What is the recommended management for Post-Traumatic Stress Disorder (PTSD)?

Management of Post-Traumatic Stress Disorder (PTSD)

Trauma-focused psychotherapy should be used as first-line treatment for PTSD, with specific manualized approaches including Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), or Eye Movement Desensitization and Reprocessing (EMDR) showing superior outcomes compared to pharmacotherapy alone. 1, 2

First-Line Treatment Algorithm

1. Trauma-Focused Psychotherapy:

   • Implement one of these evidence-based approaches:
     • Prolonged Exposure (PE)
     • Cognitive Processing Therapy (CPT)
     • Eye Movement Desensitization and Reprocessing (EMDR)
   • These therapies directly address traumatic memories and their impact on thoughts, emotions, and behaviors
   • Deliver in 8-12 weekly sessions, with each session typically lasting 60-90 minutes
   • Video teleconferencing is an effective delivery method when in-person therapy is unavailable 1

2. Pharmacotherapy (if needed concurrently or if psychotherapy is unavailable):

   • First-line medications:
     • Sertraline (50-200 mg/day) 3
     • Paroxetine (20-60 mg/day) 4
     • Venlafaxine (extended-release)
   • Start at lower doses and titrate up based on response and tolerability
   • Continue effective medication for at least 6-12 months to prevent relapse 2

Treatment Monitoring and Adjustment

• Use standardized PTSD measures (e.g., PCL-5) to track progress weekly
• If inadequate response after 8-12 weeks:
  1. Switch to an alternative trauma-focused therapy approach
  2. Adjust medication dose or switch to another first-line medication
  3. Consider combination therapy (psychotherapy + medication)

Important Cautions

• Strongly avoid benzodiazepines - they may worsen outcomes and lack empirical support 1, 2
• Avoid cannabis and cannabis-derived products - not recommended per current guidelines 1
• For patients with nightmares, consider targeted treatment (e.g., prazosin) rather than benzodiazepines 2

Special Considerations

• Comorbidities: Psychiatric comorbidities (especially depression and substance use) are common in PTSD and should be treated concurrently 2
• Treatment Duration: Effective treatment should continue for at least 6-12 months, with periodic reassessment 2, 3
• Delivery Method: Secure video teleconferencing is effective for delivering psychotherapy when validated for that format 1

Emerging Treatments

While several novel approaches show promise in preliminary research, including MDMA-assisted psychotherapy, ketamine, and transcranial magnetic stimulation 5, these are not yet included in clinical practice guidelines and should not replace established first-line treatments.

Treatment Efficacy

The effectiveness of trauma-focused psychotherapies is well-established, with higher response rates compared to pharmacotherapy alone 1, 2. While SSRIs like sertraline and paroxetine have demonstrated efficacy in multiple controlled trials 6, they typically produce partial symptom reduction rather than complete remission 6.

The most recent evidence strongly supports prioritizing trauma-focused psychotherapy as the cornerstone of PTSD treatment, with pharmacotherapy serving as an important adjunct or alternative when psychotherapy is not feasible or insufficient alone 1, 2.