Should we follow the FDA and give SSRIs for PTSD or venture off label with a fabled

Prazacin?

Experts are divided, and today we'll look at both sides of the argument.

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

I'm Chris Aiken, the editor-in-chief of the Carlat Psychiatry Report, keeping psychiatry honest since 2003. I'm Chris Aiken, the editor-in-chief

of the Carlat Psychiatry Report. And I'm Kelly Newsom, a psychiatric MP and a dedicated reader of

every issue. We're going to end our series on PTSD with a focus on medications. We save that for last, not because it's the best,

but because meds are generally not as effective as therapy is here. I'd start with that message

for patients, as we already live in a culture that prioritizes meds over pretty much all else

in mental health.

But if your patient still prefers medication or they haven't had success with therapy,

go ahead and try medication.

People tend to respond best to the treatment they prefer.

For first-line treatments, we usually go with the FDA,

but we have some reasons to second-guess the FDA's picks in PTSD. There are two FDA-approved options, Certraline and Peroxatine,

but these SSRIs have problems. Surterline only worked in two out of seven trials, and some

analysis find it only effective in women with

civilian trauma. For peroxatine, the data is more robust, but the side effects are worse.

This one has some of the highest rates of withdrawal problems, fatigue, sexual side effects,

and anticholinergic effects, and it has the worst pregnancy safety of any SSRI.

If you do start with an SSRI, I prefer fluoxetine, Prozac, in PTSD.

Fluoxetine might be off-label, but it does have more studies in PTSD than the FDA-approved

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