PTSD Evidence Based Practice Recommendations
Jason's Box Best Practice Group
Dr. Sam Moreno, Michelle Schnack
Compilation & consolidation of the research and recommendations located in:
The VA/DoD Clinical Practice Guideline for the Management of Post-Traumatic Stress (2010)
For the full version: http://www.healthquality.va.gov/PTSD-FULL-2010c.pdf
For the summary: http://www.healthquality.va.gov/ptsd/ptsd-sum_2010a.pdf
The VA’s National Center for PTSD, Clinician’s Guide to Medications for PTSD
http://www.ptsd.va.gov/professional/pages/clinicians-guide-to-medications-for-ptsd.asp
The International Society for Traumatic Stress Studies Treatment Guidelines for PTSD (2005)
For links to the treatment guidelines: http://www.istss.org/TreatmentGuidelines/3337.htm
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I. First, an explanation of the ratings used in recommendations…
Evidence Rating System
SR
A
A strong recommendation that clinicians provide the intervention to eligible patients. Good
evidence was found that the intervention improves important health outcomes and concludes that
benefits substantially outweigh harm.
B
A recommendation that clinicians provide (the service) to eligible patients. At least fair evidence
was found that the intervention improves health outcomes & concludes that benefits outweigh harm
C
No recommendation for or against the routine provision of the intervention is made. At least fair
evidence was found that the intervention can improve health outcomes but concludes that the
balance of benefits and harms is too close to justify a general recommendation.
D
Recommendation is made against routinely providing the intervention to asymptomatic patients. At
least fair evidence was found that the intervention is ineffective or that the harms outweigh benefits.
I
The conclusion is that the evidence is insufficient to recommend for or against routinely providing
the intervention. Evidence that the intervention is effective is lacking, of poor quality, or
conflicting, and the balance of benefits and harms cannot be determined.
SR = Strength of recommendation Level of Evidence (LE)
I
At least one properly done RCT
II-1
Well-designed controlled trial without randomization
II-2
Well-designed cohort or case-control analytic study, preferably from more than one source
II-3
Multiple time series evidence with/without intervention, dramatic results of uncontrolled
experiment
III
Opinion of respected authorities, descriptive studies, case reports, and expert committees
Overall Quality [QE]
Good
High grade evidence (I or II-1) directly linked to health outcome
Fair
High grade evidence (I or II-1) linked to intermediate outcome; or Moderate grade evidence (II-2
or II-3) directly linked to health outcome
Poor
Level III evidence or no linkage of evidence to health outcome
Final Grade of Recommendation [SR]
The Net Benefit of the Intervention
Quality of Evidence
Substantial
Moderate
Small
Zero or Negative
Good
A
B
C
D
Fair
B
B
C
D
Poor
I
I
I
I
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II. Screening Recommendations
All new patients should be screened for symptoms of PTSD initially & then annually, or more
frequently, if clinically indicated. [B]
There is insufficient evidence to recommend one PTSD screening tool versus another. The following
screening tools have been validated and should be considered for use:
- Primary Care PTSD Screen (PC-PTSD)
- Short Screening Scale for DSM IV PTSD
1
2
Evidence Screening all patients for PTSD symptoms.
Screening tools:
Primary Care PTSD Screen
PTSD Brief Screen
Short Screening Scale for DSM IV
PTSD Checklist (PCL)
- PTSD Brief Screen
- PTSD Checklist (PCL)
Sources Breslau et al., 1999a
Leskin & Westrup, 1999
Prins et al., 1999
Taubman et al., 2001
LE
II-2
QE
Fair
SR
B
II-2
Fair
B
Breslau et al., 1999a
Leskin & Westrup, 1999
Prins et al., 1999
Terhakopian, et al 2008
All patients with PTSD should be assessed for safety & dangerousness including current risk to self or
others, and historical patterns of risk:
- SI or HI, intent, means, history, behaviors, co-morbidities (substance use, medical conditions)
- Family and social environment – including risks to the family
- Ongoing health risks or risk-taking behavior
- Medical/psychiatric co-morbidities or unstable medical conditions
Recommendation
Sources
LE
QE
SR
1
Assess for dangerousness including
suicidal or homicidal ideation, intent,
means, history, behaviors, and comorbidities
B
Assess family, social environment –
including risks for family
Assess ongoing health risks or risktaking behaviors
III
II-2
III
II-2
II
II
II
II-2
III
II
II-2
II
II-2
II
III
III
Good
2
Breslau, 2000
Bullman & Kang, 1994
Ferrada-Noli et al., 1998
Kaslow et al., 2000
Marshall et al., 2001
Prigerson & Slimack, 1999
Swanson et al., 2002
Zivin, 2007
Seng, 2002
Swanson, 2002
Acierno et al., 1996
Hutton et al., 2001
Vieweg et al., 2006
Davidson et al., 1991
Farrell et al., 1995; Weisberg et al., 2002
Hoge et al., 2007; Gill et al., 2009
Good
B
Good
B
Good
B
3
4
Assess medical or psychiatric comorbidities or unstable medical
condition
LE = Level of Evidence; QE = Quality of Evidence; SR= Recommendation
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III. Treatment Recommendations
A. EARLY INTERVENTIONS TO PREVENT PTSD
Early Interventions after Exposure to Trauma (<4 days after exposure)
Balance of Benefit and Harm
SR
Significant
Benefit
I
--
Some Benefit
Unknown
Benefit
Psychological First Aid
No Benefit /
Potential Harm
Spiritual support
--
--
Psychological debriefing
Psychoeducation & normalization
Social support
D
--
--
Early Interventions after Exposure to Trauma (4-30 days after exposure)
Balance of Benefit and Harm
SR
Significant
Benefit
A
Brief CBT
(4-5 sessions)
B
C
Some Benefit
Unknown Benefit
No Benefit
Social support
D
Individual psychological debriefingW
Formal psychotherapy for
asymptomatic survivors W
Benzodiazepines, Typical
Antipsychotics, risperidone* W
Atypical antipsychotics as
Monotherapy*
I
Psychoeducation
& normalization
Imipramine
Group psychological debriefing
Propranolol, Prazosin
Other Antidepressants
Anticonvulsants
Atypical Antipsychotics as
Adjunct (except risperidone)*
Spiritual support
Psychological First Aid
*VA/DoD Clinical Practice Guideline has been revised as follows: 1) atypical antipsychotics are not recommended as
mono therapy for PTSD, 2) risperidone is contraindicated for use as an adjunctive agent (potential for harm), and 3) there is
insufficient evidence to recommend any other atypical antipsychotic as an adjunctive agent for PTSD
(http://www.ptsd.va.gov/professional/pages/clinicians-guide-to-medications-for-ptsd.asp)
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B. TREATMENT INTERVENTIONS FOR PTSD
Providers should explain to all patients with PTSD all available & effective options for PTSD.
Patient education is recommended for all patients with PTSD & their family members. [C]
Patient and provider preferences should drive the selection of evidence-based psychotherapy and/or
evidence-based pharmacotherapy as the first line treatment.
Psychotherapies should be provided by practitioners trained in the method of treatment.
All clinicians should be trained in trauma-informed care.
A collaborative care approach to therapy administration, with care management, may be considered,
although supportive evidence is lacking specifically for PTSD.
Psychotherapy Interventions for Treatment of PTSD
Balance Benefit and Harm
SR
Significant Benefit
A
Trauma-focused psychotherapy that includes
component of exposure and/or cognitive
restructuring (i.e., CBT, EMDR, Exposure
Therapy, etc.) ; or,
Some Benefit
Unknown Benefit
Stress Inoculation training
B
C
Patient Education
Imagery Rehearsal Therapy
Psychodynamic Therapy
Hypnosis
Relaxation Techniques
Group Therapy
I
Family Therapy
Web-based CBT
Acceptance and
Commitment Therapy
Dialectical Behavior
Therapy
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Adjunctive Problem-Focused Method/Services for PTSD
If patient:
Service/Training
Is not fully informed about aspects of health needs & does
not avoid high-risk behaviors
Provide patient education
Does not have sufficient self-care & independent living
skills
Refer to self-care/independent living skills
training services
Does not have safe, decent, affordable, stable housing that is
consistent with treatment goals
Use and/or refer to supported housing services
Does not have a family that is actively supportive and/or
knowledgeable about treatment for PTSD
Implement family skills training
Is not socially active
Implement social skills training
Does not have a job that provides adequate income and/or
fully uses his or her training & skills
Implement vocational rehabilitation training
Is unable to locate & coordinate access to services
Use case management services
Does not request spiritual support
Provide access to religious/spiritual advisors
and/or other resources
OTHER CONDITIONS
Has a borderline personality disorder with parasuicidal
behaviors
Consider DBT
Has concurrent substance abuse problem
Integrated PTSD substance abuse treatment
(i.e., Seeking Safety)
Symptom Response by Drug Class and Individual Drug (based on controlled trials)
SSRI
SNRI
TCAs
MAOIs
Sympatholytics
Other Antidepressants
Fluoxetine
Sertraline
Paroxetine
Venlafaxine
Amitriptyline/
Imipramine
Phenelzine
Prazosin
Mirtazapine
Nefazodone
Global
Improvement
X
X
X
X
X
Reexperiencing
X
X
X
X
X
Avoidance/
Numbing
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Hyperarousal
X
X
X
X
*VA/DoD Clinical Practice Guideline has been revised as follows: 1) atypical antipsychotics are not recommended as
mono therapy for PTSD, 2) risperidone is contraindicated for use as an adjunctive agent (potential for harm), and 3) there is
insufficient evidence to recommend any other atypical antipsychotic as an adjunctive agent for PTSD
(http://www.ptsd.va.gov/professional/pages/clinicians-guide-to-medications-for-ptsd.asp)
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Pharmacotherapy for PTSD
Balance of Benefit and Harm
SR
Significant
A
SSRIs
Some Benefit
Unknown
No Benefit
SNRIs
B
Mirtazapine
Prazosin (for
sleep/nightmares)
TCAs
Nefazodone [Caution]
MAOIs (phenelzine) X
C
Prazosin (for global PTSD)
D
Benzodiazepines[Harm]
Tiagabine
Guanfacine
Valproate
Topiramate
Risperidone, as adjunct
[Harm] *
Atypical antipsychotics,
as monotherapy *
I
Atypical antipsychotic, as
adjunct (besides risperidone
which is contraindicated)*
Typical antipsychotics
Buspirone
Non-benzodiazepine
hypnotics
Bupropion
Trazodone (adjunctive)
Gabapentin
Lamotrigine
Propranolol
Clonidine
SR = Strength of recommendation (see Introduction); X= Attention to drug to-drug and dietary interactions
*VA/DoD Clinical Practice Guideline has been revised as follows: 1) atypical antipsychotics are not recommended as
mono therapy for PTSD, 2) risperidone is contraindicated for use as an adjunctive agent (potential for harm), and 3) there is
insufficient evidence to recommend any other atypical antipsychotic as an adjunctive agent for PTSD
(http://www.ptsd.va.gov/professional/pages/clinicians-guide-to-medications-for-ptsd.asp)
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Monotherapy:
Strongly recommend that patients with PTSD be offered SSRIs, for which fluoxetine, paroxetine, or
sertraline have strongest support, or SNRIs, for which venlafaxine has strongest support. [A]
Recommend mirtazapine, nefazodone, TCAs, amitriptyline & imipramine, or MAOIs (phenelzine). [B]
Recommend against guanfacine, anticonvulsants (tiagabine, topiramate, valproate) as monotherapy [D]
Existing evidence does not support the use of bupropion, buspirone, and trazodone, anticonvulsants
(lamotrigine or gabapentin) or atypical antipsychotics as monotherapy in the management of PTSD. [I]
There is evidence against the use of benzodiazepines, atypical antipsychotics as monotherapy,*** and
risperidone as adjunct*** in management of PTSD. [D]
Insufficient evidence to support the use of prazosin as monotherapy in the management of PTSD. [I]
Augmented Therapy for PTSD:
Recommend adjunctive treatment with prazosin for sleep/nightmares. [B]
Insufficient evidence to recommend a sympatholytic, anticonvulsant, or atypical antipsychotic (besides
risperidone, which is contraindicated)*** as an adjunct. [I]
Treatment Response and Follow-Up
Step
1
2
Patient
Condition
Initial
Treatment
Non response
to initial dose
Options
• Psychotherapy AND/OR
• SSRI/SNRI
• Assess adherence
Reassess
at:*
2 weeks **/
4 weeks
4-6 weeks
• Increase dose
• Consider longer duration
• Switch to another SSRI or SNRI
• Add psychotherapy
• Consider referral to specialty care
3
Failed second
trial of
antidepressant
• Switch to another SSRI/SNRI or mirtazapine
8-12 weeks
• Add psychotherapy
• Augment with prazosin (sleep/nightmare)
4
Failed three
trials
including
augmentation
• Re- evaluate diagnosis and treatment
> 12 weeks
• Switch to TCA
• If no response consider nefazodone (monitoring side effects), or
phenalzine (with careful consideration of risks)
• Consider referral to specialty care
* Times are general guidelines and may vary considerably / **If treatment is not tolerable, switch to another antidepressant.
***VA/DoD Clinical Practice Guideline has been revised as follows: 1) atypical antipsychotics are not recommended as
mono therapy for PTSD, 2) risperidone is contraindicated for use as an adjunctive agent (potential for harm), and 3) there is
insufficient evidence to recommend any other atypical antipsychotic as an adjunctive agent for PTSD
(http://www.ptsd.va.gov/professional/pages/clinicians-guide-to-medications-for-ptsd.asp)
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