What is the best treatment for a 17-year-old female with PTSD, depression, and substance use after alleged sexual abuse?

Treatment Approach for 17-Year-Old Female with PTSD, Depression, and Substance Use Following Sexual Assault

Initiate trauma-focused cognitive behavioral therapy (TF-CBT) immediately without delay, as this patient requires urgent psychiatric intervention given her active suicidal ideation, and current evidence demonstrates that direct trauma processing is both safe and necessary even in the presence of substance use. 1, 2

Immediate Safety Assessment and Psychiatric Intervention

This patient requires immediate mental health evaluation by an experienced trauma specialist because she has active suicidal ideation (wanting to jump off a bridge). 3, 4 The presence of suicidal thoughts, combined with her history of sexual assault, depression, and substance use, places her at extremely high risk and cannot be delayed. 3, 4

• Screen specifically for current suicidal plans, access to means, protective factors, and any homicidal ideation. 3, 4
• Assess for other self-harm behaviors including self-mutilation and eating disorders, which are significantly elevated in adolescent sexual assault survivors. 3, 4
• If you are not comfortable performing this psychiatric assessment yourself, refer immediately to an experienced mental health professional—this is not optional. 3, 4

Primary Treatment: Trauma-Focused Cognitive Behavioral Therapy

Begin TF-CBT immediately as the first-line treatment, targeting her PTSD symptoms, intrusive thoughts, shame, guilt, and trauma-related cognitions. 1, 2, 5 Do not delay trauma processing with a prolonged "stabilization phase"—current evidence refutes this outdated approach and shows that direct trauma-focused treatment is safe and effective even with co-occurring substance use. 1, 2

• TF-CBT demonstrates large effect sizes for PTSD and depression reduction with low attrition rates (18%) in adolescents with co-occurring substance use. 5
• The therapy should directly address her specific trauma-related cognitions including shame, guilt, and fear of judgment, as changes in these cognitions mediate improvements in both PTSD and depression. 5, 6
• Both in-person and video-based delivery are equally effective, allowing flexibility based on her preference and access. 2, 4

Critical point: Research demonstrates that treating PTSD symptoms leads to reductions in substance use severity—PTSD symptom reduction mediates alcohol and drug use improvements both during and after treatment. 6 This means addressing her trauma directly will help her cannabis use, not worsen it.

Integrated Substance Use Treatment

Address her occasional alcohol use and cannabis use within the trauma-focused framework rather than as separate sequential treatments. 5, 7

• Integrated cognitive behavioral approaches that combine trauma processing with substance use interventions show significant reductions in cannabis use among adolescents with PTSD. 5
• Monitor substance use with validated measures and consider urine drug screens to track progress objectively. 5
• Avoid benzodiazepines entirely—evidence shows 63% of patients receiving benzodiazepines developed PTSD at 6 months compared to only 23% receiving placebo. 2

Pharmacological Considerations

Consider pharmacotherapy as an adjunct to TF-CBT if symptoms are severe or if she does not respond adequately to psychotherapy alone. 8

• SSRIs (such as sertraline) may be considered, though evidence for comorbid PTSD and substance use is mixed. 8
• Prazosin, guanfacine, or atomoxetine (noradrenergic medications) show promise for comorbid PTSD and substance use. 8
• Topiramate or N-acetylcysteine may help with both PTSD symptoms and substance use reduction. 8
• Any pharmacological treatment requires expert consultation and should complement, not replace, trauma-focused psychotherapy. 2

Depression Management

Her depression symptoms (sleep disturbances, decreased appetite, low energy, social withdrawal) will likely improve as PTSD symptoms are addressed through TF-CBT. 5, 6

• Monitor depression severity with standardized measures throughout treatment. 5
• Address her negative self-concept, self-blame, and feelings of violated trust directly in therapy. 3, 4
• If depression persists despite PTSD improvement, consider adding antidepressant medication. 8

Multidisciplinary Care Coordination

Establish a coordinated care team including her primary care provider, trauma-specialized mental health professional, and substance use counselor if available. 2, 4

• Connect her with a sexual assault care center that has professionals experienced in treating adolescent assault victims. 3
• Assess her social support system—encourage her to share information with her mother (her primary caregiver) or another trusted adult, as parental support is crucial during this vulnerable time. 3
• Consider funding through the Victims of Crime Act for tests and treatments. 3

Follow-Up and Monitoring

Schedule frequent follow-up visits initially (within 1 week, then at 2 weeks, then regularly). 3

• Reassess suicidal ideation at every visit—this remains the highest priority safety concern. 3, 4
• Monitor for risky behaviors including poor contraception use, increased substance use, and self-harm. 3, 4
• Track PTSD symptoms, depression severity, and substance use frequency with validated measures. 5
• Ensure she has 24/7 access to crisis resources including suicide hotlines and emergency psychiatric services. 3

Critical Pitfalls to Avoid

Do not delay trauma processing. The evidence is clear that direct trauma-focused treatment should begin immediately, not after months of "stabilization." 1, 2 Delaying trauma work is an outdated approach contradicted by current research showing that TF-CBT is safe and effective even with active substance use. 1, 5

Do not treat her substance use separately before addressing trauma. Integrated treatment that addresses both simultaneously is more effective, and PTSD symptom reduction actually drives substance use improvement. 5, 7, 6

Do not minimize her suicidal ideation. Sexual assault survivors have significantly elevated rates of suicide attempts, and her active thoughts of jumping off a bridge require immediate expert intervention. 3, 9

Do not assume she needs to "get stable" before processing trauma. She is already experiencing severe distress—the trauma processing itself is the path to stability. 1, 2