Medication Therapy for PTSD
Selective Serotonin Reuptake Inhibitors (SSRIs), specifically sertraline and paroxetine, are recommended as first-line pharmacological treatments for PTSD due to their FDA approval and strong evidence supporting their efficacy. 1
First-Line Pharmacological Treatments
SSRIs
Sertraline: FDA-approved for PTSD treatment 2
- Demonstrated efficacy in maintaining response for up to 28 weeks following 24 weeks of open-label treatment
- Periodic re-evaluation of long-term usefulness is recommended
Paroxetine: FDA-approved for PTSD treatment 3
- Effective in 12-week placebo-controlled trials
- Long-term efficacy beyond 12 weeks requires periodic re-evaluation
SNRIs
- Venlafaxine: Considered as first-line or second-line treatment 1
- Starting dose: 37.5 mg daily
- Target dose: 225 mg daily
- Requires blood pressure monitoring due to potential hypertension
Second-Line Pharmacological Treatments
Serotonin-Potentiating Non-SSRIs
Trazodone: Consider when sleep disturbance is prominent 1
- Dosage: 25-600 mg (mean 212 mg)
- Side effects: daytime sedation, dizziness, headache, priapism, orthostatic hypotension
Mirtazapine: Consider based on promising results in open-label studies 4
Alpha-1 Antagonists for Nightmares
Prazosin: Specifically for PTSD-related nightmares 1
- Starting dose: 1 mg at bedtime
- Average effective dose: 3 mg
- Recommended by American Academy of Sleep Medicine and International Society for Traumatic Stress Studies
Clonidine (0.2-0.6 mg in divided doses): Consider for PTSD-associated nightmares and hyperarousal 1
Third-Line and Adjunctive Treatments
Atypical Antipsychotics
- Consider for PTSD with prominent paranoia or flashbacks 1
- Useful as augmentation to SSRIs in refractory cases
- Options include:
- Olanzapine
- Risperidone
- Aripiprazole
- Require close monitoring for side effects
Anticonvulsants
- Topiramate: Some evidence for efficacy in treating PTSD-related nightmares 1
- Consider where impulsivity and anger predominate 4
Medications to Avoid
Benzodiazepines
- Should be avoided in PTSD as they may worsen outcomes 1
- Moderate-certainty evidence supports their ineffectiveness in controlled studies
- Potential depressogenic effects and possibility of worsening PTSD 4
Treatment Duration and Monitoring
- Continue medication for at least 12-24 months after achieving remission to prevent relapse 1
- Relapse rates are significantly lower when medication is maintained (5-16% vs. 26-52% when discontinued)
- Monitor closely during initial weeks for:
- Worsening symptoms
- Suicidal ideation
- Side effects, particularly with atypical antipsychotics
Special Considerations
- Address comorbidities such as depression, anxiety, and substance use disorders 1, 5
- Consider testing for obstructive sleep apnea in patients with PTSD-related sleep disturbance 5
- Common pitfalls to avoid:
- Premature discontinuation of treatment
- Inadequate dosing
- Overlooking nightmares
- Ignoring comorbidities
- Benzodiazepine use
Remember that trauma-focused psychotherapy is recommended as the first attempt for PTSD treatment, with medication considered as an adjunctive treatment or when psychotherapy is not available or effective 1, 5.