The effectiveness of medication in treating psychotraumatic disorders has been recognized for over 30 years. It is important to note that taking medication to manage symptoms is not a sign of failure. Medication should be combined with psychotherapy and is not used on its own. Medications can enhance the effectiveness of the necessary psychotherapeutic process.

For the past decade or so, neither the value nor the effectiveness of pharmacological approaches has been questioned in the field of psychotraumatology. Historically, the 1980s saw the development—following the disorder’s inclusion in diagnostic classifications—of the very first clinical studies that sought to evaluate the effectiveness of antidepressant treatments for post-traumatic stress disorder. The data are now clear and relatively consistent, to the point where there are actual recommendations available.

Reasons for Medication / Objectives of Pharmacological Management

The diversity of symptoms, combined with high comorbidity and the complexity of interactions between neurobiological processes and the individual’s adaptation to the event, suggests numerous potential pharmacological targets across the various systems involved: the central nervous system, the hypothalamic-pituitary axis, and catecholaminergic or serotonergic pathways.

This efficacy has been demonstrated through controlled studies and robust open-label trials to such an extent that, in addition to recommendations from professional societies and consensus conferences, certain molecules have received official indications in many countries in Europe and North America.

The specific meanings that this prescription may carry must be discussed with the patient (failure to cope, feeling of having lost one’s mind, magical expectation that the trauma will simply disappear…). The prescriber will therefore attempt, within a necessary therapeutic alliance with the patient, to define the goals sought by the drug treatment while taking into account the context in which it is administered. To name a few: control of biological and physiological stress reactions, restoration of coping strategies, reduction of disability and improvement in quality of life, reduction of symptoms related to potential comorbidities… In addition to reducing the target symptoms of the various domains of PTSD (re-experiencing/avoidance/hyperarousal), benefits will also be sought regarding depressive symptoms, anhedonia (diminished or lost ability to experience pleasure), dissociative symptoms, or impulsivity. Benefits are also expected in managing common comorbidities: depression, other anxiety disorders, substance abuse, and suicidal behaviors.

Medications Used

Currently, a consensus is emerging in the literature based on numerous controlled studies, all of which rely on validated tools, robust methodologies, and sufficiently large samples. Overall efficacy is significant for medications that indisputably reduce the intensity of all symptoms, aid in clinical recovery, and appear to substantially restore quality of life and overall functioning in individuals with a diagnosed post-traumatic stress disorder (PTSD). In addition to numerous robust open-label trials, a large number of controlled, randomized, double-blind, placebo-controlled studies have been conducted in recent years. These studies involve more than 20 molecules from several different therapeutic classes.

The subject of numerous studies concluding on their efficacy and tolerability, selective serotonin reuptake inhibitors (SSRIs) currently represent the first-line class in the pharmacology of established PTSD. Fluoxetine was the first to be studied, and the results demonstrating its specific efficacy—that is, independent of any antidepressant activity—have been replicated in several controlled studies.

Sertraline and paroxetine have received official approval in many countries for the treatment of established PTSD. These marketing authorizations were supported by robust multicenter controlled studies conducted on large populations.

Nefazodone and trazodone have shown promising efficacy but are rarely used in France.

The class of anticonvulsants holds great promise for the future. The use of carbamazepine, topiramate, or gabapentin—alone or in combination with SSRIs—has been found to be effective, as has lamotrigine.

Traditional antipsychotics have demonstrated targeted efficacy for certain symptoms associated with chronic, complex, and treatment-resistant PTSD. Currently, atypical antipsychotics such as olanzapine, risperidone, or quetiapine have shown clinical promise, particularly at low doses and as adjunctive therapy to SSRIs.

Recent years have also seen the emergence of guidelines, primarily through the ISTSS (International Society for Traumatic Stress Studies) and NICE (National Institute for Health and Care Excellence). Although they do not formally call into question previous findings, they nevertheless conclude that further research is needed, both for the class of serotonergic and tricyclic antidepressants (fluoxetine, sertraline, paroxetine, venlafaxine, amitriptyline, and imipramine) as for anticonvulsants (carbamazepine, divalproex, lamotrigine, tiagabine, and topiramate) and antipsychotics (olanzapine and risperidone). Such guidelines also apply to other compounds: clonidine, cortisol, d-cycloserine, ketamine, oxytocin, broforamine, prazosin, and propranolol. According to the ISTSS, the efficacy of quetiapine appears to be supported by a very high level of scientific evidence, in any case superior to that of SSRIs.

Finally, it is worth noting the very recent development of chemically facilitated psychotherapies, a likely avenue for the future that remains insufficiently explored in the management of psychotraumatic disorders.

References:

Ducrocq F, Vaiva G, Cottencin O. Pharmacological treatment of psychotraumatic disorders. Psychotherapies for victims. Paris: Dunod; 2006. p. 41-5.
Bastien DL. Pharmacological treatment of combat-induced PTSD: a literature review. Br J Nurs. 2010;19(5):318-21.

[English] Pharmacotherapy for post-traumatic stress disorder (PTSD). Stein DJ et al. Cochrane Database of Systematic Reviews, 2006

Bisson, J. I., Berliner, L., Cloitre, M., Forbes, D., Jensen, T. K., Lewis, C., . . . Shapiro, F. (2019). The International Society for Traumatic Stress Studies New Guidelines for the Prevention and Treatment of Posttraumatic Stress Disorder: Methodology and Development Process. J Trauma Stress, 32(4), 475-483. doi:10.1002/jts.22421

Post-traumatic stress disorder. NICE guideline Published: December 5, 2018. www.nice.org.uk/guidance/ng116