Pharmacotherapy for posttraumatic stress disorder: Review with clinical applications

Abstract

Abstract-Posttraumatic stress disorder (PTSD) is a prevalent psychiatric diagnosis among veterans and has high comorbidity with other medical and psychiatric conditions. This article reviews the pharmacotherapy recommendations from the 2010 revised Department of Veterans Affairs/Department of Defense Clinical Practice Guideline (CPG) for PTSD and provides practical PTSD treatment recommendations for clinicians. While evidence-based, trauma-focused psychotherapy is the preferred treatment for PTSD, pharmacotherapy is also an important treatment option. First-line pharmacotherapy agents include selective serotonin reuptake inhibitors and the selective serotonin-norepinephrine reuptake inhibitor venlafaxine. Second-line agents have less evidence for their usefulness in PTSD and carry a potentially greater side effect burden. They include nefazodone, mirtazapine, tricyclic antidepressants, and monoamine oxidase inhibitors. Prazosin is beneficial for nightmares. Benzodiazepines and antipsychotics, either as monotherapy or used adjunctively, are not recommended in the treatment of PTSD. Treating co-occurring disorders, such as major depressive disorder, substance use disorders, and traumatic brain injury, is essential in maximizing treatment outcomes in PTSD. The CPG provides evidence-based treatment recommendations for treating PTSD with and without such cooccurring disorders.

Efficacy of Intravenous Ketamine for Treatment of Chronic Posttraumatic Stress Disorder

“…Of note, ketamine demonstrated a superior effect to that of midazolam, despite the fact that midazolam may have a potential acute benefit in a study of patients with chronic PTSD, because it is also a well-known anxiolytic. Although practice guidelines recommend against the use of benzodiazepines for the treatment of PTSD, 4 The biological mechanisms underlying the effects of ketamine, a glutamate NMDA receptor antagonist, in patients with PTSD are unknown. The role of glutamate in memory formation, including trauma-related memories, and in the pathophysiology of PTSD has recently received increased attention.…”

“…[3][4][5] Accumulating evidence for the role of glutamate, the most widely distributed excitatory neurotransmitter, in mediating stress responsivity, the formation of traumatic memories, and the pathophysiology of PTSD, suggests a potential benefit for novel pharmacotherapeutic interventions for this disorder. 6,7 Recently, intravenous (IV) ketamine, an antagonist of the glutamate N-methyl-D-aspartate (NMDA) receptor, has emerged as an effective, rapidly acting intervention for patients with treatment-resistant depression when administered at subanesthetic doses of 0.5 mg/kg.…”

Life Sciences—Life Writing: PTSD as a Transdisciplinary Entity between Biomedical Explanation and Lived Experience

“…Drugs showing varying treatment success are from diverse pharmacological classes, e.g., selective serotonin reuptake inhibitors, α-adrenergic antagonists, anticonvulsants, mood stabilizers, antipsychotics, β-blockers, benzodiazepines, glucocorticoids, tricyclic antidepressants, and monoamine oxidase inhibitors [40,41].…”

Posttraumatic Stress Disorder

“…Therefore, a number of pharmacological agents that either inhibit the release of monoamines or block the effects of monoamines released during stress are employed with varying success and side-effect profiles across individuals in the treatment of PTSD and its comorbidities. These medications, which have been sorely understudied using traditional multisite methods that rely on average population responses, as well as with regard to individualized predictors of response, include the serotonin-selective reuptake inhibitors (SSRIs), norepinephrine antagonists such as prazosin, and other agents that may target and block serotonergic, noradrenergic, and dopaminergic receptors in the cortex and amygdala, so as to restore appropriate amygdala/PFC balance (Jeffreys, Capehart, & Friedman, 2012).…”