What are the first‑line treatment options for post‑traumatic stress disorder (PTSD) in adults and adolescents?

Treatment of PTSD

Initiate trauma-focused psychotherapy immediately as first-line treatment—specifically Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), or Eye Movement Desensitization and Reprocessing (EMDR)—which results in 40-87% of patients no longer meeting PTSD criteria after 9-15 sessions. 1

First-Line Treatment: Trauma-Focused Psychotherapy

The VA/DoD Clinical Practice Guideline and American Psychological Association both strongly recommend trauma-focused psychotherapies as the primary intervention for PTSD, with the strongest evidence supporting three specific approaches: 1, 2

• Prolonged Exposure (PE): Involves systematic confrontation with trauma memories and avoided situations, demonstrating 40-87% remission rates after 9-15 sessions 1
• Cognitive Processing Therapy (CPT): Addresses negative trauma-related appraisals that fuel emotion dysregulation, with equivalent efficacy to PE 1
• Eye Movement Desensitization and Reprocessing (EMDR): Provides comparable outcomes to PE and CPT, with support from over 30 randomized controlled trials 3, 4

Network meta-analyses confirm EMDR (SMD -2.07) and trauma-focused CBT (SMD -1.46) demonstrate the largest effect sizes for PTSD symptom reduction compared to waitlist controls, with sustained effects at follow-up. 4

Critical Paradigm: No Stabilization Phase Required

Do not delay trauma-focused treatment by requiring a prolonged stabilization phase, even in patients with complex presentations including multiple traumas, severe comorbidities, dissociative symptoms, or emotion dysregulation. 1, 5

• No randomized controlled trials demonstrate that patients with complex PTSD require or benefit from prolonged stabilization before trauma processing 1
• Emotion dysregulation, dissociative symptoms, and negative self-concept improve directly through trauma processing itself, without requiring separate stabilization interventions 1, 6
• Delaying trauma-focused treatment communicates to patients that they are incapable of dealing with traumatic memories, reducing self-confidence and motivation 5
• History of childhood sexual abuse, multiple traumas, or severe comorbidities does not negatively affect PTSD treatment response 7

Pharmacotherapy: Second-Line Treatment

Consider medication when psychotherapy is unavailable, ineffective, the patient refuses psychotherapy, or residual symptoms persist after psychotherapy. 1

FDA-Approved First-Line Medications:

• Sertraline: FDA-approved for PTSD, demonstrated significantly greater reduction in CAPS scores and CGI improvement compared to placebo in two 12-week trials (mean dose 146-151 mg/day) 8, 2
• Paroxetine: FDA-approved for PTSD, with 20-40 mg/day doses showing significant superiority over placebo on CAPS-2 scores and CGI-I response rates 9, 2
• Venlafaxine: Recommended as alternative SSRI/SNRI option at 32.5-300 mg/day 1, 10

Critical Limitation of Pharmacotherapy:

Relapse rates after medication discontinuation are substantially higher (26-52%) compared to patients maintained on medication (5-16%), and much higher than relapse rates after completing trauma-focused psychotherapy. 1 This underscores the superiority of psychotherapy for durable treatment response.

If pharmacotherapy is used, continue treatment for minimum 6-12 months after symptom remission before considering discontinuation. 7

Treatment for Specific Symptoms

PTSD-Related Nightmares:

• Prazosin is strongly recommended (Level A evidence) for PTSD-related nightmares 1, 10
• Dosing: Start 1 mg at bedtime, increase 1-2 mg every few days, average effective dose 3 mg (range 1-13 mg) 7
• Monitor for orthostatic hypotension 7

Sleep Disturbances:

• Trazodone 25-600 mg may be considered, though 60% experience side effects including daytime sedation 1
• Screen for obstructive sleep apnea, which is common in PTSD patients with sleep disturbance 10

Medications to AVOID

Never prescribe benzodiazepines for PTSD treatment. Evidence demonstrates 63% of patients receiving benzodiazepines developed PTSD at 6 months compared to only 23% receiving placebo. 1, 7 Benzodiazepines worsen PTSD outcomes and should be avoided entirely. 6

Never provide psychological debriefing (single-session intervention within 24-72 hours post-trauma), as randomized controlled trials show it may be harmful. 1, 7

Treatment Algorithm

1. Immediately offer trauma-focused psychotherapy (PE, CPT, or EMDR) without requiring stabilization phase, even in complex presentations 1, 6
2. If psychotherapy unavailable, ineffective, or patient refuses: Add or substitute SSRI (sertraline or paroxetine) or venlafaxine 1, 10
3. For persistent nightmares: Add prazosin regardless of other treatments 1, 10
4. For residual symptoms after psychotherapy: Consider adding pharmacotherapy as adjunct 1
5. Continue pharmacotherapy 6-12 months minimum after remission if used 7

Adolescent Considerations

The same trauma-focused psychotherapies (PE, CPT, EMDR) are recommended for adolescents with PTSD. 1 For adolescents with complex presentations including self-harm and suicidality, Dialectical Behavior Therapy for Adolescents (DBT-A) has randomized controlled trial evidence demonstrating reduction in suicidality and self-harm, though trauma-focused therapy should not be delayed. 7

Common Pitfalls to Avoid

• Never label patients as "too complex" for trauma-focused therapy: This assumption lacks empirical support and restricts access to effective interventions 1, 5
• Never require prolonged stabilization before trauma processing: Patients with severe comorbidities, dissociation, or emotion dysregulation benefit from immediate trauma-focused treatment 5, 6
• Never use bupropion for PTSD: It has failed to demonstrate efficacy in controlled trials and is explicitly not recommended by VA/DoD guidelines 7
• Never use clonazepam for nightmares: It showed no improvement in nightmare frequency or intensity compared to placebo 7

Treatment Accessibility

Trauma-focused psychotherapy can be effectively delivered via secure video teleconferencing when in-person options are unavailable, with similar outcomes to in-person treatment. 7, 11 This improves access for patients in areas with limited specialty mental health resources.