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Management of Treatment-Resistant Posttraumatic Stress Disorder

  • Anxiety, Obsessive Compulsive, and Related Disorders (CB Nemeroff, Section Editor)
  • Published:
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Opinion statement

Purpose of review The management of treatment-resistant posttraumatic stress disorder (TRPTSD) is a complex clinical challenge, and many patients may continue to endure a heavy symptom burden, even despite the best available treatments. We review the recent literature to provide an update on the evidence base and offer guidance to clinicians on available approaches, including a number of novel and emerging options.

Recent findings If adequate trials of treatment with first-line antidepressants (SSRIs or venlafaxine) or trauma-focused psychotherapy have failed, dosage increase, switching to an alternative first-line option, or combining medication and psychotherapy are reasonable initial approaches. If these remain insufficient, augmentation strategies should be offered, including addition of second-generation antipsychotics (such as risperidone) or the adrenergic antagonist prazosin (especially if sleep disturbance or nightmares are problematic). Further options include the use of other antidepressants (most notably mirtazapine, duloxetine, and trazodone), and the anticonvulsants topiramate or lamotrigine, though the evidence for these is relatively weak. Having tried all these possibilities, the clinician may wish to suggest complementary approaches such as yoga, mindfulness meditation, or acupuncture for symptom reduction and overall well-being. Emerging alternatives, if available, could also be considered, such as augmentation of exposure therapy with d-cycloserine or MDMA, or the use of device-based brain stimulation (such as transcranial magnetic stimulation), though the evidence for these is still preliminary.

Summary Comprehensive assessment of TRPTSD, including a thorough evaluation of associated comorbidity, should inform individualized care, incorporating a process of shared decision-making. Despite the complex clinical challenge of TRPTSD, clinicians should remain hopeful however, that translational neuroscience and clinical trials of emerging approaches will allow progressively better treatment alternatives to be established.

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Authors and Affiliations

  1. Department of Psychiatry and Mental Health, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa

    Jonathan A. Starke MBChB, MMed & Dan J. Stein MD, PhD

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  1. Jonathan A. Starke MBChB, MMed
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  2. Dan J. Stein MD, PhD
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Correspondence to Jonathan A. Starke MBChB, MMed.

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Conflict of Interest

In the past 3 years, Dr. Stein has received research grants and/or consultancy honoraria from Biocodex, Lundbeck, Servier, and Sun. Dr. Starke declares no conflict of interest.

Human and Animal Rights and Informed Consent

With regard to the authors’ research cited in this paper, all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. In addition, all applicable international, national, and/or institutional guidelines for the care and use of animals were followed.

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This article is part of the Topical Collection on Anxiety, Obsessive Compulsive, and Related Disorders

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Starke, J.A., Stein, D.J. Management of Treatment-Resistant Posttraumatic Stress Disorder. Curr Treat Options Psych 4, 387–403 (2017). https://doi.org/10.1007/s40501-017-0130-0

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