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Update on
Pharmacotherapies for PTSD
Michelle Pent, MD, MPH
April 29, 2011
Presentation
• Anxiety-spectrum disorder
• DSM-IV criteria
– A: Exposure to traumatic event with perceive
threat to life or physical integrity and response
of intense fear
– B: Re-experience of the traumatic event
– C: Avoidance of stimuli associated with the
trauma
– D: Hyperarousal
Target Symptoms
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Intrusive ruminations
Nightmares
Flashbacks
Hyperarousal
Hypervigilance
Associated irritability, anger, poor focus
and concentration, and physiologic
distress
Neurochemistry
• Amygdala
• Central Nervous System
– Norepinephrine, Serotonin, Dopamine, GABA
• Peripheral Nervous System
– Sympathetic Nervous System
– “Fight or flight”
Treatment
• Psychotherapy
• Pharmacotherapy
• Most evidence suggests psychotherapy
is most effective
– CBT
– EMDR
– DBT where indicated
Complimentary Treatments
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Yoga/Meditation
Acupuncture
Mindfulness Training
Relaxation Therapy
Pharmacotherapy
• Objective is to improve symptoms by
minimizing anxiety
– Selective Serotonin Reuptake Inhibitors
– Other antidepressants
– Anxiolytics
– Other
Selective Serotonin Reuptake
Inhibitors (SSRIs)
• Raise serotonin levels in the brain
• Remain standard of care for anxiety
disorders
• Linked with
– Improvement in baseline level of anxiety
– Diminished intrusive ruminations
SSRIs
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Fluoxetine (Prozac)
Sertraline (Zoloft)
Fluvoxamine (Luvox)
Paroxetine (Paxil)
Citalopram (Celexa)
Escitalopram (Lexapro)
SSRIs
• Lag time before efficacy
– Usually 4-6 weeks
– Adequate trial a minimum of 8 weeks
• Side effects
– Nausea, diarrhea
– Weight gain
– Agitation
– Sexual dysfunction
Other Antidepressants
• Selective Serotonin Norepinephrine
Reuptake Inhibitors (SNRIs)
– Venlafaxine (Effexor)
– Duloxetine (Cymbalta)
– Desvenlafaxine (Pristiq)
• Tricyclic Antidepressants
– Amitryptyline (Elavil)
– Doxepin (Sinequan)
Anxiolytics
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Benzodiazepines
Alpha adrenergic antagonists
Buspirone
Antihistamines
Benzodiazepines
• Diminish anxiety by enhancing GABA in
the central nervous system
• No longitudinal effect on anxiety
• Significant tolerance and dependence
– Essentially contraindicated in patients with
history of substance abuse
• Intended for short term use
• Increasingly considered inappropriate for
long term treatment of anxiety disorders
Benzodiazepines
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Diazepam (Valium)
Lorazepam (Ativan)
Alprazolam (Xanax)
Clonazepam (Klonopin)
Oxazepam (Serax)
Chlordiazepoxide (Librium)
Temazepam (Restoril)
Other Anxiolytics
• Buspirone (Buspar)
– Serotonin agent
– May cause headache, nausea
• Antihistamines
– Diphenhydramine (Benadryl)
– Hydroxyzine (Vistaril)
– Side effects include sedation, confusion at
high doses
Other Anxiolytics
• Alpha adrenergic antagonists
– Blood pressure medications
– Prazosin (Minipress)
– Clonidine (Catapres)
– Side effects include dizziness and other
complications of low blood pressure
Other Anxiolytics
• Gabapentin
– Anticonvulsant/Mood Stabilizer
– Enhances GABA in central nervous system
– Some usefulness for anxiety
– Limited addictive potential
Use of Antipsychotics
• May be useful as anxiolytics
• Use does not necessarily imply psychosis
• Significant sedation, weight gain,
metabolic disturbance
• Most commonly used
– Quetiapine (Seroquel)
– Olanzapine (Zyprexa)
– Ziprasidone (Geodon)
Treating Sleep
Sleep
• Review of sleep hygiene is critical
• Complimentary treatments can also be
effective
Sleep
• Benzodiazepine analogues
– Eszopiclone (Lunesta)
– Zolpidem (Ambien)
– Addictive potential
• Benzodiazepines
– Short term use
Sleep
• Trazodone (Desyrel)
– Often exacerbates nightmares
• Mirtazapine (Remeron)
– Associated with weight gain
• Melatonin
– Ramelteon (Rozerem)
Sleep
• Antihistamines
• Alpha antagonists
• Sedating antipsychotics
– Seroquel, Zyprexa
Choosing a Medication?
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Safety
Tolerability
Efficacy
Cost
• Educate patient that symptoms unlikely
to improve with medication in the
absence of psychotherapy
Questions?