From Helpful to Harmful: A Quick Guide to PTSD Medications

What trauma therapists need to know about their clients’ prescriptions

Trauma treatment is complicated. Just like there are lots of different therapeutic angles to come from there are also a zillion ways that prescribers attack posttraumatic stress disorder (PTSD) with medications. But how do you know if your client’s regimen is a solid one? Could it be causing more harm than good?

My name is Dr. Jess Beachkofsky and I’m a psychiatrist who was trained in the military and ran an inpatient unit in an Army hospital. I have some strong opinions. All of these are founded in evidence based medicine but with my own perspective based on over 15 years of psychiatric experience.

Medications Approved for Treatment of Trauma and PTSD

Let's dig into the medications approved for treating people with trauma disorders like PTSD. So there are only two medications that have Food and Drug Administration (FDA) approval for treating PTSD and an additional med that’s recommended by the Veterans Administration (VA).

The medications that have the FDA approval for treating PTSD are Zoloft (sertraline) and Paxil (paroxetine) which are both selective serotonin reuptake inhibitors (SSRIs). And then there's one serotonin norepinephrine reuptake inhibitor (SNRI), which is Effexor (venlafaxine), and is recommended by the VA. 

As of this writing, the most commonly prescribed mental health medication in the United States is Zoloft and in many cases it’s a great choice. Although only these few medications are indicated for the treatment of PTSD, we generally accept that all SSRIs have similar efficacy and so that widens our choices to include Prozac (fluoxetine), Lexapro (escitalopram), and Celexa (citalopram). And Pristiq (desvenlafaxine) is another SNRI that may be effective.

How SSRIs Help

With the SSRIs we're talking about (mostly) blocking serotonin and the SNRIs block serotonin as well as norepinephrine. Let’s very briefly review the mechanism behind SSRIs. 

We have theories that tell us there’s not enough serotonin between neurons in certain areas of the brain, which affects connections and the ability to send signals from neuron to neuron and region to region. The serotonin that is there gets picked up by the serotonin transporter too fast and so it can’t send its message. When someone takes an SSRI, the medication gets picked up by the transporter instead of the serotonin which allows for more serotonin to build up between the neurons so the message gets sent. SNRIs work to block the transporters for serotonin and norepinephrine. 

These Meds Don’t Work For Everyone 

This really is a pretty cool solution (when it works anyway). But we’re still missing a piece of the puzzle because just like with treating depression or anxiety, not all people with a trauma disorder respond to SSRIs. It’s thought that there’s only about a 60% response rate and only 20-30% of those go on to complete remission.

Those odds aren’t great so it’s no surprise that you can see all kinds of creative med regimens! Prescribers are motivated to help people feel better and we have a lot of different classes of medications to try to help to do just that. 

The problem though is that some of these medications are contraindicated when treating PTSD and others have poor efficacy and limited data for use. Nevermind the long term medical complications that can put people at risk just from taking the medication (whether it helps or not!).

What’s the Best Fit?

You already have people in your practice that are on an SSRI, or that may be prescribed one sometime soon. So even though there are only those 3 medications that are recommended for treating PTSD, often, as prescribers, we will choose any of the medications in that class that seem like they would be the best fit for the patient.

All the medications in the class of SSRIs are considered to work very similarly and if somebody were on a medication that was not FDA approved for PTSD and they were doing well, there's no reason to change it. I tend to choose a particular SSRI for a patient based on what side effects are most likely or what kind of dosing strategy will best fit their lifestyle. The results will be similar but still vary somewhat for each unique person.

So if somebody came to me and said, "well, I saw that Prozac is FDA approved and I want to start that medication", as long as there's no reason not to start that medication, I'm happy to discuss it and then write them for Prozac. But if they're new to medication and I'm worried about side effects and I want to start really, really low, maybe I’d choose Lexapro instead. It's not FDA approved to treat PTSD, but it is a really well tolerated SSRI so it might be the right place to start for someone who’s new to taking medications.

Effexor (venlafaxine)

Effexor is an SNRI so it acts on serotonin and norepinephrine. This means we tend to see different results, generally related to side effects and tolerability. When starting this medication, the increase in norepinephrine can be activating and sometimes causes people to feel more anxious or jittery. I generally don’t start people on this medication as a first choice, but if they’ve tried one or two SSRIs without great results, I will often switch to Effexor to see if that extra norepinephrine blockade will be helpful. Sometimes it is and unfortunately sometimes it isn’t, which can be frustrating for everyone!

Other Medications Combined with SSRIs for PTSD

It’s likely that you may see some clients with PTSD on other medications besides SSRIs or SNRIs. People may take other meds to address anxiety, anger, insomnia, nightmares, and irritability.

Non-controlled Sleep Meds

Trazodone and Remeron (mirtazapine) are common non-controlled medications (i.e. not regulated by the Drug Enforcement Agency) used for sleep. They’re older antidepressant meds that have sedation as a side effect which is often helpful for getting a better night’s sleep. Hydroxyzine can also be helpful for sleep and is an antihistamine somewhat similar to Benadryl (diphenhydramine).  

Melatonin is also a reasonable option for sleep but not generally in the way it’s marketed! This is a hormone that signals to the brain that it’s dark out and time to wind down (not that it’s actually bedtime). Ideally it’s taken about 2 hours before the time someone wants to go to sleep at a very low dose of 0.5mg - 1mg. Higher doses at bedtime are only indicated for short-term management of jet lag.

Controlled Sleep Meds

It is not recommended that patients are on benzodiazepines for sleep such as Restoril (temazepam), due to GABA effects and the potential for overuse. And that’s the same for other controlled sleep medications as well (the Z drugs) like Ambien (zolpidem), Lunesta (eszopiclone), and Sonata (zaleplon). The newer sleep drugs that work on Orexin are probably better choices in trauma patients, but are still controlled substances and are sometimes hard to get approved by insurance. 

Anxiolytics

Sometimes medications are added to help address anxiety that the SSRI or SNRI doesn’t cover or the client may have a comorbid anxiety disorder. Hydroxyzine is an as-needed medication that can be used for anxiety at lower doses and for insomnia at higher doses. Buspar (buspirone) is a medication that’s scheduled twice daily for anxiety and also works on the serotonin system but the mechanism of action is different than with SSRIs. But they can be taken together and this is a common strategy for managing anxiety.

Benzodiazepines like Xanax (alprazolam) and Klonopin (clonazepam) are not recommended for patients with PTSD as mentioned above. These are as-needed controlled substances that work on the GABA system and have high abuse potential. There are also some theories that medications that act on GABA may hinder the effects of the high quality therapy you’re providing, so that’s yet another reason to try to keep people away from this class of medications if at all possible!

Prazosin

There's also a medication called prazosin that was used very frequently for a while, especially in the VA population, and was touted as something to help with PTSD’s hyper-arousal

symptoms and nightmares. It turns out that after we got a lot more data about it, it's not really separating from placebo. 

So unless I have a patient who's on it and absolutely loves it and thinks it's amazing, I generally don't have patients on prazosin any more. But since it has a pretty mild side effect profile I’ll occasionally try it on someone who’s really struggling with nightmares and is willing to move forward after transparency and consent. 

Antipsychotics

Some patients, if they have a lot of anger or aggression, may be started on antipsychotic medications. The most commonly prescribed antipsychotics for PTSD are Risperdal (risperidone), Seroquel (quetiapine), and Zyprexa (olanzapine). Seroquel is often prescribed at low doses for insomnia too. 

I tend to stay away from antipsychotic medications as much as possible because of increased side effects and long term medical implications. Patients often complain of feeling sedated, shaky, or weight gain and I don't want to put my patients at risk for obesity, diabetes, or heart disease, all of which increase with antipsychotic medications. These medications are very effective for treating psychotic disorders though, so there are definitely certain patients that benefit from them.

Mood Stabilizers

Depakote (valproic acid) is a mood stabilizer that's sometimes used for anger and aggression. The data's not great for this medication, but it is commonly prescribed to patients with trauma disorders with the hopes that it will help mitigate anger and irritability. This is a very good medication for bipolar disorder but as a treatment for symptoms associated with a PTSD diagnosis, it’s not usually very effective. Again, I don't often prescribe this due to side effects such as weight gain and it requires lab monitoring which can be another challenge for people who take it. 

There are other mood stabilizers, Lamictal (lamotrigine), Tegratol (carbamazepine), and Trileptal (oxcarbazepine), that are sometimes prescribed as well but these are much less common than Depakote and there is even less research to support their use.

Propranolol

One specific medication that I think it's important for you to be aware of is propranolol. This is a beta blocker that's often prescribed as needed for anxiety, especially performance anxiety. It's an old blood pressure medication that psychiatrists tend to use in very low doses to help with anxiety. 

Those physical responses that people get when they feel anxious or scared, shaking, sweating, increased heart rate and breathing rate, all of those things can be triggering for patients who’ve experienced trauma as it can bring back the sensations of being in harm’s way again. Especially if you have somebody you're doing prolonged exposure therapy or cognitive processing therapy with, and they're really struggling to get through certain aspects of treatment because they're so physically activated, this may be something that is worth asking about. When their physiology is going crazy and they just can't get through their sessions, propranolol can help them get the work done and stick with therapy all the way through!

You could reach out to your client’s prescriber directly, or just inform your client, "Hey, why don't you ask about this medication, propranolol, the next time you see your prescriber and see if they think that it would be helpful." It’s potentially great for helping somebody get more out of their therapy by feeling comfortable engaging deeper.

Medications Long Term for Trauma and PTSD

If people want to feel better and the medication helps them feel better, then I think that's great. But in many cases the medications are just a tool until they can get maximum benefits from therapy which offers the sustained, integrated results people are looking for!

These medications, the SSRIs and SNRIs, don't appear to have any long term medical problems based on our decades and decades of data. Some people may end up being on medications long term because they see better results with than without them. And knowing that they’re generally safe can help people feel at ease. 

Many people stay on meds for blood pressure forever. When they take it their blood pressure is normal, and when they stop, it goes back up again. There’s nothing wrong with someone who takes medication every day because it improves their functionality and quality of life. And that’s what we’re really measuring against here! If there aren’t side effects and someone does better with meds than without, then that’s a pretty easy decision. As long as they maximize therapy!

Demystifying Meds for Trauma Therapists

Magic does not suck. What does? Not feeling comfortable answering med questions from your clients!

But you can, and it can feel easy and aligned too.

No, you’re not a prescriber, but their shrink is so busy that you’re definitely better than Reddit.

I’m Dr. B and my wand is pointing you to my Magic Pill Picker! Kinda like the easy button but real! https://brainbiteswithdrb.com/magicpillpicker 

Demystify medications for the 3 most common mental health issues with this handy guide!