What are the recommended non-sedative treatments for post-traumatic stress disorder (PTSD)?

Non-Sedative Treatments for PTSD

Trauma-focused psychotherapy is strongly recommended as the first-line treatment for persistent symptoms of PTSD, with significantly superior outcomes compared to medication alone. 1

First-Line Psychotherapy Options

Cognitive Behavioral Therapy (CBT) approaches have the strongest evidence for treating PTSD:

• Prolonged Exposure (PE): Systematically exposes patients to trauma-related memories and situations they've been avoiding
• Cognitive Processing Therapy (CPT): Helps patients challenge and modify unhelpful beliefs related to the trauma
• Eye Movement Desensitization and Reprocessing (EMDR): Combines exposure to traumatic memories with bilateral sensory stimulation

These trauma-focused psychotherapies have demonstrated superior efficacy compared to medication alone and should be initiated first when available 1. Exposure therapy in particular has gained the strongest support across diverse populations and has been successfully implemented in community clinics in the US and Israel 2.

First-Line Pharmacological Options (Non-Sedating)

When psychotherapy is unavailable, declined, or insufficient, the following medications are recommended:

1. SSRIs (Selective Serotonin Reuptake Inhibitors):

   • Sertraline: 50-200 mg/day (FDA-approved for PTSD) 3
   • Paroxetine: 20-60 mg/day (FDA-approved for PTSD) 1
   • Fluoxetine: Has demonstrated efficacy in clinical trials 4

2. SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors):

   • Venlafaxine: Considered a second-line option with promising results 4, 5

Treatment Algorithm

1. Start with trauma-focused psychotherapy when available and acceptable to the patient

   • PE, CPT, or EMDR for 8-12 weeks

2. If psychotherapy is unavailable, declined, or insufficient:

   • Start SSRI (sertraline 50 mg/day or paroxetine 20 mg/day)
   • Titrate dose based on response and tolerability
   • Continue for at least 6-12 months to prevent relapse 4

3. For partial response to SSRIs:

   • Consider augmentation with atypical antipsychotics for residual symptoms 6
   • Consider prazosin specifically for nightmares and sleep disturbances 1

4. For non-response to SSRIs:

   • Switch to venlafaxine or another SSRI
   • Consider referral to specialized mental health services

Important Considerations

• Avoid benzodiazepines: Despite their anxiolytic properties, benzodiazepines are ineffective for PTSD and may worsen outcomes 1, 6

• Medication discontinuation: When discontinuing SSRIs, taper gradually as there is a significant risk of relapse upon discontinuation 2

• Treatment duration: Maintenance treatment for 6-12 months decreases relapse rates 4

• Cultural factors: Cultural adaptation of CBT should be considered as cultural factors significantly influence the presentation and treatment of PTSD 1

For Specific Symptom Management

• For PTSD-related nightmares: Prazosin (starting at 1 mg at bedtime, gradually increased to effective dose, average 3 mg, range 1-15 mg) 1

• For hyperarousal symptoms: Consider clonidine (0.2-0.6 mg in divided doses) with blood pressure monitoring 1

• For residual symptoms: Consider topiramate or other anticonvulsants, particularly when impulsivity and anger predominate 4, 5

Treatment Efficacy

Response rates to SSRIs typically range from 53-85% of patients, though complete remission occurs in only 20-30% of cases 4, 7. This underscores the importance of considering combination treatments and addressing specific symptom clusters when full remission is not achieved with first-line treatments.