Is DORA (type of therapy or intervention) an effective treatment approach for patients with post-traumatic stress disorder (PTSD)?

DORA for PTSD: Not Recommended

DORA (Dual Orexin Receptor Antagonists) are not evidence-based treatments for PTSD and should not be used for this indication. The available evidence does not support DORA medications as effective interventions for post-traumatic stress disorder.

First-Line Treatment: Trauma-Focused Psychotherapy

Trauma-focused psychotherapy should be offered as the primary treatment for PTSD, with 40-87% of patients no longer meeting PTSD criteria after 9-15 sessions. 1

The strongest evidence supports three specific approaches:

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

These therapies demonstrate more durable benefits than medication alone, with lower relapse rates after treatment completion compared to medication discontinuation. 1 Network meta-analysis shows EMDR (standardized mean difference -2.07) and trauma-focused CBT (SMD -1.46) are most effective at reducing PTSD symptoms post-treatment. 2

Pharmacotherapy: When and What to Use

If psychotherapy is unavailable, ineffective, or the patient strongly prefers medication, SSRIs are the first-line pharmacological treatment. 3, 1

First-Line Medications:

• Sertraline (FDA-approved for PTSD) 4, 5, 6
• Paroxetine (FDA-approved for PTSD) 4, 5, 6
• Venlafaxine 1, 5, 6

SSRIs show consistent positive results across multiple placebo-controlled trials with small but statistically significant effect sizes (SMD -0.28). 5 However, relapse is common after medication discontinuation, with 26-52% of patients relapsing when shifted from sertraline to placebo compared to only 5-16% maintained on medication. 1

For Specific Symptoms:

For PTSD-related nightmares specifically:

• Prazosin is strongly recommended (Level A evidence), starting at 1 mg at bedtime, increased by 1-2 mg every few days until effective (average dose 3 mg, range 1-13 mg). 1, 7, 5

Critical Medications to Avoid

Benzodiazepines should be avoided entirely in PTSD treatment. Evidence shows 63% of patients receiving benzodiazepines developed PTSD at 6 months compared to only 23% receiving placebo. 1, 8 The 2023 VA/DoD guideline strongly recommends AGAINST benzodiazepines for PTSD. 1

Psychological debriefing (single-session intervention within 24-72 hours post-trauma) should not be used, as randomized controlled trials do not support its usefulness and it may be harmful. 3, 1

Treatment Algorithm

1. Offer trauma-focused psychotherapy immediately (PE, CPT, or EMDR) without mandatory stabilization phases, even in complex presentations. 1, 8

2. If psychotherapy unavailable or refused: Start SSRI (sertraline or paroxetine). 1, 4

3. If nightmares persist despite initial treatment: Add prazosin. 1, 7

4. Continue medication for 6-12 months minimum after symptom remission before considering discontinuation. 1

5. Monitor for relapse if medications are discontinued, as relapse rates are significantly higher than after completing psychotherapy. 1

Common Pitfalls

Do not delay trauma-focused treatment for prolonged stabilization phases. Current evidence demonstrates that trauma-focused therapy should not be delayed even in patients with multiple traumas, severe comorbidities, dissociation, or emotion dysregulation. 1, 8 Delaying treatment may be demoralizing and iatrogenic. 8

Do not label patients as "complex" or "complicated" unnecessarily, as this has iatrogenic effects, suggesting standard treatments will be ineffective and inadvertently communicating that the patient is incapable of dealing with traumatic memories. 8