Pharmacotherapy for post-traumatic stress disorder

PTSD is a common disorder with high comorbidity and a tendency toward chronicity, which responds slowly to treatment and, in many patients, may not totally resolve even with long-term treatment. For most persons with PTSD, a combined approach to treatment is beneficial, at least in the acute stages of the illness. Pharmacotherapy is an important component of treatment during the acute stages of the illness and may be necessary on a long-term basis for many patients. Because the data from controlled trials of pharmacotherapy are limited, it is not possible to present a unified approach or develop a consensus that is well supported by research findings. What has emerged from the available data is that antidepressants, particularly those with serotoninergic properties, are helpful for core PTSD symptoms when given at higher dose levels for at least 5 to 8 weeks. The TCAs as a group appear to be effective in amelioration of the intrusive symptoms and of anxiety and depressive symptoms, while having little effect on avoidance symptoms. Initial data from studies of the SSRIs suggests that they may have greater efficacy than other drugs in the treatment of avoidance and numbing symptoms and may effect enough overall global improvement in PTSD symptoms that some patients will no longer meet the diagnostic criteria. The hyperarousal symptoms may respond somewhat to antidepressants, but should symptoms continue to be disabling, buspirone or benzodiazepines may be indicated. In choosing a benzodiazepine, those less likely to have distressing withdrawal symptoms, such as clonazepam and chlordiazepoxide, should be considered. Clonazepam, with its serotoninergic properties, may prove to be a particularly efficacious drug. For some patients, phenelzine may be a good choice because it has proven efficacy for the intrusive PTSD symptoms, for depressive symptoms, and for some symptoms of autonomic arousal, such as panic attacks. Other agents to be considered for alleviation of hyperarousal symptoms are lithium, anticonvulsants, and clonidine. In addressing the symptoms of poor impulse control, lithium, beta-blocking drugs, and carbamazepine may be helpful. Brief psychotic episodes should respond to a neuroleptic, although psychoticlike dissociative spells may be nonresponsive.