What strategies can prevent Post-Traumatic Stress Disorder (PTSD) relapse?

From the Guidelines

Preventing PTSD relapse requires a comprehensive approach combining therapy maintenance, medication management, and lifestyle strategies, with a strong emphasis on continuing evidence-based therapies like Cognitive Processing Therapy (CPT), Prolonged Exposure (PE), or Eye Movement Desensitization and Reprocessing (EMDR) even after initial symptom improvement, as recommended by the 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guideline 1. To prevent PTSD relapse, the following strategies can be employed:

• Continue with evidence-based therapies like CPT, PE, or EMDR, scheduling periodic "booster sessions" every 3-6 months.
• If prescribed medications like SSRIs (sertraline 50-200mg daily, paroxetine 20-60mg daily, or fluoxetine 20-80mg daily), maintain them for at least 12 months after symptom stabilization, tapering gradually under medical supervision, as supported by studies on medication discontinuation and relapse 1.
• Develop a personalized relapse prevention plan identifying triggers and early warning signs, with specific coping strategies for each.
• Practice stress management through daily mindfulness meditation (10-15 minutes), deep breathing exercises, or progressive muscle relaxation.
• Maintain healthy sleep habits with consistent bedtimes, avoiding screens before bed, and limiting caffeine and alcohol.
• Build a support network of trusted individuals and consider joining a PTSD support group. These approaches work by reinforcing trauma processing, maintaining neurotransmitter balance, reducing physiological stress responses, and providing social connection that buffers against stress. Key considerations include:
• The use of specific manualized psychotherapies over pharmacotherapy, as recommended by the CPG 1.
• The importance of secure video teleconferencing to deliver recommended psychotherapy when that therapy has been validated for use with video teleconferencing or when other options are unavailable.
• The recommendation against use of benzodiazepines, cannabis, or cannabis-derived products. By prioritizing these evidence-based strategies, individuals can reduce their risk of PTSD relapse and improve their overall quality of life.

From the FDA Drug Label

Patients receiving continued sertraline treatment experienced significantly lower relapse rates over the subsequent 28 weeks compared to those receiving placebo. To prevent PTSD relapse, continued treatment with sertraline is recommended, as it has been shown to significantly lower relapse rates compared to placebo 2.

• The dose of sertraline needed for maintenance treatment is not known to be identical to the dose needed to achieve an initial response.
• Patients should be periodically reassessed to determine the need for maintenance treatment 2.

From the Research

Prevention of PTSD Relapse

To prevent PTSD relapse, several strategies can be employed, including:

• Continuation and maintenance treatment with selective serotonin reuptake inhibitors (SSRIs) for 6-12 months, which has been shown to decrease relapse rates 3
• Trauma-focused psychological interventions, such as cognitive behavioural therapy with a trauma focus (CBT-TF), cognitive processing therapy (CPT), cognitive therapy (CT), eye movement desensitisation and reprocessing (EMDR), and prolonged exposure (PE) 4
• Pharmacological approaches, including SSRIs, serotonin-potentiating non-SSRIs, and anticonvulsants, which have been found to be effective in reducing PTSD symptoms 3, 5, 6

Medications for PTSD Prevention

The following medications have been found to be effective in preventing PTSD relapse:

• SSRIs, such as sertraline, paroxetine, and fluoxetine, which are considered first-line treatment for PTSD 3, 5, 6
• Serotonin-potentiating non-SSRIs, such as venlafaxine, nefazodone, trazodone, and mirtazapine, which have been found to be effective in reducing PTSD symptoms 3
• Anticonvulsants, such as carbamazepine, valproic acid, topiramate, and gabapentin, which have been found to be effective in reducing PTSD symptoms, particularly in patients with co-morbid bipolar disorder 3

Psychological Interventions for PTSD Prevention

The following psychological interventions have been found to be effective in preventing PTSD relapse:

• CBT-TF, which has been found to be effective in reducing PTSD symptoms 4
• CPT, which has been found to be effective in reducing PTSD symptoms 4
• CT, which has been found to be effective in reducing PTSD symptoms 4
• EMDR, which has been found to be effective in reducing PTSD symptoms 4
• PE, which has been found to be effective in reducing PTSD symptoms 4