PTSD: Overview

Much of the following is based on a lecture by Bruce P. Capehart, M.D. given on 5/10/2012, as part of the Massachusetts General Hospital Psychiatric Academy series From the War Zone to the Home Front: Supporting the Mental Health of Veterans and Their Families.

What helps in the treatment of PTSD

1) Evidence Based Psychotherapy (Cognitive Behavioral, EMDR, Cognitive Processing Therapy)

2) The right medication

3) Treating insomnia

4) Avoiding alcohol and drugs

5) Treating chronic pain

I will briefly cover medications.

In general it is not a good idea to rely too heavily in medication. Psychotherapy has proven to be more effective in a larger number of patients. There are only 2 medications approved for PTSD, sertraline and paroxetine.  However, there is good evidence for venlafaxine and fluoxetine as well and these 4 medications are the first-line pharmacological treatments for PTSD. Higher doses and longer durations are often needed to get a response.

Nefasadone is a very useful second-line med, and would probably be considered a first-line treatment if not for rare liver toxicity. It’s sedating properties can help with insomnia.

Mirtazapine is useful, particularly as an augmentation to a first-line med. It’s sedative properties can help with sleep.

Prazosin has been useful for nightmares and a recent article in the American Journal of Psychiatry confirmed it’s benefits for nightmares and found that it improved overall symptom levels.

Medications that can be useful as add-ons but for which good evidence is lacking include buspirone, trazodone, bupropion, tricyclic antidepressants, and second-generation anti-psychotics (studies using risperidone have not found it to be helpful0.

There is general agreement that benzodiazepines should not be used alone, and if used for a co-morbid condition it is best to use them for short periods of time.

Anti-epileptic medications (with the possible exception of topirimate) and guanfacine have not been helpful.

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