What medication would you add to sertraline (SSRI) for a 35-year-old male patient with PTSD experiencing sleep disturbances and nightmares 4 nights a week?

From the Guidelines

Prazosin would be the most appropriate addition to sertraline for this 35-year-old male PTSD patient experiencing frequent sleep disturbances and nightmares. I would recommend starting prazosin at a low dose of 1mg at bedtime for the first week, then increasing to 2mg for the second week, and potentially titrating up to 3-15mg based on response and tolerability 1. The medication should be taken 1-2 hours before bedtime. Prazosin is an alpha-1 adrenergic antagonist that blocks the effects of norepinephrine, which is often elevated in PTSD and contributes to nightmares and sleep disruption.

Some key points to consider when prescribing prazosin include:

• Monitoring for potential side effects including dizziness, lightheadedness, and first-dose orthostatic hypotension 1
• Taking the first dose when the patient can remain lying down for several hours afterward to minimize side effects
• Regularly checking blood pressure, especially during dose adjustments
• Prazosin specifically targets the hyperarousal and re-experiencing symptoms of PTSD while the sertraline addresses the broader spectrum of PTSD symptoms, making this combination particularly effective for patients with prominent sleep disturbances 1

Other options, such as quetiapine, temazepam, and propranolol, may also be considered, but the evidence supporting their use is not as strong as that for prazosin 1. For example, quetiapine has been shown to be effective in reducing nightmare frequency, but it may have more significant side effects compared to prazosin 1. Temazepam and propranolol may also be used, but their efficacy in reducing nightmares is less well-established compared to prazosin 1.

Overall, prazosin is the most appropriate choice for this patient due to its efficacy in reducing nightmares and sleep disturbances, as well as its relatively favorable side effect profile 1.

From the Research

Treatment Options for Sleep Disturbances in PTSD

The patient in question is experiencing sleep disturbances and nightmares 4 nights a week, despite being on sertraline (SSRI) for PTSD. To address this issue, the following medications could be considered:

• Temazepam: a benzodiazepine that can help with sleep disturbances, but its use is generally not recommended for PTSD-related sleep disorders due to its adverse effect profile 2
• Quetiapine: an atypical antipsychotic that may be effective for treatment-resistant nightmares and insomnia, although its use can be associated with significant adverse effects 2
• Propranolol: a beta-blocker that is not typically used to treat sleep disturbances in PTSD
• Prazosin: an alpha-1 adrenergic receptor antagonist that has been shown to be effective in reducing nightmares and improving sleep quality in patients with PTSD 3, 4, 5, 6

Rationale for Prazosin

Prazosin has been studied extensively for its use in treating PTSD-related nightmares and sleep disturbances. The evidence suggests that prazosin can:

• Reduce the frequency and intensity of nightmares 3, 4, 5, 6
• Improve sleep quality and duration 4, 6
• Have a relatively rapid response time, with improvements seen within weeks 5
• Be effective in both military and civilian populations with PTSD 4, 5

Considerations

When considering the addition of prazosin to the patient's treatment regimen, it is essential to:

• Monitor for hypotension, particularly after the first dose 5
• Gradually increase the dose to maintenance levels, typically 2-6 mg at night 5
• Be aware of the potential for breakthrough symptoms between doses, given the short half-life of prazosin 3