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E. Initiate Therapy For PTSD                      (For more details see the section on Intervention )

Pharmacotherapy Interventions

OBJECTIVE

To minimize signs and symptoms of PTSD and maintain function.

BACKGROUND

There is growing evidence that PTSD is characterized by specific psychobiological dysfunctions, which has contributed to a growing interest in the use of medications to treat trauma-related biological effects (references).

RECOMMENDATIONS

  1. Strongly recommend selective serotonin reuptake inhibitors (SSRIs) for the treatment of PTSD.
  2. Recommend tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) as second-line treatments for PTSD.
  3. Consider an antidepressant therapeutic trial of at least 12 weeks before changing therapeutic regimen.
  4. Consider a second-generation (e.g., nefazodone, trazodone, venlafaxine, mirtazapine, bupropion, etc) in the management of PTSD.
  5. Consider prazosin to augment the management of nightmares and other symptoms of PTSD.
  6. Recommend medication compliance assessment at each visit.
  7. Since PTSD is a chronic disorder responders to pharmacotherapy may need to continue medication indefinitely; however it is recommended that maintenance treatment should be periodically reassessed.
  8. There is insufficient evidence to recommend a mood stabilizer (e.g. lamotrigine) for the treatment of PTSD.
  9. There is insufficient evidence to recommend atypical antipsychotics for the treatment of PTSD.
  10. There is insufficient evidence to support the recommendation for a pharmacological agent to prevent the development of PTSD.
  11. Recommend against the long-term use of benzodiazepines to manage core symptoms in PTSD.
  12. Recommend against typical antipsychotics in the management of PTSD.

DISCUSSION

See Intervention Section : Pharamcotherapy

Psychotherapy Interventions

RECOMMENDATIONS

  1. Providers should explain to all patients with PTSD the range of available and effective therapeutic options for PTSD. [Expert Consensus]
  2. Cognitive Therapy [CT], Exposure Therapy [ET], Stress Inoculation Training [SIT], and Eye Movement Desensitization and Reprocessing [EMDR] are strongly recommended for treatment of PTSD in military & non-military populations. EMDR has been found to be as effective as other treatments in some studies and less effective than other treatments in some other studies. [ A*]
  3. Imagery Rehearsal Therapy [IRT] and Psychodynamic Therapy may be considered for treatment of PTSD. [B*]
  4. Patient education is recommended as an element of treatment of PTSD for all patients. [C*]
  5. Consider Dialectical Behavioral Therapy (DBT) for patients with a borderline personality disorder typified by parasuicidal behaviors. [B]
  6. Consider hypnotic techniques especially for symptoms associated with PTSD, such as pain, anxiety, dissociation and nightmares, for which hypnosis has been successfully used. [*B]
  7. Specialized PTSD psychotherapies may be augmented by additional problem specific methods /services, and pharmacotherapy. [Expert Consensus]
  8. Combination of cognitive therapy approaches (e.g., ET plus CT), while effective, has not proven to be superior to either component alone. [B]
  9. Specific psychotherapy techniques may not be uniformly effective across all patients. When selecting a specific treatment modality, consideration of patient characteristics such as gender, type of trauma (e.g., combat vs. other trauma), and past history may be warranted. [Expert Consensus]
  10. Patient and provider preferences should drive the selection of evidence-based psychotherapy and/or evidence-based pharmacotherapy as the first line treatment. [Expert Consensus]
  11. Selection of individual interventions should be based upon patient preference, provider level of skill and comfort with a given modality, efforts to maximize benefit and minimize risks to the patient, and consideration of feasibility and available resources. [Expert Consensus]
  12. Psychotherapies should be provided by practitioners who have been trained in the particular method of treatment, whenever possible. [Expert Consensus]
  13. A stepped care approach to therapy administration may be considered, though supportive evidence is lacking. [Expert Consensus]

* detailed evidence tables for each therapy are included in the applicable Discussion sections.

Note: Psychotherapy interventions are aimed at reduction of symptoms severity and improvement of global functioning. However, the clinical relevance and importance of other outcome indicators (e.g., improvement of quality of life, physical & mental health) are not currently well known.

DISCUSSION

See Psychotherapy Therapy Summary.

  1. Selection Of Therapy For PTSD
  2. Cognitive Therapy (CT)
  3. Exposure Therapy (ET)
  4. Stress Inoculation Training (SIT)
  5. Eye Movement Desensitization and Reprocessing (EMDR)
  6. Imagery Rehearsal Therapy (IRT)
  7. Psychodynamic Therapy
  8. Patient Education
  9. Group Therapy
  10. Dialectical Behavior Therapy
  11. Hypnosis
  12. Psychosocial Adjunctive Methods/Services
  13. Spiritual Support