Choosing treatments for PTSD

The treatment of post traumatic stressRelating to injury or concern. disorder (PTSD) is multi-faceted. Patient education and social support are important, particularly in the early stages, to help minimize the impact of the traumatic event. Support from family and friends is very valuable. Local and national support groups, if available, can help to remove the stigma associated with PTSD.[1]

Studies suggest that only a small proportion of people with PTSD receive any treatment, and even fewer receive treatment that is adequate.[2] However, treatment is available.

The main aspects of treatment are:[1]

Psychotherapy

Certain forms of psychotherapy have been shown to be very effective in the treatment of PTSD. The mainstay of therapy is cognitive behavioural therapy (CBT), which looks at thought patterns and the behaviours associated with them.[1] Eye movement desensitization and reprocessing (EMDR) has also been shown to be effective, although the underlying mechanism of action is not known.[3]

Learn more about psychotherapy in PTSD.

Medications

The medications that appear to be most effective in PTSD, with the best safety profile, are the antidepressant medications selective serotonin reuptake inhibitors (SSRIs). Other groups of antidepressants can also be effective, although are less commonly used owing to associated side effects. Finally, drugs called 'atypical antipsychotic drugs' are also used sometimes, although less frequently. Further research is needed to assess the benefits of anticonvulsants and beta blockers.[4,5]

Learn more about medications in PTSD.

Psychotherapy treatment for PTSD

There is strong evidence for the value of psychotherapy in PTSD.[3] The main form of psychotherapy used in PTSD is cognitive behavioural therapy (CBT).[1]

CBT is a form of psychotherapy that examines thought patterns and their associated behaviours, and also attempts to reframe the meaning of the traumatic event. It helps people to confront their fear, and develop anxiety-management tools. The various forms of CBT include 'exposure' and 'cognitive restructuring'. Studies have shown that CBT is effective in reducing the symptoms of PTSD.[1,3,4]

Exposure therapy involves reliving the traumatic event in the imagination or actually confronting safe situations that remind the patient of the trauma, for example going back to the site of the traumatic event. This leads to the understanding that exposure does not lead to a feared outcome, and helps create an organized memory of the event.[6]

Unfortunately, while CBT has been shown to be effective in the treatment of PTSD, there is still some uncertainty about how long it's effects last and whether maintenance treatment is needed.[7]

Eye movement desensitization and reprocessing (EMDR) involves developing a mental image of a traumatic event and the negative thoughts related to it while tracking a stimulus back and forth. Although the mechanism of EMDR is not well understood, it appears to be effective.[3,6]

One study found that two-thirds of patients completing a course of CBT or EMDR no longer met the criteria for PTSD.[8]

Although research supports the use of CBT and EMDR, minimal studies have been done on other forms of psychotherapy in CBT.[7,9]

Family therapy and other group therapies may be helpful, as PTSD can have a profound effect on people who are close to the patient.[1,4]

Anxiety management can help to teach people sets of skills for coping with stressRelating to injury or concern.. Examples include relaxation training and breathing exercises.[6]

Medical treatment for PTSD

Several medications appear to be effective in the treatment of PTSD, particularly the group of antidepressant medications, selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). These drugs are also well-tolerated.[4-7]

Other groups of antidepressant medications that appear to be moderately effective in PTSD include tricyclic antidepressants and monoamine oxidase inhibitors. However, these drugs tend to be associated with more side effects, and so are used less frequently.[1,4,5]

An adequate amount of time should be allowed to see whether medications such as SSRIs or SNRIs are effective for a person with PTSD - usually at least four months.[7]

If an initial trial with an SSRI or a SNRI is not effective, trying another medication may help.

Research suggests that while medications can help with the symptoms of PTSD, often, they provide relief from them rather than a cure.[7]

A group of medications called 'atypical antipsychotic drugs' are also sometimes used, although less frequently. They can be combined with SSRI antidepressants, and can reduce some of the symptoms of PTSD.[4]

Other medications such as anticonvulsants have shown promise in early studies, but have not been properly researched for their benefit in PTSD. Beta blockers may have a benefit in reducing certain symptoms of PTSD, for example bringing down the heart rate; however, research is needed before these can be recommended.[6]

References: 
  1. Grinage BD. Diagnosis and management of post-traumatic stressRelating to injury or concern. disorder. Am Fam Physician 2003; 68: 2401-8,2409.
  2. Wittchen HU, Gloster A, Beesdo K et al. Posttraumatic stressRelating to injury or concern. disorder: diagnostic and epidemiological perspectives. CNS Spectr. 2009; 14: 1(Suppl 1): 5-12.
  3. Cloitre M. Effective psychotherapies for posttraumatic stressRelating to injury or concern. disorder: a review and critique. CNS Spectr. 2009; 14: 1(Suppl 1): 32-43.
  4. Budur K, Falcone T and Franco K. Diagnosing and managing posttraumatic stressRelating to injury or concern. disorder. Cleveland Clinic Journal of Medicine 2006; 73: 121-9.
  5. Schoenfeld FB, Marmar CR and Neylan TC. Current concepts in pharmacotherapy for posttraumatic stressRelating to injury or concern. disorder. Psychiatric Services 2004; 55: 519-31.
  6. Semple D and Smyth R. Oxford Handbook of Psychiatry 2009; 2nd Edition.
  7. Stein DJ, Cloitre M, Nemeroff CB et al. Cape town consensus on posttraumatic stressRelating to injury or concern. disorder. CNS Spectr 2009; 14: 1(Suppl 1): 52-8.
  8. Bradley R, Greene J, Russ E et al. A multidimensional meta-analysis of psychotherapy for PTSD. Am J Psychiatry 2005; 162: 214-27.
  9. Bisson JI, Ehlers A, Matthews R et al. Psychological treatments for chronicA disease of long duration generally involving slow changes. post-traumatic stressRelating to injury or concern. disorder. British Journal of Psychiatry 2007; 190: 97-104.