Medication Summary
While a large number of medications have been tried, few have been shown to have any efficacy. The SSRIs and SNRIs are generally the first-line medications for adults, but only sertraline and paroxetine have FDA approval. Their efficacy in children and adolescents is not proven. Moreover, they have significant side effects. They carry Black Box warnings for suicidal ideation. Benzodiazepines increase the risk of PTSD developing. [42, 43, 44, 45, 33, 46]
Agitation is best treated with clonidine and guanfacine.
Some research has shown that propranolol given in the first hours after the traumatic event leads to reduced hyperarousal in the future. One study found that PTSD patients who actively recalled their traumatic event under the influence of propranolol showed a substantial decrease in symptom ratings on the Clinician-Administered PTSD Scale (CAPS) and the patient-rated PTSD Checklist–Specific (PCL-S) measures compared with patients who received placebo. [26]
Insomnia is a common problem for patients with PTSD. It may be treated though reinforcing sleep hygiene and CBT. Clonidine and prazosin may be helpful. Prazosin decreases trauma-related nightmares. [36] Trazodone may be helpful.
Antipsychotics and anticonvulsants have been tried. One study shows that adding risperidone to standard antidepressant therapy significantly improves outcomes in patients with PTSD without causing additional adverse effects. A meta-analysis of almost 400 patients showed that those who received risperidone as an add-on treatment not only experienced significant improvements in overall and key aspects of PTSD symptoms but also demonstrated significant reductions in anxiety scores compared to those who received placebo. [47]
There is a huge placebo effect for medication. You are likely to find benefit with whatever you give, but it is probably placebo effect.
Selective serotonin reuptake inhibitors
Class Summary
The selective serotonin reuptake inhibitors (SSRIs) work by blocking the reuptake of serotonin. SSRIs such sertraline (Zoloft) and paroxetine (Paxil) have been FDA approved to treat PTSD as well as other disorders.
Sertraline (Zoloft)
Sertraline is an SSRI that is FDA approved for the treatment of PTSD, panic disorder, social anxiety, and obsessive-compulsive disorder. It may be particularly useful in women who have experienced sexual or physical assaults.
Paroxetine (Paxil, Pexeva)
Paroxetine is FDA approved to treat PTSD. It is used to reduce symptom severity of PTSD. It is a potent, selective inhibitor of neuronal serotonin reuptake. It also has a weak effect on norepinephrine and dopamine neuronal reuptake. It is also FDA approved for panic disorder, depression, social anxiety disorder, and obsessive-compulsive disorder.
Fluoxetine (Prozac)
Fluoxetine selectively inhibits presynaptic serotonin reuptake with minimal or no effect on the reuptake of norepinephrine or dopamine. SSRIs such as fluoxetine have less sedation, cardiovascular, and anticholinergic effects than the tricyclic antidepressants (TCAs). Studies have shown this drug to be superior for measures of PTSD severity, disability, and high end-state function.
Beta-blockers
Class Summary
Beta-blockers such as propranolol are useful in controlling some symptoms of PTSD caused by hyperarousal. A pilot study revealed propranolol is effective for decreasing physiological signs of hyperarousal for up to 1 week when used shortly after patients with PTSD reexperience their traumatic event. [48] Ideally, propranolol is to be used within 6 hours of the initial traumatic event, well before a diagnosis of PTSD is made. Larger randomized, placebo-controlled studies are warranted to confirm these findings.
Propranolol (Inderal LA, Inderal XL, Hemangeol, Innopran XL)
Propranolol is a nonselective beta-adrenergic receptor blocking agent. It has been found to relieve exaggerated startle response, explosiveness, nightmares, and intrusive reexperiencing in some patients with PTSD. Propranolol has not been FDA approved for these indications.
Alpha-1 Receptor Antagonists
Class Summary
Novel pilot studies in combat veterans suggest alpha-1 antagonists have efficacy on the sleep-associated symptoms of PTSD. Alpha-1 antagonists have not been FDA approved for this indication.
Prazosin (Minipress)
Prazosin is an alpha-1 adrenergic blocker that is indicated for hypertension. Studies indicate that a nighttime dose of prazosin (10-15 mg) decreases nightmares and sleep disturbances in combat veterans with PTSD and increases normal dreaming patterns. Additional pilot trials have suggested that a midmorning dose of prazosin also helps to decrease daytime PTSD symptoms in civilian and military patients. However, larger, randomized, placebo-controlled trials are needed to confirm these results.
Alpha-2 Adrenergic Agonists
Class Summary
Agents in this class may decrease vasomotor tone and heart rate by stimulating alpha2-adrenoreceptors in the brain stem and activating an inhibitory neuron.
Clonidine (Catapres, Catapres-TTS, Duracion, Kapvay)
Clonidine is a central alpha-adrenergic agonist that is commonly used as an antihypertensive agent. It stimulates alpha2-adrenoreceptors in the brain stem and activates an inhibitory neuron, resulting in a decrease in vasomotor tone and heart rate. Clonidine may have potential effects on the hyperarousal symptoms of PTSD. It may also help in patients experiencing nightmares.
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Brain structures involved in dealing with fear and stress.
