Treatment Options for PTSD
Providers have several options to consider for the treatment of posttraumatic stress disorder (PTSD) in service members. Providers should consider not only effectiveness, but also access to services, availability of prescribed treatment, training of available providers, and patient preferences when choosing an evidence-based treatment option. Use of both psychotherapy and psychopharmacological treatments are appropriate for some patients.
Psychotherapy for PTSD
The first line of treatment for PTSD should include an evidence-based psychotherapy and/or psychopharmacology. Per the VA/DoD PTSD CPG, the most empirically-supported psychotherapies include one or more of several productive therapeutic approaches including exposure to traumatic memories, stimuli or situations; cognitive restructuring of trauma-related beliefs; and stress reduction techniques. The table below summarizes effective psychotherapeutic approaches for PTSD treatment that are detailed in the VA/DoD PTSD CPG. These approaches are not exclusive of one another and are sometimes blended into a hybrid treatment.
Providers should receive the appropriate training prior to delivering psychotherapy for PTSD. Information about training opportunities can be found in the Education and Training section.
|Therapy Approach||Therapeutic Elements||Examples|
|Exposure-based Therapies||Includes in-vivo, imaginal, or narrative (oral and/or written) exposures to traumatic memories, situations, or stimuli. These therapies generally include elements of cognitive restructuring (e.g., evaluating the accuracy of beliefs about danger) as well as relaxation techniques.||
Prolonged Exposure Therapy (PE)
Brief Eclectic Psychotherapy
|Cognitive-based Therapies||Emphasizes cognitive restructuring strategies including challenging beliefs connected to the traumatic event. Includes relaxation techniques and discussion of the traumatic event either orally or through writing.||
Cognitive Processing Therapy (CPT)
|Stress Inoculation Training||Especially emphasizes breathing retraining and muscle relaxation. May also include cognitive approaches and exposure techniques.||Stress Inoculation Training (SIT)|
|Eye Movement Desensitization and Reprocessing||
Typically includes alternating eye movements, exposure elements (e.g., holding distressing traumatic memories in mind without verbalizing them) cognitive approaches (e.g., identifying a negative cognition, an alternative positive cognition, and assessing the validity of the cognition), and relaxation/self-monitoring techniques (e.g., “body scan”).
|Eye Movement Desensitization and Reprocessing Therapy (EMDR)|
Pharmacological Treatment Options
Medications can help address symptoms of PTSD, as well as treat related comorbid diagnoses. The VA/DoD PTSD CPG notes that there is no evidence to recommend the use of medication in the early period (4 to 30 days) following a trauma to prevent PTSD. However, a short course (less than six days) of medication to manage associated symptoms (sleep disturbances, pain, or irritability) may be considered. The VA/DoD PTSD CPG strongly recommends against the use of benzodiazepines to prevent the development of PTSD.
Providers should periodically review the literature for the most current evidence when prescribing medications for the treatment of PTSD.
It is important to remember that marketing messages, patient preferences, and clinical customs may not be consistent with the evidence base. An initial pharmacological approach should include a first-line monotherapy trial before proceeding to subsequent strategies. Providers should allow sufficient time for response and monitor the patient for outcomes and side effects.
Adherence is critical to pharmacological treatment success and providers should communicate therapy expectations, as well as side effects and information for contacting the provider with questions or concerns in order to improve adherence to medication.
The evidence base is strongest for selective serotonin reuptake inhibitors (SSRIs), which are often used to treat depression. The Federal Drug Administration approved two SSRIs (sertraline and paroxetine) in the treatment of PTSD, but strong evidence also supports off-label use of the SSRI fluoxetine as a first line treatment. The serotonin norepinephrine reuptake inhibitor (SNRI) venlafaxine has also received strong research support in the treatment of PTSD and providers can consider it as a first line treatment. Although SSRIs should typically be the preferred initial class of medication for treatment of PTSD, providers should consider a patient’s response or side effect history, as well as comorbidities, when choosing medication and dosage. Providers should tailor medication choices to the individual patient.