Treatment Recommendation for PTSD Score 13 (Moderate Symptoms)
Initiate trauma-focused cognitive behavioral therapy (TF-CBT) immediately, specifically Cognitive Processing Therapy (CPT), Cognitive Therapy (CT), or Prolonged Exposure (PE), as these represent first-line treatment with the strongest evidence for moderate PTSD symptoms. 1, 2
First-Line Treatment: Trauma-Focused Psychotherapy
Trauma-focused CBT should be offered as the initial treatment, with 40-87% of patients no longer meeting PTSD criteria after 9-15 sessions. 3, 1
The three manualized therapies with the strongest evidence are Cognitive Processing Therapy (CPT), Cognitive Therapy (CT), and Prolonged Exposure (PE). 2
Eye Movement Desensitization and Reprocessing (EMDR) is equally effective, showing the largest effect size (SMD -2.07) in network meta-analyses and can be used if the patient prefers it over exposure-based approaches. 2, 4
Treatment should consist of 9-15 sessions focusing specifically on the traumatic event(s) that triggered the PTSD symptoms. 1, 5
When to Consider Pharmacotherapy
Add an SSRI (sertraline or paroxetine) only if trauma-focused psychotherapy is unavailable, the patient strongly prefers medication, or psychotherapy alone proves insufficient after adequate trial. 3, 1, 6, 7
Sertraline and paroxetine are the only FDA-approved medications for PTSD, with demonstrated efficacy in reducing reexperiencing, avoidance, and hyperarousal symptoms. 6, 7
If medication is initiated, plan for longer-term treatment as relapse rates are 26-52% when medication is discontinued, compared to only 5-16% for those maintained on medication. 1
Relapse rates are substantially lower after completing CBT compared to discontinuing medication, making psychotherapy the more durable treatment option. 3, 1
Critical Pitfalls to Avoid
Do not offer psychological debriefing (single-session intervention within 24-72 hours of trauma)—this approach is not supported by evidence and may be harmful. 3, 1
Avoid benzodiazepines entirely, as 63% of patients receiving benzodiazepines developed PTSD at 6 months compared to only 23% receiving placebo. 3, 1
Do not delay treatment waiting for "natural recovery"—while some patients improve spontaneously, those with moderate symptoms (score 13) warrant active intervention. 3
Treatment Algorithm
Refer immediately for trauma-focused CBT (CPT, CT, or PE) with a trained therapist. 1, 2
Schedule 9-15 weekly sessions of exposure-based or cognitive therapy. 1, 5
If psychotherapy is unavailable or declined, initiate sertraline 50 mg daily (can increase to 200 mg) or paroxetine 20 mg daily (can increase to 50 mg). 6, 7
For combined treatment, add medication only if psychotherapy response is insufficient after 6-8 sessions. 3, 1
Reassess symptoms every 4 weeks using standardized measures to track treatment response. 6, 7
Alternative Options if First-Line Treatment Fails
If exposure therapy is not tolerated, stress inoculation training or cognitive therapy without exposure components remain effective alternatives. 3, 1
Internet-based or video-delivered CBT produces similar effect sizes to in-person treatment and improves access for patients in areas with limited specialist availability. 1
Group CBT with trauma focus can be considered if individual therapy is unavailable, though individual therapy shows stronger evidence. 3
Evidence Quality Considerations
The recommendation for trauma-focused CBT is based on multiple high-quality randomized controlled trials with consistent positive results across diverse trauma populations. 2, 4, 8, 9
Network meta-analyses including 90 trials and 6,560 individuals confirm EMDR and TF-CBT as most effective interventions with sustained effects at follow-up. 4
Medication evidence comes from FDA-approved indications based on multiple placebo-controlled trials, though effect sizes are generally smaller than psychotherapy. 6, 7