Australian guidelines for the treatment of PTSD [847] recommend that pharmacotherapies be used as an adjunct to trauma-focused CBT if the person has not gained benefit from psychological treatment. There is, however, little evidence to suggest that combining psychological and pharmacological interventions leads to improved outcomes. When pharmacotherapies are considered, SSRIs are the recommended first line option (see Table 38). The use of mirtazapine and TCAs is recommended only as a second-line option, and phenelzine may be considered for people with treatment-resistant symptoms. However, as noted previously, extreme caution should used when be prescribing TCAs and MAOIs.
Trials of pharmacotherapy for PTSD comorbid with AOD use disorders have examined the use ofthe antidepressants sertraline, desipramine, and paroxetine, as well as naltrexone and disufiram, pharmacotherpies for alcohol use disorders [837, 849-853]. Early work by Brady and colleagues examining the use of sertraline provided initial evidence of safety and evidence of efficacy among people with less severe alcohol dependence and earlier onset PTSD [849, 850]. More recently, Hien and colleagues [851] investigated the use of sertraline in combination with the psychotherapy Seeking Safety. In this study, Seeking Safety plus sertraline was found to be superior to Seeking Safety with placebo in reducing PTSD symptoms. Improvements in alcohol use and dependence were equivalent between groups.
Petrakis and colleagues [852] conducted an RCT comparing the efficacy of desipramine (a noradrenergic antidepressant) and paroxetine (a serotonergic antidepressant) with and without adjunctive naltrexone among veterans with comorbid PTSD and alcohol dependence. Both groups of antidepressants produced a significant decrease in PTSD symptoms, with greater reductions in alcohol use seen among those who received desipramine. Adjunctive use of naltrexone was associated with a greater reduction in craving, but did not confer any advantage over placebo in terms of alcohol use. These findings are contrary to those found in Foa and colleagues [837] who found naltrexone to be associated with both reductions in craving and alcohol use among individuals with this comorbidity.
Petrakis and colleagues [853] also investigated the use of naltrexone and disulfiram, administered either alone or in combination, compared with placebo. All groups demonstrated equivalent improvement in PTSD symptomology, but the use of either naltrexone, disulfiram, or the combination of these medications led to greater improvements in alcohol use than placebo. However, unwanted side effects were more common among individuals who received the combination of naltrexone and disulfiram.