Alternative/off-label medications for PTSD?

October 26, 2022 9:23 AM

The evidence base is strongest for paroxetine, sertraline, and fluoxetine for PTSD. Sometimes venlafaxine is used as well. Are there other medications that have a better side effect profile?

Unwelcome side effects are gastrointestinal problems, sexual side effects, fatigue, malaise, restlessness/anxiety, and weight gain. Or, insult to the liver.

The person this is about - who already has three compromised GI organs! - had a horrible time on sertraline, was switched to Lexapro which is only marginally better. (The Zoloft experience is here: https://ask.metafilter.com/367050/Is-this-normal-for-Zoloft-sertraline )

(The doctor doesn’t care about the side effects and is insisting on pushing through. Is totally uninterested in the person’s hypothyroidism or lithium levels, never took bloodwork… super unimpressed but it took almost a year to see this person. Looking for someone else, in the meantime stuck.)

Focus though here is, what other than SSRIs or SNRIs can help with (C)PTSD, and is less likely to cause the unwanted symptoms.

posted by cotton dress sock to Health & Fitness (18 answers total)

Response by poster: She also won’t prescribe anything to bridge the gap until this crap is supposed to work. (Which recent research suggests may not even occur.) I guess some psychiatrists do.
posted by cotton dress sock at 9:27 AM on October 26, 2022

Does she know about MDMA assisted therapy for PTSD? There are a few clinics here and there which do this. There's an organization with some more info and links.
posted by seanmpuckett at 9:31 AM on October 26, 2022 [4 favorites]

I also came here to recommend MDMA assisted therapy.
posted by bbqturtle at 9:57 AM on October 26, 2022 [2 favorites]

Unfortunately, I don't think SSRIs/SNRIs have particularly high efficacy for PTSD. It's not nothing (i.e., better than placebo), but the benefits are generally not amazing, as I understand it. I think physicians tend to prescribe them in cases like this not because they're super effective but because they're generally safe, usually better than nothing, and reasonably tolerated by most people (though it sounds like your person is not among the latter group!).

If this person can access the MAPS MDMA trial that seanmpuckett linked to, that would be a good option, but getting in is probably a longshot at this point. There are also underground therapists that do it illegally, but I don't really know how one would go about finding them.

With the disclaimer of n=1, as someone with PTSD, I've found medication to be of limited utility (lots of costs in terms of side effects, for little to no benefit). I have an as-needed prescription for a benzo to deal with the occasional panic attack situation, but I otherwise have seen much more benefit from seeing a psychotherapist specialized in trauma and engaging in therapy specifically directed toward it, if that's an option for this person. For me it was worth it: it's the only thing that's helped at all.
posted by Kosh at 10:19 AM on October 26, 2022 [5 favorites]

Is finding a new doctor somewhere else an option? I know you say you're looking (I'll say "you" here to mean the person you're writing about, just for clarity) but what about finding someone in a different health system, even if it requires a bit of a drive? Maybe call some different providers to ask if they have a "cancellation list" that might allow you to be seen more quickly. Explain the situation and say that you will take an appointment with anyone who can handle psych medication management, you just want the soonest available. If you have a primary care doctor, explain what's going on and ask for recommendations.

Regardless of the suggested treatment, I would have a problem with any physician who claims to "not care" about side effects and refuses to mitigate them. I know finding a good doctor is not always easily, especially when you are looking for a psych provider, but if the actual situation is anywhere near what you've described here, I would not be uncomfortable, at best, with continuing to entrust this person with my care. Even if you do try the recommended SSRI and can work through any side effects, is this really the kind of person you want to continue returning to? Can you trust that she actually has your best interests in mind?

Yes, sometimes side effects are not completely avoidable or are outweighed by the benefits of a given treatment, but I would not be okay with this physician's attitude towards side effects and their mitigation. It just seems so casually dismissive. The way you've written about her makes it seem like she believes that dealing with medication side effects is just a matter of inadequate mental toughness, rather than an actual quality of life issue.
posted by easy, lucky, free at 10:25 AM on October 26, 2022 [1 favorite]

I'm a huge fan of EMDR and have found it extraordinarily helpful for PTSD and some other issues. I also have friends pursuing MDMA treatment as mentioned by others who have had great success.
posted by Ink-stained wretch at 10:27 AM on October 26, 2022 [11 favorites]

I don't want to abuse the edit feature, so I'll say that even if you don't mesh well with the first doctor to have an available appointment, I really cannot imagine them being worse than your existing doctor. Her specifically saying that she won't offer anything to help mitigate side effects, even if it were possible to do so, really rubs me the wrong way.
posted by easy, lucky, free at 10:27 AM on October 26, 2022 [1 favorite]

I have (C)PTSD and I have a scrip for Xanax, which I use for panic attacks and stressful bumps in the road. It is very helpful. It's habit-forming, though, so can't be used by everyone. I have no personal experience with EMDR but have often considered it based on friends' positive experiences.
posted by scratch at 10:51 AM on October 26, 2022 [1 favorite]

I just had my first appointment of somatic experiencing therapy and I can imagine that it would depend on the therapist but I feel more hopeful than I have in a long long time. I’ve been feeling very very unstable and unwell since about February with lots of flashbacks and anger. I’m trying mirtzipine, but I don’t really feel like I’m depressed so much as at the mercy of my fight or flight response and on edge etc. he explained that the energy and the energy of my anger needs somewhere to go and my not having boundaries is something I experience physically (sensitivity to noise, other peoples movements) and gives me a lot of stress and upset so I feel this is promising. Edit to add: I did present as depressed when I started the mirtzipine but that was probably the side effect of a different medication I then stopped taking.
posted by pairofshades at 11:02 AM on October 26, 2022 [1 favorite]

Came in to say exactly what Kosh wrote above. Though I did have a little benefit from SSRIs when I was at my very worst.
After a long wait, I got into a dedicated program for PTSD patients (and I am technically hospitalized, though not really). It is finally making a huge difference. The best programs AFAIK are those with forest/garden therapy, but in this country they are only available for veterans. I was surprised that I got a lot out of group therapy, I am no longer in it, because some of my issues are not suited for groups, but I strongly recommend.
posted by mumimor at 1:03 PM on October 26, 2022 [3 favorites]

Try using herbal relaxation aids which contain hops + valerian. You can typically find these at pharmacies in my area; they're cheap and have very few side effects or interactions.

I have similar problems to your friend - I have CPTSD, I'm still trying to find prescription drugs that work for me, but this relaxes me - physically and mentally - better than some antidepressants I've been on.
posted by wandering zinnia at 2:34 PM on October 26, 2022 [1 favorite]

Response by poster: Thank you so much, everyone, for taking the time to share your thoughts and experiences, it’s very much appreciated. Lots of love to you, too.

easy, lucky, free - could not agree with you more. We’ve called every psychiatrist in a two-hour radius, none are taking patients or even holding cancellation lists. Will try again and may go further afield since telemedicine is now a regular thing. Not holding my breath because the backlog is outrageous, there are just not enough psychiatrists in our province. We’re in Ontario, Canada.
posted by cotton dress sock at 3:50 PM on October 26, 2022 [2 favorites]

My sympathies, cotton dress sock. My partner had to wait a year to be seen by an ADHD clinic and it's entirely out-of-pocket.
posted by seanmpuckett at 4:15 PM on October 26, 2022 [2 favorites]

Propanolol- there are great studies about its effectiveness, especially in reducing things like nightmares and flashbacks. Easy on the GI system, do be aware that in a subset of people it can cause bronchial spasm and asthma like symptoms, which stop when taken off the medication. It’s not one which requires a taper if it doesn’t work out.
posted by Bottlecap at 4:39 PM on October 26, 2022 [2 favorites]

Oh, and because it’s not a controlled substance most general practitioners are willing to prescribe.
posted by Bottlecap at 4:40 PM on October 26, 2022 [1 favorite]

Response by poster: Really sorry to hear that, seanmpuckett. Nightmare, eh. Partner waited 11 months. Only to meet with this approach. He’s disheartened, to say the very least. People fight so hard to make it through every day of those weeks, months, years.

Thank you, Bottlecap, that’s really interesting, will ask about it.
posted by cotton dress sock at 4:52 PM on October 26, 2022

I've had phenomenally bad luck taking SSRI's, SNRIs, (and TCA's and a whole host of other antidepressant drugs) for PTSD; they don't work well, and yeah, I had horrible digestive issues when on all that action. There are precious few drugs that treat PTSD well, and even fewer that overlap with a cPTSD diagnosis if that applies.

Prazosin can help with certain panic and activation symptoms, and specifically nightmares/night terrors; the side effects I found to be not-awful (difficulty exercising, because the mechanism throttles your heart rate), but it just ended up not being super effective over time for me,

Psilocybin, while not durable for me,(ie, did not provide long term relief) did help for several months after taking it (a very large dose) under the supervision of an experienced professional, and followup integration of that experience. While their risk tolerance for law involvement may be different, there are dispensaries operating openly in Vancouver, who appear to mail order across Canada. Bonus points for: non habit forming, fairly low risk profile medically. There are lots of therapists that will help with integration and support, but not with distribution. Most studies surrounding this have been applied more to depression, not trauma, and only with large doses, not micro doses. Micro dosing is a very 'popular' term that has no definition, and should be at least approached with caution and skepticism. There are currently no controlled studies of microdosing for any mental health condition. Which is not to say it doesn't help or work, but it's kind of the wild west choose your own adventure type of scenario, that I personally think should have some supervision, but everyone's got their own tolerance for that kind of situation.

Regarding MDMA, please only consider clinical trials. if they seek out an unlicensed, underground provider, obtaining pharmaceutical grade MDMA is nearly impossible. If they decide to do this regardless, buy testing kits. Use them religiously. MDMA can be frequently cut with other amphetamines, which contradict the results of clinical studies.
posted by furnace.heart at 4:55 PM on October 26, 2022 [2 favorites]

There's evidence for the efficacy of MAOIs for PTSD. A lot of doctors don't prescribe them because of (mostly overblown) worries about drug interactions (there are some, and they are serious, but the medication and food interactions are not nearly as common as previously thought, and most patients for whom other treatments have failed find them tolerable).

This essay about patient satisfaction with their mental health drugs is one of the better pieces I've read to explain why doctors continue to push treatments that patients tell them aren't working. I'm so sorry you're going through this.
posted by decathecting at 2:28 PM on October 27, 2022 [1 favorite]