1. 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

2. Assess remaining PTSD symptoms
SSRI
Assess remaining PTSD symptoms
Sleep assessment

3. 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.

4. SSRIs: Evidence of Efficacy

5. Paroxetine
Sertraline
FDA-approved

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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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.

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

17. Next Video: Management of Psychotic Symptoms in PTSD