would provide an important new treatment option for Veterans with PTSD, which could be rapidly integrated into clinical practice.