The Path to Recovery in Post-traumatic Stress Disorder: Combining Guidelines, Clinician Experience, and Patient Perspectives

In this article series, we look at clinical guidelines from around the globe. For a feasible approach, we have chosen a sample of nine international guidelines for this review on the management of post-traumatic stress disorder. The purpose is not to make an in-depth comparison of all existing guidelines, but to highlight the areas of greatest overlap and considerable differences.

In summary

• There is general consistency in recommendations across post-traumatic stress disorder (PTSD) clinical practice guidelines

• Guidelines describe trauma-focused psychotherapies as first-line psychological treatment

• Across guidelines, selective serotonin reuptake inhibitors (SSRIs)—specifically fluoxetine, sertraline, and paroxetine—as well as the serotonin and norepinephrine reuptake inhibitor (SNRI) venlafaxine, are widely accepted as first-line pharmacological treatments of PTSD

• A limited number of guidelines offer specific recommendations for nightmares despite their treatment resistance and association with increased suicide risk

• Guideline recommendations can be combined with patient preferences and values, as well as clinician experience and judgement, to ensure patients are receiving the best care possible

Clinical guidelines for the treatment of PTSD have been developed and revised as research continues and evidence for treatments evolves.¹ A systematic review of treatment guidelines for PTSD conducted in 2021 identified 14 international guidelines published between 2004 and 2020.² What are the primary recommendations for the treatment of PTSD? Here, we focus on key recommendations for nine guidelines, published internationally within the last 10 years (2013–2020).²

There is general consistency in recommendations across clinical practice guidelines for PTSD

All nine guidelines reviewed describe trauma-focused psychotherapies as first-line psychological treatment (Table 1).² This may include cognitive behavioral therapy (CBT), trauma-focused CBT, cognitive processing therapy (CPT), prolonged exposure (PE) therapy, image rehearsal therapy (IRT), or eye movement desensitization and reprocessing (EMDR) therapy.²

Four of the nine guidelines (World Health Organization [WHO],³ Department of Veterans Affairs and Department of Defense [VA/DOD],⁴ National Institute for Health and Care Excellence [NICE],⁵ Phoenix Australia – Centre for Posttraumatic Mental Health [Phoenix]⁶) recommend psychotherapy over available pharmacological therapies as first-line treatment for PTSD (Table 1).^2,5 This guidance is supported by a 2016 meta-analysis that compared the two approaches head-to-head and found significantly greater effect sizes for trauma-focused psychotherapies compared with available medications for the treatment of PTSD.⁷

It is important to note that psychotherapy may not be appropriate for all patients. Cost, availability, comorbidities (e.g. depression), or patient values and preferences may warrant a clinician choosing to use medication as first-line treatment.²

While none of the guidelines reviewed recommend available pharmacological therapies over psychotherapy as first-line treatment for PTSD, when medications are necessary or preferred, SSRIs—specifically fluoxetine, sertraline, and paroxetine—as well as the SNRI venlafaxine, are widely accepted as first-line pharmacological treatment of PTSD (Table 1).² This recommendation is supported by a 2015 systematic review and meta-analysis that found statistically significant improvements in PTSD symptom severity with paroxetine, fluoxetine, and venlafaxine, when compared with placebo.⁸ Medications listed in the guidelines may differ in terms of approval status in some regions, e.g. in the United States and the United Kingdom, only paroxetine and sertraline are indicated for PTSD.^5,9

What about nightmares?

Less than half (44%) of the nine guidelines reviewed (VA/DOD,⁴ The South African Society of Psychiatrists [SASOP],¹⁰ Anxiety Disorders Association of Canada [ADAC],¹¹ British Association for Psychopharmacology [BAP]¹²) address the targeted treatment of nightmares (Table 1).^2,4,10–12 Despite this, it remains important that clinicians consider nightmares when developing a treatment plan for patients with PTSD. Nightmares in the context of PTSD are often resistant to treatment, and are associated with a significantly increased risk for suicide.^13–15 Of the four guidelines that recommend targeted treatment of nightmares, all mention prazosin as a potential option, although the strength of recommendation varies from no recommendation to first line.^2,4,10–12 Evidence of varying quality exists as well for psychotherapy (e.g. IRT) for the targeted treatment of nightmares; however, further research in this area is needed.²

Guideline recommendations are not one-size-fits-all

While evidence-based guidelines are considered an essential tool to guide patient care, they have limitations, including gaps in available guidance.¹⁶ For instance, in the management of PTSD, there is a notable gap in recommendations regarding the targeted treatment of nightmares. Healthcare providers (HCPs) can note these gaps and tailor treatment plans based on their expertise, as well as patient values and preferences. By combining guideline recommendations with clinical judgment and experience, clinicians can ensure that patients are receiving the best care possible.

 

This document is for educational purposes and is not intended to replace approved clinical guidelines. Readers are advised to refer to their country-specific guidelines when making clinical decisions.

Further reading

• Martin A, et al. Treatment Guidelines for PTSD: A Systematic Review. J Clin Med 2021;10:4175.
  A systematic review to assess the quality of international treatment guidelines for PTSD, and to identify differences between guideline recommendations.

• Hamblen JL, et al. “Will it work for me?” Developing patient-friendly graphical displays of posttraumatic stress disorder treatment effectiveness. J Trauma Stress 2022;35:999–1010.
  A review of randomized trials of the most effective individual, trauma-focused psychotherapies and first-line antidepressants for adults with PTSD, which was then used to create simple visual displays to help patients better understand the benefits of specific treatments. HCPs can use the icon arrays developed in this review to facilitate communication with patients regarding PTSD treatment effectiveness.

• Geldenhuys C, et al. Pharmacological Management of Nightmares Associated with Posttraumatic Stress Disorder. CNS Drugs 2022;36:721–737.
  A current narrative review aimed to critically appraise proven as well as novel pharmacological agents used in the treatment of post-traumatic nightmares.

Guideline Digest: Post-traumatic Stress Disorder. Connecting Psychiatry. Published May 2023.

SC-US-75911 

SC-CRP-13481

April 2023