PTSD Medication: Types, Side Effects, & Management

Selective Serotonin Reuptake Inhibitors (SSRIs)

SSRIs are the most commonly prescribed medications to manage symptoms of depression and anxiety. Their mechanism of action includes decreasing the reuptake of serotonin in the brain, which allows for increased serotonin in the brain. More recently, studies have found that SSRIs can be used to treat a wider range of disorders; some of these include PTSD, obsessive compulsive disorder (OCD), panic disorder, and even bulimia nervosa. Some SSRI medications are FDA-approved for the treatment of different types of trauma.¹ It is important for patients to discuss with their care team if SSRI medications are a good option.

SSRI treatment can be initiated for PTSD after the diagnosis has formally been made, and it typically takes about six weeks for patients to feel its effects. As previously mentioned, the first line of PTSD treatment for all adults and children greater than six years of age is therapy. If medications are included as part of the treatment plan, then SSRIs or SNRIs are the first line medication.^1,2 It is important for patients to discuss with their care team if SSRI medications are a good option.

SSRIs include:

• Sertraline (Zoloft, FDA approved)
• Paroxetine (Paxil, FDA approved)
• Citalopram (Celexa)
• Escitalopram (Lexapro)
• Fluoxetine (Prozac)

Side Effects of SSRIs

While these medications are generally well tolerated, there are a number of SSRI side effects that patients should be aware of, which include:

• Nausea/vomiting
• Insomnia
• Sexual dysfunction
• Serotonin syndrome
• Suicidal ideation under the age of 25
• EKG abnormalities such as QT prolongation

Patients should note any side effects they experience from their PTSD medication and bring them to the provider’s attention. If a patient is experiencing severe symptoms, such as tremors, call 911 or go to the nearest emergency room.

Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs)

SNRIs are a class of medication that, like SSRIs, are primarily used to treat symptoms of depression and anxiety. While they are also FDA approved for many other disorders, such as panic disorder, they have not yet been approved by the FDA to treat PTSD. SNRIs are similar to SSRIs in that they both stop the reuptake of serotonin, however SNRIs also stop the reuptake of norepinephrine, thereby increasing their concentration in the brain.²

Similar to SSRI medications, SNRI medications can be initiated after a PTSD diagnosis has been established, and can also take a minimum of six weeks for patients to begin feeling their effects.² Patients should discuss with their health provider if SNRI medications are a good option along with trauma-based therapy.

Some of the most common SNRIs include:

• Duloxetine (Cymbalta)
• Venlafaxine (Effexor)

Side Effects of SNRIs

SNRI medications are generally well tolerated, however there are a number of side effects similar to those of SSRIs, which can commonly include:²

• Nausea/vomiting
• Anxiety
• Increased blood pressure/ heart rate
• Dry mouth
• Sexual dysfunction

A more severe side effect of SSRIs and SNRIs is serotonin syndrome, which is a potentially life-threatening condition caused by an overabundance of serotonin. Symptoms of serotonin syndrome can include:

• Mental status changes: anxiety, agitation, disorientation, restlessness, excitement
• Neuromuscular abnormalities: tremors, muscle rigidity, clonus, hyperreflexia, Bilateral Babinski signs, akathisia
• Autonomic hyperactivity: hypertension, tachycardia, tachypnea, hyperthermia, mydriasis, diaphoresis, dry mucus membranes, flushed skin, shivering, vomiting, diarrhea, hyperactive bowel sounds, arrhythmia

If these symptoms begin to affect a patient’s daily functioning, it is important to bring them to the attention of the prescriber. If these side effects are not tolerable, it may be worth trying a different medication. Call 911 or go to the nearest emergency room if more severe symptoms such as tremors, seizures, or high blood pressure develop.

Tricyclic Antidepressants (TCAs)

TCA medications are an older class of antidepressants that are sometimes used for PTSD, typically only used if patients do not respond to other treatment options. TCAs target multiple receptors in the brain, and can cause a larger number of adverse side effects than SSRIs or SNRIs.

TCAs are not approved by the FDA for treatment of PTSD. However, there have been smaller studies with less follow up that showed significant reduction in PTSD symptoms after receiving TCA treatment.³

Some of the most common TCA medications include:

• Phenelzine (Nardil)
• Desipramine (Norpramin)
• Imipramine (Tofranil)

Side Effects of TCA Medications

TCA medications work on multiple receptors in the brain and are therefore associated with a larger number and frequency of side effects.

Some of the side effects of TCA medications can include:³

• Constipation
• Dizziness
• Dry eyes
• Sedation
• Weight gain/appetite increase
• Urinary retention
• EKG abnormalities (QT prolongation)

TCA medications should not be combined with other antidepressant medications due to the increased risk of serotonin syndrome.They should be started at lower doses and increased slowly. Patients should see their physician if the adverse effects begin affecting their daily functioning. If this is the case, the doctor may decrease your dose or try a different medication altogether. Go to the nearest emergency room or call 911 if a patient experiences tremors, seizures, high blood pressure and palpitations.

Alpha-1 Blockers

Alpha-1 blockers were first approved by the FDA to treat hypertension, but are now widely used to treat nightmares associated with PTSD. They work by blocking alpha-1 receptors in the brain, which lowers patients’ blood pressure. The proposed mechanism is that alpha-1 blockers treat the hyperarousal seen during these episodes, which is thought to decrease the sleep disturbances and nightmares accordingly.⁵ There may also be benefits to decreasing hyperarousal symptoms of PTSD during the day time.

The most common Alpha-1 blocker used to treat PTSD nightmares is Prazosin, which was first FDA-approved in the 1970s to treat hypertension. While it is widely used for treatment of PTSD, it has not yet been FDA-approved for that indication. In a research study, the results found a clinically significant decrease in nightmares for patients taking prazosin versus placebo, however there was no decrease in overall PTSD symptoms or sleep quality.⁵

Patients suffering from nightmares due to PTSD should ask their providers if prazosin is good for them.

Side Effects of Alpha-1 Blockers

While Prazosin is generally well-tolerated, it may cause some side effects, some of which may be particularly dangerous for older patients.

Some of the side effects caused by alpha-1 blockers are:⁵

• Decreased blood pressure
• Dizziness
• Nausea
• Headache

It is important that patients discuss any side effects with their primary care providers. Patients should contact 911 or report to their nearest ER if they have very low blood pressure or experience a fall.

Mood Stabilizers

Mood stabilizers are medications used mainly for patients suffering from bipolar and seizure disorders. While they are not typically used to treat PTSD, there have been studies that show clinically significant improvement in symptoms, but unfortunately these studies are limited to a smaller patient population and a smaller follow-up period.

The theory behind their benefits in PTSD treatment comes from the idea that patients with PTSD react more strongly to stress and tend to bounce between emotions more rapidly, and may benefit from medication to help with these variations in mood. They are not approved for use in PTSD by the FDA and should be used with caution.⁶

Some of the most common mood stabilizers are:

• Lithium
• Carbamazepine (Tegretol)
• Valproic acid

Mood stabilizers could be considered if first-line treatments such as SSRIs and SNRIs are not effective for treatment. If a patient has had difficulties responding to other medications, they should contact their doctor to see if mood stabilizers may be a better fit.

Side Effects of Mood Stabilizers

Mood stabilizers can have a significant side effect profile, and should be started at lower doses and titrated up to avoid severe adverse reactions. It is important to bring side effects to a primary care provider’s attention. Similarly, when on mood stabilizers, providers may want to have regular follow-ups in order to monitor thyroid and liver functions.

Common side effects of mood stabilizers used to treat PTSD include:⁶

• Tremors
• Weight gain
• Nausea/vomiting
• Rash
• Decreased thyroid function
• Liver injury

Benzodiazepines

Benzodiazepines are anti-anxiety medications used as a second line of treatment to help acute symptoms of anxiety, such as panic attacks, typically prescribed along with SSRIs and SNRIs. They are not routinely used to treat PTSD.

Benzodiazepines are controlled by the DEA due to the increased likelihood of patients developing an addiction, and should be used with caution. Similarly, patients with PTSD are at a higher risk of substance abuse and should avoid medications that have addictive properties, which is why there is actually a contraindication between improvement of PTSD symptoms and benzodiazepine use.⁴

Some of the most common benzodiazepines include:

• Lorazepam (Ativan)
• Diazepam (Valium)
• Chlordiazepoxide HCl (Librium)

Side Effects of Benzodiazepines

Benzodiazepines are highly addictive substances associated with severe side effects, which is why they are rarely utilized to treat PTSD and anxiety.

Patients may experience some of the following symptoms:⁴

• Addiction
• Abuse
• Overdose
• Sedation
• Dizziness
• Nausea/vomiting

If a patient is experiencing any of these symptoms, they should contact their provider to address the side effects.

How to Get PTSD Medication

Before patients can get PTSD medication prescribed, they must first have a PTSD diagnosis. The diagnosis and treatment process for PTSD begins at whichever level people feel most comfortable with. It can be discussed with a primary care doctor, psychologist, or psychiatrist.

Once the diagnosis is formally made, it is important that the patient and provider create a shared treatment plan. Patients could elect to start with therapy alone or in conjunction with a pharmacological treatment. Please note that some primary care providers may want you to follow up with a psychiatrist for this treatment after the diagnosis is made; if so, they will typically provide a referral and recommendations for providers in the area.

What to Ask Your Doctor Before Starting PTSD Medication

The decision to start medications can be a big one, and it is important that patients feel comfortable taking that step forward. A patient’s treatment plan should be agreed upon between the patient and the doctor. It is important that they understand why they are taking the medication and what symptoms it will help to alleviate. Similarly, it is important to understand dosage, how often they should take the medication, and any adverse effects they may need to look out for.

Here are several potential questions patients could ask their doctor before starting–or even fully deciding on–a PTSD medication:

• What symptoms is this medication supposed to improve?
• What are the common side effects?
• What are the dangerous side effects?
• What medications can I not take with this medication?
• What is the dosage and how often should I take medications everyday?
• How long should I wait before I see symptoms improve?

How Long Does Treatment Last?

PTSD is a chronic condition that requires long-term treatment, but that treatment plan can change over time based on the severity of symptoms.

Most patients that are started on SSRI/SNRI medications typically feel their effects after six to eight weeks of treatment. However, some people may feel these effects sooner. Patients should schedule regular follow-ups with their providers to discuss whether or not the medical therapy is helping, if the side effect profile is tolerable, and whether patients would like to change their treatment plan. Along with medications, patients should be getting trauma-based therapy as well and discussing symptoms with their entire care team. It is very important that patients do not change their plan without first consulting their providers, as it increases the risks of adverse effects.

What Medications & Substances Should I Avoid If I Have PTSD?

Patients should avoid taking benzodiazepines for the treatment of their PTSD. While patients may benefit initially, benzodiazepines are controlled substances by the DEA due to their addictive side effects. Patients with PTSD are at increased risk of substance abuse, which puts them at higher risk for negative effects of benzodiazepines.⁴

Patients should also avoid taking stimulant medications for the treatment of their PTSD. Stimulants are also highly controlled substances, typically used for treating ADHD, and are not recommended for patients with PTSD due to their highly addictive side effect profile. Studies have shown that patients treated with stimulants in their diet experienced worsening symptoms of their PTSD. While caffeinated products do not need to be completely eliminated from diet, it is recommended that patients monitor their daily caffeine intake.⁷

Can PTSD Be Treated Without Medication?

The first line treatment for PTSD involves trauma-based therapy. There are multiple types of therapies used to treat PTSD without involving medications. If patients elect to use medications as well, providers will still highly recommend therapy along with it.

The four most common therapies used to treat PTSD are:⁸

1. Cognitive Processing Therapy (CPT)

CPT is a branch of CBT that is specific to patients that have experienced trauma. It aims to change maladaptive thoughts that may develop after a traumatic incident.

2. Prolonged Exposure Therapy (PE)

Prolonged exposure therapy is typically done within 8-15 sessions. The main goal of PE is to teach about PTSD while also providing patients with rebreathing techniques, and common reactions to trauma. Exposure to stressors, , whether imaginary or in reality, is also performed in this type of therapy.

3. Eye Movement Desensitization and Reprocessing Therapy (EMDR)

EMDR is one of the most effective treatments for PTSD which aims to desensitize the body to the trauma and also to teach the brain how to recognize that the traumatic event is in the past.

4. Cognitive Behavioral Therapy (CBT)

CBT aims to combine both CPT and PE in order to expose patients to their trauma in a controlled setting and to teach patients to change maladaptive thoughts

Choosing the Best Treatment for You

While there are guidelines for certain FDA-approved medications and first line therapy for PTSD, the specific treatments suggested will depend on a patient’s medical history, symptoms, and any concerns patients may have.

It is highly recommended that therapy be part of the treatment plan for all patients. If patients feel that the type of therapy they are trying does not improve their PTSD symptoms, it is important to try other types of approved therapy instead of giving up on therapy altogether. Similarly, if patients feel that therapy is helping but they need additional help, they should speak to their provider about whether trying a medication will be a good option for them.

 Final Thoughts

The treatment options for PTSD are diverse and involve both pharmacological and psychological approaches. Therapy is highly recommended as the first line of treatment with PTSD, but there are also FDA-approved medications to treat PTSD, such as SSRIs. If you are struggling with PTSD, or think you may be experiencing symptoms of PTSD, contact your provider to get started with the process of receiving a diagnosis and treatment.