First-Line Treatment for PTSD with Comorbid Depression
Trauma-focused psychotherapy should be initiated immediately as first-line treatment, even in the presence of comorbid depression, with SSRIs (sertraline or paroxetine) added concurrently or as an alternative when psychotherapy is unavailable or strongly preferred by the patient. 1, 2
Primary Treatment: Trauma-Focused Psychotherapy
The three evidence-based psychotherapies with strongest support are Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), and Eye Movement Desensitization and Reprocessing (EMDR), with 40-87% of patients no longer meeting PTSD criteria after 9-15 sessions. 1, 2
Depression symptoms generally improve following trauma-focused psychotherapy without requiring separate interventions, and treatment response to prolonged exposure is unrelated to depression symptom severity. 3, 1
Comorbid major depressive disorder does not reduce the efficacy of trauma-focused treatments, and depression improves directly through trauma processing itself. 3, 1
No prolonged stabilization phase is required before initiating trauma-focused therapy, even with severe comorbidities—this is a critical point as delaying trauma-focused treatment is a common pitfall. 3, 1
Pharmacotherapy as Adjunct or Alternative
Sertraline (50-200 mg/day) or paroxetine (20-50 mg/day) are the only FDA-approved medications for PTSD and should be considered when psychotherapy is unavailable, ineffective, or the patient strongly prefers medication. 1, 4, 2
SSRIs can be started concurrently with psychotherapy, particularly when depression is prominent, though psychotherapy alone often suffices for both conditions. 1, 5
Continue SSRI treatment for a minimum of 6-12 months after symptom remission, as discontinuation leads to 26-52% relapse rates compared to only 5-16% when maintained on medication. 1, 4
Treatment Sequencing for Comorbid Depression
When both PTSD and depression are present, target PTSD first with trauma-focused therapy (specifically CPT), as this approach shows better outcomes than treating depression first. 6
A sequential approach of CPT followed by Behavioral Activation for residual depression symptoms (if needed) demonstrates superior results, with 49% achieving remission of both PTSD and depression at follow-up compared to 18% with CPT alone. 6
The majority of depression symptoms resolve through trauma-focused treatment alone without requiring additional depression-specific interventions. 3, 1
Critical Medications to Avoid
Benzodiazepines must be avoided entirely in PTSD treatment, as 63% of patients receiving benzodiazepines developed PTSD at 6 months compared to only 23% receiving placebo. 1, 7
Psychological debriefing (single-session intervention within 24-72 hours post-trauma) should not be used, as it may be harmful. 1, 8
Treatment Durability and Outcomes
Relapse rates are significantly lower after completing trauma-focused psychotherapy compared to medication discontinuation, demonstrating more durable benefits with psychotherapy. 1, 2
With appropriate trauma-focused treatment, 40-87% of patients no longer meet PTSD criteria, and comorbid depression typically resolves concurrently. 1, 7