What is the recommended medication algorithm for a teenager with post-traumatic stress disorder (PTSD)?

Medication Algorithm for PTSD in Teenagers

Trauma-focused psychotherapy (Prolonged Exposure, Cognitive Processing Therapy, or EMDR) is the mandatory first-line treatment for adolescent PTSD, with medication reserved only for situations where psychotherapy is unavailable, refused, or has left residual symptoms after completion. 1, 2

Step 1: Prioritize Trauma-Focused Psychotherapy

• Start with trauma-focused psychotherapy as the exclusive initial intervention for adolescent PTSD, as 40-87% of patients no longer meet PTSD criteria after 9-15 sessions, with significantly lower relapse rates compared to medication discontinuation (26-52% relapse with sertraline vs. lower rates post-psychotherapy). 1, 2

• The three evidence-based options with strongest support are Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), and Eye Movement Desensitization and Reprocessing (EMDR), all showing equivalent efficacy regardless of trauma type or comorbidities. 1, 3, 4

• Adolescents with complex presentations (multiple traumas, severe comorbidities, dissociation, or emotion dysregulation) should receive trauma-focused therapy immediately without prolonged stabilization phases, as delaying trauma-focused treatment can be demoralizing and inadvertently communicate that patients cannot handle their traumatic memories. 1, 3

Step 2: When to Consider Medication

Add pharmacotherapy only when:

• Psychotherapy is genuinely unavailable or inaccessible in your geographic area 2, 3
• The adolescent refuses or cannot engage in psychotherapy after thorough discussion 2, 3
• Residual symptoms persist after completing a full course of trauma-focused psychotherapy 2, 3
• The patient or family strongly prefers medication despite education about superior psychotherapy outcomes 1

Step 3: Medication Selection Algorithm

First-Line Medication: SSRIs

Sertraline is the preferred first-line medication for adolescent PTSD when pharmacotherapy is indicated:

• Initiate sertraline at 25 mg daily for the first week, then increase to 50 mg daily. 5
• Dose range: 50-200 mg/day based on clinical response and tolerability, with mean effective doses in PTSD trials of 146-151 mg/day. 5
• Sertraline demonstrated significantly greater improvement than placebo on PTSD symptom clusters (reexperiencing, avoidance, hyperarousal) and global functioning measures. 5
• Assess treatment response at 8 weeks; if inadequate response with good adherence, consider switching to paroxetine or adding trauma-focused psychotherapy. 3

Alternative First-Line SSRIs:

• Paroxetine or fluoxetine can be used if sertraline is not tolerated, though sertraline and paroxetine are the only FDA-approved medications for PTSD. 6, 7

Second-Line Medication:

• Venlafaxine (serotonin-norepinephrine reuptake inhibitor) at 32.5-300 mg/day when SSRIs are not tolerated or ineffective. 1

Step 4: Adjunctive Medications for Specific Symptoms

For PTSD-Related Nightmares and Sleep Disturbance:

• Prazosin is the evidence-based choice for PTSD-related nightmares (Level A evidence): 1, 7

  • Initial dose: 1 mg at bedtime
  • Titrate by 1-2 mg every few days
  • Average effective dose: 3 mg (range 1-13 mg)
  • Monitor for orthostatic hypotension

• Screen for obstructive sleep apnea in adolescents with PTSD-related sleep disturbance, as this condition is common and requires separate treatment. 7

Step 5: Medications to Absolutely Avoid

Never prescribe benzodiazepines (alprazolam, clonazepam, lorazepam) for adolescent PTSD:

• Evidence demonstrates 63% of patients receiving benzodiazepines developed PTSD at 6 months compared to only 23% receiving placebo, indicating benzodiazepines worsen PTSD outcomes. 1, 2
• Benzodiazepines have particularly high abuse potential in adolescents and those with trauma histories. 2
• Clonazepam showed no improvement in PTSD-related nightmares compared to placebo in controlled trials. 1

Step 6: Treatment Duration and Monitoring

• Continue SSRI treatment for minimum 6-12 months after symptom remission before considering discontinuation, as early discontinuation leads to high relapse rates (26-52%). 1, 5

• Reassess at 4 weeks and 8 weeks using standardized instruments (PTSD Checklist for DSM-5) to monitor symptom relief, side effects, and treatment adherence. 3, 7

• If minimal improvement after 8 weeks with good adherence, adjust by: 3

  • Adding trauma-focused psychotherapy to medication (preferred)
  • Switching to different SSRI
  • Increasing dose to maximum tolerated (up to 200 mg/day sertraline)

Step 7: Combination Treatment Strategy

• Combination of trauma-focused psychotherapy plus SSRI is optimal for severe or treatment-resistant cases, as psychotherapy provides more durable benefits and allows for eventual medication discontinuation with lower relapse risk. 3

• When combining treatments, initiate psychotherapy first or simultaneously with medication, rather than using medication as monotherapy. 1, 3

Critical Pitfalls to Avoid

• Do not use psychological debriefing (single-session intervention within 24-72 hours post-trauma), as randomized controlled trials show it may be harmful. 1

• Do not delay trauma-focused therapy for prolonged stabilization phases, even in complex presentations with suicidality, substance use history, or severe comorbidities. 1, 3

• Do not prescribe propranolol, hydrocortisone, or benzodiazepines for acute stress reactions, as they have limited benefit in preventing chronic PTSD. 1

• Do not continue ineffective medication beyond 8 weeks without adjusting the treatment plan. 3

Special Considerations for Adolescents

• Lower body weights in children and adolescents require careful dose titration to avoid excess dosing, particularly when advancing from 25 mg to higher doses. 5

• Secure video teleconferencing can effectively deliver trauma-focused therapy with equivalent outcomes when in-person psychotherapy is unavailable, improving access for adolescents in rural or underserved areas. 1, 3

• Psychiatric comorbidities (depression, anxiety, substance use) are common in adolescent PTSD and should be treated concurrently, with trauma-focused therapy often improving comorbid symptoms without requiring separate interventions. 1, 7