What is the first-line treatment for Post-Traumatic Stress Disorder (PTSD)?

First-Line Treatment for PTSD

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

Evidence-Based Treatment Hierarchy

Primary Recommendation: Trauma-Focused Psychotherapy

• The 2023 VA/DoD Clinical Practice Guideline strongly recommends specific manualized trauma-focused psychotherapies over pharmacotherapy as first-line treatment, with individual therapy being the preferred initial approach. 1

• The three trauma-focused psychotherapies with the strongest evidence are:

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

• These interventions demonstrate more durable benefits than medication alone, with relapse rates appearing lower after CBT completion compared to medication discontinuation. 1

• Trauma-focused psychotherapy should be offered directly without mandatory stabilization phases, even in complex PTSD presentations with multiple traumas, traumatic brain injuries, or past substance use disorders. 1, 3

When Pharmacotherapy Should Be Considered

• Medication should be considered when psychotherapy is unavailable, ineffective, the patient refuses psychotherapy, or the patient strongly prefers medication. 1

• The 2023 VA/DoD guideline recommends three specific medications as first-line pharmacotherapy:

  • Sertraline (FDA-approved for PTSD, starting dose 50 mg/day) 1, 4, 5
  • Paroxetine (FDA-approved for PTSD, effective at 20-40 mg/day) 1, 6, 5
  • Venlafaxine 1, 7

• SSRIs show consistent positive results across multiple trials with a favorable adverse effect profile, but relapse is common after discontinuation (26-52% relapse rate when shifted to placebo versus 5-16% maintained on medication). 1

• Minimum treatment duration for SSRIs is 6-12 months after symptom remission to prevent relapse. 1

Treatment Delivery Options

• Secure video teleconferencing can effectively deliver recommended psychotherapy when in-person options are unavailable, with video or computerized interventions producing similar effect sizes to in-person treatment. 1

• Individual trauma-focused psychotherapy has stronger evidence than group therapy and is the preferred first-line approach. 1

Critical Medications to AVOID

• The 2023 VA/DoD guideline strongly recommends AGAINST benzodiazepines for PTSD treatment, as evidence shows 63% of patients receiving benzodiazepines developed PTSD at 6 months compared to only 23% receiving placebo. 1, 5

• Propranolol, hydrocortisone, and benzodiazepines for acute stress reactions have limited benefit in preventing chronic PTSD and should be avoided. 1

• Bupropion, citalopram, divalproex, mirtazapine, tiagabine, and topiramate failed to differentiate from placebo in controlled trials. 7

Common Pitfalls to Avoid

• Psychological debriefing administered within 24-72 hours after trauma is not supported by evidence and may be harmful. 1, 3

• Delaying trauma-focused treatment with prolonged stabilization phases is not supported by evidence and may have iatrogenic effects. 8

• Many PTSD sufferers prefer psychotherapy to medication when given a choice, making shared decision-making important. 1

Adjunctive Treatment for Specific Symptoms

• Prazosin is strongly recommended (Level A evidence) for PTSD-related nightmares, starting at 1 mg at bedtime and titrating by 1-2 mg every few days until effective. 1, 3