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Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence
The evidence is suggestive but not sufficient to conclude efficacy ofSSRIs in general populations with PTSD. The available evidence isfurther suggestive that SSRIs are not effective in populations consistingof predominantly male veterans with chronic PTSD.
Comment: If one divides the SSRI studies into categories that include combat veterans with chronic PTSD (Friedman et al., 2007; Hertzberg et al., 2000; and van der Kolk et al., 1994) and veterans with more recent exposure to war (Martenyi et al., 2002; Zohar et al., 2002) (all of these male or predominately male) then the 3 studies with male veterans with chronic PTSD have negative results and the preponderance of the studies with civilian populations (9 of 11) are positive (Brady et al., 2000; Connor et al., 1999; Davidson et al., 2001; Marshall et al., 2001, 2007; Martenyi et al., 2002; Tucker et al., 2000, 2001; van der Kolk et al., 1994), and the 2 non-positive studies (Davidson et al., 2006; van der Kolk et al., 2007 ) show nonsignificant trends favoring the SSRI (sertraline in one study, fluoxetine in the other). (This analysis counts van der Kolk’s 1994 study with veteran and civilian groups as 2 studies.)
Limitations (e.g., high dropout rates) warrant “suggestive but not sufficient to conclude the efficacy” rather than “sufficient to conclude the efficacy” of SSRIs. The positive studies tend to be large and well conducted by all criteria other than dropout rates and use of LOCF to address missing data. Three of the larger, well-conducted positive studies have dropout rates that do not exceed 31 percent per group and the rates are similar in the treatment groups. The assumption that LOCF provides a conservative estimate in medication studies is supported by the extant short-term and long-term medication treatment trajectory data that shows continuing improvement over time. Additional evidence that predominantly male veteran populations with chronic PTSD are less responsive to treatments in general comes from Schnurr et al. (2003), which is one of the few studies to not find an advantage of exposure-based cognitive-behavioral therapy over an active control. The Cochrane systematic review (Stein et al., 2006) that utilized meta-analysis (and is referred to in the report in Chapter 3, section on SSRIs) also supports the efficacy of SSRIs for PTSD in the general population.
Novel Antipsychotic Medications Conclusion
There is evidence that is suggestive but not sufficient to conclude theefficacy of new generation antipsychotic medications as add-on or adjunctive for the treatment of PTSD.