Initial pharmacotherapy for posttraumatic stress disorder in adults and young people
Psychosocial interventions are first line for posttraumatic stress disorder (PTSD) in adults and young people. Pharmacotherapy may be used as an adjunct to psychosocial interventions, or as an alternative when psychosocial interventions are unavailable, not effective or not preferred.
When evaluating treatment options for a young person, also consider:
- there are few data on psychotropic use in young people because young people are poorly represented in clinical trials
- young people are more susceptible to developing activation and suicidal thoughts when starting treatment with an antidepressant; this effect has been most often observed with selective serotonin reuptake inhibitors (SSRIs)
- if pharmacotherapy is used, it should ideally be started by a clinician with expertise in using psychotropics in young people.
For treatment considerations for females of childbearing potential, including advice on contraception, preconception planning and psychotropic use, see here.
For considerations in managing anxiety disorders such as PTSD during the perinatal period, see here or for considerations in partners, see here.
For patients presenting during an acute crisis, if possible, use nonpharmacological measures, including verbal de-escalation and psychological intervention, to reduce the risk of harm. If the patient remains acutely agitated and is at risk of harming themselves or others, see the advice on drug therapy for acute behavioural disturbance in adults or older people.
If an antidepressant is indicated for PTSD, initial choice should be informed by:
- the drug’s adverse effect profile, potential for drug interactions and safety in overdose
- the patient’s comorbidities
- the patient’s age:
- older adults are more likely to have multiple comorbidities or be more sensitive to antidepressant adverse effects (eg hyponatraemia with selective serotonin reuptake inhibitors [SSRIs])
- young people are more susceptible to developing activation and suicidal thoughts when starting treatment with an antidepressant; this effect has been most often observed with SSRIs. Despite this, SSRIs remain a first-line option when antidepressant therapy is indicated; paroxetine, however, should be avoided because it has been associated with an increased risk of suicidal thoughts and behaviours, and other serious adverse events
- the patient’s response to previous treatments and family history of response to treatments
- tolerability when stopping treatment
- whether the patient is planning pregnancy or is pregnant or breastfeeding (also see Considerations in managing anxiety disorders during the perinatal period).
There is evidence for the SSRIs fluoxetine, paroxetine and sertraline in PTSD but comparative trials are lacking. There is also some evidence for venlafaxine, a serotonin noradrenaline reuptake inhibitor (SNRI), but patients with PTSD may be particularly sensitive to its adverse effects. Although there are no data for other SSRIs and SNRIs, they are likely to have similar effectiveness.
If an SSRI or SNRI is considered appropriate for PTSD, individualise the choice of drug (see above). Lower doses may be needed in older people; consult a source of drug information. Use:
1 citalopram 20 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 10 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 40 mg is reached. Note that response may not be evident for 8 weeks or longer. If there is an acceptable response, continue at the same dose for 12 months, then consider deprescribing posttraumatic stress disorder citalopram citalopram citalopram
OR
1 escitalopram 10 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 5 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 20 mg is reached. Note that response may not be evident for 8 weeks or longer. If there is an acceptable response, continue at the same dose for 12 months, then consider deprescribing posttraumatic stress disorder escitalopram escitalopram escitalopram
OR
1 fluoxetine 20 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 10 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 60 mg is reached. Note that response may not be evident for 8 weeks or longer. If there is an acceptable response, continue at the same dose for 12 months, then consider deprescribing posttraumatic stress disorder fluoxetine fluoxetine fluoxetine
OR
1 fluvoxamine 50 mg orally, at night. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 25 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 300 mg is reached. Doses above 150 mg daily may be given in 2 divided doses for better tolerability. Note that response may not be evident for 8 weeks or longer. If there is an acceptable response, continue at the same dose for 12 months, then consider deprescribing posttraumatic stress disorder fluvoxamine fluvoxamine fluvoxamine
OR
1 paroxetine 20 mg orally, in the morning1. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 10 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 50 mg is reached. Note that response may not be evident for 8 weeks or longer. If there is an acceptable response, continue at the same dose for 12 months, then consider deprescribing posttraumatic stress disorder paroxetine paroxetine paroxetine
OR
1 sertraline 50 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 25 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 200 mg is reached. Note that response may not be evident for 8 weeks or longer. If there is an acceptable response, continue at the same dose for 12 months, then consider deprescribing posttraumatic stress disorder sertraline sertraline sertraline
OR
2 desvenlafaxine 50 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 50 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 200 mg is reached. Note that response may not be evident for 8 weeks or longer. If there is an acceptable response, continue at the same dose for 12 months, then consider deprescribing posttraumatic stress disorder desvenlafaxine desvenlafaxine desvenlafaxine
OR
2 duloxetine 60 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 30 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 120 mg is reached. Note that response may not be evident for 8 weeks or longer. If there is an acceptable response, continue at the same dose for 12 months, then consider deprescribing posttraumatic stress disorder duloxetine duloxetine duloxetine
OR
2 venlafaxine 75 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 37.5 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 300 mg is reached. Note that response may not be evident for 8 weeks or longer. If there is an acceptable response, continue at the same dose for 12 months, then consider deprescribing. posttraumatic stress disorder venlafaxine venlafaxine venlafaxine