What is the recommended treatment for a patient with post-traumatic stress disorder (PTSD)?

Treatment for PTSD

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

First-Line Treatment: Trauma-Focused Psychotherapy

The 2023 VA/DoD Clinical Practice Guideline strongly recommends trauma-focused psychotherapy over pharmacotherapy as the initial treatment approach. 1 The three evidence-based options with the strongest support are:

• Prolonged Exposure (PE): Systematically confronts trauma-related memories and situations 1
• Cognitive Processing Therapy (CPT): Addresses maladaptive trauma-related beliefs 1
• Eye Movement Desensitization and Reprocessing (EMDR): Processes traumatic memories through bilateral stimulation 1

These therapies demonstrate superior durability compared to medication, with significantly lower relapse rates after treatment completion versus medication discontinuation (26-52% relapse with sertraline discontinuation compared to lower rates post-CBT). 1, 2

Delivery Modalities

• Individual therapy has the strongest evidence and is preferred first-line 1
• Video teleconferencing produces similar effect sizes to in-person treatment and effectively expands access 1
• Group therapy is an acceptable alternative when individual therapy is unavailable 1

Complex Presentations

Trauma-focused therapy should be routinely offered to patients with complex presentations without requiring a prolonged stabilization phase first. 1 This includes patients with:

• Multiple traumas or childhood abuse history 1, 3
• Severe comorbidities (depression, substance use disorders, even psychotic disorders) 1
• Emotion dysregulation or dissociative symptoms 1, 3

The evidence shows that emotion dysregulation and dissociative symptoms improve directly through trauma processing itself, without requiring extensive pre-treatment stabilization. 3 Delaying trauma-focused treatment by insisting on prolonged stabilization communicates to patients that they are incapable of dealing with traumatic memories and reduces motivation for active trauma processing. 3

Pharmacotherapy: When and What to Use

Indications for Medication

Consider pharmacotherapy when: 1, 2

• Psychotherapy is unavailable or inaccessible
• The patient refuses psychotherapy
• Residual symptoms persist after completing psychotherapy
• Patient strongly prefers medication over psychotherapy

First-Line Medications

The FDA-approved medications and those with strongest evidence are: 1, 2, 4, 5

SSRIs (choose one):

• Sertraline: 50-200 mg/day (FDA-approved for PTSD) 1, 4, 6
• Paroxetine: 20-50 mg/day (FDA-approved for PTSD) 1, 5, 6
• Fluoxetine: Effective but not FDA-approved for PTSD 2, 6

SNRI:

• Venlafaxine: 32.5-300 mg/day (second-line when SSRIs not tolerated) 1, 6

Medication Duration

• Continue SSRI treatment for at least 6-12 months after symptom remission before considering discontinuation 1, 2
• Discontinuation leads to high relapse rates: 26-52% relapse when shifted to placebo versus only 5-16% maintained on medication 1, 2
• Periodically reassess the need for continued pharmacotherapy, as psychotherapy may allow for eventual medication discontinuation with lower relapse risk 2

Adjunctive Medications for Specific Symptoms

For PTSD-related nightmares and sleep disturbance:

• Prazosin: Start 1 mg at bedtime, increase 1-2 mg every few days, average effective dose 3 mg (range 1-13 mg), monitor for orthostatic hypotension 1, 7
• This has Level A evidence from the American Academy of Sleep Medicine 1

Critical Medications to AVOID

Benzodiazepines: Absolutely Contraindicated

The 2023 VA/DoD guideline strongly recommends AGAINST benzodiazepines for PTSD treatment. 1 Evidence shows:

• 63% of patients receiving benzodiazepines (clonazepam/alprazolam) developed PTSD at 6 months compared to only 23% receiving placebo 1, 2
• They worsen PTSD outcomes and have high abuse potential, especially in patients with substance use history 2
• Avoid reintroducing benzodiazepines even for insomnia given their negative impact 1

Other Ineffective or Harmful Interventions

• Psychological debriefing (single-session intervention within 24-72 hours post-trauma) is not supported by evidence and may be harmful 1, 8
• Beta blockers have no evidence supporting their use as monotherapy for established PTSD; they have been studied only for prevention immediately post-trauma 1
• Propranolol and hydrocortisone for acute stress reactions have limited benefit in preventing chronic PTSD 1

Treatment Algorithm

1. Offer trauma-focused psychotherapy first (PE, CPT, or EMDR) for 9-15 sessions 1
2. If psychotherapy unavailable or refused: Start SSRI (sertraline 50-200 mg/day or paroxetine 20-50 mg/day) 1, 2
3. If inadequate response after 8 weeks: Switch to different SSRI or add trauma-focused therapy 2
4. For persistent nightmares: Add prazosin (titrate to 3 mg average dose) 1
5. Continue successful treatment for 6-12 months minimum after symptom remission 1, 2
6. Avoid benzodiazepines entirely regardless of anxiety severity 1, 2

Common Pitfalls to Avoid

• Do not delay trauma-focused treatment by requiring prolonged stabilization phases in complex cases 3
• Do not label patients as "too complex" for standard trauma-focused therapy, as this has iatrogenic effects 3
• Do not prescribe benzodiazepines even for severe anxiety or insomnia in PTSD 1, 2
• Do not discontinue effective medication prematurely; maintain treatment for at least 6-12 months after remission 1, 2
• Do not use psychological debriefing immediately after trauma exposure 1