By Mark Schiller, MD
Psychotherapy is the keystone of PTSD treatment. Nevertheless, medications play an important role and are often included to facilitate the psychotherapeutic treatments. Medication can help improve core symptoms as well as other problems related to the traumatic experience, such as depression, anxiety, or excessive alcohol or drug use.
For people who have experienced trauma, there may be changes in the brain that are linked to their ability to manage stress. Specifically, people with PTSD have changes in the balance of certain chemicals - called neurotransmitters - in the brain than those who do not have PTSD. These imbalances in different neurotransmitter systems are the focus of medication treatment.
There are different classes of medications that are used to address different types of symptoms:
These medications can help core symptoms of PTSD as well as symptoms of depression and anxiety. One type of antidepressant –SSRIs – a class that increases serotonin in the brain, is the mainstay of treatment. In fact, the only two medications that are specifically approved for the treatment of PTSD by the FDA are the SSRIs paroxetine (Paxil) and sertraline (Zoloft). However, it is common practice among psychiatrists and physicians in general to use off-label medications. There is evidence that other SSRIs and a number of non-SSRI antidepressants, such as duloxetine (Cymbalta) and mirtazapine (Remeron), are also effective in treating PTSD. One exception to the efficacy of antidepressants in PTSD treatment is bupropion (Wellbutrin). However, antidepressants don’t necessarily reduce the full range of PTSD symptoms on their own; they help mostly in reducing irritability, intrusive memories, and related depression.
These drugs also can improve feelings of anxiety and stress for a short time to relieve severe anxiety and related problems. Hyperadrenergic (anxiety/over excitement) symptoms due to an excess of norepinephrine are prominent in PTSD consist of hyperarousal, re-experiencing, anxiety, a rapid heart rate, and excessive sweating. There has been a good deal of focus on developing medications that address these symptoms. There is a growing body of evidence that a type of adrenergic receptor blocker called prazosin is useful in reducing traumatic dreams and improving sleep.
Insomnia is a common symptom of PTSD. In addition to Prazosin, which is useful in treating nightmares and night terrors a number of medications that act as sedatives have shown evidence of effectiveness.
The antipsychotic quetiapine (Seroquel) has shown some promise in reducing PTSD symptoms. It is also fairly sedating and likely useful in treating insomnia.
Mirtazapine (Remeron), which is an antidepressant generally effective in PTSD can also have specific benefits in treating insomnia.
What has not shown effectiveness in treating the insomnia related to PTSD are the medications generally called hypnotics - benzodiazepines such as lorazepam (Ativan) or alprazolam (Xanax). These should generally be avoided in treating PTSD. In addition to being hypnotics, they are generally thought of as anxiety medications, but do not appear to have long term effectiveness in PTSD. Instead, they may actually impede the extinction of fear responses over time and impede recovery. These medications are also readily abused and somewhat addictive, which is a problematic given the high rates of substance use problems in patients with PTSD.
There is also interest in the use of anticonvulsants, or seizure medications, in PTSD. Glutamate is an excitatory neurotransmitter found in excess in PTSD. GABA is an inhibitory neurotransmitter that is decreased in PTSD. Anticonvulsants can have positive effects in modulating glutamate activity or increasing the actions of GABA. Medications such as valproic acid (Depakote), carbamazepine (Tegretol), lamotrigine (Lamictal) and gabapentin (Neurontin) may have some use in stabilizing mood, reducing anger and aggression, or decreasing anxiety. In particular some recent studies have raised curiosity in the use of topiramate (Topamax); with one study of combat vets showing significant reductions in intrusive memories, nightmares, flashbacks, sleep problems, irritability and anger, and startle reactions.
The research on the use of medications in PTSD has been quite limited up to now. This has begun to change with more and more people suffering from this disorder. New options are becoming available every day. Yet, it is clear that medications are no panacea and a broad treatment approach combining medication and psychotherapeutic treatment is the best combination for success in treating PTSD.