Treatment of Post-Traumatic Stress Disorder (PTSD)
Specific manualized trauma-focused psychotherapies—prolonged exposure, cognitive processing therapy, or eye movement desensitization and reprocessing (EMDR)—are more effective than pharmacotherapy for treating PTSD and should be offered as first-line treatment. 1
Evidence-Based Treatment Hierarchy
First-Line: Trauma-Focused Psychotherapy
The 2023 VA/DoD Clinical Practice Guideline provides a strong recommendation for specific manualized psychotherapies over pharmacotherapy for PTSD treatment. 1 The three recommended psychotherapies are:
- Prolonged Exposure (PE) 1
- Cognitive Processing Therapy (CPT) 1
- Eye Movement Desensitization and Reprocessing (EMDR) 1
These therapies demonstrate superior outcomes, with 40-87% of patients no longer meeting PTSD criteria after 9-15 sessions. 2, 3 This response rate substantially exceeds the 50-60% response rate seen with SSRIs. 4
Critical advantage of psychotherapy: Relapse rates are dramatically lower after completing trauma-focused therapy compared to medication discontinuation—only 5-16% relapse after CBT completion versus 26-52% relapse when sertraline is discontinued. 2, 3, 5
Delivery Modality
Secure video teleconferencing is equally effective for delivering these psychotherapies when the therapy has been validated for telehealth use or when in-person options are unavailable. 1 This addresses the common barrier that trauma-focused psychotherapy is typically limited to large cities and medical schools. 3
Second-Line: Pharmacotherapy
Medication should be considered only when psychotherapy is unavailable, the patient refuses psychotherapy, or residual symptoms persist after psychotherapy. 2
FDA-Approved Medications
When pharmacotherapy is indicated, the 2023 VA/DoD guideline recommends:
Dosing and duration: SSRIs should be continued long-term (at least 6-12 months after symptom remission) due to high relapse rates upon discontinuation. 2 Assess treatment response after 8 weeks; if inadequate with good compliance, consider switching SSRIs or augmenting with trauma-focused therapy. 2
Gender consideration: In PTSD trials, post-hoc analyses revealed significant SSRI efficacy in women but essentially no effect in the relatively smaller number of men studied. 5 The clinical significance of this gender interaction remains unknown. 5
Adjunctive Treatment for Nightmares
Prazosin (1-16 mg at bedtime) can be added for treatment-resistant nightmares and sleep disturbances, with therapeutic benefit occurring within one week. 7, 8, 9, 10, 11 Start at 1 mg with monitoring for orthostatic hypotension after the first dose, then gradually increase to maintenance levels of 2-6 mg at night for civilians or 10-16 mg for military patients. 7
Medications to ABSOLUTELY AVOID
The 2023 VA/DoD guideline provides strong recommendations against:
- Benzodiazepines - Evidence shows 63% of patients receiving benzodiazepines developed PTSD at 6 months compared to only 23% receiving placebo, demonstrating harm rather than benefit. 2, 3
- Cannabis or cannabis-derived products 1
These agents worsen PTSD outcomes and carry high abuse potential, particularly in patients with substance use history. 2
Clinical Algorithm
- Offer trauma-focused psychotherapy first (PE, CPT, or EMDR) via in-person or validated telehealth delivery 1
- If psychotherapy unavailable or refused: Initiate paroxetine, sertraline, or venlafaxine 1
- If nightmares persist despite treatment: Add prazosin 7, 8, 9
- Never prescribe: Benzodiazepines or cannabis products 1, 2
- Reassess at 8 weeks: If inadequate medication response, switch SSRIs or add psychotherapy 2
Common Pitfalls
Do not offer psychological debriefing immediately after trauma (within 24-72 hours)—this intervention is not supported by evidence and may be harmful. 3
Do not assume medication and psychotherapy are equivalent—the evidence clearly demonstrates psychotherapy provides more durable benefits with lower relapse rates. 2, 3
Do not discontinue SSRIs prematurely—continue for at least 6-12 months after symptom remission to prevent relapse. 2, 5