Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ONGOING

not pregnant or breast-feeding

1st line – active monitoring

Back
ONGOING
|
not pregnant or breast-feeding
|
symptoms <3 months: mild
1st line – 

active monitoring

Active monitoring in patients with subthreshold symptoms of PTSD within 1 month of a traumatic event.

A follow-up contact should be arranged within 1 month.[43]

The systematic provision of single- or multiple-session interventions, focused on the traumatic event, to individuals who have very recently experienced trauma (including interventions often referred to as debriefing) should not occur.[42][43][44][69][70][71]

1st line – active monitoring

Back
ONGOING
|
not pregnant or breast-feeding
|
symptoms <3 months: moderate
1st line – 

active monitoring

Active monitoring in patients with subthreshold symptoms of PTSD within 1 month of a traumatic event.

A follow-up contact should be arranged within 1 month.[43]

Some patients with moderate symptoms may be considered for therapies usually reserved for severe symptoms; however, this is largely determined by patient choice.

The systematic provision of single- or multiple-session interventions, focused on the traumatic event, to individuals who have very recently experienced trauma (including interventions often referred to as debriefing) should not occur.[42][43][44][69][70][71]

1st line – trauma-focused cognitive behavioral therapy

Back
ONGOING
|
not pregnant or breast-feeding
|
symptoms <3 months: severe
1st line – 

trauma-focused cognitive behavioral therapy

Recommended in patients with severe symptoms (i.e., distress caused is felt to be unmanageable by the patient, and/or symptoms cause significant impairment in social and/or occupational functioning, and/or there is considered to be significant risk of suicide, harm to self, or harm to others) present for <3 months after the trauma.[42][69][73]

If treatment starts within the first month after the trauma, shorter interventions (i.e., 5 sessions) may be effective. Otherwise, duration of treatment should normally be 8 to 12 sessions when the PTSD results from a single event. Duration of treatment beyond 12 sessions should be considered if several problems need to be addressed (e.g., traumatic bereavement, multiple traumatic events, chronic disability resulting from trauma, presence of comorbidities).

Treatment sessions should be regular and frequent (i.e., usually at least once a week), and longer sessions (e.g., 90 minutes) are often necessary when the trauma is discussed in the treatment session.

It may initially be too difficult for people to disclose details of their traumatic event. In such cases, it may be necessary to devote several sessions to establishing a trusting therapeutic relationship and emotional stabilization before addressing the traumatic event.

The systematic provision of single- or multiple-session interventions, focused on the traumatic event, to individuals who have very recently experienced trauma (including interventions often referred to as debriefing) should not occur.[42][43][44][69][70][71]

1st line – trauma-focused cognitive behavioral therapy (TFCBT)

Back
ONGOING
|
not pregnant or breast-feeding
|
symptoms ≥3 months
1st line – 

trauma-focused cognitive behavioral therapy (TFCBT)

Patients with any severity of symptoms present for ≥3 months should be offered a trauma-focused psychological therapy such as TFCBT.[44][73][74][75]

Duration of treatment should normally be 8 to 12 sessions when the PTSD results from a single event. Duration of treatment beyond 12 sessions should be considered if several problems need to be addressed (e.g., traumatic bereavement, multiple traumatic events, chronic disability resulting from trauma, presence of comorbidities).

Treatment sessions should be regular and frequent (i.e., usually at least once a week), and longer sessions (e.g., 90 minutes) are often necessary when the trauma is discussed in the treatment session.

It may initially be too difficult for people to disclose details of their traumatic event. In such cases, it may be necessary to devote several sessions to establishing a trusting therapeutic relationship and emotional stabilization before addressing the traumatic event or to consider offering a non-trauma-focused CBT-based intervention.

Consider – pharmacotherapy

Back
ONGOING
|
not pregnant or breast-feeding
|
symptoms ≥3 months
Consider – 

pharmacotherapy

Treatment recommended for SOME patients in selected patient group

Owing to the small effect sizes in systematic reviews, pharmacotherapy should be considered only after trauma-focused psychological treatment has been initiated, or in the following situations: when a patient expresses a preference not to engage in a trauma-focused psychological treatment, or cannot start a psychological therapy because of serious ongoing threat of further trauma (e.g., a threat of ongoing domestic violence); when a patient has failed to respond to or could not tolerate a course of trauma-focused psychological treatment; when there is a lack of timely availability of psychological treatments; or as an adjunct to psychological treatment in adults where there is significant comorbid depression or severe hyperarousal that has a significant impact on the ability to benefit from psychological treatment.[42][43][44][83][84]

The strongest evidence is for the selective serotonin-reuptake inhibitors (SSRIs) paroxetine, fluoxetine, and sertraline, although it is acknowledged that these agents have low effect.[75][85][86][87][88]​ An SSRI licensed for panic disorder should be offered first-line.[43]​​

If there is no response to a particular SSRI, consider increasing the dose (within approved limits), switching to a different SSRI, or starting on the serotonin-norepinephrine reuptake inhibitor (SNRI) venlafaxine. Venlafaxine reduces PTSD symptoms as well as functional disability, and may also be an appropriate option for patients who do not tolerate SSRIs.[85][89]

In the absence of an adequate response, SSRI or venlafaxine therapy may be augmented with risperidone, quetiapine, or the alpha-1 adrenoceptor antagonist prazosin.[89] Quetiapine and risperidone are both atypical antipsychotics. Risperidone has shown some promising results as an augmentation treatment for patients with PTSD who have shown a partial response to an SSRI, although a large study of veterans did not find risperidone to be superior to placebo.[83][88][90][91] Prazosin has shown efficacy in specifically reducing the severity and frequency of trauma-related nightmares.[88] Owing to its proven efficacy as monotherapy, quetiapine may be used alone if neither SSRIs nor venlafaxine are tolerated.[89]

If clinically significant symptoms are still evident despite treatment with an SSRI, venlafaxine, risperidone (adjunct), prazosin (adjunct), or quetiapine (adjunct or monotherapy), a less evidence-based treatment may be considered.[89] Three single randomized controlled trials found evidence of superiority over placebo for the tricyclic antidepressant amitriptyline, the monoamine oxidase inhibitor phenelzine, and the newer tetracyclic antidepressant mirtazapine.[92][93][94] Due to the small size of these individual studies, amitriptyline, phenelzine, and mirtazapine are considered less preferred options. One Cochrane review concluded that amitriptyline and mirtazapine may improve PTSD symptoms based on low-certainty evidence.[85]

If there is a response to drug treatment, the drug should be continued for at least 12 months before gradual withdrawal, usually over a 4-week period, although some patients may require a longer period of withdrawal.

Primary options

paroxetine: 20 mg orally once daily initially, increase gradually according to response, maximum 60 mg/day

OR

fluoxetine: 20 mg orally once daily initially, increase gradually according to response, maximum 80 mg/day

OR

sertraline: 50 mg orally once daily initially, increase gradually according to response, maximum 200 mg/day

Secondary options

venlafaxine: 37.5 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 300 mg/day

OR

paroxetine: 20 mg orally once daily initially, increase gradually according to response, maximum 60 mg/day

or

fluoxetine: 20 mg orally once daily initially, increase gradually according to response, maximum 80 mg/day

or

sertraline: 50 mg orally once daily initially, increase gradually according to response, maximum 200 mg/day

or

venlafaxine: 37.5 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 300 mg/day

-- AND --

quetiapine: consult specialist for guidance on dose

or

risperidone: consult specialist for guidance on dose

or

prazosin: consult specialist for guidance on dose

Tertiary options

quetiapine: consult specialist for guidance on dose

OR

amitriptyline: 25 mg orally once daily initially, increase gradually according to response, maximum 200 mg/day

OR

mirtazapine: 15 mg orally once daily initially, increase gradually according to response, maximum 45 mg/day

OR

phenelzine: 15 mg orally three times daily initially, increase gradually according to response, maximum 60 mg/day

1st line – eye movement desensitization and reprocessing (EMDR)

Back
ONGOING
|
not pregnant or breast-feeding
|
symptoms ≥3 months
1st line – 

eye movement desensitization and reprocessing (EMDR)

Patients with any severity of symptoms present for 3 months or longer should be offered a trauma-focused psychological therapy such as EMDR.[44][73][75]

Procedures are based on stimulating the person's own information processing in order to help integrate the targeted event as an adaptive contextualized memory. People are made ready to attend to the memory and associations while their attention is also engaged by a bilateral physical stimulation (e.g., eye movements, taps, or tones).

Duration of treatment should normally be 8 to 12 sessions when the PTSD results from a single event. Duration of treatment beyond 12 sessions should be considered if several problems need to be addressed (e.g., traumatic bereavement, multiple traumatic events, chronic disability resulting from trauma, presence of comorbidities).

Consider – pharmacotherapy

Back
ONGOING
|
not pregnant or breast-feeding
|
symptoms ≥3 months
Consider – 

pharmacotherapy

Treatment recommended for SOME patients in selected patient group

Owing to the small effect sizes in systematic reviews, pharmacotherapy should be considered only after trauma-focused psychological treatment has been initiated, or in the following situations: when a patient expresses a preference not to engage in a trauma-focused psychological treatment, or cannot start a psychological therapy because of serious ongoing threat of further trauma (e.g., a threat of ongoing domestic violence); when a patient has failed to respond to or could not tolerate a course of trauma-focused psychological treatment; when there is a lack of timely availability of psychological treatments; or as an adjunct to psychological treatment in adults where there is significant comorbid depression or severe hyperarousal that has a significant impact on the ability to benefit from psychological treatment.[42][43][44][83][84]

The strongest evidence is for the selective serotonin-reuptake inhibitors (SSRIs) paroxetine, fluoxetine, and sertraline, although it is acknowledged that these agents have low effect.[75][85][86][87][88]​ An SSRI licensed for panic disorder should be offered first-line.[43]​​

If there is no response to a particular SSRI, consider increasing the dose (within approved limits), switching to a different SSRI, or starting on the serotonin-norepinephrine reuptake inhibitor (SNRI) venlafaxine. Venlafaxine reduces PTSD symptoms as well as functional disability, and may also be an appropriate option for patients who do not tolerate SSRIs.[85][89]

In the absence of an adequate response, SSRI or venlafaxine therapy may be augmented with risperidone, quetiapine, or the alpha-1 adrenoceptor antagonist prazosin.[89] Quetiapine and risperidone are both atypical antipsychotics. Risperidone has shown some promising results as an augmentation treatment for patients with PTSD who have shown a partial response to an SSRI, although a large study of veterans did not find risperidone to be superior to placebo.[83][88][90][91] Prazosin has shown efficacy in specifically reducing the severity and frequency of trauma-related nightmares.[88] Owing to its proven efficacy as monotherapy, quetiapine may be used alone if neither SSRIs nor venlafaxine are tolerated.[89]

If clinically significant symptoms are still evident despite treatment with an SSRI, venlafaxine, risperidone (adjunct), prazosin (adjunct), or quetiapine (adjunct or monotherapy), a less evidence-based treatment may be considered.[89] Three single randomized controlled trials found evidence of superiority over placebo for the tricyclic antidepressant amitriptyline, the monoamine oxidase inhibitor phenelzine, and the newer tetracyclic antidepressant mirtazapine.[92][93][94] Due to the small size of these individual studies, amitriptyline, phenelzine, and mirtazapine are considered less preferred options. One Cochrane review concluded that amitriptyline and mirtazapine may improve PTSD symptoms based on low-certainty evidence.[85]

If there is a response to drug treatment, the drug should be continued for at least 12 months before gradual withdrawal, usually over a 4-week period, although some patients may require a longer period of withdrawal.

Primary options

paroxetine: 20 mg orally once daily initially, increase gradually according to response, maximum 60 mg/day

OR

fluoxetine: 20 mg orally once daily initially, increase gradually according to response, maximum 80 mg/day

OR

sertraline: 50 mg orally once daily initially, increase gradually according to response, maximum 200 mg/day

Secondary options

venlafaxine: 37.5 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 300 mg/day

OR

paroxetine: 20 mg orally once daily initially, increase gradually according to response, maximum 60 mg/day

or

fluoxetine: 20 mg orally once daily initially, increase gradually according to response, maximum 80 mg/day

or

sertraline: 50 mg orally once daily initially, increase gradually according to response, maximum 200 mg/day

or

venlafaxine: 37.5 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 300 mg/day

-- AND --

quetiapine: consult specialist for guidance on dose

or

risperidone: consult specialist for guidance on dose

or

prazosin: consult specialist for guidance on dose

Tertiary options

quetiapine: consult specialist for guidance on dose

OR

amitriptyline: 25 mg orally once daily initially, increase gradually according to response, maximum 200 mg/day

OR

mirtazapine: 15 mg orally once daily initially, increase gradually according to response, maximum 45 mg/day

OR

phenelzine: 15 mg orally three times daily initially, increase gradually according to response, maximum 60 mg/day

2nd line – alternative psychological therapy

Back
ONGOING
|
not pregnant or breast-feeding
|
symptoms ≥3 months
2nd line – 

alternative psychological therapy

Patients who have no (or only limited) improvement with a trauma-focused psychological treatment should be offered an alternative form of trauma-focused psychological treatment or non-trauma-focused cognitive behavioral therapy: whichever was not tried in the first instance.

Consider – pharmacotherapy

Back
ONGOING
|
not pregnant or breast-feeding
|
symptoms ≥3 months
Consider – 

pharmacotherapy

Treatment recommended for SOME patients in selected patient group

Owing to the small effect sizes in systematic reviews, pharmacotherapy should be considered only after trauma-focused psychological treatment has been initiated, or in the following situations: when a patient expresses a preference not to engage in a trauma-focused psychological treatment, or cannot start a psychological therapy because of serious ongoing threat of further trauma (e.g., a threat of ongoing domestic violence); when a patient has failed to respond to or could not tolerate a course of trauma-focused psychological treatment; when there is a lack of timely availability of psychological treatments; or as an adjunct to psychological treatment in adults where there is significant comorbid depression or severe hyperarousal that has a significant impact on the ability to benefit from psychological treatment.[42][43][44][83][84]

The strongest evidence is for the selective serotonin-reuptake inhibitors (SSRIs) paroxetine, fluoxetine, and sertraline, although it is acknowledged that these agents have low effect.[75][85][86][87][88]​ An SSRI licensed for panic disorder should be offered first-line.[43]​​

If there is no response to a particular SSRI, consider increasing the dose (within approved limits), switching to a different SSRI, or starting on the serotonin-norepinephrine reuptake inhibitor (SNRI) venlafaxine. Venlafaxine reduces PTSD symptoms as well as functional disability, and may also be an appropriate option for patients who do not tolerate SSRIs.[85][89]

In the absence of an adequate response, SSRI or venlafaxine therapy may be augmented with risperidone, quetiapine, or the alpha-1 adrenoceptor antagonist prazosin.[89] Quetiapine and risperidone are both atypical antipsychotics. Risperidone has shown some promising results as an augmentation treatment for patients with PTSD who have shown a partial response to an SSRI, although a large study of veterans did not find risperidone to be superior to placebo.[83][88][90][91] Prazosin has shown efficacy in specifically reducing the severity and frequency of trauma-related nightmares.[88] Owing to its proven efficacy as monotherapy, quetiapine may be used alone if neither SSRIs nor venlafaxine are tolerated.[89]

If clinically significant symptoms are still evident despite treatment with an SSRI, venlafaxine, risperidone (adjunct), prazosin (adjunct), or quetiapine (adjunct or monotherapy), a less evidence-based treatment may be considered.[89] Three single randomized controlled trials found evidence of superiority over placebo for the tricyclic antidepressant amitriptyline, the monoamine oxidase inhibitor phenelzine, and the newer tetracyclic antidepressant mirtazapine.[92][93][94] Due to the small size of these individual studies, amitriptyline, phenelzine, and mirtazapine are considered less preferred options. One Cochrane review concluded that amitriptyline and mirtazapine may improve PTSD symptoms based on low-certainty evidence.[85]

If there is a response to drug treatment, the drug should be continued for at least 12 months before gradual withdrawal, usually over a 4-week period, although some patients may require a longer period of withdrawal.

Primary options

paroxetine: 20 mg orally once daily initially, increase gradually according to response, maximum 60 mg/day

OR

fluoxetine: 20 mg orally once daily initially, increase gradually according to response, maximum 80 mg/day

OR

sertraline: 50 mg orally once daily initially, increase gradually according to response, maximum 200 mg/day

Secondary options

venlafaxine: 37.5 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 300 mg/day

OR

paroxetine: 20 mg orally once daily initially, increase gradually according to response, maximum 60 mg/day

or

fluoxetine: 20 mg orally once daily initially, increase gradually according to response, maximum 80 mg/day

or

sertraline: 50 mg orally once daily initially, increase gradually according to response, maximum 200 mg/day

or

venlafaxine: 37.5 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 300 mg/day

-- AND --

quetiapine: consult specialist for guidance on dose

or

risperidone: consult specialist for guidance on dose

or

prazosin: consult specialist for guidance on dose

Tertiary options

quetiapine: consult specialist for guidance on dose

OR

amitriptyline: 25 mg orally once daily initially, increase gradually according to response, maximum 200 mg/day

OR

mirtazapine: 15 mg orally once daily initially, increase gradually according to response, maximum 45 mg/day

OR

phenelzine: 15 mg orally three times daily initially, increase gradually according to response, maximum 60 mg/day

2nd line – non-trauma-focused psychological therapy

Back
ONGOING
|
not pregnant or breast-feeding
|
symptoms ≥3 months
2nd line – 

non-trauma-focused psychological therapy

Non-trauma-focused psychological interventions such as cognitive behavioral therapy (CBT) are recommended in patients who are not ready to engage with trauma-focused interventions and for those who are unlikely to be able to tolerate trauma-focused intervention.

All non-trauma-focused CBT programs for PTSD include an element of psychological education as well as cognitive therapy and/or stress management.

Consider – pharmacotherapy

Back
ONGOING
|
not pregnant or breast-feeding
|
symptoms ≥3 months
Consider – 

pharmacotherapy

Treatment recommended for SOME patients in selected patient group

Owing to the small effect sizes in systematic reviews, pharmacotherapy should be considered only after trauma-focused psychological treatment has been initiated, or in the following situations: when a patient expresses a preference not to engage in a trauma-focused psychological treatment, or cannot start a psychological therapy because of serious ongoing threat of further trauma (e.g., a threat of ongoing domestic violence); when a patient has failed to respond to or could not tolerate a course of trauma-focused psychological treatment; when there is a lack of timely availability of psychological treatments; or as an adjunct to psychological treatment in adults where there is significant comorbid depression or severe hyperarousal that has a significant impact on the ability to benefit from psychological treatment.[42][43][44][83][84]

The strongest evidence is for the selective serotonin-reuptake inhibitors (SSRIs) paroxetine, fluoxetine, and sertraline, although it is acknowledged that these agents have low effect.[75][85][86][87][88]​ An SSRI licensed for panic disorder should be offered first-line.[43]​​

If there is no response to a particular SSRI, consider increasing the dose (within approved limits), switching to a different SSRI, or starting on the serotonin-norepinephrine reuptake inhibitor (SNRI) venlafaxine. Venlafaxine reduces PTSD symptoms as well as functional disability, and may also be an appropriate option for patients who do not tolerate SSRIs.[85][89]

In the absence of an adequate response, SSRI or venlafaxine therapy may be augmented with risperidone, quetiapine, or the alpha-1 adrenoceptor antagonist prazosin.[89] Quetiapine and risperidone are both atypical antipsychotics. Risperidone has shown some promising results as an augmentation treatment for patients with PTSD who have shown a partial response to an SSRI, although a large study of veterans did not find risperidone to be superior to placebo.[83][88][90][91] Prazosin has shown efficacy in specifically reducing the severity and frequency of trauma-related nightmares.[88] Owing to its proven efficacy as monotherapy, quetiapine may be used alone if neither SSRIs nor venlafaxine are tolerated.[89]

If clinically significant symptoms are still evident despite treatment with an SSRI, venlafaxine, risperidone (adjunct), prazosin (adjunct), or quetiapine (adjunct or monotherapy), a less evidence-based treatment may be considered.[89] Three single randomized controlled trials found evidence of superiority over placebo for the tricyclic antidepressant amitriptyline, the monoamine oxidase inhibitor phenelzine, and the newer tetracyclic antidepressant mirtazapine.[92][93][94] Due to the small size of these individual studies, amitriptyline, phenelzine, and mirtazapine are considered less preferred options. One Cochrane review concluded that amitriptyline and mirtazapine may improve PTSD symptoms based on low-certainty evidence.[85]

If there is a response to drug treatment, the drug should be continued for at least 12 months before gradual withdrawal, usually over a 4-week period, although some patients may require a longer period of withdrawal.

Primary options

paroxetine: 20 mg orally once daily initially, increase gradually according to response, maximum 60 mg/day

OR

fluoxetine: 20 mg orally once daily initially, increase gradually according to response, maximum 80 mg/day

OR

sertraline: 50 mg orally once daily initially, increase gradually according to response, maximum 200 mg/day

Secondary options

venlafaxine: 37.5 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 300 mg/day

OR

paroxetine: 20 mg orally once daily initially, increase gradually according to response, maximum 60 mg/day

or

fluoxetine: 20 mg orally once daily initially, increase gradually according to response, maximum 80 mg/day

or

sertraline: 50 mg orally once daily initially, increase gradually according to response, maximum 200 mg/day

or

venlafaxine: 37.5 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 300 mg/day

-- AND --

quetiapine: consult specialist for guidance on dose

or

risperidone: consult specialist for guidance on dose

or

prazosin: consult specialist for guidance on dose

Tertiary options

quetiapine: consult specialist for guidance on dose

OR

amitriptyline: 25 mg orally once daily initially, increase gradually according to response, maximum 200 mg/day

OR

mirtazapine: 15 mg orally once daily initially, increase gradually according to response, maximum 45 mg/day

OR

phenelzine: 15 mg orally three times daily initially, increase gradually according to response, maximum 60 mg/day

2nd line – pharmacotherapy alone

Back
ONGOING
|
not pregnant or breast-feeding
|
symptoms ≥3 months
2nd line – 

pharmacotherapy alone

Owing to the small effect sizes in systematic reviews, pharmacotherapy should be considered only after trauma-focused psychological treatment has been initiated, or in the following situations: when a patient expresses a preference not to engage in a trauma-focused psychological treatment, or cannot start a psychological therapy because of serious ongoing threat of further trauma (e.g., a threat of ongoing domestic violence); when a patient has failed to respond to or could not tolerate a course of trauma-focused psychological treatment; when there is a lack of timely availability of psychological treatments; or as an adjunct to psychological treatment in adults where there is significant comorbid depression or severe hyperarousal that has a significant impact on the ability to benefit from psychological treatment.[42][43][44][83][84] 

The strongest evidence is for the selective serotonin-reuptake inhibitors (SSRIs) paroxetine, fluoxetine, and sertraline, although it is acknowledged that these agents have low effect.[75][85][86][87][88]​ An SSRI licensed for panic disorder should be offered first-line.[43]​​

If there is no response to a particular SSRI, consider increasing the dose (within approved limits), switching to a different SSRI, or starting on the serotonin-norepinephrine reuptake inhibitor (SNRI) venlafaxine. Venlafaxine reduces PTSD symptoms as well as functional disability, and may also be an appropriate option for patients who do not tolerate SSRIs.[85][89]

In the absence of an adequate response, SSRI or venlafaxine therapy may be augmented with risperidone, quetiapine, or the alpha-1 adrenoceptor antagonist prazosin.[89] Quetiapine and risperidone are both atypical antipsychotics. Risperidone has shown some promising results as an augmentation treatment for patients with PTSD who have shown a partial response to an SSRI, although a large study of veterans did not find risperidone to be superior to placebo.[83][88][90][91] Prazosin has shown efficacy in specifically reducing the severity and frequency of trauma-related nightmares.[88] Owing to its proven efficacy as monotherapy, quetiapine may be used alone if neither SSRIs nor venlafaxine are tolerated.[89]

If clinically significant symptoms are still evident despite treatment with an SSRI, venlafaxine, risperidone (adjunct), prazosin (adjunct), or quetiapine (adjunct or monotherapy), a less evidence-based treatment may be considered.[89] Three single randomized controlled trials found evidence of superiority over placebo for the tricyclic antidepressant amitriptyline, the monoamine oxidase inhibitor phenelzine, and the newer tetracyclic antidepressant mirtazapine.[92][93][94] Due to the small size of these individual studies, amitriptyline, phenelzine, and mirtazapine are considered less preferred options. One Cochrane review concluded that amitriptyline and mirtazapine may improve PTSD symptoms based on low-certainty evidence.[85]

If there is a response to drug treatment, the drug should be continued for at least 12 months before gradual withdrawal, usually over a 4-week period, although some patients may require a longer period of withdrawal.

Primary options

paroxetine: 20 mg orally once daily initially, increase gradually according to response, maximum 60 mg/day

OR

fluoxetine: 20 mg orally once daily initially, increase gradually according to response, maximum 80 mg/day

OR

sertraline: 50 mg orally once daily initially, increase gradually according to response, maximum 200 mg/day

Secondary options

venlafaxine: 37.5 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 300 mg/day

OR

paroxetine: 20 mg orally once daily initially, increase gradually according to response, maximum 60 mg/day

or

fluoxetine: 20 mg orally once daily initially, increase gradually according to response, maximum 80 mg/day

or

sertraline: 50 mg orally once daily initially, increase gradually according to response, maximum 200 mg/day

or

venlafaxine: 37.5 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 300 mg/day

-- AND --

quetiapine: consult specialist for guidance on dose

or

risperidone: consult specialist for guidance on dose

or

prazosin: consult specialist for guidance on dose

Tertiary options

quetiapine: consult specialist for guidance on dose

OR

amitriptyline: 25 mg orally once daily initially, increase gradually according to response, maximum 200 mg/day

OR

mirtazapine: 15 mg orally once daily initially, increase gradually according to response, maximum 45 mg/day

OR

phenelzine: 15 mg orally three times daily initially, increase gradually according to response, maximum 60 mg/day

pregnant or breast-feeding

1st line – active monitoring

Back
ONGOING
|
pregnant or breast-feeding
|
symptoms <3 months: mild
1st line – 

active monitoring

Active monitoring in patients with subthreshold symptoms of PTSD within 1 month of a traumatic event.

A follow-up contact should be arranged within 1 month.[43]

The systematic provision of single- or multiple-session interventions, focused on the traumatic event, to individuals who have very recently experienced trauma (including interventions often referred to as debriefing) should not occur.[42][43][44][69][70][71]

1st line – active monitoring

Back
ONGOING
|
pregnant or breast-feeding
|
symptoms <3 months: moderate
1st line – 

active monitoring

Active monitoring in patients with subthreshold symptoms of PTSD within 1 month of a traumatic event.

A follow-up contact should be arranged within 1 month.[43]

Some patients with moderate symptoms may be considered for therapies usually reserved for severe symptoms; however, this is largely determined by patient choice.

The systematic provision of single- or multiple-session interventions, focused on the traumatic event, to individuals who have very recently experienced trauma (including interventions often referred to as debriefing) should not occur.[42][43][44][69][70][71]

1st line – trauma-focused cognitive behavioral therapy

Back
ONGOING
|
pregnant or breast-feeding
|
symptoms <3 months: severe
1st line – 

trauma-focused cognitive behavioral therapy

Recommended in patients with severe symptoms (i.e., distress caused is felt to be unmanageable by the patient, and/or symptoms cause significant impairment in social and/or occupational functioning, and/or there is considered to be significant risk of suicide, harm to self, or harm to others) present for <3 months after the trauma.[44][69][73]

If treatment starts within the first month after the trauma, shorter interventions (i.e., 5 sessions) may be effective. Otherwise, duration of treatment should normally be 8 to 12 sessions when the PTSD results from a single event. Duration of treatment beyond 12 sessions should be considered if several problems need to be addressed (e.g., traumatic bereavement, multiple traumatic events, chronic disability resulting from trauma, presence of comorbidities).

Treatment sessions should be regular and frequent (i.e., usually at least once a week), and longer sessions (e.g., 90 minutes) are often necessary when the trauma is discussed in the treatment session.

It may initially be too difficult for people to disclose details of their traumatic event. In such cases, it may be necessary to devote several sessions to establishing a trusting therapeutic relationship and emotional stabilization before addressing the traumatic event.

The systematic provision of single- or multiple-session interventions, focused on the traumatic event, to individuals who have very recently experienced trauma (including interventions often referred to as debriefing) should not occur.[42][43][44][69][70][71]

1st line – trauma-focused cognitive behavioral therapy (TFCBT)

Back
ONGOING
|
pregnant or breast-feeding
|
symptoms ≥3 months
1st line – 

trauma-focused cognitive behavioral therapy (TFCBT)

Patients with any severity of symptoms present for ≥3 months should be offered a trauma-focused psychological therapy such as TFCBT.[44][73][75]

Duration of treatment should normally be 8 to 12 sessions when the PTSD results from a single event. Duration of treatment beyond 12 sessions should be considered if several problems need to be addressed (e.g., traumatic bereavement, multiple traumatic events, chronic disability resulting from trauma, presence of comorbidities).

Treatment sessions should be regular and frequent (i.e., usually at least once a week), and longer sessions (e.g., 90 minutes) are often necessary when the trauma is discussed in the treatment session.

It may initially be too difficult for people to disclose details of their traumatic event. In such cases, it may be necessary to devote several sessions to establishing a trusting therapeutic relationship and emotional stabilization before addressing the traumatic event.

1st line – eye movement desensitization and reprocessing (EMDR)

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ONGOING
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pregnant or breast-feeding
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symptoms ≥3 months
1st line – 

eye movement desensitization and reprocessing (EMDR)

Patients with any severity of symptoms present for 3 months or longer should be offered a trauma-focused psychological therapy such as EMDR.[44][73][75]

Procedures are based on stimulating the person's own information processing in order to help integrate the targeted event as an adaptive contextualized memory. People are made ready to attend to the memory and associations while their attention is also engaged by a bilateral physical stimulation (e.g., eye movements, taps, or tones).

Duration of treatment should normally be 8 to 12 sessions when the PTSD results from a single event. Duration of treatment beyond 12 sessions should be considered if several problems need to be addressed (e.g., traumatic bereavement, multiple traumatic events, chronic disability resulting from trauma, presence of comorbidities).

2nd line – alternative trauma-focused psychological therapy

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ONGOING
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pregnant or breast-feeding
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symptoms ≥3 months
2nd line – 

alternative trauma-focused psychological therapy

Patients who have no (or only limited) improvement with a trauma-focused psychological treatment should be offered an alternative form of trauma-focused psychological treatment or non-trauma-focused cognitive behavioral therapy: whichever was not tried in the first instance.

2nd line – non-trauma-focused psychological therapy

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ONGOING
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pregnant or breast-feeding
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symptoms ≥3 months
2nd line – 

non-trauma-focused psychological therapy

Non-trauma-focused cognitive behavioral therapy (CBT) is recommended in patients who are not ready to engage with trauma-focused interventions and for those who are unlikely to be able to tolerate trauma-focused intervention.

All non-trauma-focused CBT programs for PTSD include an element of psychological education as well as cognitive therapy and/or stress management.

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