PTSD: New Guidelines

Approximately 7 in 10 U.S. adults will experience a traumatic event at some point in their lifetime. Such exposure can lead to substantial problems, including PTSD, a condition in which symptoms persisting >1 month after exposure cause clinically significant distress or functional impairment. Evidence suggests that primary care patients presenting with new anxiety, fear, or insomnia should be screened for PTSD. 

A new guideline published in the Annals of Internal Medicine by the U.S. Veterans Affairs/U.S. Department of Defense (VA/DOD) separates validated treatments from those with weak or insufficient evidence. The authors argue that this guideline can apply to both military and civilian patients.

Assessment & Diagnosis

RecommendationStrength
When screening for PTSD, we suggest using the Primary Care PTSD Screen for DSM-5.Weak for
For confirmation of the diagnosis of PTSD, we suggest using a validated, structured, clinician-administered interview, such as the CAPS-5 or PSSI-5.Weak for
To detect changes in PTSD symptom severity over time, we suggest the use of a validated instrument, such as the PTSD Checklist for DSM-5, or a structured clinician-administered interview, such as the CAPS-5.Weak for
Source: Schnurr et al. Ann Intern Med. 2024

Evidence for the Primary Care PTSD Screen (PC-PTSD-5) is based on 2 studies conducted in veterans within the VA care system. Both study samples were predominantly white male veterans, thus there is a need for more research to establish appropriate cut point scores in other populations. Nevertheless, the PC-PTSD-5 appears to have better sensitivity and specificity for PTSD than other screening tools such as the GAD-7 (66% sensitive and 81% specific, according to a 2007 study using a cut-off score of ≥10). 

Treatment

RecommendationStrength
We recommend individual psychotherapies over pharmacologic interventions for the treatment of PTSD.Strong for
We recommend the following individual, manualized, trauma-focused psychotherapies for the treatment of PTSD: CPT, EMDR, or PE.Strong for
We recommend paroxetine, sertraline, or venlafaxine for the treatment of PTSD.Strong for
There is insufficient evidence to recommend for or against amitriptyline, bupropion, buspirone, citalopram, desvenlafaxine, duloxetine, escitalopram, eszopiclone, fluoxetine, imipramine, mirtazapine, lamotrigine, nefazodone, olanzapine, phenelzine, pregabalin, rivastigmine, topiramate, or quetiapine for the treatment of PTSD.Neither for or against
There is insufficient evidence to recommend for or against psilocybin, ayahuasca, dimethyltryptamine, ibogaine, or lysergic acid diethylamide for the treatment of PTSD.Neither for or against
We suggest against divalproex, guanfacine, ketamine, prazosin, risperidone, tiagabine, or vortioxetine for the treatment of PTSD.Weak against
We recommend against benzodiazepines for the treatment of PTSD.Strong against
We recommend against cannabis or cannabis derivatives for the treatment of PTSD.Strong against
Source: Schnurr et al. Ann Intern Med. 2024

Psychotherapies are recommended over pharmacotherapy due to greater efficacy, fewer adverse effects, and patient preference, despite feasibility and engagement barriers. Recommendations are strongest for cognitive processing therapy (CPT), eye movement desensitization and reprocessing (EMDR), and prolonged exposure (PE). The authors recommend against group, marital, or family therapy.

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