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

Best Treatment for Post-Traumatic Stress Disorder (PTSD)

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. 1

First-Line Treatment Options

• Trauma-focused psychotherapies have the strongest evidence base and should be the initial treatment for PTSD 1, 2
• Specific effective trauma-focused therapies include:
  • Exposure therapy (40-87% of patients no longer meet PTSD criteria after treatment) 1
  • Cognitive therapy (53-65% of patients no longer meet criteria) 3
  • Stress inoculation training (42-50% of patients no longer meet criteria) 3
  • Eye Movement Desensitization and Reprocessing (EMDR) 4, 5
• These trauma-focused therapies should be offered directly without mandatory stabilization phases, even in complex PTSD presentations 2

Pharmacotherapy Options

• SSRIs are the first-line medication choice if psychotherapy is unavailable, declined by the patient, or insufficient 1, 6
• Sertraline and paroxetine are FDA-approved for PTSD treatment 7, 8, 9
• In clinical trials, 53-85% of patients receiving SSRIs were classified as treatment responders, compared to 32-62% with placebo 3
• Prazosin is strongly recommended for treatment of PTSD-related nightmares 2
• Relapse is common after medication discontinuation (26-52% relapse rate when shifted from sertraline to placebo) compared to only 5-16% of patients maintained on medication 3, 1

Treatment Algorithm

1. Start with trauma-focused psychotherapy (exposure therapy, cognitive therapy, stress inoculation training, or EMDR) 1, 5
2. If psychotherapy is unavailable, declined, or insufficient, initiate SSRI treatment (sertraline or paroxetine) 1, 6
3. For patients with prominent nightmares, consider adding prazosin 2
4. If first-line treatments fail, consider:
   • Alternative trauma-focused psychotherapy 1
   • Different SSRI 6
   • Serotonin-potentiating non-SSRIs (venlafaxine, nefazodone, trazodone, mirtazapine) as second-line pharmacotherapy 6
   • Combined psychotherapy and pharmacotherapy approach 10

Comparative Effectiveness

• Long-term follow-up studies suggest psychotherapeutic treatments show greater benefit than pharmacological treatments alone 10
• Relapse rates appear lower after completion of CBT compared to discontinuation of medication 3, 1
• Network meta-analyses suggest combined treatments may be superior to pharmacological treatments alone for long-term outcomes 10

Important Clinical Considerations

• Avoid psychological debriefing immediately after trauma as it may be harmful 1, 2
• Benzodiazepines should be avoided or used only short-term due to potential depressogenic effects and possibility of worsening PTSD 6
• For complex PTSD, a phase-based approach may be beneficial, focusing first on stabilization and emotion regulation before trauma processing 1
• Monitor for medication discontinuation effects, as relapse is common after stopping pharmacotherapy 3, 1