Medication Approach for Trauma-Related PTSD in a 15-Year-Old
Start sertraline 25 mg daily for the first week, then increase to 50 mg daily, with further titration up to 200 mg daily based on response, while simultaneously initiating trauma-focused psychotherapy (Prolonged Exposure, Cognitive Processing Therapy, or EMDR) without delay. 1, 2, 3
First-Line Pharmacotherapy: SSRIs
Sertraline is the medication of choice for adolescents with trauma-related PTSD, starting at 25 mg daily for week one, then 50 mg daily, with dose adjustments every 2-4 weeks up to a maximum of 200 mg daily based on clinical response and tolerability. 3, 4, 5
Sertraline targets all three core PTSD symptom clusters: reexperiencing/intrusion, avoidance/numbing, and hyperarousal, with demonstrated efficacy in controlled trials showing significant improvement on the Clinician-Administered PTSD Scale (CAPS). 3, 6
Continue sertraline for a minimum of 6-12 months after symptom remission to prevent relapse, as discontinuation leads to relapse rates of 26-52% when shifted to placebo compared to only 5-16% maintained on medication. 1, 7
If sertraline is not tolerated, paroxetine (starting 10-20 mg daily, up to 60 mg daily) is an alternative FDA-approved SSRI for PTSD with similar efficacy. 1, 6
Concurrent Trauma-Focused Psychotherapy (Non-Negotiable)
Initiate trauma-focused psychotherapy immediately alongside medication—do not delay therapy for a "stabilization phase," as this approach is potentially iatrogenic and communicates to the adolescent that they cannot handle their memories. 1, 2
Trauma-focused CBT, Prolonged Exposure, Cognitive Processing Therapy, or EMDR should begin within 2 weeks of starting medication, with 40-87% of patients no longer meeting PTSD criteria after 9-15 sessions. 1, 2, 8
Psychotherapy provides more durable benefits than medication alone, with lower relapse rates after CBT completion compared to medication discontinuation. 1
Comorbid depression (common in trauma-related PTSD) typically improves alongside PTSD symptoms during trauma-focused therapy without requiring separate depression-specific interventions. 1, 8
Treatment Timeline and Monitoring
| Timeframe | Action |
|---|---|
| Week 1 | Sertraline 25 mg daily; schedule first trauma-focused therapy session. [3,4] |
| Week 2-4 | Increase sertraline to 50 mg daily if tolerated; begin weekly trauma-focused therapy. [3,5] |
| Week 4-8 | Titrate sertraline to 100-150 mg daily based on response; continue weekly therapy; monitor PTSD symptoms, depression, and sleep. [3,6] |
| Week 8-12 | Further titrate to 200 mg daily if needed; expect significant improvement after 9-15 therapy sessions. [1,3] |
| Months 3-6 | Continue therapy until protocol completion (typically 12-17 sessions). [1] |
| Months 6-12 | Maintain sertraline for minimum 6-12 months after remission before considering taper. [1,7] |
Adjunctive Medication for Specific Symptoms
If nightmares persist despite adequate SSRI dosing, add prazosin starting at 1 mg at bedtime, titrating by 1-2 mg every few days to an average effective dose of 3 mg (range 1-13 mg), with monitoring for orthostatic hypotension. 1, 8, 9
If severe aggression or mood dysregulation persists after 6-8 weeks of adequate SSRI therapy, consider adding a mood stabilizer such as valproate 250-500 mg twice daily, titrating to therapeutic blood level of 40-90 mcg/mL. 2
Critical Medications to Avoid
Never use benzodiazepines (alprazolam, clonazepam, lorazepam) in adolescents with PTSD, as evidence shows 63% of patients receiving benzodiazepines developed PTSD at 6 months compared to only 23% receiving placebo. 1, 2, 8
Bupropion is not recommended for PTSD treatment, as it has failed to demonstrate efficacy in controlled trials and is explicitly excluded from evidence-based PTSD treatment guidelines. 1, 6
Avoid psychological debriefing (single-session intervention within 24-72 hours post-trauma), as randomized controlled trials show it may be harmful and increase subsequent PTSD rates. 10, 1, 8
Common Pitfalls to Avoid
Do not delay trauma-focused therapy while waiting for medication to "stabilize" the patient—this approach lacks empirical support, reduces patient confidence, and worsens outcomes. 1, 2, 8
Do not label the adolescent as "too complex" for trauma-focused therapy based on depression, multiple traumas, or emotion dysregulation, as these factors do not reduce treatment response and such labeling is iatrogenic. 1, 2, 8
Do not use medication as monotherapy—SSRIs are adjunctive to trauma-focused psychotherapy, which remains the gold-standard first-line treatment with superior long-term outcomes. 1, 4, 5
Monitor for worsening suicidal ideation during the first 4-8 weeks of SSRI initiation, as adolescents may be at increased risk during this period. 4, 5
Expected Outcomes
PTSD symptom remission: 40-87% of adolescents will no longer meet PTSD diagnostic criteria after completing 9-15 sessions of trauma-focused psychotherapy combined with adequate SSRI therapy. 1, 2
Depression improvement: Depressive symptoms typically improve significantly as PTSD symptoms resolve, even without depression-specific interventions. 1, 8, 3
Functional improvement: SSRIs improve social and occupational functioning and overall quality of life in adolescents with PTSD. 5
Relapse prevention: Maintaining sertraline for 6-12 months after remission reduces relapse risk from 26-52% to 5-16%. 1, 7