First-Line Treatment for PTSD
Trauma-focused psychotherapy—specifically Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), or Eye Movement Desensitization and Reprocessing (EMDR)—is the first-line treatment for PTSD in adults, with 40-87% of patients no longer meeting diagnostic criteria after 9-15 sessions. 1, 2, 3
Evidence-Based Treatment Hierarchy
Primary Intervention: Trauma-Focused Psychotherapy
The 2023 VA/DoD Clinical Practice Guideline and the American Psychological Association both strongly recommend trauma-focused psychotherapy as the initial treatment approach, prioritizing it over pharmacotherapy. 1, 3 The three interventions with the strongest evidence base are:
- Prolonged Exposure (PE): 9-15 weekly sessions demonstrating large effect sizes (Cohen's d ~-1.0 or greater) and numbers needed to treat (NNT) <4 to achieve loss of PTSD diagnosis 1, 4
- Cognitive Processing Therapy (CPT): 12-17 weekly sessions with comparable efficacy to PE, particularly effective for trauma-related negative appraisals 1, 4
- Eye Movement Desensitization and Reprocessing (EMDR): Equivalent effectiveness to PE and CPT, offering an alternative for patients who cannot tolerate exposure-based approaches 1, 5, 3
Begin trauma-focused therapy immediately without requiring a stabilization phase, even in patients with complex presentations including dissociation, emotion dysregulation, severe comorbidities, or suicidal ideation. 1, 2, 6 The assumption that patients need extensive stabilization before trauma processing is not supported by evidence and delays effective treatment. 7, 2
When to Consider Pharmacotherapy
Pharmacotherapy should be used as second-line treatment in specific circumstances: 1, 2
- Psychotherapy is unavailable or inaccessible
- Patient strongly prefers medication over psychotherapy
- Residual symptoms persist after completing psychotherapy
- Patient is unable or unwilling to engage in psychotherapy
If pharmacotherapy is indicated, sertraline or paroxetine are the only FDA-approved medications for PTSD. 8, 3 Sertraline is typically initiated at 50 mg daily and titrated to 100-200 mg daily based on response. 1 The 2023 VA/DoD guideline also recommends venlafaxine as a first-line pharmacologic option. 1
Critical Implementation Points
Treatment Durability
Psychotherapy produces more durable benefits than medication alone. Relapse rates after completing trauma-focused psychotherapy are substantially lower (5-16%) compared to medication discontinuation (26-52% relapse when shifted from sertraline to placebo). 1, 2 This difference in durability strongly favors psychotherapy as the primary intervention.
Comorbidity Does Not Change the Algorithm
Comorbid depression, panic disorder, or other psychiatric conditions do not diminish PTSD treatment response and should not delay trauma-focused therapy. 1, 2 Depressive symptoms typically improve alongside PTSD symptoms during trauma-focused treatment, and treatment response is unrelated to baseline depression severity. 1 Panic symptoms linked to trauma reminders decrease as physiological reactivity diminishes with successful trauma processing. 1
Complex PTSD Presentations
Patients with childhood trauma, multiple traumas, dissociation, or emotion dysregulation should receive trauma-focused therapy immediately without a prolonged stabilization phase. 7, 1, 6 Current evidence demonstrates that affect dysregulation and dissociative symptoms improve directly through trauma processing itself, not through separate stabilization interventions. 7, 6 Delaying trauma-focused treatment may inadvertently communicate to patients that they are incapable of dealing with traumatic memories, reducing self-confidence and motivation. 7, 2
Common Pitfalls to Avoid
Never Use Psychological Debriefing
Do not provide psychological debriefing (single-session intervention within 24-72 hours post-trauma), as randomized controlled trials show it is ineffective and may be harmful. 1, 2, 9
Avoid Benzodiazepines
Benzodiazepines are contraindicated in PTSD treatment. Evidence shows 63% of patients receiving benzodiazepines developed PTSD at 6 months compared to only 23% receiving placebo. 1, 6 The 2023 VA/DoD guideline strongly recommends against their use. 1
Do Not Delay Trauma-Focused Treatment
Do not postpone trauma-focused therapy for a "stabilization" period in patients with complex presentations. 2, 6 This practice lacks evidence support and may worsen outcomes by delaying access to effective treatment. 7, 2
Treatment Timeline
| Timeframe | Action |
|---|---|
| Week 1 | Initiate trauma-focused psychotherapy (PE, CPT, or EMDR) with weekly sessions [1,3] |
| Weeks 1-4 | If psychotherapy unavailable or patient prefers medication, start sertraline 50 mg daily, titrate to 100-200 mg [1] |
| Weeks 9-15 | Expect 40-87% of patients to achieve remission (no longer meeting PTSD criteria) after completing therapy protocol [1,2] |
| Months 6-12 | If using medication, continue for minimum 6-12 months after symptom remission before considering discontinuation [1] |
Adjunctive Interventions
For persistent nightmares despite trauma-focused therapy, add prazosin 1 mg at bedtime, titrating to an average effective dose of 3 mg (range 1-13 mg), monitoring for orthostatic hypotension. 1 This has Level A evidence from the American Academy of Sleep Medicine specifically for PTSD-related nightmares. 1