Evidence-Based Reviews

Can medications prevent PTSD in trauma victims?

Current Psychiatry. 2007 September;6(9):47-55

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Similarly, in a randomized controlled trial, 22 patients were given temazepam for 7 nights, starting approximately 14 days after exposure to a traumatic event. Six weeks later, 55% of those receiving temazepam and 27% of those receiving placebo met criteria for PTSD.²⁶

In summary, benzodiazepines might be helpful when given for a few days after traumatization to control overwhelming anxiety but could be harmful over a longer term.

Other agents for PTSD

Antidepressants. Early trauma-related symptoms of depression predict later development of PTSD.²⁷ Thus, antidepressants have been proposed for early intervention in addition to their well-established role as first-line treatment of PTSD.²⁸

One study supports this idea: a 7-day randomized double-blind trial that compared the tricyclic antidepressant imipramine with chloral hydrate in pediatric burn patients with acute stress disorder (ASD). Imipramine was more effective (83% response) than chloral hydrate (38% response) in reducing ASD symptoms.²⁹

Drugs in development. Three new medications being explored for treating anxiety and depression also might be useful for PTSD prevention. Neuropeptide Y (NPY) agonists,³⁰ substance P antagonists,³¹ and CRH-antagonists³² are thought to hold promise because of their more proximate roles—compared with monoamine neurotransmitters such as dopamine, norepinephrine and serotonin—in mediating the stress response.

Box 2

3-step acute treatment of recently traumatized patients

Manage the post-trauma environment:

Move the victim to safety.
Treat pain effectively.
Avoid stress from interrogations, separation from loved ones, or unstable housing.

Avoid crisis incident stress debriefing (CISD), which could enhance physiologic hyperarousal and is not recommended as first-line treatment for most trauma victims. CISD was designed for and is best received by emergency personnel.

Consider prescribing antidepressants for patients thought to be particularly vulnerable to develop posttraumatic stress disorder (PTSD). Risk factors include:

history of PTSD, depression, or anxiety disorder
severe trauma (such as from sexual assault or torture)
physical injury, when antidepressants with analgesic properties might be useful.

Analyzing the evidence

Insufficient evidence exists to determine which strategies might be most effective to prevent PTSD, what optimal dosing might be, and which traumatized individuals might be best targeted with these approaches.

Beta-blockers and corticosteroids—the most theoretically compelling strategies—are the most difficult agents to use for PTSD prevention because they have the most medical contraindications. In addition, evidence supporting their ability to prevent PTSD is meager at best.
Prazosin is intriguing but has contra-indications similar to those of beta blockers, no studies of secondary prevention, and no clear indication that it works for the overall PTSD syndrome.
Opioids are restricted agents with substantial contraindications.
Evidence is limited but points most strongly toward earlier use of antidepressants. Early trauma-related symptoms of depression predict later development of PTSD,²⁷ and a number of selective serotonin reuptake inhibitors—such as citalopram, fluoxetine, paroxetine, and sertraline—are FDA-approved or used off-label for treating PTSD.³³

Clinical Point

Antidepressants with analgesic properties might be useful in patients whose trauma is associated with physical injury

Prescribing recommendations. Consider practicality, ease of use, and safety of the proposed medication when choosing a drug for PTSD prevention (Table 3).²² Based on the evidence, the most reasonable posttrauma approach (Box 2) might be to consider starting an approved antidepressant for individuals thought to be particularly vulnerable to PTSD because of:

past history of PTSD, depression, or anxiety disorder
severity of the trauma (such as in cases of sexual assault or torture)
pain (antidepressants with analgesic properties—such as venlafaxine or duloxetine—might be useful in patients whose trauma is associated with physical injury, although neither is FDA-approved to treat PTSD).

Table 3

4 considerations when choosing a drug for PTSD prevention

Potential benefits	Practicality, ease of use, and safety of the proposed medication
Potential drug-drug or drug-disease interactions	Asthma, diabetes, and trauma are relative contraindications to the use of antiadrenergics and corticosteroids
Psychiatric comorbidities	A patient’s history of substance use disorder makes opioid analgesics a concern
Clinical experience	Agents already prescribed safely and broadly in clinical practice are easiest to test and to use

Related resources

Mental health and mass violence: Evidence-based early psychological intervention for victims/survivors of mass violence. A workshop to reach consensus on best practices. Rockland, MD: National Institute of Mental Health; 2002. www.nimh.nih.gov.
Post-traumatic stress disorder: the management of PTSD in adults and children in primary and secondary care (clinical guideline 26). London, UK: National Institute for Clinical Excellence; 2005. www.nice.org.uk.
Ursano RJ, Bell C, Eth S, et al. Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Am J Psychiatry 2004;161(suppl 11):3-31.

Drug brand names

Alprazolam • Xanax
Amitriptyline • Elavil
Citalopram • Celexa
Clonazepam • Klonopin
Clonidine • Catapres
Duloxetine • Cymbalta
Fluoxetine • Prozac
Gabapentin • Neurontin
Guanfacine • Tenex
Imipramine • Tofranil
Lamotrigine • Lamictal
Paroxetine • Paxil
Prazosin • Minipress
Propranolol • Inderal
Sertraline • Zoloft
Temazepam • Restoril
Venlafaxine • Effexor