A new medication is knocking on the door for FDA approval on PTSD, and it isn't MDMA.

Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003.

I'm Chris Aiken, the editor-in-chief of the Carlat Psychiatry Report, and my co-host, Kelly Newsom, is out sick.

She has lost her voice, and we'll miss her today.

Last week, we looked at first-line medications for PTSD.

But before we venture too far off-label today, let's recap that episode.

Medications take second place to therapy in PTSD, because therapy has bigger, short, and long-term effects. When it comes to

medications, some experts recommend SSRI's first line, while others recommend a personalized approach

favoring praisesin first line if insomnia,

nightmares, and nocturnal hyperarousal are prominent, an SSRI's first line for other cases.

The debate, though, does not end there. When choosing an SSRI, some recommend the FDA-approved options first, like

Certraline and peroxatine, while others argue that fluoxetine, Prozac, has a better risk-benefit

profile in PTSD, with both better efficacy data than Certraline and better tolerability data than peroxatine.

There's a reason the experts can't agree. The data just isn't clear in either direction.

Today, we're going to look at what to do when those first line options fail, and here the data is even less clear. Here's how I look at that.

Just how clear the data is is going to affect how collaborative I am, as well as how big the

risks are. For example, let's take plosopine and lemotrogen. There the data is clear and the risk

is big. I mean, there's no ambiguity about whether clozapine causes neutropenia or whether Lomotrogen causes Stevens-Johnson syndrome. Those are big risks. So when a patient comes in, say, with low blood count on closopine or a rash on Lomotrogen, I am going to have zero collaboration

about this decision of whether to stop those medicines.

But when it comes to questions like should we use topirimate for PTSD, for that kind

of decision, collaboration needs to be higher because the risks are not as big and the data is not as clear on what is the right or wrong thing to do.

So what I'll do is talk to the patient about the meaning of off-label use, the promising but uncertain studies, and the risks with the medication so we can decide on it together.

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