- Which medication is best?
- Do medications help get a person's life back in order?
- Are any of the medications addictive?
- What does my clinician need to know to prescribe medication?
- Can medications affect an unborn or breast-feeding baby?
- Do I need any tests before starting medication?
- Which medication should I start on?
- How do medications work?
- How rapidly do medications work?
- How are medications handled in the body?
- How should I store medications?
- What if I am running out of medication?
- What if I forget a dose?
- Can I use oral contraceptives (birth control pills) while on medication?
- Can medications be used safely in people with heart or blood pressure problems?
- Will medications interfere with my sexual drive and orgasm?
- Can I exercise while taking medication?
- How long should I take medication?
- What about herbal and other nutritional supplements?
- What if the medication I am taking doesn't work?
In general, SSRIs are considered the first-line medication treatment for PTSD, because they show the strongest evidence for efficacy and tolerability. However, the decision should be made between you and your clinician, based on your needs and your medical history.
Do medications help get a person's life back in order?
While medications can help reduce symptoms of PTSD, they are not "cure-alls." Personal problems resulting from PTSD may continue to exist and unrelated life problems are unlikely to be helped by these medications. Many forms of psychotherapy and other forms of counseling are helpful with these issues, as is a general understanding of the disorder by the sufferer, family members, and close friends.
Are any of the medications addictive?
The only class of medication that could be of concern are the benzodiazepines, and this would be a problem for only a very few people (those who have a history of drug and/or alcohol abuse.) Most people who take benzodiazepines use them in the prescribed amounts for an appropriate medical indication. It is important to realize that physical dependence (not addiction) is common with regular use of benzodiazepines. If they are stopped too rapidly, unpleasant physical withdrawal symptoms can occur. Following a discontinuation program recommended by your doctor can help you avoid these problems.
What does my clinician need to know to prescribe medication?
As with most medications, your clinician will need to know about your family and personal medical history, other medications you are on and your occupation and hobbies. A thorough family history is important in helping select the best medication and dosage level. Medication interactions are an important consideration, so be sure to inform your clinician of every medication you take, including over-the-counter and herbal remedies. Your occupation and hobbies are important, because certain medications may make it dangerous to operate machinery or drive a vehicle. The main point is to inform your clinician about all medical conditions, medications, etc., especially if you are being treated by several clinicians. If you are not sure whether certain facts should be brought out, mention them and let your clinician decide how important they are. Without such information, a clinician would have difficulty treating you safely and effectively.
Can medications affect an unborn or breast-feeding baby?
The use of medications during pregnancy and breast-feeding is a complicated issue. It is known that these medicines cross from the mother's blood to the fetus so it is important to discuss possible risks with your clinician to determine whether the dosage of the particular medication you are taking should be lowered or temporarily discontinued. In general, the most commonly used medications for PTSD, the SSRIs, have a good safety record when taken during pregnancy. However, one SSRI, paroxetine was recently identified as causing heart defects in some babies and it is now in FDA pregnancy category D, while all other antidepressants remain in category C (a less risky category).
Birth defects have occurred occasionally in babies whose mothers have taken medication during pregnancy, but whether the medications actually caused the abnormalities is difficult to know (even without any exposure to medicines, a small percentage of babies will be born with malformations).
With regard to breast-feeding, all of the PTSD medications will pass into breast milk and, as a result, small amounts will reach the infant. While unlikely, it is possible that a breast-fed infant could experience mild side effects from some of these medications.
In general, to be on the safe side you should discuss with your clinician the potential risks and benefits of any medication you might be taking during pregnancy or while breast-feeding. The most conservative approach would be to avoid all medicines at these times unless the severity of the disorder made this impossible. Remember that exposure therapy can be an effective treatment for PTSD, and it could be an attractive alternative to medication during pregnancy and breast-feeding.
Do I need any tests before starting medication?
Laboratory tests may or may not be necessary before starting medication therapy. Depending on your medical history, age and the medication you will use, your clinician may want you to have some blood tests (often including a test of thyroid function) and an electrocardiogram (ECG or EKG).
Which medication should I start on?
The choice of a specific medication is something for you and your clinician to decide, based on a number of factors. In general, SSRI antidepressants are usually tried first, followed by other antidepressants, anticonvulsants and antipsychotics. If you tolerated and responded to a certain antidepressant in the past, the same medication would usually be the logical choice, just as medications you did not tolerate or respond to should probably be avoided. With your help, your clinician can prescribe the medication best suited to your specific needs.
The exact causes of PTSD are still unknown and so are the mechanisms of action of medications used to treat PTSD. Brain neurotransmitters (chemical messengers) such as serotonin and norepinephrine, and modulators such as neuroactive peptides (that increase or decrease the effects of neurotransmitters) are altered in PTSD. Medications that treat PTSD are thought to work by restoring a better balance of neurotransmitters and neuromodulators.
How rapidly do medications work?
On average, it takes about two weeks for an antidepressant medication to begin to work. During the first week or two, side effects may be more apparent than improvement. After about two weeks, side effects are usually less noticeable and PTSD symptoms begin to get weaker. Improvement is gradual and some people may not start to improve for four to six weeks. It is important not to get discouraged if you are not feeling better early in the course of the treatment. If you are discouraged, be sure to share these feelings with your clinician. Anticonvulsant mood stabilizers usually follow a similar time course of side effects first, then benefits after a few weeks.
Benzodiazepines produce their benefits and side effects quickly, often in the first few days after they are begun. However, due to side effects and possible dependency, they are usually not the medication of first choice.
How are medications handled in the body?
When taken by mouth, medications are slowly absorbed into the bloodstream and carried to all body tissues, including the brain. Most medications used to treat PTSD are gradually excreted from the body after they have been broken down (metabolized) by the liver. Since the liver is the major organ of medication metabolism, diseases or medications affecting the liver may change medication metabolism and necessitate adjustment of dose. As people grow older, they also metabolize medications more slowly.
How should I store medications?
Keeping a current week's supply in a plastic container divided into daily compartments can help you remember to take your medication on schedule. The rest should be stored in their original prescription container, away from sources of heat or moisture and out of contact with direct sunlight. Do not store medication in the bathroom medicine cabinet where heat and moisture may cause them to break down. The liquid forms of citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), paroxetine (Paxil) and sertraline (Zoloft) do not have to be refrigerated. Since all medication in large amounts are potentially poisonous, they must be kept out of reach of children. Be sure to discard medicine that is outdated or not needed.
What if I am running out of medication?
If you are close to running out of medication, contact your clinician immediately to arrange to get more. In order to be effective, medication must maintain a certain blood level. That's why they are not prescribed on an "as needed" basis. Also, if you plan to stop taking medication, it is not a good idea to stop abruptly. Instead, a more gradual tapering will make it easier for your body to adjust. A decision to stop treatment should be discussed with your clinician.
Since dosage schedules vary, it is important to ask your clinician what to do if you forget a dose. Until you have done this, a safe rule to follow is:
- If you have missed your regular time by three hours or less, you should take that dose when you remember it.
- If it is more than three hours after the dose should have been taken, just skip the forgotten dose and resume your medication at the next regularly scheduled time. Your proper blood level will soon be reached again.
- If you are taking just one daily dose, take it whenever you remember it as long as it is still the same day. If the entire day has passed, just resume with your regular dose the next day.
Never double up on doses of your PTSD medications to "catch up" on those you have forgotten unless your clinician instructs you to do so. Increased doses may lead to dangerously high blood levels. A pill container with separate compartments for individual doses may be helpful to keep you on schedule.
Can I use oral contraceptives (birth control pills) while on medication?
Yes. Antidepressant and antianxiety medications do not speed up the metabolism of the hormones in birth control pills, so there should be no increased risk of birth control failure. However, some anticonvulsant mood stabilizers may speed up metabolism of birth control pills, thereby lessening their effectiveness. All combinations of medications should be discussed with your physician and/or pharmacist.
Can medications be used safely in people with heart or blood pressure problems?
The newer antidepressants are better tolerated by people with heart disease. These include bupropion (Wellbutrin, Wellbutrin SR and Wellbutrin XL), citalopram (Celexa), duloxetine (Cymbalta), escitalopram (Lexapro), fluoxetine (Prozac and Prozac Weekly), fluvoxamine (Luvox), mirtazapine (Remeron), nefazodone, paroxetine (Paxil and Paxil CR), sertraline (Zoloft), trazodone (Desyrel) and venlafaxine (Effexor and Effexor XR). Nefazodone and trazodone can cause hypotension (low blood pressure) and bupropion, duloxetine and venlafaxine can occasionnally cause hypertension (high blood pressure) as side effects. Overall, the tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) can be more problematic in people with heart disease or high blood pressure. Antianxiety medications (anxiolytics) are usually well tolerated by individuals with heart disease. Anticonvulsant mood stabilizers and newer (atypical) antipsychotics are also usually well tolerated by individuals with heart disease. Be sure to ask your clinician about the safety of PTSD medications if you have heart disease.
Will medications interfere with my sexual drive and orgasm?
Although PTSD itself often reduces interest in sex and decreases sexual arousal, PTSD medications can sometimes have the same effect. Selective serotonin reuptake inhibitors (SSRIs), duloxetine (Cymbalta), venlafaxine (Effexor and Effexor XR), tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), and benzodiazepines can also cause difficulty reaching orgasm in men and women and difficulty with erections in men. Sometimes these problems improve over time but dose reduction, treatment with another medication or switching to a different PTSD medication may be necessary. Bupropion (Wellbutrin, Wellbutrin SR and Wellbutrin XL), nefazodone and possibly mirtazapine (Remeron) seem least likely to cause sexual problems.
Can I exercise while taking medication?
By all means! Regular exercise is a healthy activity for people of all ages and has been shown to have antidepressant effects as well. If you are taking a tricyclic antidepressant (TCA), a monoamine oxidase inhibitor (MAOI), nefazodone (Serzone) or trazodone (Desyrel), be sure to cool down gradually after vigorous physical activity since dizziness and drops in blood pressure may occur if you stop too abruptly. Your age and other medical conditions are additional factors to consider with regard to exercise. Clearance to start exercising should be obtained from your clinician.
How long should I take medication?
In order to prevent relapse after improvement, treatment should not be stopped as soon as a person feels better. (Relapse means the return of symptoms of PTSD after a person has improved because of premature lowering of dose or discontinuation of the antidepressant.) There is another term, "recurrence," which refers to a new episode of PTSD occurring after the previous episode has been treated successfully.
To decrease the possibility of both relapse and recurrence, "maintenance treatment" is often necessary. The Expert Consensus Guidelines recommend the length of treatment for a PTSD episode to be between six months and a year, but longer maintenance treatment may be beneficial. The best course of treatment for each person must be developed individually with a clinician. Keep in mind that antidepressants should not be stopped abruptly unless they are causing intolerable side effects. Gradually tapering off the dose will reduce the risk of withdrawal symptoms or an abrupt return of symptoms of PTSD. Importantly, effective psychotherapy (exposure, anxiety management and cognitive therapy) may be effective even when medications are not. The Expert Consensus Guidelines emphasize the importance of those psychotherapies with and without medications.
What about herbal and other nutritional supplements?
Some, but not all, studies have found St. John's wort, an herbal product, to be useful for treating depression of mild to moderate severity. Since St. John's wort can alter how a number of prescription drugs are broken down in the body, it is best if you discuss its use with your clinician. SAMe or S-adenosylmethionine is a natural substance found throughout the body in small amounts where it serves a variety of metabolic functions. When taken by mouth in much larger amounts, there is some evidence that it may have antidepressant activity. It is sold as a dietary supplement (and is expensive) and is not subject to the same strict governmental supervisions as prescription antidepressants. Neither St. John's wort nor SAMe are FDA-approved for treating depression. No herbal or nutritional supplements have been proven helpful for PTSD.
Vitamins and minerals can be taken with prescription antidepressants, although by themselves they are unlikely to be of benefit for depression (there are rare situations where marked deficiencies of certain vitamins can cause depressive-like presentations).
What if the medication I am taking doesn't work?
A person who does not respond to one PTSD medication may very well respond to a different one. Before switching, it is important to be sure that the dose and duration of treatment have been adequate. If individual medication are ineffective, combinations of medication or adding a "booster" medication to the PTSD medication may be necessary. Although combining medication can be quite beneficial, certain combinations can be dangerous and even possibly lethal (such as the combination of an MAOI and an SSRI). Combining medication should be done only under close supervision by a clinician experienced in their use. This is also true for herbal remedies such as St. John's wort.
Sometimes, instead of combining different PTSD medications, other drugs such as buspirone (BuSpar), carbamazepine (Carbatrol, Equetro, Tegretol), divalproex (Depakote, Depakote ER), gabapentin (Neurontin), lamotrigine (Lamictal), topiramate (Topamax), prazosin or an antipsychotic may be added to your PTSD medication. This procedure, called augmentation, is often helpful in overcoming resistant PTSD. Importantly, an effective psychotherapy (exposure, anxiety management and cognitive therapy) may be helpful even when medications are not. The APA Practice Guideline emphasized the importance of these psychotherapies with and without medications.
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