Frequently Asked Questions

The most commonly prescribed PTSD-indicated medications were low-dose trazodone used as a hypnotic (n = 116), zopiclone (n = 112), zolpidem (n = 82), doxazosin (n = 81), and quetiapine (n = 78). At the class level, antidepressants and hypnotics were the most frequently prescribed medication classes for PTSD. The study also found that SSRIs and SNRIs were widely used and often formed the basis of treatment regimens, especially among patients prescribed fewer medications.

Polypharmacy was common. Of 438 patients with a primary diagnosis of PTSD, 432 (98.6%) were prescribed at least 1 medication, with a mean of 3.04 PTSD-indicated medications per patient (SD = 1.65) and 3.69 medications per patient for any condition (SD = 1.78). The authors interpreted the frequent use of 3 or more PTSD-related medications as reflecting attempts to manage persistent symptom clusters such as sleep disturbance, nightmares, hyperarousal, and mood dysregulation in a chronically ill, highly comorbid population.

Yes. SSRIs and SNRIs remained central to PTSD treatment in the participating operational stress injury clinics and were described by the authors as broadly consistent with international guideline recommendations for first-line pharmacotherapy. The study found that these antidepressants were frequently used, particularly among patients receiving fewer medications, even though many regimens also included adjunctive symptom-targeted agents.

Patients in this sample generally had chronic illness and long treatment exposure. The mean PTSD chronicity was 8.15 years (SD = 5.27), and 274 of 438 patients (62.6%) had received pharmacologic treatment for PTSD for 5 years or longer. The authors used these findings to frame the cohort as one with extensive treatment histories rather than newly diagnosed PTSD.

Sleep-targeted prescribing was very common. Among patients prescribed at least 1 hypnotic (n = 283), 94.0% (n = 266) received it for PTSD; among those prescribed 2 or more hypnotics (n = 77), 96.1% had them prescribed for PTSD. Low-dose trazodone used as a hypnotic, zopiclone, and zolpidem were all among the most common PTSD-indicated medications, which the authors suggest may reflect efforts to manage persistent sleep disturbance in chronic PTSD.

When an SSRI or SNRI was prescribed, the most common coprescribed class was hypnotics. For patients on SSRIs (n = 158), the 5 most frequent coprescribed classes were hypnotics (63.9%), antiadrenergics (41.1%), antipsychotics (27.2%), benzodiazepines (19.6%), and atypical antidepressants (13.9%). For patients on SNRIs (n = 142), the corresponding figures were hypnotics (66.2%), antiadrenergics (40.1%), antipsychotics (28.2%), benzodiazepines (24.6%), and atypical antidepressants (19.7%).

Yes. The study found significant differences by site (P < .001) across most medication classes and antidepressant subclasses, indicating substantial variability in prescribing patterns across participating clinics. The authors note that these differences may reflect variation in patient populations, clinical complexity, operational constraints, and local practice patterns.

Psychiatrists most consistently rated clinical factors as important. Positive prior experience with a specific medication, tolerability and avoidance of known adverse effects, potential interactions with current medications or substances, and comorbid physical conditions were universally rated as important at least to some degree. Factors more often rated as not important or somewhat unimportant included provincial formulary or accessibility (45%), patient insurance coverage (25%), difficulty accessing the drug in the clinic or region (20%), and patient diet and lifestyle (20%).

The study suggests that divergence from first-line guideline recommendations often reflected clinical complexity rather than indiscriminate prescribing. Patients commonly had chronic PTSD, high rates of psychiatric and medical comorbidity, and long prior treatment histories, and clinicians appeared to add adjunctive medications to target persistent insomnia, nightmares, hyperarousal, acute anxiety, and comorbid symptoms when SSRIs or SNRIs alone were insufficient, poorly tolerated, or slow to act.

The main limitations were that the study was cross-sectional, could not capture the full clinical reasoning behind prescribing decisions, and did not examine the role of psychotherapy in shaping medication strategies. The authors also note that prescribing variability may partly reflect patient demographic differences that were not fully explored, and that the participating clinics may not represent the entire Canadian OSI network because inclusion depended in part on local ethics approval and research capacity. As a result, the findings are best interpreted as reflecting participating sites rather than all OSI clinics in Canada.