Evidence-based practice (EBP) is an approach that brings together the best available, well-researched treatments, clinician acumen, and patient interests and preferences to guide clinical decisions. The U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DoD) jointly established a process for developing Clinical Practice Guidelines (CPGs) to provide clinicians with current evidence reviews to guide treatment planning. The 2023 revision of the posttraumatic stress disorder (PTSD)/Acute Stress Disorder (ASD) CPG provides five levels of endorsement based on the quality of the evidence, the ratio of benefits and harms, patient values and preferences, and factors related to implementation.
Psychotherapy is recommended over pharmacotherapy for treatment of PTSD based on larger and more persistent improvement with the former. Among psychotherapies, the CPG recommends Cognitive Processing Therapy (CPT), Eye Movement Desensitization and Reprocessing (EMDR), and Prolonged Exposure (PE). Recommended medications include paroxetine, sertraline, and venlafaxine. Interventions with a suggestion for use, which is lower support than a recommendation, include Ehler’s cognitive therapy, Present-Centered Therapy (PCT), Written Exposure Therapy (WET) and Mindfulness-Based Stress Reduction (MBSR). The presence of comorbidities, including substance use disorders, should not preclude people from receiving a recommended or suggested treatment for PTSD.
The CPG includes two recommendations against specific treatments for PTSD, meaning that they are strongly contraindicated: benzodiazepines and cannabis and its derivatives. Several medications, electroconvulsive therapy and vagus nerve stimulation have suggestions against use as monotherapy for PTSD or as augmentation of medications for PTSD. Prazosin, while suggested against as monotherapy for treating PTSD symptoms overall, is suggested to treat nightmares. Numerous other treatments used in clinical practice alone or in combination with other treatments were deemed to lack sufficient evidence to recommend for or against their use for PTSD.
Given the number and variety of recommended and suggested treatments, clinicians may feel unsure of which treatment to offer a particular patient. The CPG and accompanying clinical algorithm direct clinicians to begin by considering one of the three recommended trauma-focused psychotherapies but shift to medication or one of the suggested treatments based on patient preference or treatment availability. Selecting a particular approach can be facilitated by patient-centered care and shared decision-making, namely encouraging collaboration between patients and providers to develop a treatment plan and accounting for patients’ preferences and values. Additionally, use of validated measures to track symptoms, i.e., measurement-based care, has important utility in guiding decisions about when to terminate treatment because the goals have been reached, when and how to troubleshoot with a patient who may not be making progress, and when an alternate treatment approach should be considered.
The COVID-19 pandemic changed the care landscape as telehealth became an overnight necessity, and many patients and clinicians now prefer this modality. Based on the extant literature, videoconferencing is a reasonable alternative to in person care when treatments have been validated for that modality or when it is the best option because of accessibility or patient preference. Patients may be highly motivated to try things that are featured in the popular press or social media, particularly if they are touted for dramatic and rapid change (e.g., psychedelic-assisted psychotherapy) or have been helpful to a friend. Because the response to interventions without insufficient evidence for a recommendation is unpredictable, it is good practice to educate patients about the value of evidence-based approaches during the treatment planning process.
The number of recommended and suggested treatment options show that there are effective treatments for PTSD. However, more work is needed to make these treatments widely available to patients with PTSD and to clear barriers that hinder clinicians from putting CPG recommendations into practice. There are also many treatments reviewed in the CPG that were deemed as having insufficient evidence that may prove to be effective, so continued research on the efficacy of these treatments is important.