SSRIs and Venlafaxine for PTSD: Guideline and Label Facts

What these medicines are

Selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) are types of antidepressant. The National Center for PTSD says they are believed to help with PTSD by acting on brain chemicals, called neurotransmitters, that are tied to managing stress.

It also says that in general the three listed here appear to work equally well for PTSD. A difference in the facts below is not a sign that one should be preferred. That choice depends on your history, and it belongs to you and your prescriber.

Sertraline

Sertraline (Zoloft) is an SSRI. Its label lists PTSD alongside major depressive disorder, obsessive-compulsive disorder, panic disorder, social anxiety disorder and premenstrual dysphoric disorder. The guideline's discussion says six industry-sponsored trials found a clinically significant benefit, and that the two trials done in Veterans showed no benefit on the clinician-rated PTSD measure.

The label names these as the most common side effects across its trials: nausea, diarrhea or loose stool, tremor, indigestion, decreased appetite, heavy sweating, ejaculation failure and decreased sex drive. It also lists pimozide among medicines not to combine with it.

Paroxetine

Paroxetine (Paxil) is an SSRI. The Paxil label lists PTSD in adults, among other conditions. The Paxil CR extended-release product has a separate label that does not list PTSD. The guideline says the six paroxetine trials it looked at gave an overall positive benefit compared with placebo, though results varied, with three showing benefit and three not.

The guideline notes people with PTSD treated with paroxetine were more likely to withdraw from treatment because of adverse events, and that it was associated with more side effects than placebo in five of those six trials. The label's common side effects include nausea, sweating, sleepiness, insomnia, dry mouth, dizziness, tremor and sexual side effects. It also warns about harm to a developing baby, so tell your prescriber if you are pregnant, planning to be, or breastfeeding.

Venlafaxine

Venlafaxine (Effexor XR) is an SNRI. The Effexor XR label lists major depressive disorder, generalized anxiety disorder, social anxiety disorder and panic disorder in adults. PTSD is not listed, so using it for PTSD is off-label. The guideline's support comes from two trials that showed benefit on clinician-rated PTSD scores.

One documented difference is blood pressure. The label reports dose-related increases and says blood pressure should be checked before and regularly during treatment. Its common side effects include nausea, sleepiness, dry mouth, sweating, decreased appetite, constipation and sexual side effects.

Boxed warning and shared safety points

All three labels have a boxed warning. Antidepressants increased the risk of suicidal thoughts and behaviors in children, teens and young adults, and everyone taking them should be closely watched for worsening and new suicidal thoughts, especially during the first few months and at dose changes. If you or someone you know is in crisis, call or text 988, or call 911. Locascio Wellness does not provide emergency services.

• MAOIs: all three labels say not to take them with, or within 14 days of stopping, this group of medicines, because of serotonin syndrome risk.
• Stopping: the labels advise a gradual dose reduction rather than stopping abruptly, so do not stop without talking to your prescriber.
• Bipolar disorder: labels say to screen for it, because these medicines can bring on mania or hypomania. Share your full history.

Other antidepressants in the guideline

The guideline says there is insufficient evidence to recommend for or against fluoxetine, citalopram and escitalopram among SSRIs, or desvenlafaxine and duloxetine among SNRIs. For fluoxetine it notes this is a change: the 2017 edition recommended it, and a later review found no benefit. Its label does not list PTSD, so that use is off-label. The guideline suggests against vortioxetine for PTSD (Weak against).

Talking this through online

A licensed psychiatrist on our team treats trauma by secure video for people physically located in Pennsylvania or New York during each visit. Whether any of these is an option for you is a decision for you and your prescriber. Ask us whether our psychiatrist can help through our medication care contact form. Our online trauma treatment page explains therapy and medicine groups together. Therapy with our team is not available in New York. Finding a plan that fits can take time, and it is reasonable to feel hopeful about the process.