Is Cymbalta (Duloxetine) Effective for PTSD?
Cymbalta (duloxetine) is not a first-line treatment for PTSD and lacks FDA approval for this indication, but it may provide benefit in treatment-refractory cases, particularly when comorbid depression is present. 1
First-Line Treatment Recommendations
Selective serotonin reuptake inhibitors (SSRIs)—specifically fluoxetine, paroxetine, and sertraline—are the established first-line pharmacologic treatments for PTSD, along with the SNRI venlafaxine. 1
Trauma-focused cognitive behavioral therapy remains the primary recommended treatment approach, with pharmacotherapy reserved for patients who have residual symptoms after psychotherapy or cannot access psychotherapy. 1
Evidence for Duloxetine in PTSD
While duloxetine is not among the guideline-recommended agents, one small naturalistic study provides limited support:
In 20 treatment-refractory male combat veterans with PTSD and comorbid major depression, duloxetine 60-120 mg daily over 8 weeks produced significant improvement in both PTSD symptoms and depression. 2
Duloxetine effectively reduced nightmares, which is clinically important because decreasing nightmares improves sleep quality in PTSD patients. 2
The study authors noted these results need extension to women with PTSD, highlighting the limited generalizability of this single small study. 2
Clinical Context and Limitations
The evidence base for duloxetine in PTSD is substantially weaker than for FDA-approved SSRIs (paroxetine and sertraline). 1
Older antidepressants including tricyclics and MAOIs have proven efficacy in PTSD but are limited by side effect concerns. 3
SNRIs as a class show efficacy for PTSD, but venlafaxine has more robust evidence and explicit guideline support compared to duloxetine. 1
When Duloxetine Might Be Considered
Duloxetine could be a reasonable option in specific clinical scenarios:
Treatment-refractory PTSD after failure of first-line SSRIs, particularly when comorbid major depression is present. 2
Patients with PTSD who have comorbid pain symptoms, as duloxetine has beneficial effects on pain that may accompany PTSD. 4
Patients requiring once-daily dosing to improve adherence, as duloxetine's simple dosing regimen (60-120 mg once daily) may be advantageous. 4, 5
Dosing Strategy if Used
Start duloxetine 30 mg once daily for 1 week to minimize nausea, then increase to 60 mg once daily. 4
Therapeutic dose range is 60-120 mg once daily, with 60 mg once daily appearing as effective as divided dosing. 4
Allow at least 6-8 weeks at therapeutic doses before assessing efficacy. 6
Safety Considerations
Common side effects include nausea (most common), dizziness, dry mouth, headache, constipation, and fatigue. 5
Unlike tricyclics, duloxetine does not produce clinically important ECG changes or blood pressure elevations at therapeutic doses. 4
Avoid abrupt discontinuation—taper slowly to prevent SNRI discontinuation syndrome. 6
Avoid concomitant MAOIs due to serotonin syndrome risk. 6
Critical Pitfalls to Avoid
Do not use duloxetine as first-line therapy when guideline-recommended SSRIs (fluoxetine, paroxetine, sertraline) or venlafaxine have not been tried. 1
Do not assume treatment failure before completing an adequate 6-8 week trial at therapeutic doses (60-120 mg daily). 6
Do not overlook comorbid obstructive sleep apnea in PTSD patients with sleep disturbance, as this condition is common and requires separate treatment. 1
Remember that pharmacotherapy alone is suboptimal—trauma-focused psychotherapy should be offered when feasible. 1