Propranolol for PTSD treatment

Leo Sher, M.D.

Posttraumatic stress disorder (PTSD) is a difficult, frequently chronic and often incapacitating psychiatric disorder (1). PTSD arises in some individuals subsequent to exposure to a traumatic episode involving real or threatened harm to themselves or other people. PTSD is characterized by intrusive thoughts, nightmares and flashbacks of traumatic events, dysphoric mood and negative cognitions, avoidance of reminders of trauma, hypervigilance, and sleep abnormalities. PTSD leads to substantial social, occupational, and interpersonal dysfunction.

Various psychopharmacological agents including SSRIs and SNRIs were studied as potential treatments of PTSD (1-3). Only sertraline and paroxetine have been approved by the U.S. FDA for the treatment of PTSD. Some studies examined the use of propranolol for PTSD treatment (1-6). Published propranolol studies include a retrospective chart review, a prospective cohort study, and a number of randomized clinical trials (6).

It has been proposed that PTSD may be a result of excessive adrenergic activation instantly after trauma leading to over-consolidation of traumatic memories (5). Some authors proposed a potential use for beta-adrenergic blockers such as propranolol in the early prevention or subsequent treatment of PTSD (1). Propranolol is a beta-adrenergic antagonist that is FDA-approved for many indications including hypertension, angina, atrial fibrillation and arrhythmias, migraine prophylaxis, and essential tremor (6). Propranolol is not approved for any psychiatric indications. Propranolol is a lipophilic substance and can cross the blood brain barrier, thus blocking norepinephrine receptors in the brain, and, in theory, blocking over-consolidation (5).

Most studies suggest that propranolol administered prior to trauma memory reactivation reduce the severity of PTSD symptoms, diminish physiological responses (e.g., heart rate, skin conductance, blood pressure), and enhance cognitive performance in persons with PTSD (6). When used as a preventative measure following trauma, propranolol do not significantly decrease the risk for consequent PTSD or acute stress disorder compared to placebo or no treatment. Furthermore, individuals who were given propranolol do not reliably show improvements in PTSD symptoms in comparison to people who received placebo or no treatment. More studies investigating the use of propranolol for PTSD treatment are probably needed.

References

  1. Stein MB. Pharmacotherapy for posttraumatic stress disorder in adults. UpToDate, 2021. URL: https://www.uptodate.com/contents/pharmacotherapy-for-posttraumatic-stress-disorder-in-adults
  2. Searcy CP, Bobadilla L, Gordon WA, Jacques S, Elliott L. Pharmacological prevention of combat-related PTSD: a literature review. Mil Med. 2012 Jun;177(6):649-54. doi: 10.7205/milmed-d-11-00390.
  3. Akiki TJ, Abdallah CG. Are there effective psychopharmacologic treatments for PTSD?. J Clin Psychiatry. 2018;80(3):18ac12473. Published 2018 Dec 18. doi:10.4088/JCP.18ac12473
  4. Garakani A, Murrough JW, Freire RC, Thom RP, Larkin K, Buono FD, Iosifescu DV. Pharmacotherapy of anxiety disorders: Current and emerging treatment options. Front Psychiatry. 2020 Dec 23;11:595584. doi: 10.3389/fpsyt.2020.595584.
  5. Gibbs EN, Cates ME. The role of propranolol for post-exposure chemoprophylaxis of posttraumatic stress disorder and acute stress disorder. Mental Health Clinician 2013, 2 (7): 204–208. https://doi.org/10.9740/mhc.n131052
  6. Young C, Butcher R. Propranolol for post-traumatic stress disorder: A review of clinical effectiveness [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2020 Mar 18. URL: https://www.ncbi.nlm.nih.gov/books/NBK562942/

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