PTSD: National Center for PTSD

Shared Decision Making

Shared decision making is an approach in which providers and patients communicate together using the best available evidence to make decisions.

To learn more, take this PTSD 101 online course: Shared Decision Making for PTSD.

Diagnosis

An accurate diagnosis and assessment using either a clinical interview or structured diagnostic interview is an essential first step to correctly identify patients with PTSD and ensure they receive appropriate treatment. Brief questionnaires such as the PTSD Checklist (PCL-5) can be used to assess symptom severity and monitor treatment response.

PTSD Treatment Guidelines

A major change in the 2017 guideline is there is now a recommendation to use specific trauma-focused treatments over medications or other psychotherapies, which are both recommended as second line.

The guideline's recommendation to use individual trauma-focused psychotherapy over pharmacotherapy reflects the current state of research into PTSD treatment. Two recent meta-analyses noted that trauma-focused psychotherapies impart greater change with regard to core PTSD symptoms than pharmacotherapies, and that these improvements persist for longer time periods.^{19, 20} The trauma-focused psychotherapies with the strongest evidence from clinical trials are:

• Prolonged Exposure (PE)
• Cognitive Processing Therapy (CPT)
• Eye Movement Desensitization and Reprocessing (EMDR)

Other manualized protocols that have sufficient evidence to recommend use are:

• Specific cognitive behavioral therapies (CBTs) for PTSD
• Brief Exposure Therapy (BEP)
• Narrative Exposure Therapy (NET)
• Written Narrative Exposure

If trauma-focused psychotherapy is not available or if a patient prefers a treatment that does not require a focus on trauma, the guideline suggests individual, manualized psychotherapy that is not trauma-focused. The following are the therapies with the most evidence with direct comparisons with first-line therapies:

• Stress Inoculation Training (SIT)
• Present-Centered Therapy (PCT)
• Interpersonal Therapy (IPT)

The guideline also recommends that the presence of comorbid disorders not prevent patients from receiving the guideline-recommended treatments.

For those patients who choose not to engage in or are unable to access trauma-focused psychotherapy and opt for medication treatment, the use of the specific antidepressants as monotherapy is recommended:

• Sertraline (Zoloft^®)
• Paroxetine (Paxil^®)
• Fluoxetine (Prozac^®)
• Venlafaxine (Effexor^®)

There is a large group of medications and substances recommended against for PTSD due to low quality of evidence and risk of potential harms. That group includes:

• Atypical antipsychotics
• Benzodiazepines
• Anticonvulsants
• Ketamine
• Hydrocortisone
• D-cycloserine
• Cannabis

It is important to avoid use of benzodiazepines and atypical antipsychotics alone or in combination with other medications for treatment of PTSD because the risk and harms associated with these medications exceed their proven therapeutic benefit for PTSD.^{18, 21,22}

Despite recommendations against their use in treating PTSD, benzodiazepines and atypical antipsychotics continue to be prescribed in patients with PTSD. In VA, clinicians prescribe benzodiazepines to a third of Veterans with PTSD and do so more often in rural Veterans.^23,24 Though prescribing clinicians generally agree with practice guidelines that discourage harmful medication use in PTSD, often they do not taper patients off because tapering is too time-intensive or because the patients appear stable.²⁵ There is also a common dilemma in balancing treatments the patient thinks are useful with science and best practice.