Editing Post-traumatic stress disorder (section)

=== Medication ===
Four antidepressants (sertraline, fluoxetine, paroxetine, and venlafaxine) have been shown to have a small to modest benefit over placebo.<ref name="Hos2015"/> 

==== Antidepressants ====
[[Selective serotonin reuptake inhibitors]] (SSRIs) and [[serotonin–norepinephrine reuptake inhibitor]]s (SNRIs) may have some benefit for PTSD symptoms.<ref name=Hos2015/><ref name=Jeffreys-2012>{{cite journal |vauthors=Jeffreys M, Capehart B, Friedman MJ |title=Pharmacotherapy for posttraumatic stress disorder: review with clinical applications |journal=[[Journal of Rehabilitation Research and Development]] |volume=49 |issue=5 |pages=703–715 |date=2012 |pmid=23015581 |doi=10.1682/JRRD.2011.09.0183 |quote=While evidence-based, trauma-focused psychotherapy is the preferred treatment for PTSD, pharmacotherapy is also an important treatment option. First-line pharmacotherapy agents include selective serotonin reuptake inhibitors and the selective serotonin-norepinephrine reuptake inhibitor venlafaxine. |doi-access=free}}</ref><ref>{{cite journal |vauthors=Williams T, Phillips NJ, Stein DJ, Ipser JC |title=Pharmacotherapy for post traumatic stress disorder (PTSD) |journal=[[Cochrane Library|The Cochrane Database of Systematic Reviews]] |volume=2022 |issue=3 |pages=CD002795 |date=March 2022 |pmid=35234292 |pmc=8889888 |doi=10.1002/14651858.CD002795.pub3 }}</ref> [[Tricyclic antidepressants]] are equally effective, but are less well tolerated.<ref>{{cite journal |vauthors=Puetz TW, Youngstedt SD, Herring MP |title=Effects of Pharmacotherapy on Combat-Related PTSD, Anxiety, and Depression: A Systematic Review and Meta-Regression Analysis |journal=[[PLOS ONE]] |volume=10 |issue=5 |pages=e0126529 |date=28 May 2015 |pmid=26020791 |pmc=4447407 |doi=10.1371/journal.pone.0126529 |veditors=Hashimoto K |quote=The cumulative evidence summarized in this review indicates that pharmacotherapy significantly reduces PTSD, anxiety, and depressive symptom severity among combat veterans with PTSD. The magnitude of the overall effects of pharmacotherapy on PTSD (Δ = 0.38), anxiety (Δ = 0.42), and depressive symptoms (Δ = 0.52) were moderate... |doi-access=free |bibcode=2015PLoSO..1026529P}}</ref> Evidence provides support for a small or modest improvement with [[sertraline]], [[fluoxetine]], [[paroxetine]], and [[venlafaxine]].<ref name=Hos2015/><ref>{{cite journal |vauthors=Kapfhammer HP |title=Patient-reported outcomes in post-traumatic stress disorder. Part II: focus on pharmacological treatment |language=en, es, fr |journal=[[Dialogues in Clinical Neuroscience]] |volume=16 |issue=2 |pages=227–237 |date=June 2014 |pmid=25152660 |pmc=4140515 |doi=10.31887/DCNS.2014.16.2/hkapfhammer}}</ref> Thus, these four medications are considered to be [[First-line treatment|first-line]] medications for PTSD.<ref name=Jeffreys-2012/><ref name="Berger-2009"/> The SSRIs paroxetine and sertraline are approved by the U.S. [[Food and Drug Administration]] (FDA) approved for the [[Treatments for PTSD|treatment of PTSD]].<ref name="Shalev 2017" />

==== Benzodiazepines ====
[[Benzodiazepine]]s are not recommended for the [[Treatments for PTSD|treatment of PTSD]] due to a lack of evidence of benefit and risk of worsening PTSD symptoms.<ref name="pmid22302333">{{cite journal |vauthors=Jain S, Greenbaum MA, Rosen C |title=Concordance between psychotropic prescribing for veterans with PTSD and clinical practice guidelines |journal=[[Psychiatric Services]] |volume=63 |issue=2 |pages=154–60 |date=February 2012 |pmid=22302333 |doi=10.1176/appi.ps.201100199}}</ref> Some authors believe that the use of benzodiazepines is contraindicated for acute stress, as this group of drugs can cause [[Dissociation (psychology)|dissociation]].<ref name="pmid23062450">{{cite journal |vauthors=Auxéméry Y |title=[Posttraumatic stress disorder (PTSD) as a consequence of the interaction between an individual genetic susceptibility, a traumatogenic event and a social context] |language=fr |journal=[[L'Encéphale]] |volume=38 |issue=5 |pages=373–80 |date=October 2012 |pmid=23062450 |doi=10.1016/j.encep.2011.12.003}}</ref> Nevertheless, some use benzodiazepines with caution for short-term anxiety and insomnia.<ref name="Kapfhammer-2008">{{cite journal |vauthors=Kapfhammer HP |title=[Therapeutic possibilities after traumatic experiences] |journal=[[Psychiatria Danubina]] |volume=20 |issue=4 |pages=532–45 |date=December 2008 |pmid=19011595}}</ref><ref name="autogenerated1">{{cite book | vauthors = Reist C |date=2005 |title=Post-traumatic Stress Disorder |location= |publisher=Epocrates.com}}</ref><ref name="Maxmen2002-349">{{cite book |vauthors=Maxmen JS, Ward NG |title=Psychotropic drugs: fast facts |place=New York |publisher=[[W.W. Norton & Company]] |year=2002 |edition=3rd |isbn=978-0-393-70301-6 |page=349}}</ref> While benzodiazepines can alleviate acute anxiety, there is no consistent evidence that they can stop the development of PTSD and may actually increase the risk of developing PTSD 2–5 times.<ref name=Gui2015/> Benzodiazepines should not be used in the immediate aftermath of a traumatic event as they may increase symptoms related to PTSD.<ref name="Shalev 2017" />

Benzodiazepines may reduce the effectiveness of psychotherapeutic interventions, and there is some evidence that benzodiazepines may actually contribute to the development and chronification of PTSD. For those who already have PTSD, benzodiazepines may worsen and prolong the course of illness, by worsening psychotherapy outcomes, and causing or exacerbating aggression, depression (including suicidality), and substance use.<ref name=Gui2015/> Drawbacks include the risk of developing a [[benzodiazepine dependence]], [[Drug tolerance|tolerance]] (i.e., short-term benefits wearing off with time), and [[benzodiazepine withdrawal syndrome|withdrawal syndrome]]; additionally, individuals with PTSD (even those without a history of alcohol or drug misuse) are at an increased risk of [[benzodiazepine misuse|abusing benzodiazepines]].<ref name="Berger-2009" /><ref name="Martényi-2005">{{cite journal |vauthors=Martényi F |title=[Three paradigms in the treatment of posttraumatic stress disorder] |journal=[[Neuropsychopharmacologia Hungarica]] |volume=7 |issue=1 |pages=11–21 |date=March 2005 |pmid=16167463}}</ref>

Due to a number of other treatments with greater efficacy for PTSD and fewer risks, benzodiazepines should be considered [[Contraindicated|relatively contraindicated]] until all other treatment options are exhausted.<ref name=Haa2015/><ref name="VA/DoD_2010"/>

Benzodiazepines also carry a risk of disinhibition (associated with suicidality, aggression and crimes) and their use may delay or inhibit more definitive [[treatments for PTSD]].<ref name="Berger-2009"/><ref name="VA/DoD_2010">{{Cite book |title=Veterans Affairs and Department of Defense clinical practice guideline for management of post-traumatic stress. |publisher=VA/DoD |year=2010}}</ref><ref>{{cite journal |vauthors=Bandelow B, Zohar J, Hollander E, Kasper S, Möller HJ, Zohar J, Hollander E, Kasper S, Möller HJ, Bandelow B, Allgulander C, Ayuso-Gutierrez J, Baldwin DS, Buenvicius R, Cassano G, Fineberg N, Gabriels L, Hindmarch I, Kaiya H, Klein DF, Lader M, Lecrubier Y, Lépine JP, Liebowitz MR, Lopez-Ibor JJ, Marazziti D, Miguel EC, Oh KS, Preter M, Rupprecht R, Sato M, Starcevic V, Stein DJ, van Ameringen M, Vega J |title=World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of anxiety, obsessive-compulsive and post-traumatic stress disorders – first revision |journal=The World Journal of Biological Psychiatry |volume=9 |issue=4 |pages=248–312 |year=2008 |pmid=18949648 |doi=10.1080/15622970802465807 |doi-access=free}}</ref>

==== Prazosin ====
[[Prazosin]], an alpha-1 adrenergic antagonist, has been used in veterans with PTSD to reduce nightmares. Studies show variability in the symptom improvement, appropriate dosages, and efficacy in this population.<ref>{{cite journal |vauthors=Green B |s2cid=40069887 |title=Prazosin in the treatment of PTSD |journal=[[Journal of Psychiatric Practice]] |volume=20 |issue=4 |pages=253–9 |date=July 2014 |doi=10.1097/01.pra.0000452561.98286.1e |pmid=25036580}}</ref><ref>{{cite journal |vauthors=Singh B, Hughes AJ, Mehta G, Erwin PJ, Parsaik AK |title=Efficacy of Prazosin in Posttraumatic Stress Disorder: A Systematic Review and Meta-Analysis |journal=The Primary Care Companion for CNS Disorders |volume=18 |issue=4 |date=July 2016 |pmid=27828694 |doi=10.4088/PCC.16r01943 }}</ref><ref name="Waltman_2018">{{cite journal |vauthors=Waltman SM, Shearer D, Moore BA |title=Management of Post-Traumatic Nightmares: a Review of Pharmacologic and Nonpharmacologic Treatments Since 2013 |journal=[[Current Psychiatry Reports]] |publisher=Springer Science and Business Media LLC |volume=20 |issue=12 |date=2018-10-11 |issn=1523-3812 |pmid=30306339 |doi=10.1007/s11920-018-0971-2 |page=108 |s2cid=52958432}}</ref>

==== Glucocorticoids ====
[[Glucocorticoids]] may be useful for short-term therapy to protect against neurodegeneration caused by the extended stress response that characterizes PTSD, but long-term use may actually promote neurodegeneration.<ref>{{cite journal |vauthors=Griffin GD, Charron D, Al-Daccak R |title=Post-traumatic stress disorder: revisiting adrenergics, glucocorticoids, immune system effects and homeostasis |journal=[[Clinical & Translational Immunology]] |volume=3 |issue=11 |pages=e27 |date=November 2014 |pmid=25505957 |pmc=4255796 |doi=10.1038/cti.2014.26}}</ref>

==== Cannabinoids ====
{{see also| Cannabis use and trauma}}
[[Cannabis (drug)|Cannabis]] is not recommended as a [[treatment for PTSD]] because scientific evidence does not currently exist demonstrating treatment efficacy for [[cannabinoid]]s.<ref>{{cite journal |vauthors=Black N, Stockings E, Campbell G, Tran LT, Zagic D, Hall WD, Farrell M, Degenhardt L |title=Cannabinoids for the treatment of mental disorders and symptoms of mental disorders: a systematic review and meta-analysis |journal=The Lancet. Psychiatry |volume=6 |issue=12 |pages=995–1010 |date=December 2019 |pmid=31672337 |pmc=6949116 |doi=10.1016/S2215-0366(19)30401-8}}</ref><ref>{{cite journal |vauthors=O'Neil ME, Nugent SM, Morasco BJ, Freeman M, Low A, Kondo K, Zakher B, Elven C, Motu'apuaka M, Paynter R, Kansagara D |title=Benefits and Harms of Plant-Based Cannabis for Posttraumatic Stress Disorder: A Systematic Review |journal=[[Annals of Internal Medicine]] |volume=167 |issue=5 |pages=332–340 |date=September 2017 |pmid=28806794 |doi=10.7326/M17-0477 |doi-access=free}}</ref>{{efn|As an ''example ''of such research, see: Bonn-Miller MO, Sisley S, Riggs P, Yazar-Klosinski B, Wang JB, Loflin MJE, et al. (2021) The short-term impact of 3 smoked cannabis preparations versus placebo on PTSD symptoms: A randomized cross-over clinical trial. ''PLOS ONE'' 16(3): e0246990.}} However, use of cannabis or derived products is widespread among U.S. veterans with PTSD.<ref>{{cite journal |vauthors=Betthauser K, Pilz J, Vollmer LE |title=Use and effects of cannabinoids in military veterans with posttraumatic stress disorder |journal=[[American Journal of Health-System Pharmacy]] |volume=72 |issue=15 |pages=1279–84 |date=August 2015 |pmid=26195653 |doi=10.2146/ajhp140523 |type=Review}}</ref>

The cannabinoid [[nabilone]] is sometimes used for nightmares in PTSD. Although some short-term benefit was shown, adverse effects are common and it has not been adequately studied to determine efficacy.<ref name=CADTH-Nabilone-2015>{{cite journal |title=Long-term Nabilone Use: A Review of the Clinical Effectiveness and Safety |journal=CADTH Rapid Response Reports |date=October 2015 |pmid=26561692 |url=https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0079568/}}</ref> An increasing number of states permit and have legalized the use of [[medical cannabis]] for the treatment of PTSD.<ref>{{cite news |vauthors=Gregg K |url=http://www.providencejournal.com/news/20160713/raimondo-signs-law-allowing-marijuana-for-treatment-of-ptsd |title=Raimondo signs law allowing marijuana for treatment of PTSD |access-date=18 August 2016 |newspaper=[[The Providence Journal]] |date=2016-07-13 |url-status=live |archive-url= https://web.archive.org/web/20160816061718/http://www.providencejournal.com/news/20160713/raimondo-signs-law-allowing-marijuana-for-treatment-of-ptsd |archive-date=16 August 2016}}</ref>