Why Medications Aren't First-Line for PTSD

The conversation around medication as a first-line post-traumatic stress disorder (PTSD) treatment has been brewing for decades, but it recently made major headlines. In early June, a federal advisory committee for the US Food and Drug Administration (FDA) voted against considering use of the drug MDMA (also known as ecstasy) as a PTSD treatment, with the vast majority of members considering the risks too great. 

While the FDA will make the final decision on whether to approve the Schedule I psychoactive drug as a form of treatment, many point out that very few medications have been FDA-approved for PTSD. However, PTSD experts have long agreed with the committee’s recommendation: medications—including drugs like MDMA—simply aren’t the most effective forms of treatment for the mental health condition. 

Why aren’t medications considered first-line treatments?

Although medications may provide symptom relief to some survivors, drugs of any kind are not considered first-line treatments for PTSD. Although medications such as sertraline and venlafaxine can improve symptoms when taken, trauma symptoms can return after stopping the medication. This is because medications do not help survivors process through the trauma on their own, which is the purpose of psychotherapy for PTSD. Because medications do not permanently improve symptoms like therapy does, PTSD therapies such as Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) are recommended more strongly than medications. This is also true with psychedelics - the parent company behind MDMA-assisted psychotherapy is seeking FDA approval for both MDMA and its psychotherapy, not MDMA alone. 

“Medications alone may not produce permanent recovery, because the survivor still has not processed through their trauma,” says Nema Co-founder and CEO, Sofia Noori, MD, MPH. “Because of that, they are generally considered second-line unless combined with a therapy. The first-line treatments like CPT and PE lead to sustained and typically permanent improvement, while the medications do not.” 

Which medications are often used in PTSD treatment, and why?

Currently, there are three FDA-approved medications specifically indicated for PTSD, and all three of them fall within the class of selective serotonin reuptake inhibitors (SSRIs):

• Sertraline (Zoloft)
• Paroxetine (Paxil)
• Fluoxetine (Prozac)

While these are the only FDA-approved medications on the market available to treat PTSD, there are additional off-label medications with similar mechanisms that medical professionals may occasionally prescribe as well. “Though these medications can improve PTSD symptoms, the symptoms may return if a survivor stops the medication. For patients that are in great distress, it can be helpful to start both a medication to reduce distress while they complete a trauma therapy” says Noori.

While SSRIs, which are commonly prescribed as antidepressants, can effectively help alleviate symptoms of depression and anxiety for some individuals with PTSD, and potentially improve sleep and concentration, they’re not a cure for the complex mental condition. In general, the role of medications in PTSD is three-fold: 1) to manage symptoms, 2) enhance therapy outcomes, and 3) to address co-occuring conditions. 

However, there are a variety of factors that influence the need for incorporating medication for PTSD survivors, including severity of symptoms, personal preference, response to therapy, and concurrent mental health conditions. While medications may be helpful as a supplement to treatment, experts continue to firstly endorse evidence-based psychotherapies including Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), and Eye Movement Desensitization and Reprocessing (EMDR) as the foundation of PTSD treatment. 

The most common risks associated with using medications to address PTSD

While the FDA-approved medications for PTSD are well-tolerated and can help mitigate symptoms of depression and anxiety, evidence-based therapies are more highly effective for PTSD and carry no risk. Noori also points out that not all drugs are created equal—some can actually worsen PTSD. “There are some commonly prescribed medications and substances that can actually decrease the chances of trauma recovery for survivors,” she says. 

According to Noori, these particular medications include benzodiazepines like alprazolam (Xanax), clonazepam (Klonopin), and lorazepam (Ativan), which were previously prescribed for PTSD patients because of their ability to help dampen emotional distress. “However, we now know that these medications can numb people, and can reduce outcomes for survivors who complete trauma therapy,” Noori says. “For that reason, it is now recommended that folks taper their benzo when they complete PTSD treatment, and they're not recommended any longer.” 

Another substance that can impair chances of recovery is cannabis. “Patients can get medical cannabis cards for PTSD, but the data regarding their usefulness is mixed and low quality,” she says. “There is now more data that shows that cannabis can also numb people from their emotions, making it harder for them to process their trauma in therapy as well, so we also recommend that folks taper cannabis use during therapy.” 

Why is CPT considered the first-line treatment for PTSD?

Because of the extensive data demonstrating CPT’s effectiveness for treating PTSD, it’s considered a first-line treatment in nearly all practice guidelines, alongside PE. 

“CPT has been studied in over 51 randomized controlled trials, which are the most rigorous types of studies,” Noori says. “Because of this, we know that it works across different types of traumas, across diverse demographics, and it doesn't matter how far out you are from your traumatic event—it still works. Additionally, CPT has some of the longest follow up studies of up to 10 years, which show that survivors don't re-develop PTSD after completing it. Because of all this, CPT is considered a gold standard.” 

The future of PTSD treatment

PTSD has not only made headlines recently for the recommendations made against MDMA as a treatment, but for the recent surge in young people and lack of evidence-based care options. The barriers to care include everything from the cost of therapy and issues with insurance coverage to the shortage of qualified mental health providers. Noori believes there is a better way to sustainably and reliably treat the condition in a way that is accessible for everyone.

“Providing access to affordable, quality PTSD treatment is key,” Noori says. “A lot of young people know they feel distress but don't know where to turn to, and that's because there really aren't many places to do so. At Nema, our goal is to provide amazing and sensitive trauma therapy so people can recover as quickly as possible, as much as possible, and support them in staying better.” 

If you're facing challenges with PTSD, contact Nema today to learn more about how CPT and other supportive treatments tailored for PTSD can lead to lasting recovery.