a. Selection Of Therapy For PTSD

In clinical practice, providers and patients alike are often faced with important decisions relating to type, number, frequency, and dose of various psychotherapies and pharmacologic therapies. Therapies may be broadly divided into (1) evidence-based psychotherapies, (2) evidence-based pharmacotherapies, and (3) key adjunctive or supplemental treatment modalities. Providers should explain to all patients with PTSD the range of therapeutic options that are available and effective for PTSD. This discussion should include general advantages and disadvantages (including side-effects) associated with each therapeutic option. In general, PTSD therapy research has provided insufficient evidence to favor medication or evidence-based psychotherapy as a first-line treatment. There is also insufficient evidence to suggest for or against combined medication and psychotherapy over only one of the two approaches.

It may be helpful to add therapies using a stepped care approach, even though supporting evidence does not exist. The use of stepped care has been advocated for many chronic conditions including hypertension, low back pain, and depression. In stepped care, the intensity of care is augmented for patients who do not achieve an acceptable outcome with lower levels of care. Stepped care is based on three assumptions: different people require different levels of care; finding the right level of care often depends on monitoring outcomes; and moving from lower to higher levels of care based on patient outcomes often offers efficient increases in overall effectiveness.

The level or intensity of care is guided by illness trajectory (degree of chronicity and current illness severity), observed outcomes, and previously attempted therapies. Active follow-up is used to determine the level of care each patient requires over time. In PTSD for example, the patient and provider may determine that the first-line therapy will be psychotherapy. If, after a period of treatment, the patient is not responding adequately, the patient may be "stepped up" in therapeutic intensity by adding a medication, such as a selective serotonin reuptake inhibitor (SSRI) to the regimen of ongoing psychotherapy.

Contrary to clinical intuition, there is no evidence indicating the superiority of programs that combine different cognitive behavioral therapies (Rothbaum, 2001).