What are the recommended medications for treating Post-Traumatic Stress Disorder (PTSD)?

Recommended Medications for Post-Traumatic Stress Disorder (PTSD)

Selective Serotonin Reuptake Inhibitors (SSRIs), specifically sertraline and paroxetine, are the first-line pharmacological treatments for PTSD due to their FDA approval and strong evidence supporting their efficacy. 1

First-Line Pharmacological Treatments

SSRIs

• Sertraline (Zoloft)

  • FDA-approved for PTSD 2
  • Initial dose: 25 mg/day for first week
  • Target dose: 50-200 mg/day (average effective dose ~146-151 mg/day)
  • Demonstrated efficacy in 12-week placebo-controlled trials 2
  • 60% response rate compared to 38% with placebo 3
  • Common side effects: insomnia (35%), diarrhea (28%), nausea (23%), fatigue (13%) 3

• Paroxetine

  • FDA-approved for PTSD 1
  • Effective for core PTSD symptoms including avoidance and numbing 4

Second-Line Pharmacological Treatments

SNRIs

• Venlafaxine
  • Starting dose: 37.5 mg daily
  • Target dose: 225 mg daily
  • Requires blood pressure monitoring due to potential hypertension 1
  • Promising results in open-label studies 4

Other Serotonin-Potentiating Agents

• Trazodone
  • Particularly useful when sleep disturbance is prominent
  • Dosage: 25-600 mg (mean 212 mg)
  • Side effects: daytime sedation, dizziness, headache, priapism, orthostatic hypotension 1

Medications for Specific PTSD Symptoms

For Nightmares and Sleep Disturbances

• Prazosin

  • Specifically targets PTSD-related nightmares
  • Starting dose: 1 mg at bedtime
  • Average effective dose: 3 mg
  • Recommended by American Academy of Sleep Medicine 1

• Clonidine

  • Dosage: 0.2-0.6 mg in divided doses
  • Useful for nightmares and hyperarousal symptoms
  • Long history of use in severely traumatized patients 1

For PTSD with Prominent Paranoia or Flashbacks

• Atypical Antipsychotics
  • Olanzapine, risperidone, aripiprazole
  • Can be used as monotherapy or as augmentation to SSRIs in refractory cases
  • Risperidone has the strongest evidence as an add-on therapy 5
  • Requires close monitoring for side effects 1

Medications to Avoid

Benzodiazepines

• Should be avoided in PTSD as they:
  • May worsen outcomes
  • Have been shown to be ineffective in controlled studies
  • Can be depressogenic
  • May promote or worsen PTSD symptoms 1, 4
  • In one small study, 63% of participants receiving benzodiazepines met criteria for PTSD 6 months after trauma compared to only 23% receiving placebo 6

Treatment Duration and Monitoring

• Continue medication for at least 12-24 months after achieving remission to prevent relapse
• Relapse rates are significantly lower when medication is maintained (5-16% vs. 26-52% when discontinued) 1
• Monitor closely during initial weeks for:
  • Worsening symptoms
  • Suicidal ideation
  • Side effects, particularly with atypical antipsychotics 1

Special Considerations

• Comorbidities: Address concurrent depression, anxiety, and substance use disorders
• Anticonvulsants (lamotrigine, topiramate, valproic acid): Consider when bipolar disorder is comorbid or when impulsivity and anger predominate 4
• Image rehearsal therapy: A modified cognitive behavioral therapy technique recommended for PTSD-associated nightmares 1

Common Pitfalls to Avoid

1. Premature discontinuation of treatment
2. Inadequate dosing (effective doses of SSRIs for PTSD are often higher than for depression)
3. Overlooking nightmares as a treatable symptom
4. Ignoring comorbidities that may require specific treatment
5. Using benzodiazepines as primary treatment

Remember that trauma-focused psychotherapy is recommended as the first attempt for PTSD treatment, with medication considered as an important adjunctive treatment 1. The combination of pharmacotherapy and psychotherapy often yields the best outcomes, particularly in the acute stages of illness.