What are the treatment options for anxiety, depression, and post-traumatic stress disorder (PTSD)?

Treatment for Anxiety, Depression, and PTSD

For patients presenting with anxiety, depression, and PTSD, prioritize trauma-focused psychotherapy as first-line treatment, specifically Cognitive Processing Therapy (CPT), Prolonged Exposure (PE), or Eye Movement Desensitization and Reprocessing (EMDR), which demonstrate 40-87% of patients no longer meeting PTSD criteria after 9-15 sessions, with more durable benefits than medication alone. 1

Treatment Hierarchy and Decision Algorithm

First-Line: Trauma-Focused Psychotherapy

• Start with trauma-focused psychotherapy for PTSD symptoms, as this addresses the root cause and provides the most durable outcomes with lower relapse rates compared to medication discontinuation 1, 2
• The three evidence-based options with strongest support are:
  • Prolonged Exposure (PE) - involves imaginal and in vivo exposure to trauma memories 3, 4
  • Cognitive Processing Therapy (CPT) - addresses trauma-related dysfunctional beliefs 4
  • Eye Movement Desensitization and Reprocessing (EMDR) - processes traumatic memories through bilateral stimulation 4
• All three therapies show equivalent efficacy regardless of trauma type, childhood abuse history, or comorbidities 2

Managing Comorbid Depression and Anxiety

• When depression and anxiety co-occur with PTSD, prioritize treating depressive symptoms first, or use a unified protocol combining CBT treatments for both conditions 3
• Trauma-focused therapy directly improves emotion dysregulation, impulsivity, and mood instability without requiring a prolonged stabilization phase 1
• The evidence does not support delaying trauma-focused treatment for a stabilization phase, even in complex presentations with multiple comorbidities 3, 1

Pharmacotherapy: When and What to Use

Indications for Medication

• Consider pharmacotherapy when: 2
  • Psychotherapy is unavailable or inaccessible
  • Patient refuses or cannot engage in psychotherapy
  • Residual symptoms persist after completing psychotherapy
  • Patient strongly prefers medication

First-Line Medications

• For PTSD and depression: Selective Serotonin Reuptake Inhibitors (SSRIs) 1, 5, 6
  • Sertraline (FDA-approved for PTSD) 3, 7
  • Paroxetine (FDA-approved for PTSD) 3, 4
  • Fluoxetine - 20-60 mg/day for depression and OCD; also effective for PTSD 8, 7
• For generalized anxiety: SSRIs or Venlafaxine (SNRI) 5, 4
• SSRIs show 53-85% of participants classified as treatment responders in controlled trials 3

Dosing and Duration

• Fluoxetine: Start 20 mg/day in morning; may increase to 60 mg/day for OCD; maximum 80 mg/day 8
• Continue SSRI treatment for 9-12 months minimum after symptom remission to prevent relapse 3
• Relapse rates are high with medication discontinuation: 26-52% relapse when shifted from sertraline to placebo versus only 5-16% maintained on medication 1

Critical Medications to AVOID

• Benzodiazepines are contraindicated for PTSD treatment - evidence shows 63% of patients receiving benzodiazepines developed PTSD at 6 months compared to only 23% receiving placebo 1, 2
• Benzodiazepines worsen PTSD outcomes and should never be used as first-line treatment 3, 6
• Psychological debriefing within 24-72 hours post-trauma is not recommended and may be harmful 3, 1

Monitoring and Treatment Adjustments

Assessment Schedule

• Assess treatment response at 4 weeks and 8 weeks using standardized validated instruments 3
• Monitor for symptom relief, side effects, adverse events, and patient satisfaction 3

When to Adjust Treatment

• After 8 weeks with little improvement despite good adherence, adjust the regimen: 3
  • Add psychological intervention to pharmacotherapy
  • Switch to different SSRI
  • Add pharmacotherapy to psychotherapy
  • Switch from group to individual therapy if applicable
• If symptoms are stable or worsening at any point, re-evaluate and revise the treatment plan 3

Combined Treatment Approach

• Combination of trauma-focused psychotherapy plus SSRI is the optimal strategy for severe or treatment-resistant cases 5, 9
• This approach addresses both neurobiological and psychological components of the disorders 9
• Psychotherapy provides more durable benefits, allowing for eventual medication discontinuation with lower relapse risk 2

Common Pitfalls to Avoid

Do Not Delay Trauma Processing

• Avoid recommending prolonged stabilization phases before trauma-focused therapy, even in complex presentations with multiple traumas, substance use history, or severe comorbidities 3, 1
• Delaying trauma-focused treatment can be demoralizing and inadvertently communicate that patients cannot handle their traumatic memories 3

Monitor for SSRI Side Effects

• Watch for anxiety, insomnia, anorexia, and weight loss - common with fluoxetine (12-16% report anxiety/nervousness versus 7-9% with placebo) 8
• Screen for hyponatremia, especially in elderly patients or those on diuretics 8
• Assess for activation of mania/hypomania, particularly in patients with bipolar spectrum disorders 8

Accessibility Considerations

• When in-person psychotherapy is unavailable, secure video teleconferencing can effectively deliver trauma-focused therapy with equivalent outcomes 1
• Individual therapy has stronger evidence than group therapy and should be the preferred format 1