First-Line Treatment for PTSD
Trauma-focused psychotherapy—specifically Cognitive Processing Therapy (CPT), Prolonged Exposure (PE), Cognitive Therapy (CT), or Eye Movement Desensitization and Reprocessing (EMDR)—should be offered immediately as first-line treatment for PTSD. 1, 2
Evidence-Based Psychotherapy Options
The strongest evidence supports trauma-focused cognitive behavioral therapy (TF-CBT) and EMDR as first-line treatments:
TF-CBT demonstrates 40-87% of patients no longer meeting PTSD criteria after 9-15 sessions, compared to less than 5% with no intervention and 10-55% with supportive counseling or relaxation alone 3, 4
CPT, CT, and PE are the specific manualized therapies with the strongest evidence among trauma-focused approaches 3, 2
EMDR shows equivalent efficacy to TF-CBT with sustained effects at follow-up and robust evidence for symptom reduction 2, 5, 6
Stress Inoculation Training (SIT) shows 42-50% of patients losing PTSD diagnosis, though research interest has diminished in recent years 3
When to Consider Pharmacotherapy
Medication should be considered as second-line or adjunctive treatment:
Use SSRIs (fluoxetine, paroxetine, sertraline) or venlafaxine when psychotherapy is unavailable, ineffective, or strongly preferred by the patient 1, 7
Expect relapse rates of 26-52% when medication is discontinued, compared to more durable benefits after completing CBT 4, 1
For PTSD-related nightmares specifically, prazosin starting at 1 mg at bedtime (increasing by 1-2 mg every few days) is recommended 1, 7
Critical Pitfalls to Avoid
Never use benzodiazepines: 63% of patients receiving benzodiazepines developed PTSD at 6 months versus only 23% receiving placebo 4, 1
Do not provide psychological debriefing within 24-72 hours after trauma—this may be harmful 4, 1
Do not delay trauma-focused treatment by insisting on a prolonged stabilization phase, even for complex PTSD presentations, as this communicates incapability and reduces motivation 3, 8
Avoid labeling patients as "complex" or "complicated", as this has iatrogenic effects suggesting standard treatments won't work 3, 8
Treatment Delivery Considerations
Video teleconferencing or computerized interventions produce similar effect sizes to in-person treatment and should be used when access is limited 4, 1
Many patients prefer psychotherapy to medication when given a choice, though medication is more widely available outside major medical centers 4
Treat comorbid conditions (depression, substance use) concurrently rather than sequentially 7