Posttraumatic Stress Disorder PharmacotherapyKaplan & Sadock's Synopsis of Psychiatry:Behavioral Sciences/Clinical Psychiatry, 10th Edition

2009APA guideline for PTSD2014 Up-to-date Supervisor:VS /Speaker:

Selective serotonin reuptake inhibitors1st line treatment.reduce symptoms from all PTSD symptom clusters, effective in improving symptoms unique to PTSD, not just those of depression or other anxiety disorders.Buspiron may be of use.

SSRI for Non-Combat-Related PTSDParoxetine

Sertraline

Fluoxetine

SSRI for Combat-Related PTSDFluoxetine (X)Sertraline(X)

But..144combat veterans of the Balkan Wars

fluoxetine (O)recently traumatizedreceived less treatmentfor their symptoms prior studyyounger, less chronicity

Serotonin-norepinephrine reuptake inhibitors fewer studies assessing SNRIsTwo randomized trials foundvenlafaxine extended-release (37.5300 mg/day) to be effective.

Other Antidepressants NefazodoneMirtazapine (up to 45 mg/day)TCA

Insufficient or conflicting evidence

AntipsychoticsRisperidone, OlanzapineMixed effective findingreserved for the short-term control of severe aggression and agitationAdjunctive use for PTSD symptoms resistant toSSRIs/SNRIs

Does not support the use of atypical antipsychotics to augment SSRIs or SNRIs in the treatment of PTSD in military veterans.Fewer, and only smaller, trials in the non-military population, which have shown mixed findings.*

AntipsychoticsAdministration of RisperidoneStartat 0.5mg increase after 5 to 7 days if the response is inadequate up to 4mg/dayIf no clinical benefit after 2-3 weeks of treatment at the maximal tolerated dose, gradually discontinue the medication.

Does not support the use of atypical antipsychotics to augment SSRIs or SNRIs in the treatment of PTSD in military veterans.Fewer, and only smaller, trials in the non-military population, which have shown mixed findings.*

Alpha-adrenergic receptor blockersPrazosin : greater improvement in nightmares, sleep quality, and PTSD symptoms.

Administrationstarted at 1 mg HSgradually increased to 3-10 mg as toleratedBe careful of orthostatic hypotensionAvoid sudden discontinuation due to rebound hypertension

Antiadrenergic agentssuggested by the theories about noradrenergic hyperactivity in the disorder.*

Benzodiazepinesshould be avoided in patients with a history of substance use.useful to treat acute, severe symptoms of hyperarousal during an emergent situation.no evidence for continued use after the acute situation has subsided.

should be monitored for signs of abuse of the prescribed drug.*

Mood stabilizersfindings have been mostly negative

Summary1st line treatment was SSRI:

Paroxetine, Sertraline, FluoxetineSNRI:venlafaxine - some evidenceOther Antidepressants: Nefazodone, Mirtazapine, TCA - insufficient evidenceAntipsychotics : Adjunctive use for PTSD symptoms resistant toSSRIs/SNRIs blocker: Prazosin adjunctive use for sleep problem

Does not support the use of atypical antipsychotics to augment SSRIs or SNRIs in the treatment of PTSD in military veterans.Fewer, and only smaller, trials in the non-military population, which have shown mixed findings.*Does not support the use of atypical antipsychotics to augment SSRIs or SNRIs in the treatment of PTSD in military veterans.Fewer, and only smaller, trials in the non-military population, which have shown mixed findings.*Antiadrenergic agentssuggested by the theories about noradrenergic hyperactivity in the disorder.*should be monitored for signs of abuse of the prescribed drug.*