Medications For Combat PTSD

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3. Other drugs for special circumstances

   1. Trazodone (Desyrel) for sleep

      Trazodone is a non-toxic anti-depressant that has a useful side-effect: It causes drowsiness, and people don't get tolerant to this effect. Because fluoxetine slows the rate that the liver breaks down trazodone, much lower doses are needed for sleep by patients on fluoxetine than people who are not on fluoxetine.

   2. Quinine for nocturnal myoclonus

      This is the "sleep jerks." If quinine works, the veteran himself may not notice much but his wife has much better sleep.

   3. Low-dose antipsychotics for violent urges: thioridazine (Mellaril), mesoridazine (Serentil), etc.

      The key here is brief treatment on an as-needed basis, controlled by the veteran himself [for a limited time, when hospitalization is not possible]. The doses needed have been low, and I prefer the sedating anti-psychotics like thioridizine and mesoridizine, which appear to carry the least risk of dangerous (neuroleptic malignant syndrome) or possibly irreversible (tardive dyskinesia) complications. An unexpected additional use for these drugs also involves brief, low-dose treatment: to help someone who wants to get off marijuana get through the withdrawal syndrome.

4. Future drugs

   Many combat veterans with PTSD feel dead inside. It is possible that this psychic numbing comes from the brain making its own opium-like substances, and that opiate blockers can give people back their feelings. It is not yet clear whether this works.

   I hope the future will bring a drug like clonidine (trade name: Catapres) that people do not develop a tolerance to. In my experience, about one out of five combat veterans with PTSD experience major improvement of almost all of their PTSD symptoms on clonidine -- but the heartbreak has been that they grew tolerant to it in about a week. Any future drug in this family that does not induce tolerance to this effect will relieve much suffering. A new drug in this family, guanfacine (tradename, Tenex) has recently appeared, but I have no experience with it and have not heard any reports of usefulness to combat veterans with PTSD.

   The most helpful drugs are likely to be ones that don't yet exist.

D. Drugs to avoid

One of the useful things I do for veterans I see is help them identify and get off of drugs that they use (whether prescribed by doctors of not) that are harming them. Some of what I say here is likely to be controversial.

1. Benzodiazepines: diazepam (Valium), alprazolam (Xanax), lorazepam (Ativan), etc.

   Disinhibition: All the drugs in this class are similar to alcohol. Some people who "lose all their inhibitions" on either alcohol or benzos or both. This "dis-inhibition" can affect practically anything that a person thinks he might like to do -- but doesn't do -- when sober. It has included suicide and murder, but most often involves saying things that cumulatively do great damage to a veteran's life. A lot of family stress among veterans comes from things said to wives and children the veteran wishes he hadn't said, the moment it was out of his mouth. One of the inhibitions that benzos weakens is the inhibition about saying hurtful things to people we love. Memory loss: All of the benzos weaken the ability to remember what happened a short time ago, including things you yourself did or said. The more potent the benzo, the more it wipes out short-term memory -- this is probably why Halcion (generic name: triazolam) has been such a bad actor, it's one of the most potent. Here's a little scene that everyone has experienced one way or another:

"I'm going out for cigarettes -- want anything?" "Quart of orange juice and a box of Pampers." "OK" Half hour later you're back -- with your cigarettes! No one is 100% on things like this, but people on benzos are sometimes close to zero.

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Short-term memory is something that everyone needs to make relationships work, at home, at work, or anywhere. There's the additional stress that combat vets have when they find themselves forgetting -- they have been in real situations where people died because someone forgot. The tension and guilt that this creates in everyday life can be unbearable, and veterans often do not know that their benzodiazepines are responsible for memory lapses.

continue: PTSD and the Dangers of Benzos, Caffeine, Yohimbine

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Reviewed: 04/2006