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

Treatment of Post-Traumatic Stress Disorder (PTSD)

The most effective first-line treatments for PTSD are trauma-focused psychotherapies, particularly cognitive behavioral therapy with a trauma focus (CBT-TF), cognitive processing therapy (CPT), cognitive therapy (CT), eye movement desensitization and reprocessing (EMDR), and prolonged exposure (PE), with SSRIs (sertraline and paroxetine) as the recommended pharmacological options when psychotherapy is unavailable or ineffective. 1, 2, 3

First-Line Treatment Options

Psychotherapy

• Trauma-focused psychotherapies should be offered as first-line treatment for PTSD, with exposure therapy showing 40-87% of patients no longer meeting PTSD criteria after 9-15 sessions 4
• The most effective trauma-focused therapies include:
  • Exposure therapy (imaginal and in vivo exposure to trauma memories and reminders) 4
  • Cognitive therapy (identifying and challenging trauma-related dysfunctional beliefs) 4
  • Stress inoculation training (anxiety management techniques including breathing, relaxation, cognitive restructuring) 4
  • Eye movement desensitization and reprocessing (EMDR) 4

Pharmacotherapy

• SSRIs are the first-line medication option when psychotherapy is unavailable or patient preference favors medication 1, 5
• Two SSRIs have FDA approval for PTSD treatment:
  • Sertraline (50-200 mg/day) 6
  • Paroxetine (20-50 mg/day) 7
• Medication treatment should be continued for at least 6-12 months to decrease relapse rates 6, 5

Treatment Algorithm

1. Initial Treatment Decision:

   • Offer trauma-focused psychotherapy as first-line treatment 1, 2
   • Consider medication if psychotherapy is unavailable or patient preference strongly favors medication 1

2. If Choosing Psychotherapy:

   • Select one of the evidence-based trauma-focused therapies (CBT-TF, CPT, CT, EMDR, or PE) 4, 3
   • Deliver 9-15 sessions of the selected therapy 4

3. If Choosing Pharmacotherapy:

   • Start with sertraline (50-200 mg/day) or paroxetine (20-50 mg/day) 6, 7
   • Maintain treatment for at least 6-12 months 6, 5

4. For Complex PTSD:

   • Consider a phase-based approach: stabilization, trauma processing, and reintegration 1, 8
   • Begin with stabilization focusing on safety and emotion regulation before progressing to trauma processing 1

5. For Treatment-Resistant PTSD:

   • Consider augmentation strategies with other medication classes 9
   • Consider combination of psychotherapy and pharmacotherapy 10

Important Clinical Considerations

• Relapse is common after medication discontinuation, with 26-52% of patients relapsing when shifted from sertraline to placebo compared to only 5-16% of patients maintained on medication 4
• Psychological debriefing immediately after trauma is not recommended and may be harmful 1, 2
• Benzodiazepines should be avoided or used only short-term as they may worsen PTSD symptoms 5
• For PTSD-related nightmares, prazosin is strongly recommended (Level A evidence) 2

Evidence Quality and Limitations

• The strongest evidence supports trauma-focused psychotherapies, with multiple well-conducted randomized controlled trials 4, 3
• SSRIs have been extensively studied with consistent positive results in multiple placebo-controlled trials 4, 5
• Relapse rates appear lower after completion of CBT compared to discontinuation of medication 4
• The distinction between standard PTSD and complex PTSD remains somewhat controversial, but treatment approaches are similar 1, 8
• Labeling a patient's condition as "complex" may inadvertently delay access to effective trauma-focused treatments 2, 8

Maintenance Treatment

• For psychotherapy: After successful treatment, periodic reassessment is recommended to determine need for additional sessions 4
• For pharmacotherapy: Sertraline has demonstrated maintained efficacy for up to 28 weeks following 24 weeks of treatment 6
• Patients should be periodically reassessed to determine the need for maintenance treatment 6