PTSD Pharmacotherapy

Table C1: Summary Table
R	Significant Benefit	Some Benefit
A	Cognitive Therapy [CT] Exposure Therapy [ET] Stress Inoculation Training [SIT] Eye Movement Desensitization and Reprocessing [EMDR]
B		Imagery Rehearsal Therapy [IRT] Psychodynamic Therapy
C
I		PTSD - Patient Education Group Therapy

R = level of recommendation(see appendix A)

Table C2: Adjunctive Treatments
B		Dialectical Behavioral Therapy [DBT]
B		Hypnosis

R = level of recommendation(see appendix A)

Table C3. Problem-Focused Psychosocial **Adjunctive Methods/Services**
	If the client and clinician together conclude that the patient with PTSD:	Service/Training
1.	Is not fully informed about aspects of health needs and does not avoid high-risk behaviors (e.g., PTSD, substance)	Provide patient education
2.	Does not have sufficient self-care and independent living skills	Refer to self-care/independent living skills training services
3.	Does not have safe, decent, affordable, stable housing that is consistent with treatment goals	Use and/or refer to supported housing services
4.	Does not have a family that is actively supportive and/or knowledgeable about treatment for PTSD	Implement family skills training
5.	Is not socially active	Implement social skills training
6.	Does not have a job that provides adequate income and/or fully uses his or her training and skills	Implement vocational rehabilitation training
7.	Is unable to locate and coordinate access to services such as those listed above	Use case management services
8.	Does request spiritual support	Provide access to religious/spiritual advisors and/or other resources
	OTHER CONDITIONS
9.	Does have a borderline personality disorder typified by parasuicidal behaviors	Consider Dialectical Behavioral Therapy
10.	Does have concurrent substance abuse problem	Integrated PTSD substance abuse treatment (e.g., Seeking Safety)

Hospitalization:
There have been no satisfactory studies on inpatient treatment for patients with PTSD or other post-traumatic disorders. Clinical consensus supports that it is appropriate for crisis intervention, management of complex diagnostic cases, delivery of emotionally intense therapeutic procedures, and relapse prevention.

OBJECTIVE

Provide guidance to providers for the selection of treatment for patients with PTSD

RECOMMENDATIONS

Providers should explain to all patients with PTSD the range of available and effective therapeutic options for PTSD. [Expert Consensus]
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*]
Imagery Rehearsal Therapy [IRT] and Psychodynamic Therapy may be considered for treatment of PTSD. [B*]
Patient education is recommended as an element of treatment of PTSD for all patients. [C*]
Consider Dialectical Behavioral Therapy (DBT) for patients with a borderline personality disorder typified by parasuicidal behaviors. [B]
Consider hypnotic techniques especially for symptoms associated with PTSD, such as pain, anxiety, dissociation and nightmares, for which hypnosis has been successfully used. [*B]
Specialized PTSD psychotherapies may be augmented by additional problem specific methods /services, and pharmacotherapy. [Expert Consensus]
Combination of cognitive therapy approaches (e.g., ET plus CT), while effective, has not proven to be superior to either component alone. [B]
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]
Patient and provider preferences should drive the selection of evidence-based psychotherapy and/or evidence-based pharmacotherapy as the first line treatment. [Expert Consensus]
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]
Psychotherapies should be provided by practitioners who have been trained in the particular method of treatment, whenever possible. [Expert Consensus]
Group treatment for patients with PTSD may be considered, although current findings do not favor any particular type of group therapy over other types.
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.

Supportive psychotherapy is not considered to be effective for the treatment of ptsd. However, if the patient has reasonable control over his/her symptoms and is not in severe and acute distress, the goal may be to prevent relapse and supportive therapy may be helpful in that endeavor. Or, for the patient with certain co-morbid disorders, supportive therapy may be all they can tolerate without causing additional harm. Psychodynamic, interpersonal, experiential (e.g., Gestalt therapy), and many other approaches may also be beneficial parts of an effectively integrated approach. Most experienced therapists integrate diverse therapies, which are not mutually exclusive in a fashion that is designed to be especially beneficial to a given patient.