Let's face it, when our patients are in distress, we use whatever meds we think might be helpful, whether the FDA has given its blessing or not. Not a single one of the nostrums discussed in this article is FDA-approved for PTSD, but they are all commonly used when nothing else works.

Benzodiazepines. Who among us has not tried a dusting of Klonopin (clonazepam) for patients with intrusive memories and hyperarousal that are not responding to SSRIs? I have two surprises for you. Number one: only three tiny controlled trials have been published examining the use of benzos in PTSD. Number two: they've all been negative. In fact, one study found that giving recent trauma victims Klonopin or Xanax (alprazolam) in the hopes of preventing the development of PTSD was quite countertherapeutic: six months after the trauma, 69% of the benzo group developed PTSD, vs. only 15% of the placebo group (J Clin Psychiatry 1996; 57:390-394). Does this mean that the occasional short-term use of a benzo for insomnia is contraindicated? Probably not, but don't think that you're targeting core PTSD symptoms.

Topamax (topiramate). Somehow, based on a single openlabel study of Topamax for 35 patients with chronic PTSD, published in 2002, funded by the manufacturer and cowritten by one of its employees (J Clin Psychiatry 2002;63:16-20), a powerful Topamax buzz got generated in the psychiatric community, and for a while it seemed everyone was prescribing it for flashbacks. Let's get sane here.

This was a chart review study of 35 consecutive PTSD patients who sought treatment for their symptoms. Almost all patients were also diagnosed with either depression or bipolar disorder, and all but seven were on at least one other psychotropic medication, to which Topamax was added. Topamax was started at 25 mg QD, and increased by 25 to 50 mg every three to four days until there was a clinical response. The results were impressive: 79% reported either partial or full suppression of nightmares, and 86% reported similar improvement in flashbacks. The average effective dose was 79 mg QD.

So what's there not to like about Topamax for PTSD? Not much, if it works like this for everybody. But without a control group, we can't rule out a placebo effect, nor do we know how long the improvement lasted. Caveat treater!

Neurontin (gabapentin). Where Topamax has trod, you know Neurontin can't be far behind. In another chart review study (Ann Clin Psychiatry 2001; 13:141-6), researchers reviewed records of 30 PTSD patients who had been given adjunctive Neurontin, with a dose range of 300- 3600 mg QD. Most patients slept better on Neurontin, and had fewer nightmares, but other PTSD symptoms weren't touched much. That would make Neurontin a pretty expensive sleeping pill in PTSD, but at least it's non-addictive.

Atypical Antipsychotics. A good review article has recently been published focusing on antipsychotics in PTSD (Ann Clin Psychiatry 2003;15:193-201). The strongest evidence is for Risperdal (risperidone), which has been found helpful as adjunctive treatment in two double blind controlled trials. Adjunctive Zyprexa (olanzapine) was more effective than placebo in one controlled trial, but didn't differ from placebo when used as monotherapy in another trial. Beyond this, we're dealing with small case reports, which have profiled patients here and there who have had robust responses to Risperdal, Zyprexa, and Seroquel (quetiapine).

TCR VERDICT: They’re off-label so use with caution!