What is the best way to manage Post-Traumatic Stress Disorder (PTSD)?

Management of Post-Traumatic Stress Disorder (PTSD)

Begin immediately with trauma-focused psychotherapy—specifically Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), or Eye Movement Desensitization and Reprocessing (EMDR)—as first-line treatment, with 40-87% of patients no longer meeting PTSD criteria after 9-15 sessions. 1, 2

First-Line Treatment: Trauma-Focused Psychotherapy

Initiate trauma-focused psychotherapy without delay, even in patients with complex presentations including dissociation, emotion dysregulation, or severe symptoms. 2, 3 The assumption that patients need extensive stabilization before trauma processing is not supported by evidence and delays effective treatment. 3

Recommended Psychotherapy Options (Equal Efficacy)

• Prolonged Exposure (PE) 1, 2
• Cognitive Processing Therapy (CPT) 1, 2
• Eye Movement Desensitization and Reprocessing (EMDR) 1, 2, 4
• Cognitive Therapy (CT) 1, 4

All four approaches demonstrate strong evidence with 40-87% of patients achieving remission after 9-15 sessions. 1, 2 Individual therapy has stronger evidence than group formats and should be prioritized. 2

Delivery Modalities

• Secure video teleconferencing can effectively deliver these therapies when validated for this modality or when in-person options are unavailable. 1, 2
• Video or computerized interventions produce similar effect sizes to in-person treatment. 2

Second-Line Treatment: Pharmacotherapy

Use pharmacotherapy when: 2, 3

• Psychotherapy is unavailable or inaccessible
• Patient strongly prefers medication
• Residual symptoms persist after psychotherapy
• Patient is unable or unwilling to engage in psychotherapy

Recommended Medications (First-Line Pharmacotherapy)

The 2023 VA/DoD guideline strongly recommends three specific medications: 1, 2

1. Sertraline (50-200 mg/day)

   • Initiate at 25 mg/day for first week, then increase to 50-200 mg/day based on response 5
   • Mean effective dose in trials: 146-151 mg/day 5
   • Demonstrated significant superiority over placebo on CAPS and CGI scores 5

2. Paroxetine (20-50 mg/day)

   • Both 20 mg and 40 mg doses demonstrated superiority over placebo 6
   • No clear evidence that 40 mg provides greater benefit than 20 mg 6

3. Venlafaxine (dose range per clinical response) 1, 2

Critical Medication Duration Considerations

Continue SSRI treatment for 6-12 months minimum after symptom remission. 2 Relapse rates are 26-52% when medication is discontinued compared to only 5-16% when maintained on medication. 1, 2 In contrast, relapse rates are significantly lower after completing psychotherapy compared to medication discontinuation. 2, 3

Medications to AVOID

The 2023 VA/DoD guideline strongly recommends AGAINST: 1

• Benzodiazepines: 63% of patients receiving benzodiazepines developed PTSD at 6 months compared to only 23% receiving placebo. 2, 7 They worsen PTSD outcomes and should be avoided entirely. 2
• Cannabis or cannabis-derived products 1
• Beta blockers: No evidence supporting their use as monotherapy for established PTSD; studied only for prevention immediately post-trauma. 2

Treatment Algorithm

Step 1: Immediate Initiation

Start trauma-focused psychotherapy (PE, CPT, EMDR, or CT) without requiring a prolonged stabilization phase. 2, 3, 7 This applies even to patients with dissociative symptoms, emotion dysregulation, or multiple traumas. 2, 7

Step 2: Assess Response at 9-15 Sessions

Treatment response should be evident within 9-15 sessions. 2, 7 If inadequate response, consider:

• Adding pharmacotherapy (sertraline, paroxetine, or venlafaxine) 1, 2
• Switching to alternative trauma-focused psychotherapy 4

Step 3: Maintenance Treatment

• After psychotherapy completion: Most patients achieve durable response; periodically reassess need for continued treatment 2, 3
• If using medication: Anticipate need for several months or longer of sustained treatment given high relapse rates upon discontinuation 2, 5

Special Populations and Comorbidities

Treat psychiatric comorbidities concurrently with trauma-focused therapy. 3 Trauma-focused treatment addresses root causes of emotion dysregulation that fuel comorbid symptoms. 3 Do not delay trauma-focused treatment for patients with:

• Dissociative symptoms 2, 7
• Emotion dysregulation 2, 7
• Substance use disorders (past) 2
• Traumatic brain injuries 2
• Multiple traumas 2

Critical Pitfalls to Avoid

• Never provide psychological debriefing within 24-72 hours after trauma—this intervention is not supported by evidence and may be harmful. 2, 3, 7
• Do not label patients as "too complex" for trauma-focused treatment—this delays access to effective interventions. 3
• Do not insist on prolonged stabilization phases—this communicates to patients they are incapable of dealing with traumatic memories and reduces motivation. 7
• Avoid benzodiazepines entirely—they worsen outcomes and increase PTSD development risk. 2, 7

Dropout Considerations

Dropout from trauma-focused psychological treatments is higher than for other forms of psychological treatment for PTSD in adults. 4 However, this should not deter offering these treatments as first-line, given their superior efficacy. 1, 2

Military Personnel and Veterans

Results for trauma-focused psychotherapy are less impressive in military personnel and veterans compared to civilian populations. 4 Consider this when setting expectations, but still offer trauma-focused psychotherapy as first-line treatment per VA/DoD guidelines. 1