Re-posted from the United States Department of Veterans Affairs: Clinician's Guide to Medications for PTSD
Posttraumatic Stress Disorder (PTSD) has biological, psychological, and social components. Medications can be used in treatment to address the biological basis for PTSD symptoms and co-morbid Axis I diagnoses. Medications may benefit psychological and social symptoms as well. While studies suggest that cognitive behavioral therapies such as prolonged exposure (PE) and cognitive processing therapy (CPT) have greater effects in improving PTSD symptoms than medications, some people may prefer medications or may benefit from receiving a medication in addition to psychotherapy.
Placebo-controlled double-blind randomized controlled trials are the gold standard for pharmacotherapy. Less strongly supported evidence includes open trials and case reports. It is important for the clinician to question the level of evidence supporting the medications prescribed in PTSD treatment. There are a variety of factors influencing prescribing, including marketing, patient preferences, and clinical custom, all of which can be inconsistent with the evidence base.
Currently, the evidence base is strongest for the selective serotonin reuptake inhibitors (SSRIs). The only two FDA approved medications for the treatment of PTSD are sertraline (Zoloft) and paroxetine (Paxil) (1, 2). All other medication uses are off label, though there are differing levels of evidence supporting their use. In addition to sertraline and paroxetine, there is strong evidence for the SSRI fluoxetine (Prozac) and for the serotonin norepinephrine reuptake inhibitor (SNRI) venlafaxine (Effexor) which are considered first-line treatments in the VA/DoD Clinical Practice Guideline for PTSD. There are a number of biological changes which have been associated with PTSD, and medications can be used to modify the resultant PTSD symptoms. Veterans whose PTSD symptoms have been present for many years pose a special challenge. Studies indicate they are more refractory to the beneficial effects of medications for PTSD symptoms (3).
What core PTSD symptoms are we trying to treat?
The three main PTSD symptom clusters are listed below:
- Re-experiencing. Examples include nightmares, unwanted thoughts of the traumatic events, and flashbacks.
- Avoidance. Examples include avoiding triggers for traumatic memories including places, conversations, or other reminders. The avoidance may generalize to other previously enjoyable activities.
- Hyperarousal. Examples include sleep problems, concentration problems, irritability, increased startle response, and hypervigilance.