Treatment of post-traumatic stress disorder

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The goals are to decrease core symptoms, disability, and comorbidity and improve quality of life. Immediately after the trauma, patients should receive treatment individualized to their presenting symptoms (eg, nonbenzodiazepine hypnotic or short courses of CBT). Brief courses of CBT in close proximity to the trauma can help prevent PTSD. If symptoms persist for 3 to 4 weeks, and there is social or occupational impairment, patients should receive pharmacotherapy or psychotherapy, or both.

Psychotherapies for PTSD include stress management, eye movement desensitization and reprocessing (EMDP), and psychoeducation. Trauma-focused CBT (TFCBT) and EMDP are more effective than stress management or group therapy to reduce PTSD symptoms.

Sertraline and paroxetine are approved for acute treatment of PTSD, and sertraline is approved for long-term management.

Antiadrenergics and atypical antipsychotics can be used as augmenting agents.

The SSRIs are believed to be more effective for numbing symptoms than other drugs. About 60% of sertraline-treated patients showed improvement in arousal and avoidance/ numbing symptoms.

Mirtazapine was effective in doses up to 45 mg/day and is a second-line agent. Amitriptyline and imipramine, are also second-line drugs. Phenelzine is a thirdline drug.

If there is no improvement in the acute stress response 3 to 4 weeks following trauma, SSRIs should be started in a low dose with slow titration upward toward antidepressant doses. Eight to 12 weeks is an adequate duration of treatment to determine response. Responders to drug therapy should continue treatment for at least 12 months. When discontinued, drug therapy should be tapered slowly over 1 month or more to reduce the likelihood of relapse.

Prazosin, in daily doses of 1 to 4 mg, can be useful in some patients with PTSD.

Risperidone, quetiapine, α1-adrenergic antagonists, antidepressants, mood stabilizers, and anticonvulsants may be used as augmenting agents in partial responders.

See patients frequently for the first 3 months, then monthly for 3 months. In months 6 to 12, patients can be seen every 2 months. Monitor for symptom response, suicidal ideation, disability, side effects, and treatment adherence.

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