What is the best medication for anxiety and post-traumatic stress disorder (PTSD) in someone with a history of alcohol use?

From the Guidelines

Selective serotonin reuptake inhibitors (SSRIs) like sertraline (Zoloft) are generally considered the best first-line medication for treating both anxiety and PTSD in someone with a history of alcohol use. Sertraline typically starts at 25-50mg daily, gradually increasing to an effective dose of 50-200mg daily as needed and tolerated, as shown in studies such as 1. Treatment should continue for at least 6-12 months after symptom improvement, with any discontinuation done gradually to avoid withdrawal symptoms. SSRIs are preferred because they effectively treat both conditions without being habit-forming or having abuse potential, unlike benzodiazepines which should be avoided in those with substance use histories, as noted in 1. Additionally, SSRIs may help reduce alcohol cravings in some patients. Other good options include venlafaxine (Effexor) or mirtazapine (Remeron) if SSRIs aren't effective or well-tolerated. Some considerations for treatment selection include availability, feasibility, and patient preference, as discussed in 1. However, when considering the best medication, SSRIs remain the top choice due to their efficacy and safety profile. Psychotherapy, particularly trauma-focused cognitive behavioral therapy, should be used alongside medication for optimal results, although there are no direct comparisons between medication and CBT in the treatment of PTSD, as mentioned in 1. Patients should be monitored for side effects, particularly during the first few weeks of treatment when insomnia, nausea, or increased anxiety might temporarily occur before therapeutic benefits begin. Key points to consider in treatment include:

• Starting with a low dose of sertraline and gradually increasing as needed and tolerated
• Continuing treatment for at least 6-12 months after symptom improvement
• Avoiding benzodiazepines due to their potential for abuse
• Considering alternative medications like venlafaxine or mirtazapine if SSRIs are not effective
• Using psychotherapy alongside medication for optimal results
• Monitoring patients for side effects, especially during the initial treatment phase.

From the FDA Drug Label

Posttraumatic Stress Disorder (PTSD) Sertraline Hydrochloride Oral Concentrate is indicated for the treatment of posttraumatic stress disorder in adults The efficacy of sertraline in the treatment of PTSD was established in two 12-week placebo-controlled trials of adult outpatients whose diagnosis met criteria for the DSM-III-R category of PTSD Panic Disorder Sertraline Hydrochloride Oral Concentrate is indicated for the treatment of panic disorder in adults, with or without agoraphobia, as defined in DSM-IV The efficacy of sertraline was established in three 10 to 12 week trials in adult panic disorder patients whose diagnoses corresponded to the DSM-III-R category of panic disorder

The best medication for anxiety and post-traumatic stress disorder (PTSD) in someone with a history of alcohol use is sertraline.

• Sertraline is indicated for the treatment of PTSD and panic disorder.
• The efficacy of sertraline in the treatment of PTSD and panic disorder was established in placebo-controlled trials 2. However, it is crucial to note that the medication should be used under the guidance of a physician, especially considering the patient's history of alcohol use.

From the Research

Medication Options for Anxiety and PTSD with a History of Alcohol Use

• The selective serotonin reuptake inhibitors (SSRIs) are considered the first-line treatment for post-traumatic stress disorder (PTSD) due to their efficacy and favorable adverse effect profile 3.
• Sertraline, paroxetine, and fluoxetine are the most extensively studied SSRIs for PTSD, with sertraline and paroxetine being US FDA-approved for PTSD 3.
• For individuals with a history of alcohol use, combining Seeking Safety (SS), a present-focused cognitive-behavioral therapy, with sertraline may be beneficial in reducing PTSD and alcohol use disorder (AUD) symptoms 4.

Considerations for Treatment

• Recent cannabis use and drug use severity can predict poorer adherence to prolonged exposure (PE) therapy and worse treatment outcome 5.
• Individuals with a lifetime diagnosis of both an alcohol and drug disorder may be at higher risk for dropout and poorer treatment outcome 5.
• Selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) are commonly used in the treatment of PTSD and anxiety disorders 6.

Trauma-Related Drinking to Cope

• The self-medication model suggests that individuals may use alcohol to cope with trauma symptoms, and trauma-related drinking to cope (TRD) may serve as a mechanism through which PTSD symptoms influence alcohol use problems (AUPs) 7.
• TRD may be a more specific screening tool for AUP risk among individuals endorsing PTSD symptoms compared to generalized drinking to cope motives 7.