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

Treatment of Post-Traumatic Stress Disorder (PTSD)

Trauma-focused psychotherapies are the recommended first-line treatment for PTSD, with medications such as sertraline and paroxetine serving as second-line options or adjuncts to therapy. 1

First-Line Treatment: Trauma-Focused Psychotherapies

• Trauma-focused psychotherapies that directly address the traumatic event are considered the most effective treatments for PTSD and should be offered as first-line treatment 1
• Evidence-based trauma-focused psychotherapies include:
  • Prolonged Exposure (PE) 1
  • Cognitive Processing Therapy (CPT) 1
  • Eye Movement Desensitization and Reprocessing (EMDR) therapy 2, 1
  • Cognitive Behavioral Therapy (CBT) focused on trauma 1

Phase-Based Approach for Complex PTSD

• For complex PTSD (cPTSD), a phase-based approach is recommended by expert consensus 2:
  • Phase I: Stabilization - focusing on safety, reducing self-regulation problems, and improving emotional competencies 2
  • Phase II: Trauma processing - directly addressing and processing trauma memories 2
  • Phase III: Reintegration - consolidating treatment gains and adapting to current life circumstances 2

Pharmacotherapy Options

• Two FDA-approved medications for PTSD:
  • Sertraline (50-200 mg/day) - maintenance treatment may be needed for up to 28 weeks 3
  • Paroxetine (20-50 mg/day) - demonstrated efficacy in multiple controlled trials 4
• Pharmacotherapy should be considered when:
  • Patients have residual symptoms after psychotherapy 5
  • Patients are unable or unwilling to access psychotherapy 5
  • Additional symptom management is needed alongside psychotherapy 6

Special Considerations for Sleep Disturbances

• Sleep disturbances are common in PTSD and may require targeted treatment 5
• Prazosin is effective for PTSD-related sleep disturbance and nightmares 5
• Patients with PTSD should be evaluated for obstructive sleep apnea, which is common in this population 5

Treatment Algorithms and Decision-Making

1. Initial Treatment Decision:

   • Begin with trauma-focused psychotherapy for most patients 1
   • Consider medication if psychotherapy is unavailable or patient preference strongly favors medication 2

2. For Complex PTSD:

   • Begin with stabilization phase focusing on safety and emotion regulation 2
   • Progress to trauma processing only when patient has adequate coping skills 2
   • Complete treatment with reintegration phase 2

3. For Partial Response:

   • Consider combination of psychotherapy and medication 6
   • Add targeted treatments for specific residual symptoms (e.g., prazosin for nightmares) 5

Common Pitfalls and Caveats

• Psychological debriefing immediately after trauma is not recommended and may be harmful 2
• Benzodiazepines have not proven useful in controlled trials and may cause rebound effects upon discontinuation 7
• Relapse is common after medication discontinuation; longer-term treatment may be necessary 2, 3
• The distinction between PTSD and complex PTSD remains controversial, with some evidence suggesting differences in symptom severity rather than type 2

Emerging Treatments

• MDMA-assisted psychotherapy and other psychedelic treatments show promise but are not yet FDA-approved 1, 8
• Combining psychedelics with evidence-based psychotherapies may enhance treatment response 1, 8
• Other investigational approaches include neuropeptide Y, oxytocin, cannabinoids, and neuroactive steroids 8