PTSD Pharmacotherapy Evidence Table

PHARMACOTHERAPY EVIDENCE TABLE

Drug	Source of Evidence	Result	n	QE	Quality	R
SSRI
Sertraline (FDA approved)	*Brady et al., 2000 Davidson et al., 2002 Davidson et al., 2001a Davidson et al., 2001b Londborg et al., 2001 Rapaport et al., 2002 Smajkic et al., 2001 Zohar et al., 2002	Significant improvement, CAPS-2, CGI Study of effect on individual symptoms Effective for prevention of PTSD relapse Significant responder rate, CAPS-2 Significant response maintained x 36 weeks Significant response maintained x 64 weeks Significant improvement, Bosnian refugees Numeric advantage (only), Israeli vets	187 ? 96 208 128 359 15 42	I II-2 I I II-1 I/II-1 II-2 I	G F G G G G F G	A
Paroxetine (FDA approved)	Marshall, et al., 2001 Smajkic et al., 2001 Tucker, et al., 2001	Significant improvement, CAPS-2 & CGI Significant improvement, Bosnian refugees Significant improvement, CAPS-2	551 12 307	I II-2 I	G F G	A
Fluoxetine	Barnett et al., 2002 *Connor et al., 1999 Hertzberg et al., 2000 Malik et al., 1999 Martenyi et al., 2002a Martenyi et al., 2002b Meltzer-Brody, et al., 2000	Study of tolerability. Well-tolerated "Superior" response for civilian patients No response for combat vets with severe s/s Significant improvement on SF-36 Effective for prevention of PTSD relapse Effective: improvement in TOP-8, CGI Reduced all symptom clusters of PTSD	65 53 12 16 131 301 53	I I I I I I II-2	G G F F G G F	A
Citalopram	Blaha et al., 1999 Khouzam et al., 2001 Seedat et al., 2000	Reduction in PTSD and scarring, burn pts. Remission of some s/s for Gulf War vets Significant improvement, CAPS-2	? 2 14	III III II-1	P P F	C
Fluvoxamine (not on VA formulary)	Escalona et al., 2002 Neylan et al., 2001	Appears to improve PTSD symptoms Improved sleep quality for Vietnam vets	15 21	III III	P P	I
TCA
Amitriptyline	*Davidson et al., 1990 Davidson et al., 1993	Effective for core symptoms of PTSD Significant improvement: IES, CGI, HAMD	46 62	I I	G G	B
Clomipramine	Muraoka et al., 1996?	One case report	1	III	P	I
Desipramine	*Reist et al., 1989	Did not show efficacy; no statistics	27	III	P	I
Imipramine	*Kosten et al., 1991	Significant improvement, CAPS-2, IES	41	I	G	B
Nortriptyline	Zygmont et al., 1998 Dow et al., 1997	Effective for traumatic grief symptoms Improvement in CGE for dual diagnosis	22 ?	II-1 ?	G F	B
Protriptyline	No studies, 1990-2003
MAOI/RIMA
Brofaromine	Baker et al., 1995 Connor et al., 2001 Katz et al., 1994	Trial did not show efficacy over placebo Significant improvement in CAPS Significant improvement in CAPS-2 & CGI	146 177 64	I I I	G G G	B
Phenelzine	Kosten et al., 1991 Shestatzky et al., 1988	Significant improvement in IES Did not show efficacy; no statistics	37 13	I III	G P	B
Moclobemide	Neal et al., 1997	Significant improvement	20	II-1	G	B
Sympatholytics
Clonidine	Kinzie & Leung, 1989	Cambodian refugees improved, dual therapy	68	III	P	I
Guanfacine	Horrigan & Barnhill, 1996	?				C
Prazosin	Raskind et al., 2003 Raskind et al., 2002 Raskind et al., 2000 Taylor & Raskind, 2002	Significant improvement, CAPS, CGI Significant improvement in dream scores Improvement in nightmare item, CAPS Improvement in CGIC and nightmares	10 59 4 5	I II-2 II-2 II-2	F F F F	C
Propranolol	Finestone & Manly, 1994 Pitman et al., 2002 Reist et al., 2001 Taylor & Cahill, 2002	? Significant improvement post acute stress Recall of arousing story was reduced Effective for reemergent PTSD s/s	41 38 1	I II-2 III	G F P	C (acute)
Novel Antidepressants
Bupropion	Canive et al., 1998	No change in total CAPS score	17	II-2	F	I
Nefazodone	Davis et al., 2000 Garfield et al., 2001 Gillin et al., 2001 Hertzberg et al., 1998 Hidalgo et al., 1999 Zisook et at., 2000	Significant improvement in CAPS, HAM-D Significant improvement in CAPS, anxiety Significant improvement in sleep, CAPS CGI scores were "much improved" High response rate; pooled data, 6 studies PTSD symptoms lessened, CAPS	36 14 12 10 105 19	II-2 II-2 II-2 II-2 II-2 II-2	G F F F F F	C
Trazadone	Hertzberg et al., 1996 Warner et al., 2001	Four patients "much improved" Reduction in nightmares; 9 reports priapism	6 74	III III	P III	I
Venlafaxine	Hamner et al., 1998 Smajkic et al., 2001	Case report of positive response Significant improvement, Bosnian refugees	1 5	III II-2	P F	I
Mirtazapine	Bahk et al., 2002 Connor et al., 1999	Significant improvement in IES, MADRS Clinical improvement in > 50% of patients	15 6	III III	P P	I
Mood Stabilizers/Anticonvulsants
Carbamazepine	Ford, 1996	Case report of a positive response	1	III	P	I
Gabapentin	Brannon et al., 2000 Hamner et al., 2001	Case report of a positive response Effective for insomnia, adjunct treatment	1 30	III II-2	P F	C
Lamotrigine	*Hertzberg et al., 1999	Promising results	14	I	F	C
Topiramate	Berlant, 2002 Berlant, 2001	Significant suppression of nightmares Case report of positive response	35 3	II-1 III	F P	C
Valproate	Clark et al., 1999 Fesler, 1991 Ford, 1996	Significant ? intrusion, hyperarousal, HAM Significant ? hyperarounsal in Vietnam vets One case report of a + response	16 16 1	II-2 II-2 III	F	C
Benzodiazepines
Benzodiazepines	Kosten et al., 2000	Not associated with adverse outcomes	370	II-2	F	I
Alprazolam	*Braun et al., 1990 (concern: rebound anxiety) Gelpin et al., 1996 Risse et al., 1990 Shalev et al., 1998	Did not show efficacy. No statistics No beneficial effect Withdrawal s/s after discontinuation No effect on response to loud tones	16 16 8 9	II-2 II-1 III III	F F P F	D
Clonazepam	Fossey & Hamner, 1994 Gelpin et al., 1996 Shalev & Rogel-Fuchs, 1992	A source of sexual dysfunction No beneficial effect No effect on auditory startle	42 20 N/A	III II-1 III	P F F	I
Lorazepam	Tulen et al., 1991	Physiological endpoints only (HR)	9	I	F	I
Temazepam	Mellman et al., 1998	Short-term for acute stress, + response	4	III	P	I
Typical Antipsychotics
Chlorpromazine	Leber et al., 1999	One case report	1	III	P	D
Thioridazine	Dillard et al., 1993	One case report of a + response	1	III	P	D
Haloperidol	No studies, 1990-2003
Second-generation Antipsychotics
Clozapine	Hamner, 1996	One case report of a + response	1	III	P	I
Olanzapine	Butterfield et al., 2001 Labbate & Douglas, 2000 Petty et al., 2001 Prior, 2001 Roefaro & Mukherjee, 2001 Stein et al., 2002	No beneficial effect. High placebo response Letter Significant improvement in CAPS, CGI Letter Therapy-induced hyperglycemic coma Adjunct to SSRI. Significant improvement in measures, but not in global response	15 48 1 19	I II-1 III I	G G P F	I
Quetiapine	Hamner et al., 2003 Sattar et al., 2002	Significant improvement in CAPS One case report of a + response	20 1	II-1 III	F P	I
Risperidone	Eidelman, et al., 2000 Hamner et al., 2003 Krashin & Oates, 1999 Leyba, 1998 Monnelly & Ciraulo, 1999 Stanovic et al., 2001	4 cases of flashbacks, post physical trauma Adjunct to other meds, comorbid psychoses Two case reports of a + response 4 cases of a + response 1 case of a + response Burn patients reported fewer symptoms	4 40 2 4 1 10	III I III III III 111	P G P P P P	I
Ziprasidone	Haddad & Anderson, 2002	Review of the issue of QTc prolongation	N/A
Nonbenzodiazepine Hypnotics
Zolpidem	Dieperink & Drogemuller, 1999 Lavie, 2001 (review)	25 cases of a + response Fewer side effects for this class, in general	32 N/A	III	P	I
Zaleplon	No studies, 1990-2003
Zopiclone	No studies, 1990-2003
Non-benzodiazepine Antianxiety
Buspirone	Duffy & Malloy, 1994 Wells et al., 1991	Significant improvement, SI-PTSD & BDI "Clinical efficacy"	8 3	II-2 III	F P	I

* in Stein et al., 2000 (Cochrane Review)

Studies of pharmacotherapy for PTSD in individuals exposed to trauma that assessed clinical outcomes were included. Evidence from randomized controlled trials was considered to be of highest quality, followed by observational evidence. Other sources were evaluated when randomized controlled trials and observational studies were not available or did not provide adequate evidence. Studies were excluded if they did not evaluate response to pharmacotherapy and if they did not evaluate individuals exposed to trauma.