Introduction
The Clinical Practice guideline by the Department of Veterans Affairs (VA) and the US Department of Defense (DoD) offers evidence-based recommendations for assessing, diagnosing, preventing, and treating Posttraumatic Stress Disorder (PTSD) and Acute Stress Disorder. The guideline is a valuable resource for healthcare professionals, aiming to enhance the quality of care provided to individuals affected by these disorders.1
Recommendations1
Assessment and Diagnosis of PTSD
Screening for PTSD: The guideline suggests using the Primary Care PTSD Screen for DSM-5 when conducting initial screenings for PTSD. This approach provides a comprehensive and structured assessment to identify potential cases. (Strength: Weak, Category: Reviewed, New replaced)
Diagnosis Confirmation: For confirming a diagnosis of PTSD, the guideline recommends using a validated structured clinician-administered interview, such as the Clinician-Administered PTSD Scale or PTSD Symptom Scale – Interview Version. This method ensures accurate and consistent diagnosis across different healthcare settings. (Strength: Weak, Category: Reviewed, New replaced)
Monitoring Symptom Changes: To track changes in the severity of PTSD symptoms over time, the guideline proposes using validated instruments like the PTSD Checklist for DSM-5 or the Clinician-Administered PTSD Scale. These tools facilitate ongoing assessment and help gauge treatment effectiveness. (Strength: Weak, Category: Reviewed, New replaced)
Treatment of PTSD
Treatment Selection
Psychotherapies vs Pharmacologic Interventions: The guideline strongly recommends individual psychotherapies over pharmacologic interventions as the primary treatment for PTSD. It reflects the significance of therapeutic approaches in addressing the complex nature of PTSD. (Strength: Strong, Category: Reviewed, New replaced).
Psychotherapy
Trauma-Focused Psychotherapies: The guideline strongly recommends individual, manualized trauma-focused psychotherapies for treating PTSD, including Cognitive Processing Therapy, Eye Movement Desensitization and Reprocessing, and Prolonged Exposure. These therapies have demonstrated efficacy in addressing traumatic experiences. (Strength: Strong, Category: Reviewed, New replaced)
Additional Psychotherapies: The guideline suggests several other individual, manualized psychotherapies for treating PTSD, such as Ehlers’ Cognitive Therapy for PTSD, Present-Centered Therapy, and Written Exposure Therapy. These options offer a range of choices tailored to individual patient needs. (Strength: Weak, Category: Reviewed, New replaced)
Insufficient Evidence: There is currently insufficient evidence to support or oppose using certain individual psychotherapies for treating PTSD. These therapies include Accelerated Resolution, Acceptance and Commitment, and Interpersonal Psychotherapy. More research is needed to establish their effectiveness. (Strength: Neither for nor against, Category: Reviewed, New replaced)
Components of Psychotherapy: The guideline emphasizes the need for further research to determine the efficacy of using individual components of manualized psychotherapy protocols compared to the full therapy protocol for treating PTSD. (Strength: Neither for nor against, Category: Reviewed, Not changed)
Group Therapy: There is insufficient evidence to support or oppose any specific manualized group therapy for treating PTSD. More research is needed in this area to provide clear recommendations. (Strength: Neither for nor against, Category: Reviewed, New replaced)
Adjunctive Group Therapy: The guideline notes a lack of evidence to support or oppose group therapy as an adjunct for treating PTSD. Further research is required to ascertain the role of group therapy in the treatment process. (Strength: Neither for nor against, Category: Reviewed, New replaced)
Couples Therapies: The guideline suggests insufficient evidence for or against using certain couples therapies for treating PTSD, such as Behavioral Family Therapy, Structured Approach Therapy, or Cognitive Behavioral Conjoint Therapy. More research is necessary to establish their efficacy. (Strength: Neither for nor against, Category: Reviewed, Not changed)
Pharmacotherapy
Recommended Pharmacotherapy: The guideline strongly recommends using specific medications, including paroxetine, sertraline, or venlafaxine, to treat PTSD. These medications have shown effectiveness in managing PTSD symptoms. (Strength: Strong, Category: Reviewed, New replaced)
Limited Evidence: For a range of medications, including amitriptyline, bupropion, and fluoxetine, there is currently insufficient evidence to recommend for or against their use in treating PTSD. Additional research is needed to determine their efficacy. (Strength: Neither for nor against, Category: Reviewed, New replaced)
Exploring Alternative Treatments: The guideline acknowledges that there is insufficient evidence to recommend for or against the use of certain substances like psilocybin, ayahuasca, and lysergic acid diethylamide for treating PTSD. More research is needed in this emerging area of treatment. (Strength: Neither for nor against, Category: Reviewed, New-added)
Discouraged Pharmacotherapy: The guideline suggests against the use of specific medications like Divalproex, guanfacine, and ketamine for the treatment of PTSD due to limited evidence or potential risks. (Strength: Weak against, Category: Reviewed, New-added)
Discouraged Benzodiazepines: The guideline strongly recommends against using benzodiazepines for the treatment of PTSD due to the potential for worsening symptoms and increased risks associated with their use. (Strength: Strong against, Category: Reviewed, New-added)
Cannabis and Derivatives: The guideline advises against using cannabis or cannabis derivatives for treating PTSD due to limited evidence and potential risks. (Strength: Strong against, Category: Reviewed, Amended)
Complementary, Integrative, and Alternative Approaches
Mindfulness-Based Stress Reduction: The guideline suggests using Mindfulness-Based Stress Reduction as a weak recommendation for treating PTSD. This approach can provide additional avenues for managing symptoms and improving overall well-being. (Strength: Weak, Category: Reviewed, New replaced)
Mind-Body Interventions: The guideline acknowledges a lack of evidence to recommend specific mind-body interventions like acupuncture, guided imagery, and relaxation training to treat PTSD. More research is needed to assess their potential benefits. (Strength: Neither for nor against, Category: Reviewed, New replaced)
Exploring Options: There is currently insufficient evidence to recommend for or against certain interventions, such as recreational and animal-assisted therapy, for treating PTSD. These approaches require further investigation to determine their effectiveness. (Strength: Neither for nor against, Category: Reviewed, New replaced)
Technology-based Treatment
Video Teleconferencing: The guideline strongly recommends the use of secure video teleconferencing to deliver treatments recommended in previous sections when validated for use with this technology. It can expand access to effective treatments, especially in remote or underserved areas. (Strength: Strong, Category: Reviewed, New replaced)
Mobile Apps and Self-Help Interventions: There is currently insufficient evidence to recommend for or against using mobile apps or other self-help-based interventions for treating PTSD. Further research is needed to assess their potential benefits. (Strength: Neither for nor against, Category: Reviewed, New added)
Internet-based Cognitive Behavioral Therapy: The guideline acknowledges the need for more research to determine the efficacy of facilitated internet-based cognitive behavioural therapy for treating PTSD. This emerging treatment approach warrants further investigation. (Strength: Neither for nor against, Category: Reviewed, New replaced)
Treatment of Nightmares
Prazosin: The guideline suggests using prazosin as a weak recommendation for treating nightmares associated with PTSD. Prazosin has shown potential benefits in managing these distressing symptoms. (Strength: Weak, Category: Reviewed, Amended)
Addressing Nightmares: There is currently insufficient evidence to recommend for or against specific treatments like Imagery Rehearsal Therapy and Exposure Relaxation and Rescripting Therapy for nightmares associated with PTSD. Additional research is needed to establish their effectiveness. (Strength: Neither for nor against, Category: Reviewed, New added)
Treatment of PTSD with Co-Occurring Conditions
Co-Occurring Conditions: The guideline suggests that co-occurring substance use disorder and other disorder(s) should not preclude the application of treatments recommended in previous sections for PTSD. Comprehensive treatment planning should address all relevant conditions. (Strength: Weak, Category: Reviewed, New replaced)
Conclusion
The VA/DoD Clinical Practice Guideline for managing PTSD and acute stress disorder is an evidence-based resource for healthcare professionals caring for individuals affected by these conditions. By providing a thorough evaluation of assessment, prevention, and treatment strategies, the guideline empowers healthcare providers to make informed decisions and offer effective interventions. As research continues to evolve, the guideline will adapt to reflect the latest insights and advancements, ultimately improving the well-being and quality of life for those struggling with PTSD and acute stress disorder.
References
- VA/DoD Clinical Practice Guideline for Management of Posttraumatic Stress Disorder and Acute Stress Disorder. [Cited: August 11, 2023]. Available from: https://www.healthquality.va.gov/guidelines/MH/ptsd/VA-DoD-CPG-PTSD-Full-CPG.pdf
