Key Takeaways

From the Authors As published in the article
  1. Pharmacotherapy for posttraumatic stress disorder (PTSD) within Canadian operational stress injury (OSI) clinics commonly involves polypharmacy and adjunctive medication use, particularly among patients with chronic PTSD, extensive treatment histories, and psychiatric comorbidities.
  2. Although selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors remain the foundation of PTSD treatment, clinicians frequently incorporate symptom-targeted agents (eg, hypnotics, antiadrenergics, and antipsychotics) to address persistent insomnia, nightmares, hyperarousal, and comorbid symptoms.
  3. Substantial variation in prescribing across OSI clinics highlights the need for clearer pragmatic guidance, shared case review, and cross-site quality-improvement strategies to support consistent, evidence-informed care while preserving individualized clinical judgment.
Extended Takeaways
  1. Medication use was nearly universal in this cohort: 432 of 438 patients (98.6%) received at least 1 medication, with a mean of 3.04 (SD = 1.65) PTSD-indicated medications per patient, suggesting that medication reconciliation and cumulative adverse-effect monitoring should be routine in operational stress injury clinics.
  2. Sleep-targeted prescribing was prominent across regimens, with low-dose trazodone used as a hypnotic (n = 116), zopiclone (n = 112), and zolpidem (n = 82) among the most common PTSD-indicated agents; persistent insomnia appears to be a major driver of treatment complexity in chronic posttraumatic stress disorder care.
  3. Among patients prescribed only 1 medication for PTSD (n = 59), sertraline (15.3%) was most common, whereas in those prescribed 6–9 medications (n = 34), nabilone (52.9%), doxazosin (52.9%), and trazodone (47.1%) predominated, indicating a shift from standard antidepressant monotherapy toward symptom-cluster targeting as regimen complexity increases.
  4. When an SSRI or SNRI was used, the most frequent coprescribed class was hypnotics (SSRIs: 63.9%, SNRIs: 66.2%), followed by antiadrenergics (SSRIs: 41.1%, SNRIs: 40.1%) and antipsychotics (SSRIs: 27.2%, SNRIs: 28.2%); clinicians should anticipate and monitor common augmentation patterns rather than assuming antidepressant monotherapy.
  5. Long treatment exposure was common: the average chronicity of PTSD was 8.15 years (SD = 5.27), and 62.6% had received pharmacologic treatment for PTSD for ≥5 years, which may help explain why adjunctive and maintenance prescribing extended beyond first-line guideline recommendations.
  6. Formulary and access factors were less influential than clinical considerations in psychiatrist self-report, with provincial formulary/accessibility rated as not important or somewhat unimportant by 45% and patient’s insurance coverage by 25%; prescribing decisions in these clinics appear to be driven more by prior response, tolerability, interactions, and comorbid physical illness.
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Physicians Postgraduate Press, Inc. (PPP) makes no warranties about the accuracy or completeness of any information published in The Journal of Clinical Psychiatry or other PPP materials, and disclaims liability for any use or non-use of that information. Clinicians should not rely solely on these materials and should exercise their own professional judgment when making patient care decisions on an individualized basis.

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