Assessment and Management of Non-Sleep Symptoms: Using SSRIs (Node 3) David N. Osser, MD, Associate Professor of Psychiatry Harvard Medical School Brockton Division of the VA Boston Healthcare System

Assess remaining PTSD symptoms SSRI Assess remaining PTSD symptoms Sleep assessment

Assess remaining PTSD symptoms SSRI Assess remaining PTSD symptoms Sleep assessment First-line option: Remaining PTSD symptoms If no prominent sleep disturbances Cascade E, Kalali AH, Kennedy SH. Real-world data on SSRI antidepressant side effects. Psychiatry (Edgmont) 2009;6:16–8.

SSRIs: Evidence of Efficacy

Paroxetine Sertraline FDA-approved

Weak evidence supporting use of SSRIs in PTSD Paroxetine Sertraline FDA-approved SMD= 0.23

Levels of efficacy, according to NICE guidelines Clinically meaningful: SMD ≥ 0.5 0.5 National Collaborating Centre for Mental Health. Posttraumatic stress disorder: the management of PTSD in adults and children in primary and secondary care. London; Leicester, UK: Gaskell and the British Psychological Society, 2005

Levels of efficacy, according to NICE guidelines Clinically meaningful: SMD ≥ 0.5 Clinically important: SMD ≥ 0.8 0.5 0.8 National Collaborating Centre for Mental Health. Posttraumatic stress disorder: the management of PTSD in adults and children in primary and secondary care. London; Leicester, UK: Gaskell and the British Psychological Society, 2005

Levels of efficacy, according to NICE guidelines Clinically meaningful: SMD ≥ 0.5 Clinically important: SMD ≥ 0.8 0.5 0.8 SSRIs National Collaborating Centre for Mental Health. Posttraumatic stress disorder: the management of PTSD in adults and children in primary and secondary care. London; Leicester, UK: Gaskell and the British Psychological Society, 2005

Levels of efficacy, according to NICE guidelines Clinically meaningful: SMD ≥ 0.5 Clinically important: SMD ≥ 0.8 0.5 0.8 ? SSRIs National Collaborating Centre for Mental Health. Posttraumatic stress disorder: the management of PTSD in adults and children in primary and secondary care. London; Leicester, UK: Gaskell and the British Psychological Society, 2005

Paroxetine: evidence of efficacy in PTSD Best evidence of efficacy (effect size 0.4) Efficacy Sexual dysfunction Constipation Sedation Drug interactions Discontinuation syndrome Disadvantages Baker DG, Nievergelt CM, Risbrough VB. Post-traumatic stress disorder: emerging concepts of pharmacotherapy. Expert Opin Emerg Drugs 2009;14:251–72

Paroxetine: evidence of efficacy in PTSD Best evidence of efficacy (effect size 0.4) Efficacy Sexual dysfunction Constipation Sedation Drug interactions Discontinuation syndrome Disadvantages Baker DG, Nievergelt CM, Risbrough VB. Post-traumatic stress disorder: emerging concepts of pharmacotherapy. Expert Opin Emerg Drugs 2009;14:251–72

Sertraline: evidence of efficacy in PTSD Weaker evidence of efficacy Especially in male combat veterans FDA-approved for both genders Not approved in England for males with PTSD Friedman MJ, Marmar CR, Baker DG, Sikes CR, Farfel GM. Randomized, double-blind comparison of sertraline and placebo for posttraumatic stress disorder in a Department ofVeterans Affairs setting. J Clin Psychiatry 2007;68:711–20

Fluoxetine, citalopram and escitalopram Effect size: 0.25 National Collaborating Centre for Mental Health. Posttraumatic stress disorder: the management of PTSD in adults and children in primary and secondary care. London; Leicester, UK: Gaskell and the British Psychological Society, 2005

Fluoxetine, citalopram and escitalopram Effect size: 0.25 Open-label trials Open-label trials QTc prolongation Cascade E, Kalali AH, Kennedy SH. Real-world data on SSRI antidepressant side effects. Psychiatry (Edgmont) 2009;6:16–8.

Adequate SSRI trial 4-6 weeks Sometimes up to 12 weeks

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