What are the recommended selective serotonin reuptake inhibitors (SSRIs) and their dosing for the treatment of post-traumatic stress disorder (PTSD)?

Recommended SSRIs for PTSD Treatment

Sertraline and paroxetine are the recommended first-line SSRIs for PTSD, as they are the only FDA-approved medications for this indication, with sertraline initiated at 25 mg daily for one week then increased to 50 mg daily, and paroxetine started at 20 mg daily. 1, 2, 3

First-Line SSRI Recommendations

Sertraline (FDA-Approved)

• Starting dose: 25 mg once daily for the first week 2
• Target dose: 50 mg once daily after week 1 2
• Dose range: 50-200 mg/day based on clinical response 2, 4
• Dose adjustments: Should not occur at intervals less than 1 week due to 24-hour elimination half-life 2
• Administration: Once daily, morning or evening 2

Paroxetine (FDA-Approved)

• Starting dose: 20 mg once daily 3
• Established effective dose: 20 mg/day 3
• Dose range: 20-50 mg/day (though evidence does not suggest additional benefit above 20 mg/day) 3
• Dose adjustments: If indicated, increase in 10 mg/day increments at intervals of at least 1 week 3
• Administration: Once daily, morning or evening, with or without food 3

Fluoxetine (Off-Label but Well-Studied)

• Dose range: 5-60 mg/day, with evidence supporting efficacy at doses as low as 5 mg daily 1, 4
• Common dosing: Increase after 1 week to 40-60 mg/day for optimal effect 1
• Note: Should generally be avoided in older adults due to higher rates of adverse effects 1

Second-Line SSRI Options

Escitalopram (Off-Label)

• Starting dose: 10 mg daily for 4 weeks 5
• Target dose: 20 mg daily thereafter 5
• Evidence: Open-label trial showed 45% of patients much or very much improved, with significant reductions in PTSD symptoms 5

Citalopram (Off-Label)

• Evidence: Limited but favorable data suggest potential role in PTSD treatment 5
• Caution: Daily doses should not exceed 40 mg due to risk of QT prolongation, Torsade de Pointes, and sudden death 1

Treatment Duration and Maintenance

• Acute treatment: Continue for at least 6-12 months after symptom remission 6, 4
• Maintenance therapy: PTSD efficacy is maintained for periods up to 28 weeks following 24 weeks of initial treatment 2
• Discontinuation risk: 26-52% relapse rate with sertraline discontinuation, substantially higher than post-psychotherapy relapse rates 6
• Reassessment: Periodically evaluate need for continued treatment 2, 3

Critical Treatment Considerations

Response Assessment

• Evaluate treatment response after 8 weeks of SSRI therapy 6
• If inadequate response: Consider switching SSRIs or augmenting with trauma-focused psychotherapy 6
• Expected outcomes: SSRIs show 53-85% of participants classified as treatment responders in controlled trials 6

Psychotherapy Integration

• Trauma-focused psychotherapy should be considered first-line treatment, with Prolonged Exposure, Cognitive Processing Therapy, or EMDR showing 40-87% of patients no longer meeting PTSD criteria after 9-15 sessions 6
• Medication is indicated when: Psychotherapy is unavailable, patient refuses psychotherapy, or residual symptoms persist after psychotherapy 6
• Combination advantage: Psychotherapy allows for eventual medication discontinuation with lower relapse risk compared to medication alone 6

Medications to Absolutely Avoid

• Benzodiazepines are contraindicated in PTSD, particularly in patients with substance use history, due to high abuse potential and evidence of worsening outcomes (63% developed PTSD at 6 months vs. 23% with placebo) 6
• Cannabis and cannabis-derived products should not be used 1

Common Pitfalls and Adverse Effects

• Sexual dysfunction (erectile dysfunction, delayed ejaculation, anorgasmia) can occur with SSRIs in adolescents and adults 1
• Discontinuation syndrome is particularly associated with paroxetine, but also fluvoxamine and sertraline, characterized by dizziness, fatigue, nausea, and sensory disturbances 1
• Serotonin syndrome risk: Avoid combining with MAOIs (at least 14 days washout required), and use caution when combining multiple serotonergic agents 1, 2, 3
• Gastrointestinal disturbances are the most common adverse effects, with nausea and vomiting being the most common reasons for discontinuation 1, 5