Meta-analysis of the efficacy of treatments for posttraumatic stress disorder. The tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) act on multiple neurotransmitters including serotonin and norepinephrine. But because of inconsistent results in clinical trials, topiramate is listed as having no demonstrated benefit in the 2017 VA/DoD Clinical Practice Guideline for PTSD. Study Dissociation (ISSD). Eric, a 24-year-old Rwandan refugee living in Uganda(PDF, 27KB), Narrative Exposure Therapy: A Short Term Treatment for Traumatic Stress Disorders, Second Edition. George K., Kebejian L., Ruth L., Miller C., Himelhoch S. Meta-analysis of the efficacy and safety of prazosin versus placebo for the treatment of nightmares and sleep disturbances in adults with posttraumatic stress disorder. Baclofen is used clinically as a muscle relaxant and has GABA-B receptor agonist activity. Note that there are a number of different glutamatergic receptors, including NMDA (n-methyl-d-aspartate), AMPA (-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid), kainate and metabotropic, all of which are potential targets for different medications. These symptoms must persist for more than 1 month and cause functional impairment for a diagnosis to be made. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Methods: Guidelines were identified through electronic searches of MEDLINE, CINAHL, PubMed, Embase and Science Direct, as well as web-based searches of international guideline repositories, websites of psychiatric organisations and targeted web-searches for guidelines from the three most populous English-speaking countries in each continent. %PDF-1.7 Be sure to ask all patients about substance abuse. Knig, J. Be sure to document all other medications that the patient is taking for other medical or psychiatric problems in order to avoid any drug-drug interactions that may interfere with therapeutic efficacy and which may also produce serious side effects. The real question is whether these medications are useful for core PTSD symptoms when psychotic symptoms are not present. It is not fully understood how medications affect different brain circuitry to improve symptoms. Implementing clinical guidelines in psychiatry: A qualitative study of perceived facilitators and barriers. Since some SSRIs such as citalopram can prolong cardiac intraventricular conduction (e.g. Enter your email address below and we will send you the reset instructions, If the address matches an existing account you will receive an email with instructions to reset your password, Enter your email address below and we will send you your username, If the address matches an existing account you will receive an email with instructions to retrieve your username. Stakeholder Involvement focuses on the extent to which the guideline was developed by appropriate stakeholders and represents the views of its intended users (items 46). Otto, M. W., Tolin, D. F., Simon, N. M., Pearlson, G. D., Basden, S., Meunier, S. A., Hofmann, S. G., Eisenmenger, K., Krystal, J. H., & Pollack, M. H. (2010). Elevated brain cannabinoid CB1 receptor availability in post-traumatic stress disorder: A positron emission tomography study. The data presented in this study are available within the article. A., & Rosenthal, N. R. (2007). For patients who prefer pharmacotherapy or who do not have access to trauma-focused psychotherapy, medications remain a treatment option. VA offers treatment options that are proven to be very effective for most people, and many types of professionals at VA can help you to treat PTSD. There is emerging evidence that when given a choice, most patients will select psychotherapy treatment for their PTSD symptoms rather than medications. Wachen, J. S., Dondanville, K. A., Pruiksma, K. E., Molino, A., Carson, C. S., Blankenship, A. E, Wilkinson, C., Yarvis, J. S., & Resick, P. A. found that 38.9% of patients with PTSD had missed at least one work day in the last month due to emotional problems, compared to only 5.4% of people who did not suffer from a mental health condition, and Kessler reported that a PTSD diagnosis increases the likelihood of being homeless by 150% [5,6]. Both the PCL-5 and the CAPS-5 provide a quantitative measure of the patient's PTSD symptoms and response to treatment over time. \_g. After screening patients thoroughly for such problems as sleep apnea or a TBI-related sleep problems, physicians should consider starting patients on the antihypertensive medication prazosin, said Laura Bajor, D.O., a psychiatrist with the James A. Haley Veterans' Hospital in Tampa and lead editor of the updated PTSD psychopharmacology algorithm. Whereas SSRIs as a class were included as first line medications in the 2010 VA/DoD CPG, such across-the-board endorsement is no longer recommended since some SSRIs have either not been tested or have not shown efficacy for treating PTSD. The updated ISTSS PTSD Prevention and Treatment Guidelines Methodology and Recommendations, and Position Papers on Complex PTSD are available to download through the ISTSS website, along with the evidence summaries that generated the recommendations. . This is the only potentially addictive group of medications discussed. McIntyre J. Furthermore, a recent meta-analysis found benzodiazepines to worsen symptom outcome for patients with PTSD (54). All other medications described in this guide are being used "off label" and have empirical support and practice guideline support only. All treatment guidelines for PTSD or nightmares were considered for inclusion. The first step to treatment is to talk with a healthcare provider to arrange an evaluation. Studies show that a number of medications are helpful in minimizing PTSD symptoms. Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences, Therapist Guide. Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: The EMPOWER cluster randomized trial. McAllister, T. W., Zafonte, R., Jain, S., Flashman, L. A., George, M. S., Grant, G. A., He, F., Lohr, J. Keating D., McWilliams S., Schneider I., Hynes C., Cousins G., Strawbridge J., Clarke M. Pharmacological guidelines for schizophrenia: A systematic review and comparison of recommendations for the first episode. Can. PTSD. The AGREE II criteria is a validated assessment tool, which has been used in several similar systematic reviews of treatment guidelines in the area of mental health treatment [52,53,54]. VA/DoD Clinical Practice Guideline for PTSD (2017) Get information on evidence based psychotherapies for PTSD. PTSD comprises four symptom clusters: avoidance, numbing, hyper-arousal and the hallmark re-experiencing or intrusive symptoms, which include unwanted thoughts, flashbacks and nightmares [8]. Martenyi, F., Brown, E. B., Zhang, H., Koke, S. C., & Prakash, A. Aerni, A., Traber, R., Hock, C., Roozendaal, B., Schelling, G., Papassotiropoulos, A., Nitsch, R. M., Schnyder, U., & de Quervain, D. J. ; writingoriginal draft preparation, A.M.; writingreview and editing, M.N., S.K., G.P., J.T. The first study did not address PTSD symptoms specifically, and the second study did not demonstrate an improvement in PTSD symptoms including nightmares. A randomized, double-blind, placebo-controlled trial of augmentation topiramate for chronic combat-related posttraumatic stress disorder. Many systematic reviews of treatment guidelines do not clearly describe the method by which grey literature was searched to locate guidelines, or do not describe a systematic method that could be repeated by other researchers. While direct stimulation of the cannabinoid type 1 receptor (e.g. The general characteristics of each guideline are summarised in Table 2. Unfortunately, anxiety disorders are under-diagnosed and under-treated. Three guidelines scored highly across all AGREE II domains, while others varied between domains. Frank, J. Stein M., McQuaid J., Pedrelli P., Lenox R., McCahill M. Posttraumatic stress disorder in the primary care medical setting. Methods: We screened a total of 110,667 . Davidson, J., Kudler, H., Smith, R., Mahorney, S. L., Lipper, S., Hammett, E., Saunders, W. B., & Cavenar, J. O. Jr. (1990). Efficacy and safety of sertraline treatment of posttraumatic stress disorder: A randomized controlled trial. In these situations, clinicians must use clinical judgement to determine the most appropriate course of action for the patient. Petrakis, I. L., Ralevski, E., Desai, N., Trevisan, L., Gueorguieva, R., Rounsaville, B., & Krystal, J. H. (2012). Furthermore, in one small study, cortisol administered prior to PE demonstrated significantly better retention in treatment especially among those patients with increased sensitivity to glucocorticoids. Castellani A., Girlanda F., Barbui C. Rigour of development of clinical practice guidelines for the pharmacological treatment of bipolar disorder: Systematic review. (1990). We know that psychotherapies are highly effective, she said, reiterating that the PTSD algorithm only assists with the selection of medications as part of multimodal treatment plan. While each case of PTSD has unique biological, psychological and social determinants with differing treatment implications, there are empirically supported treatments that can reduce or alleviate symptoms. Resilience as a predictor of treatment response in patients with posttraumatic stress disorder treated with venlafaxine extended release or placebo. [(accessed on 17 July 2021)]. Please switch auto forms mode to off. MAOIs can also provoke the potentially fatal serotonin syndrome when used concurrently with SSRIs. Cortisol augmentation of a psychological treatment for warfighters with posttraumatic stress disorder: Randomized trial showing improved treatment retention and outcome. The 2010 trial included 35 participants and demonstrated a significant decrease in total CAPS scores. PTSD also carries high levels of psychiatric comorbidities which may be treated with medications. Clarity of Presentation deals with the language, structure, and format of the guideline (items 1517). DSM-5 PTSD Exposure to a Traumatic event 1 re-experiencing symptom - intrusive thoughts/memories, nightmares, flashbacks, intense distress at reminders, physiological re-experiencing 1 Avoidance symptom - avoiding memories/thoughts or specific places/experiences associated with trauma 2 Negative alterations in cognition or mood -inability to remember parts of the Typically provided over a period of about three months with weekly individual sessions. Long-term treatment with paroxetine increases verbal declarative memory and hippocampal volume in posttraumatic stress disorder. Fox, H. C., Anderson, G. M., Tuit, K., Hansen, J., Kimmerling, A., Siedlarz, K. M., Morgan, P. T., & Sinha, R. (2012). Brouwers M.C., Kho M.E., Browman G.P., Burgers J.S., Cluzeau F., Feder G., Fervers B., Graham I.D., Grimshaw J., Hanna S.E., et al. It is important for the prescribing clinician to have an ongoing dialogue with the patient about their medications and side effects. The MAOI phenelzine has been shown to be effective in PTSD (28). EMDR was also included as a first-line psychological option in 43%of the guidelines (Phoenix, BAP, WHO, eTG, NICE and ISTSS). Hit enter to expand a main menu option (Health, Benefits, etc). It is based upon the original EMPOWER trial that was significantly effective in reducing benzodiazepine use in elderly adults (42). Sessions are typically scheduled once per week. Full-text documents of relevant records were then obtained and reassessed against the inclusion criteria by the same researcher. Eye movement desensitization and reprocessing versus cognitive-behavioral therapy for adult posttraumatic stress disorder: Systematic review and meta-analysis. A., & Lee, C. (2008). The evidence in certain fields is unlikely to change in 3 years, or even 10 years, while other rapidly evolving fields may require updates more frequently [40,41,42]. Clinical guidelines: Potential benefits, limitations, and harms of clinical guidelines. The trial published in 2007 included 38 participants and found no significant difference in total CAPS scores between topiramate and placebo. Woolf S., Grol R., Hutchinson A., Eccles M., Grimshaw J. All guidelines generally had lower scores in the applicability domain, while the editorial independence domain saw the greatest variance, with scores between 26100%. Email: ncptsd@va.gov Existing PTSD treatment guidelines are based on reviews of the extent to which levels of evidence sup-port particular treatments, but they do not address the all-important matter of treatment sequencing, or If not, the algorithm recommends prescribing the antidepressants sertraline or paroxetine, which have been approved by the FDA approved for these symptoms). Aurora R.N., Zak R.S., Auerbach S.H., Casey K.R., Chowdhuri S., Karippot A., Maganti R.K., Ramar K., Kristo D.A., et al. CBT = cognitive behaviour therapy, CPT = cognitive processing therapy, CT = cognitive therapy, EMDR = eye movement desensitisation and reprocessing, IRT = image rehearsal therapy, PE = prolonged exposure, SNRI = serotonin-norepinephrine reuptake inhibitor, SSRI = selective serotonin reuptake inhibitor, TCA = tricyclic antidepressant. Another example would be intolerable sexual dysfunction or gastrointestinal side effects due to the effects of increased serotonin levels in the peripheral nervous system. Ketamine as the prototype glutamatergic antidepressant: Pharmacodynamic actions, and a systematic review and meta-analysis of efficacy. Prospective investigation of the impact of cannabis use disorders on posttraumatic stress disorder symptoms among Veterans in residential treatment. There are no currently recognized medications which prevent the development of PTSD after trauma. PTSD Information Voice Mail: (802) 296-6300 Courtois C., Sonis J., Brown L.S., Cook J., Fairbank J.A., Friedman M., Gone J.P., Jones R., La Greca A. Forsner T., Hansson J., Brommels M., Wistedt A.-., Forsell Y. When you meet with a professional, be sure to work together to establish clear treatment goals and to monitor progress toward those goals. Because the event was distressing, children may not want to . In PTSD, one mechanism of action might be to stimulate neuronal connections through brain-derived neurotropic factor (BDNF) based upon animal and clinical studies (21,22). The ePub format is best viewed in the iBooks reader. Lambert, M. L., Whipple, J. L., Hawkins., E. J., Vermeersch, D. A., Nielsen, S. L., & Smart, D. W., (2003). Also, the antipsychotics can reduce psychotic symptoms in PTSD patients. Prazosin is recommended as first-line treatment for nightmares in PTSD in two guidelines (ADAC and AASM) while others recommended it as third-line therapy or included no specific recommendation but discussed potential for its use. It is postulated that prazosin may only be effective in a sub-group of patients experiencing more severe adrenergic dysfunction, who may have been excluded from the negative studies [50,51]. Around one third of guidelines recommended psychotherapy over pharmacotherapy for first-line treatment of PTSD. Y/M = Yes with modifications. Five guidelines (36%) recommended that pharmacological interventions should be second-line to psychological interventions, while the others made no specific recommendation for one over the other. There are times when medications used for PTSD treatment may positively or negatively impact these co-occurring disorders. They concluded that all guidelines should generally be reassessed for validity at 3-year intervals [40]. Brady, K., Pearlstein, T., Asnis, G. M., Baker, D., Rothbaum, B., Sikes, C. R., & Farfel, G. M. (2000). They later met and agreed by consensus on the final averaged scores. (2013). Plasma neuropeptide-Y concentrations in humans exposed to military survival training. Studies suggest that people with elevated blood pressure are more likely to respond to prazosin, while those who drink alcohol or have suicidal thoughts are less likely, she said. Waltman, S. H. (2015). Their recommendations were based on evidence from conducting a systematic review, a consensus process, or a combination of the two. Comparison of nefazodone and sertraline for the treatment of posttraumatic stress disorder. Less strongly supported evidence includes open trials and case reports. Rothbaum, B. O., Price, M., Jovanovic, T., Norrholm, S. D., Gerardi, M., Dunlop, B., Davis, M., Bradley, B., Duncan, E. J., Rizzo, A., & Ressler, K. J. Benzodiazepines for PTSD: A systematic review and meta-analysis. Department of Veterans Affairs and Department of Defense. Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: A revision of the 2005 guidelines from the British Association for Psychopharmacology. Scope and Purpose is concerned with the overall aim of the guideline, the specific health questions, and the target population (items 13). Cognitive enhancers as adjuncts to psychotherapy: Use of D-cycloserine in phobic individuals to facilitate extinction of fear. Murrough, J. W., Huang, Y., Hu, J., Henry, S., Williams, W., Gallezot, J. D., Bailey, C. R., Krystal, J. H., Carson, R. E., & Neumeister, A. Walter, K. H., Bolte, T. A., Owens, G. P., & Chard, K. M. (2012). Randomized placebo-controlled trial of methylphenidate or galantamine for persistent emotional and cognitive symptoms associated with PTSD and/or traumatic brain injury. <> He noted that about 90% of people with PTSD have some co-occurring sleep problems, frequently involving disturbed sleep due to nightmares or night terrors. - Equally effective for PD, GAD, SAD, PTSD - SSRIs are better tolerated than SNRIs - Sexual side effects are the #1 reason for patients . The authors explain their recommendations and with one click you can see the abstracts of the supporting research. Beta blockers reduce both central and peripheral manifestations of hyperarousal and may reduce aggression as well. Psychopharmacology Algorithms. It does not render individual professional advice or endorse any particular treatment for any individuals. Simpson, T.L., Malte, C.A., Dietel, B., Tell, D., Pocock, I., Lyons, R., Varon, D., Raskind, M., & Saxon, A.J. Watts, B. V., Schnurr, P. P., Mayo, L., Young-Xu, Y., Weeks, W. B., & Friedman, M. J. Implementing Cognitive Processing Therapy for Posttraumatic Stress Disorder With Active Duty U.S. Military Personnel: Special Considerations and Case Examples. In cases where a patient with PTSD is experiencing severe psychotic symptoms, both experts recommended these symptoms be treated first with antipsychotics, before addressing sleep issues. The APA notes that the most common medications used for PTSD treatment are selective serotonin reuptake inhibitors (SSRIs) such as: paroxetine (Paxil) fluoxetine (Prozac) sertraline (Zoloft). The limitations so far include a short-term benefit of a few weeks and the anesthetic nature of the drug and potential for addiction. Gelpin, E., Bonne, O., Peri, T., Brandes, D., & Shalev, A. Y. Benzos are not recommended for PTSD. Even treatments that have scientific support will not work for everyone, and carefully monitoring your progress will help you and your mental health professional decide if a different approach should be tried. Beta blockers provide post-synaptic blockade of norepinephrine at synapses and blockade of adrenalin (epinephrine) at the organs such as the heart, sweat glands, and muscles. There are self-rating scales and structured clinical interviews to monitor the effects of treatment recommended in the CPG (1). Finally, domain 6 editorial independence had the greatest variability between guidelines, with four scores of 90% or more (AASM, Phoenix, eTG and APoA) and four scores of 50% or less (CPA, WFSBP, ISTSS & SASOP) (range: 26100%). If you are in crisis or having thoughts of suicide, (2014). Since some patients may have already benefited from prazosin treatment, clinicians are invited to use their own clinical judgment about whether or not to keep their patients on prazosin. Usefulness and limitations of treatment guidelines in psychiatry. A randomized clinical trial of phenelzine and imipramine for posttraumatic stress disorder. ; All authors have read and agreed to the published version of the manuscript. A randomized, double-blind evaluation of D-cycloserine or alprazolam combined with virtual reality exposure therapy for posttraumatic stress disorder in Iraq and Afghanistan War Veterans. Because of prazosin's short half-life, divided dosage schedules may be necessary. Veterans nave to treatment recruited from the community respond as well as civilians in some studies (6) while Veterans with persistent PTSD symptoms (especially older Veterans who have received PTSD treatment for decades) may not respond as well to new treatments (7). The 2017 VA/DoD Clinical Practice Guideline for PTSD recommends trauma-focused psychotherapy as the first-line treatment for PTSD over pharmacotherapy (1). They are the serotonin potentiator, nefazodone (Serzone); the tricyclic antidepressant, imipramine (Tofranil); and the mono-amine oxidase inhibitor, phenelzine (Nardil). When it comes to alleviating symptoms of posttraumatic stress disorder (PTSD), physicians should prioritize treating patients sleep problems, said members of the Harvard South Shore Psychopharmacology Algorithms Project at this years Annual Meeting. Cognitive behavioral therapy notes how changes in any one domain can improve functioning in the other domains. It aims to improve quality of life by reducing symptoms of PTSD such as anxiety, sleep problems and difficulties with concentration. Applicability pertains to the likely barriers and facilitators to implementation, strategies to improve uptake, and resource implications of applying the guideline (items 1821). Becker, M. E., Hertzberg, M. A., Moore, S. D., Dennis, M. F., Bukenya, D. S., & Beckham, J. C. (2007). Despite some promising open label data, there have been two negative RCTs for divalproex and one negative RCT for tiagabine in treating PTSD (37-39). Rigour of Development relates to the process used to gather and synthesise the evidence, the methods to formulate the recommendations, and to update them (items 714). Nicholson, A. There were four guidelines from the US, three from international organisations (the International Society for Traumatic Stress Studies, the World Federation of Societies of Biological Psychiatry and the World Health Organisation) two each from Australia, Canada and the UK, and one from South Africa. See . Intervalla: platform for intellectual exchange, 2, 13- 19. This information enhances the clinical assessment and interview with the patient and is consistent with measurement based care strategies. However, this could lead to a new line of medication research and to newer agents with distinct mechanisms of action for treatment of PTSD. 2nd line - non-trauma-focused psychological therapy. Based upon current knowledge, most prescribing clinicians view pharmacotherapy as an important adjunct to the evidenced-based psychotherapies for PTSD. Davidson, J., Stein, D. J., Rothbaum, B. O., Pedersen, R., Szumski, A., & Baldwin, D. S. (2012). Martin A., Naunton M., Kosari S., Peterson G., Thomas J., Christiensen J. * This guideline has not been reviewed since its publication in 2006. the australian guidelines for the prevention and treatment of acute stress disorder (asd), posttraumatic stress disorder (ptsd) and complex ptsd (the guidelines) provide general and mental health practitioners, policy makers, industry, and people affected by trauma with access to recommendations reflecting current evidence on how to better The neurotransmitter serotonin has a well-recognized role in the modulation of a number of mood and anxiety disorders. Baclofen add-on to citalopram in treatment of posttraumatic stress disorder. Such symptoms include, according to her formulation: Behavioral difficulties (e.g. This guideline covers recognising, assessing and treating post-traumatic stress disorder (PTSD) in children, young people and adults. The Methodology and Recommendations document is available publicly on the internet, but the Evidence Summary documents, and reference lists are available for members only. For example, it has been hypothesized that the long-term effect of antidepressants on mood and anxiety is related to the downregulation of the targeted serotonin synaptic receptors. Simple interventions, such as enlisting family/caregiver support, can go a long way to improve adherence. Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. (2006). Because of these potentially negative effects, it is recommended that benzodiazepines not be used in PTSD. A pilot trial of prazosin, an alpha-1 adrenergic antagonist, for comorbid alcohol dependence and posttraumatic stress disorder. Tannenbaum, C., Martin, P., Tamblyn, R., Benedetti, A., & Ahmed, S (2014). Reference lists of relevant guidelines were also searched manually for further relevant guidelines. divalproex (Depakote): Requires monitoring of liver function tests due to risk of hepatotoxicity and platelet levels due to risk of thrombocytopenia. Every guideline is developed using different methodologies which can influence the quality of recommendations. Divalproex and carbamazepine require regular lab work to monitor side effects, but neither lamotrigine nor topiramate require lab work but must be titrated slowly according to package insert directions to avoid potentially serious side effects. Will self-induce its own metabolism and increase the metabolism of other medications including oral contraceptives. Casey D. Why dont physicians (and patients) consistently follow clinical practice guidelines? Hence, a guideline based on experts clinical knowledge could be highly relevant, and still recommended for use despite low scores in some domains. It is typically delivered in weekly sessions over three months individually or in groups. antihistamines or hypnotics (e.g., zolpidem [ambien], zaleplon [sonata]) may be used for short-term treatment of insomnia in persons with ptsd, and the antidepressant trazodone may be used on a. Bajor said that improving sleep should be a priority because it can impact all other aspects of PTSD treatment. A subsequent large-scale multi-site trial of risperidone as an adjunctive agent for SSRI poor/partial responders showed that there was no benefit (in comparison with a placebo group) for adjunctive use of this agent (42). Nefazodone is an effective medication. Adjunctive risperidone treatment for antidepressant-resistant symptoms of chronic military service-related PTSD. Divalproex in the treatment of posttraumatic stress disorder: a randomized, double-blind, placebo-controlled trial in a Veteran population. A molecular and cellular theory of depression. (2016). The updated algorithm includes a 36-day titration guideline to reach these levels from the initial dose of 1 mg per night. Australian Guidelines for PTSD (2020) You may switch to Article in classic view. the display of certain parts of an article in other eReaders. Exceptions may occur for patients based upon their individual histories of side effects, response, comorbidities and personal preferences. A secondary search following the same methods was completed in September 2020 to identify any guidelines published after the initial search. It is important for the patient to take an active role in his or her treatment rather than feeling they are a passive recipient of medications to alleviate their symptoms. These medications were originally developed for patients with a psychotic disorder, there has been an interest in these medications as treatment for many other psychiatric disorders including PTSD. In addition, a systematic review of CBT for PTSD found that specific trauma-focused therapies were all superior to supportive, non-trauma-focused therapies [46]. A trial of prazosin for combat trauma PTSD with nightmares in active-duty soldiers returned from Iraq and Afghanistan. We're here Monday through Friday, 8:00 a.m. to 9:00 p.m. Morgan, C. A., 3rd, Wang, S., Southwick, S. M., Rasmusson, A., Hazlett, G., Hauger, R. L., & Charney, D. S. (2000). We have also highlighted a significant lack of information regarding the targeted treatment of nightmares, despite the availability of both psychological and pharmacological treatments. When all SSRIs were grouped together and compared to placebo, a small positive effect size was seen; however, based on current evidence it seems that greater benefit would be seen using either paroxetine or fluoxetine over other SSRIs [43].
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