Pharmacotherapy for post traumatic stress disorder (PTSD)

• Published in: Cochrane database of systematic reviews 2022-03, Vol.3 (3), p.CD002795-CD002795
• Main Authors: Williams, Taryn, Phillips, Nicole J, Stein, Dan J, Ipser, Jonathan C
• Format: Article
• Language: English
• Subjects: Adolescent; Adult; Aged; Aged, 80 and over; Amitriptyline - therapeutic use; Antidepressive Agents - therapeutic use; Antidepressive Agents, Tricyclic - therapeutic use; Antipsychotic Agents - therapeutic use; Condition; Humans; Insurance medicine; Intervention; Mental health; Middle Aged; Mirtazapine - therapeutic use; Paroxetine - therapeutic use; Population; Selective Serotonin Reuptake Inhibitors - therapeutic use; Stress Disorders, Post-Traumatic - drug therapy; Young Adult
• ISSN: 1469-493X
• DOI: 10.1002/14651858.CD002795.pub3

Posttraumatic stress disorder (PTSD) is a prevalent and disabling disorder. Evidence that PTSD is characterised by specific psychobiological dysfunctions has contributed to a growing interest in the use of medication in its treatment. To assess the effects of medication for reducing PTSD symptoms in adults with PTSD. We searched the Cochrane Central Register of Controlled Trials (CENTRAL; Issue 11, November 2020); MEDLINE (1946-), Embase (1974-), PsycINFO (1967-) and PTSDPubs (all available years) either directly or via the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR). We also searched international trial registers. The date of the latest search was 13 November 2020. All randomised controlled trials (RCTs) of pharmacotherapy for adults with PTSD. Three review authors (TW, JI, and NP) independently assessed RCTs for inclusion in the review, collated trial data, and assessed trial quality. We contacted investigators to obtain missing data. We stratified summary statistics by medication class, and by medication agent for all medications. We calculated dichotomous and continuous measures using a random-effects model, and assessed heterogeneity. We include 66 RCTs in the review (range: 13 days to 28 weeks; 7442 participants; age range 18 to 85 years) and 54 in the meta-analysis.  For the primary outcome of treatment response, we found evidence of beneficial effect for selective serotonin reuptake inhibitors (SSRIs) compared with placebo (risk ratio (RR) 0.66, 95% confidence interval (CI) 0.59 to 0.74; 8 studies, 1078 participants), which improved PTSD symptoms in 58% of SSRI participants compared with 35% of placebo participants, based on moderate-certainty evidence.  For this outcome we also found evidence of beneficial effect for the noradrenergic and specific serotonergic antidepressant (NaSSA) mirtazapine: (RR 0.45, 95% CI 0.22 to 0.94; 1 study, 26 participants) in 65% of people on mirtazapine compared with 22% of placebo participants, and for the tricyclic antidepressant (TCA) amitriptyline (RR 0.60, 95% CI 0.38 to 0.96; 1 study, 40 participants) in 50% of amitriptyline participants compared with 17% of placebo participants, which improved PTSD symptoms. These outcomes are based on low-certainty evidence. There was however no evidence of beneficial effect for the number of participants who improved with the antipsychotics (RR 0.51, 95% CI 0.16 to 1.67; 2 studies, 43 participants) compared to placebo, based on very low-certainty evi