Another Expert Opinion on PTSD Treatment: Prazosin, SSRIs, and Mirtazapine
Researcher Albert Sattin has had extensive experience treating veterans with post-traumatic stress disorder (PTSD) in the U.S. Department of Veteran’s Affairs medical system. He believes that what is known as “treatment resistance” is really under-treatment, and he described his recommended regimen for thorough treatment of PTSD to this editor (Robert M. Post) at the 2015 meeting of the Society of Biological Psychiatry in May.
One of the key elements in the regimens he prescribes for patients with PTSD is prazosin, an alpha-1 antagonist drug used to treat hypertension. Extensive placebo-controlled data by another researcher, Murray Raskind, and colleagues supports the use of prazosin in PTSD. It is typically used to prevent nightmares, but Raskind, Sattin, and others find it has a broad range of positive effects in most domains of PTSD.
Sattin’s key insight is that prazosin should be administered three times a day because of its short half-life. This allows for the treatment of daytime as well as sleep-related PTSD symptoms. Sattin has patients choose from three schedules: 6am, 2pm, 10pm; 7am, 3pm, 11pm; or 8am, 4pm, 12am. Prazosin comes in 1mg, 2mg, and 5mg tablets, but patients must begin by taking the 1mg doses to reduce the risk of orthostatic hypotension (low blood pressure upon standing up), slowly increasing the dose as tolerated and if needed for symptom improvement.
Raskind reported in a poster at the same meeting that in a study of active duty combat soldiers, elevated blood pressure at baseline predicted that a patient would respond well to prazosin, so for patients with elevated blood pressure, Sattin starts with prazosin.
For other patients, Sattin begins by prescribing one of the two selective serotonin reuptake inhibitors (SSRIs) approved by the Federal Drug Administration for use in PTSD—sertraline (Zoloft) or paroxetine (Paxil)—and then adds the antidepressant mirtazapine (Remeron) if necessary. If the patient still remains symptomatic, Sattin then adds prazosin to the regimen with the added warning to take time sitting up or standing up to avoid potential dizziness from low blood pressure.
The SSRIs shut down the firing of noradrenergic (NE) and serotonergic (5HT) neurons. Sattin sees the mirtazapine as important in reversing this shut-down. Mirtazapine blocks the inhibitory alpha-2 autoreceptors on these neurons and thus increases their firing. Because mirtazapine also blocks 5HT-2 receptors and H-1 receptors (with antihistamine effects), it can be quite sedating. The sedation can help patients with the profound sleep disturbance that typically accompanies PTSD.
Editor’s Note: It is important to remember that Sattin’s opinions reported to this editor at the meeting are just that, i.e. the personal treatment preferences of one individual clinician.
Most information provided in the BNN is preliminary and based on abstracts, presentations at scientific meetings, and anecdotal reports, which cannot fully reflect the risk to benefit ratio of pursuing any particular treatment.
A patient’s treating physician, who is medically responsible for their care, must research and confirm the appropriateness of any treatment. What one doctor might recommend, another might condemn.
In this regard it is interesting to note the dramatic differences in the PTSD treatment strategies of Sattin versus researcher David Bakish, whose recommendations we described in 2014. Bakish offered an extensive, complicated treatment sequence using multiple drugs to target different symptoms of PTSD, and none of the drugs he typically uses overlap with those used by Sattin.
