What medications are used?

As of August 2007, two medications are approved for treating PTSD by the U.S. Food and Drug Administration (FDA), paroxetine (Paxil but not Paxil CR) and sertraline (Zoloft), selective serotonin reuptake inhibitors (SSRIs). FDA approval is based on multi-center double-blind studies. Read an abstract of a paroxetine study, "Efficacy and Safety of Paroxetine Treatment for Chronic PTSD: A Fixed-Dose, Placebo-Controlled Study," American Journal of Psychiatry (2001)158:1982-1988. For information about a study showing sertraline's effectiveness, "Efficacy and Safety of Sertraline Treatment of Posttraumatic Stress Disorder: a randomized control trial," JAMA (2000)283:1837-1844, click here.

Other medications in the same selective serotonin reuptake inhibitor (SSRI) class as paroxetine and sertraline are probably effective. Based on research evidence, the American Psychiatric Association (APA) Practice Guideline recommends an SSRI as the best first-line treatment for PTSD. If one SSRI is ineffective or has intolerable side effects, a second SSRI may prove beneficial and be well tolerated. The APA Guideline mentions that other antidepressants may also be useful in treating PTSD. A recent well-designed research study found venlafaxine XR (Effexor XR) to be more effective than placebo over a period of 6 months. Both duloxetine (Cymbalta) and mirtazapine (Remeron) also show promise. The SSRIs, venlafaxine, duloxetine and mirtazapine have more favorable side-effect profiles than the tricyclic antidepressants.

Tricyclic antidepressants (TCAs) could be employed if the person has had a good response to them in the past and they do not cause too many side effects, or if the person has failed to respond to or does not tolerate the SSRIs or newer antidepressants.

We are sure you've noticed by now, that we have been describing antidepressants as a treatment for PTSD, an anxiety disorder. Many medications achieve initial approvals from the FDA for one indication (in this case depression) and are later found to be helpful for other disorders. This is certainly true for the SSRIs. In addition to FDA approvals for depression, different members of the SSRI class also have FDA approvals for bulimia, generalized anxiety disorder, obsessive-compulsive disorder (fluvoxamine is FDA-approved for only this indication), panic disorder, posttraumatic stress disorder, premenstrual dysphoric disorder, and social anxiety disorder. SSRIs are broad spectrum psychopharmacologic agents and the initial FDA labeling for depression should not concern you if they are prescribed for other indications. Physicians often prescribe medications "off label" when they are found to be helpful for a particular condition, even if they have not been approved for that use by the FDA. These "antidepressants" are also effective treatments for PTSD in much the same way aspirin treats fever and inflammation as well as pain for which it is most often used.

Antianxiety medications (anxiolytics) include benzodiazepines such as alprazolam (Xanax, Xanax SR and Niravam), clonazepam (Klonopin and Klonopin Wafers), diazepam (Valium) and lorazepam (Ativan), as well as the non-benzodiazepine buspirone (BuSpar). The benzodiazepines have the merit of reducing anxiety rapidly, often within hours, but may have counterbalancing side effects early in the course of their use that include sedation and incoordination, and the development of physical dependency in those who use them for more than a few weeks. Benzodiazepines are not recommended for people who have a history of alcohol abuse or dependence. Buspirone does not cause significant physical dependency but seldom alleviates anxiety before one, two or more weeks have passed. Benzodiazepines and buspirone have not been shown to be effective treatments for PTSD when used alone. As adjunctive (add-on) medication they may be helpful.

The APA Guideline also recognized a role for anticonvulsant mood stabilizers such as divalproex (Depakote and Depakote ER), carbamazepine (Carbatrol, Equetro, Tegretol), lamotrigine (Lamictal) and topiramate (Topamax) as augmentation (add-on) if there has been a poor response to an antidepressant alone. They may be particularly helpful for those who have lots of irritability, anger or hostility as well as some specific help with reexperiencing symptoms.

Recent guidelines suggest that newer (atypical) antipsychotics (aripiprazole [Abilify], olanzapine [Zyprexa], paliperidone [Invega], quetiapine [Seroquel], risperidone [Risperdal] and ziprasidone [Geodon]) are obviously suitable for individuals with psychotic features in their PTSD or certain other psychiatric disorders plus PTSD. These antipsychotic medications may also be helpful for some individuals who have not benefited from medications indicated for PTSD.

A class of medications called monoamine oxidase inhibitors (MAOIs) has also been shown to be helpful in PTSD. However, MAOIs are rarely used because of more frequent side effects than found with SSRIs and because a careful diet must be followed to prevent dangerous increases in blood pressure.

Prazosin, a medicine traditionally used to treat high blood pressure, may be effective in treating trauma related nightmares in people who have PTSD. It is not FDA approved for PTSD but has been studied in a randomized controlled trial. It is usually used along with other PTSD medications.

Early evidence suggests that treatment with propranolol (Inderal), a beta-receptor blocker, immediately after a trauma may reduce the likelihood of developing PTSD symptoms.

In summary, SSRIs have the strongest evidence for efficacy and tolerability as treatments for PTSD, and paroxetine (Paxil) and sertraline (Zoloft) have received FDA approval for this indication. SSRIs are first-line medication treatment for PTSD. Other newer antidepressants such as venlafaxine (Effexor and Effexor XR), and possibly duloxetine (Cymbalta) and mirtazapine (Remeron), are second-line treatments if SSRIs prove ineffective or are not well tolerated. Tricyclic antidepressants would be employed if the person has had a good response to them in the past and they do not cause severe side effects, or if the person has failed to respond to or does not tolerate SSRIs, venlafaxine, duloxetine or mirtazapine. MAOIs would usually be used when they have been effective in earlier treatment or when the other classes of antidepressants have not been helpful. Anticonvulsant mood stabilizers may be added to improve a partial response to an antidepressant, while antianxiety benzodiazepines would ideally be used only briefly and intermittently to quell acute and severe anxiety symptoms. Buspirone (BuSpar) may be a helpful adjunctive treatment for anxiety symptoms in people with PTSD, although the evidence for its effectiveness is limited.

Hear from Dr. Jonathan Davidson on PTSD medications.

If a medication is well tolerated, most patients should continue to take it for 6 to 12 months if they have acute PTSD (less than 3 months duration) and for at least 12 and as long as 24 months for chronic PTSD before trying to taper off the medication. If PTSD symptoms return when medication is being discontinued, the effective dose would be resumed and usually continued for an even longer time before discontinuation is tried again.

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