Pharmacological Treatments PTSD That Have Been Studied Through Controlled Clinical Trials

(unless otherwise noted, from Foa et al., 2000 or Foa & Rothbaum, 1998)

SSRIs

Sertraline:

·         Large, double blind trials have led to recent FDA approval for sertraline (Level A quality studies – well controlled).  Responder rate of 53% for sertraline (compared to 32% for placebo).  Criterion for categorizing successful response was a 30% decrease in Sx from baseline.  (Brady et al., 2000).  Davidson et al. (1997) found 43% response with sertraline compared with 27% placebo.  Sertraline was not effective for reexperiencing Sx.  Although gains are modest, they were maintained at 28 weeks when Rx was continued (Davidson et al., 2001)

Paroxetine:

·         Also recently approved by FDA.  Reduction in Sx, as measured by CAPS, appears quite modest (Randall et al., 2001).  Difficult to accurately gauge since % response by CGI and CAPS were not reported separately.  Given significant limitations of CGI as an outcome measure (e.g., Beneke & Rasmus, 1992; Dahlke et al., 1992, see below for more info), caution in interpreting results may be warranted.

Fluoxetine:

·         Only one small, randomized clinical trial with Fluoxetine (Van der Kolk got 25.4% reduction on CAPS vs. 12.6% placebo; for non-vets in the study, 41.1 vs. 20.3% response). 

SSRIs have a broad spectrum of action on re-experiencing, avoidance/numbing, and hyperarousal (some have found just an effect on numbing and hyperarousal) (Friedman, 2000)

MAOIs

Fewer trials, and those that do exist have not been well-controlled (Level B quality study).  Some indications that they may be effective for cluster B symptoms. 

TCAs

The few available studies indicate TCAs may have a similar spectrum of action as MAOIs, but overall appear less effective (Level A quality study – well controlled).  Friedman’s (2000) review of available research found possible positive results with imipramine, mild to moderate with amitriptyline, and negative effects with desipramine.  Positive results for early intervention using imipramine for pediatric burn patients with ASD (Friedman, 2000)

Anticonvulsants

Tested on open clinical trials, but no randomized control trials.  May reduce cluster D symptoms.  Carbamazepine may reduce cluster B symptoms, and valproate may reduce cluster C symptoms.

Benzodiazepines

Friedman (2000) states that most trials with alprazolam have shown negative results.  Random assignment double blind cross over with alprazolam: symptoms specific to PTSD were not altered by alprazolam (Braun et al. 1990).  However, there are also Level B trial for alprazolam and Level C for Clonazepam indicating that they may reduce arousal.  Indications that alprazolam use during exposure therapy for panic disorder results in much higher relapse rates than would be expected for exposure therapy alone.  May have implications for PTSD.

Other Serotonergic Agents

Preliminary indications from open label trials that nefazodone may reduce anger and improve sleep.  Trazodone may be helpful as an adjunct to SRIs by reversing SRI-induced insomnia

Antipsychotics

Only clinical anecdotes for evidence. 

Regrettably, current research has found that most forms of pharmacotherapy for PTSD leave patients with significant symptoms.

Placebo response rates relatively low for PTSD (20%) compared with MDD and Panic.