VA/DOD CLINICAL PRACTICE GUIDELINE FOR 

THE MANAGEMENT OF POSTTRAUMATIC 

STRESS DISORDER AND ACUTE STRESS 

DISORDER 

Department of Veterans Affairs

Department of Defense

QUALIFYING STATEMENTS

The Department of Veterans Affairs and the Department of Defense guidelines are based upon the best 

information available at the time of publication. They are designed to provide information and assist 

decision making. They are not intended to define a standard of care and should not be construed as one.

Neither should they be interpreted as prescribing an exclusive course of management. 

This Clinical Practice Guideline is based on a systematic review of both clinical and epidemiological 

evidence. Developed by a panel of multidisciplinary experts, it provides a clear explanation of the logical 

relationships between various care options and health outcomes while rating both the quality of the 

evidence and the strength of the recommendation. 

Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of 

individual patients, available resources, and limitations unique to an institution or type of practice. Every 

healthcare professional making use of these guidelines is responsible for evaluating the appropriateness of 

applying them in the setting of any particular clinical situation.

These guidelines are not intended to represent TRICARE policy. Further, inclusion of recommendations for 

specific testing and/or therapeutic interventions within these guidelines does not guarantee coverage of 

civilian sector care. Additional information on current TRICARE benefits may be found at www.tricare.mil 

or by contacting your regional TRICARE Managed Care Support Contractor.

Version 3.0 – 2017
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Prepared by:

The Management of Posttraumatic Stress Disorder

Work Group

With support from:

The Office of Quality, Safety and Value, VA, Washington, DC

& 

Office of Evidence Based Practice, U.S. Army Medical Command

Version 3.0 – 2017 

Based on evidence reviewed through March 2016
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Table of Contents

I. Introduction..................................................................................................................................... 5

II. Background...................................................................................................................................... 5

A. Definition of Traumatic Events............................................................................................................ 5

B. Acute Stress Reaction and Diagnosis of Acute Stress Disorder ......................................................... 6

C. Diagnosis of Posttraumatic Stress Disorder........................................................................................ 8

D. DSM-IV versus DSM-5: Clinical Practice Guideline Implications......................................................11

E. Epidemiology and Impact..................................................................................................................13

III. About this Clinical Practice Guideline ............................................................................................. 16

A. Methods.............................................................................................................................................16

B. Summary of Patient Focus Group Methods and Findings................................................................20

C. Conflicts of Interest ...........................................................................................................................21

D. Scope of this Clinical Practice Guideline ...........................................................................................21

E. Highlighted Features of this Clinical Practice Guideline...................................................................22

F. Patient-centered Care .......................................................................................................................22

G. Shared Decision Making ....................................................................................................................23

H. Background on Co-occurring Conditions with Posttraumatic Stress Disorder................................23

I. Implementation................................................................................................................................. 24

IV. Guideline Work Group ................................................................................................................... 26

V. Algorithm ...................................................................................................................................... 27

Module A: Acute Stress Reaction/Disorder..............................................................................................28

Module B: Assessment and Diagnosis of Posttraumatic Stress Disorder................................................30

Module C: Management of Posttraumatic Stress Disorder.....................................................................32

VI. Recommendations......................................................................................................................... 33

A. General Clinical Management...........................................................................................................37

B. Diagnosis and Assessment of Posttraumatic Stress Disorder..........................................................39

C. Prevention of Posttraumatic Stress Disorder...................................................................................41

D. Treatment of Posttraumatic Stress Disorder....................................................................................44

E. Treatment of Posttraumatic Stress Disorder with Co-occurring Conditions...................................72

VII. Knowledge Gaps and Recommended Research.............................................................................. 76

A. Shared Decision Making and Collaborative Care..............................................................................76

B. Treatments for Acute Stress Disorder and Preventing Posttraumatic Stress Disorder ..................76
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C. Treatments for Posttraumatic Stress Disorder.................................................................................76

D. Non-Pharmacologic Biological Treatments for Posttraumatic Stress Disorder...............................78

E. Technology-based Treatments for Posttraumatic Stress Disorder..................................................78

F. Treatments for Posttraumatic Stress Disorder with Comorbidities and Co-occurring Conditions. 78

Appendix A: Evidence Review Methodology....................................................................................... 79

A. Developing the Scope and Key Questions........................................................................................79

B. Conducting the Systematic Review...................................................................................................83

C. Convening the Face-to-face Meeting................................................................................................87

D. Grading Recommendations...............................................................................................................88

E. Recommendation Categorization .....................................................................................................91

F. Drafting and Submitting the Final Clinical Practice Guideline..........................................................93

Appendix B: Patient Focus Group Methods and Findings.................................................................... 95

A. Methods.............................................................................................................................................95

B. Patient Focus Group Findings............................................................................................................95

Appendix C: Pharmacotherapy Dosing Table...................................................................................... 97

Appendix D: Evidence Table ............................................................................................................... 98

Appendix E: 2010 Recommendation Categorization Table ................................................................ 104

Appendix F: Participant List.............................................................................................................. 140

Appendix G: Literature Review Search Terms and Strategy ........................................................... 142

A. Topic-specific Search Terms............................................................................................................142

B. Search Strategies .............................................................................................................................156

Appendix H: Abbreviation List .......................................................................................................... 183

References .......................................................................................................................................... 186
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I. Introduction

The Department of Veterans Affairs (VA) and the Department of Defense (DoD) Evidence-Based Practice 

Work Group (EBPWG) was established and first chartered in 2004, with a mission to advise the “...Health 

Executive Council on the use of clinical and epidemiological evidence to improve the health of the 

population across the Veterans Health Administration and Military Health System,” by facilitating the 

development of clinical practice guidelines (CPGs) for the VA and DoD populations.[1] This CPG is intended 

to provide healthcare providers with a framework by which to evaluate, treat, and manage the individual 

needs and preferences of patients with posttraumatic stress disorder (PTSD) and acute stress disorder

(ASD), thereby leading to improved clinical outcomes.

In 2010, the VA and DoD published a CPG for the Management of Post-Traumatic Stress and Acute 

Stress Reaction (2010 PTSD CPG), which was based on evidence reviewed through March 2009. Since 

the release of that guideline, a growing body of research has expanded the general knowledge and 

understanding of PTSD and other stress related disorders, such as ASD and other acute reactions to 

trauma (sometimes referred to as acute stress reactions [ASR]). Improved recognition of the complex 

nature of ASR, ASD, and PTSD has led to the adoption of new or refined strategies to manage and treat 

patients with these conditions. 

Consequently, a recommendation to update the 2010 PTSD CPG was initiated in 2015. The updated CPG 

includes objective, evidence-based information on the management of PTSD and related conditions. It is 

intended to assist healthcare providers in all aspects of patient care, including, but not limited to, 

diagnosis, treatment, and follow-up. The system-wide goal of developing evidence-based guidelines is to 

improve the patient’s health and well-being by guiding health providers who are taking care of patients 

with PTSD along the management pathways that are supported by evidence. The expected outcome of 

successful implementation of this guideline is to:

• Enhance assessment of the patient’s condition and determine the best treatment method in

collaboration with the patient and, when possible and desired, the patient’s family and

caregivers

• Optimize the patient’s health outcomes and improve quality of life

• Minimize preventable complications and morbidity

• Emphasize the use of patient-centered care

II. Background

A. Definition of Traumatic Events 

A traumatic event is defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition 

(DSM-5) as an event (or series of events) in which an individual has been personally or indirectly exposed 

to actual or threatened death, serious injury, or sexual violence. There is a wide spectrum of psychological 

responses to traumatic events, ranging from normal, transient, non-debilitating symptoms to a transient 

ASR to an acute, time-limited and clinically-significant clinical disorder (ASD) to a persistent disorder (PTSD) 

that may become chronic, if untreated.
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The DSM-5 definition of traumatic events is the same for both ASD and PTSD, and one can meet the 

trauma definition with any one of four criteria (A1-A4) (see Table 1 and Table 2). Criterion A1 is direct 

exposure to traumatic events such as actual or threatened death, serious injury (e.g., military combat, 

physical attack, torture, man-made/natural disasters, accidents, incarceration, and exposure to warzone/urban/domestic violence) or sexual violence or assault. Criterion A2 is witnessing such events and 

includes people who directly observed such events, but were not harmed themselves. Criterion A3 is 

indirect exposure such as learning that a loved one was exposed to a traumatic event; if the loved one died 

during such an event, Criterion A3 would only be met if the death was violent or accidental. Criterion A4 

applies to exposure to repeated or extreme details of trauma, such as seeing dead body parts or severely 

injured people as part of one’s professional duties (e.g., medical, law enforcement, mortuary affairs, and 

journalism personnel). 

B. Acute Stress Reaction and Diagnosis of Acute Stress Disorder

ASR is defined as a transient normal reaction to traumatic stress and is not a DSM-5 diagnosis, although 

symptoms may be temporarily debilitating. Onset of stress-related signs and symptoms may be 

simultaneous or within minutes of the traumatic event or may follow the trauma after an interval of hours 

or several days. In most cases, symptoms will resolve rapidly with simple measures, such as reassurance, 

rest, and ensuring safety. 

Combat and operational stress reaction (COSR) is the military analog of ASR and reflects a normal, 

transient, acute reaction to a high-stress operational or combat-related traumatic event in a military 

occupational setting. ASR/COSR can present with a broad group of physical, mental, behavioral, and 

emotional symptoms and signs (e.g., depression, fatigue, anxiety, panic, decreased 

concentration/memory, hyperarousal, dissociation). Identification of a patient with ASR/COSR 

symptoms is based on observation of behavior and function as well as clinical assessments since there is 

insufficient evidence to recommend a specific screening tool. With regard to COSR, a Service Member’s 

role and functional capabilities should also be considered as well as the complexity and importance of 

his or her job. Symptoms of COSR and ability to function in an operational mission should be 

documented and collateral information pertaining to stressors or the medical history can be obtained 

from unit leaders, coworkers, or peers. Individuals who experience ASR or COSR should receive a 

comprehensive assessment of their symptoms or behavioral signs to include details about the time of 

onset, frequency, course, severity, level of distress, work performance, functional impairment, and 

other relevant information. Additionally, the individual should be assessed for medical causes of acute 

changes in behavior. Military policy indicates that Service Members with COSR who do not respond to 

initial supportive interventions may warrant referral or evacuation, though the general principle of care 

is to provide treatment as close to the Service Member’s unit/team as possible. If ASR/COSR continues 

beyond three days with persistent limitations of functioning, it is necessary to monitor Service Members 

for the possible development of ASD.

ASD, a diagnosis defined by DSM-5 (see Table 1 for full criteria), can also occur after exposure to a 

traumatic event. Symptoms must last at least three days but less than one month after exposure to the 

traumatic event for an individual to be eligible for this diagnosis.
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Individuals with ASD must have been exposed to a traumatic stressor (Criteria A1-A4). In addition, they 

must exhibit at least nine out of 14 possible symptoms that are nested within five diagnostic clusters 

(Table 1). Symptoms need to cause significant distress or functional impairment.

Table 1. DSM-5 Diagnostic Criteria for Acute Stress Disorder*[2] 

Diagnostic Criteria for ASD

Criterion A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the 

following ways:

1. Directly experiencing the traumatic event(s)

2. Witnessing, in person, the event(s) as it occurred to others

3. Learning that the event(s) occurred to a close family member or close friend

Note: In cases of actual or threatened death of a family member or friend, the event(s) must have been violent 

or accidental.

4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first

responders collecting human remains, police officers repeatedly exposed to details of child abuse)

Note: This does not apply to exposure through electronic media, television, movies, or pictures, unless this 

exposure is work related.

Criterion B. Presence of nine (or more) of the following symptoms from any of the five categories of 

intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the traumatic 

event(s) occurred: 

Intrusion Symptoms

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s)

2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic

event(s)

3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were

recurring (such reactions may occur on a continuum, with the most extreme expression being a complete 

loss of awareness of present surroundings)

4. Intense or prolonged psychological distress or marked physiological reactions in response to internal or

external cues that symbolize or resemble an aspect of the traumatic event(s)

Negative Mood

5. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction,

loving feelings)

Dissociative Symptoms

6. An altered sense of reality of one’s surroundings or oneself (e.g., seeing oneself from another’s perspective,

being in a daze, time slowing)

7. Inability to remember an important aspect of the event(s) (typically due to dissociative amnesia and not to

other factors such as head injury, alcohol, or drugs)

Avoidance Symptoms

8. Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic

event(s)

9. Efforts to avoid external reminders (e.g., people, places, conversations, activities, objects, situations) that

arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s)

Arousal Symptoms

10. Sleep disturbance (e.g., difficulty falling or staying asleep, restless sleep)

11. Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or

physical aggression toward people or objects

12. Hypervigilance

13. Problems with concentration

14. Exaggerated startle response
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Diagnostic Criteria for ASD

Criterion C. Duration of the disturbance (symptoms in Criterion B) is three days to one month after trauma 

exposure. 

Note: Symptoms typically begin immediately after the trauma, but persistence for at least three days and up to a 

month is needed to meet disorder criteria.

Criterion D. The disturbance causes clinically significant distress or impairment in social, occupational, or other 

important areas of functioning.

Criterion E. The disturbance is not attributable to the physiological effects of a substance (e.g., medication or 

alcohol) or another medical condition (e.g., mild traumatic brain injury) and is not better explained by brief 

psychotic disorder.

*Reprinted with permission by the American Psychiatric Association

C. Diagnosis of Posttraumatic Stress Disorder

PTSD is a clinically-significant condition with symptoms that have persisted for more than one month after 

exposure to a traumatic event (Criteria A1-A4) and caused significant distress or impairment in social, 

occupational, or other important areas of functioning (see Table 2 for full criteria). Criterion A for PTSD is 

the same as criterion A for ASD; however, ASD can only be within the first month after the traumatic 

event. After one month, the diagnostic question is whether PTSD is present. Individuals with PTSD must 

exhibit a specific number of symptoms from each symptom cluster (Criteria B-E). PTSD symptoms must 

persist for at least one month after the traumatic event (Criterion F) and result in significant distress or 

functional impairment (Criterion G). PTSD can also have a delayed expression, when full diagnostic criteria 

are not met until at least six months after exposure to the traumatic event. PTSD can appear alone as the 

only diagnosis, or more commonly, with another co-occurring DSM-5 disorder, such as a substance use 

disorder (SUD), mood disorder, or anxiety disorder. PTSD is also strongly associated with functional 

difficulties, reduced quality of life, and adverse physical health outcomes. 

Table 2. DSM-5 Diagnostic Criteria for Posttraumatic Stress Disorder*[2] 

DSM-5 Diagnostic Criteria for PTSD

Criterion A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the 

following ways:

1. Directly experiencing the traumatic event(s)

2. Witnessing, in person, the event(s) as it occurred to others

3. Learning that the traumatic event(s) occurred to a close family member or close friend

Note: In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or 

accidental.

4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first

responders collecting human remains, police officers repeatedly exposed to details of child abuse)

Note: This does not apply to exposure through electronic media, television, movies or pictures unless this exposure 

is work-related.
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DSM-5 Diagnostic Criteria for PTSD

Criterion B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic 

event(s), beginning after the traumatic event(s) occurred. 

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s)

2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic 

event(s)

3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were 

recurring (such reactions may occur on a continuum with the most extreme expression being a complete 

loss of awareness of present surroundings) 

4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or 

resemble an aspect of the traumatic event(s)

5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the 

traumatic event(s)

Criterion C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic 

event(s) occurred, as evidenced by one or both of the following: 

1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with 

the traumatic event(s)

2. Avoidance or efforts to avoid external reminders (people, places, conversations, activities, objects, 

situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the 

traumatic event(s)

Criterion D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or 

worsening after the traumatic event(s) occurred as evidenced by two or more of the following:

1. Inability to recall an important aspect of the traumatic event(s) (typically due to dissociative amnesia and 

not to other factors such as head injury, alcohol, or drugs)

2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am 

bad.”, “No one can be trusted.”, “The world is completely dangerous.”, “My whole nervous system is 

permanently ruined.”)

3. Persistent distorted cognitions about the cause or consequences of the traumatic event(s) that lead the 

individual to blame himself/herself or others

4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, shame)

5. Markedly diminished interest or participation in significant activities

6. Feeling of detachment or estrangement from others

7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, 

loving feelings)

Criterion E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or 

worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or 

physical aggression toward people or objects

2. Reckless or self-destructive behavior

3. Hypervigilance

4. Exaggerated startle response

5. Problems with concentration

6. Sleep disturbance (e.g., difficulty falling or staying asleep, restless sleep)

Criterion F. Duration of the disturbance (symptoms in Criteria B, C, D, and E) is more than one month.

Criterion G. The disturbance causes clinically significant distress or impairment in social, occupation, or other 

important areas of functioning.
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DSM-5 Diagnostic Criteria for PTSD

Criterion H. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, 

alcohol) or another medical condition.

Specify whether:

With dissociative symptoms: The individuals symptoms must meet the criteria for PTSD and in addition, in 

response to the stressor, the individual experiences persistent or recurrent symptoms of either of the following:

1. Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an

outside observer of, one’s mental processes or body (e.g., feeling as though one were in a dream, feeling a

sense of unreality of self or body, time moving slowly)

2. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the 

individual is experienced as unreal, dreamlike, distant, or distorted)

Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a 

substance (e.g., blackouts, behavior during alcohol intoxication) or another medical condition (e.g., complex partial 

seizures).

Specify if:

With delayed expression: If the full diagnostic criteria are not met until at least six months after the event 

(although the onset and expression of some symptoms may be immediate).

*Reprinted with permission by the American Psychiatric Association

Specific Diagnostic Issues and Questions

• As shown in Table 2, the Dissociative Subtype of PTSD is diagnosed when an individual meets all

diagnostic criteria for PTSD and also exhibits depersonalization or derealization.

• Also shown in Table 2, PTSD with delayed expression is diagnosed if full diagnostic criteria are

not met until at least six months after exposure to the traumatic event.

• Subthreshold PTSD (also sometimes designated as partial PTSD or subsyndromal PTSD) is a

diagnosis used by clinicians to characterize individuals with clinically significant posttraumatic

reactions who fail to meet full PTSD criteria (often for lack of one or two symptoms). The DSM-5

diagnosis for such individuals is Other Specified Trauma and Stress-Related Disorder (309.89).

Unfortunately, we currently lack an approved case definition for subthreshold PTSD. Individuals

designated as such in one research study may have met different criteria in another study.

Furthermore, participants in the clinical trials cited in this CPG were diagnosed with full rather

than subthreshold PTSD. As a result, we cannot be certain how well our recommendations for

treatment of full PTSD apply to those with subthreshold PTSD. (See the DSM-IV versus DSM-5:

Clinical Practice Guideline Implications section below regarding a reasonable clinical approach to

individuals with subthreshold PTSD.)

• “Complex PTSD” [3] is a term used to characterize traumatized individuals who, in addition to

usually meeting full PTSD diagnostic criteria, also exhibit prominent behavioral difficulties (such as

impulsivity and self-destructive actions), emotional difficulties (such as affect lability), cognitive

difficulties (such as dissociation), interpersonal difficulties, and somatization. The DSM-5 does not

recognize complex PTSD as a distinct, valid, and empirically-based diagnosis. Furthermore, the

recommendations in this CPG apply to individuals who meet DSM-5 criteria for PTSD whether or

not some clinicians might conclude that they also appear to have “complex PTSD.”
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D. DSM-IV versus DSM-5: Clinical Practice Guideline Implications

The diagnostic criteria for PTSD underwent substantial changes between the DSM-IV (published in 1994) 

and the DSM-5, which was published in 2013. As with other mental disorders, we lack biological markers 

for PTSD, making a provider dependent on the self-reported presence or absence of specific symptoms in 

making the diagnosis. Changes in the criteria for PTSD may carry significant implications for the diagnosis 

and treatment of the disorder. 

Changes to the PTSD diagnostic criteria included modifying the definition of a traumatic event to note that 

the sudden death of a loved one had to involve traumatic circumstances to qualify as a trauma, and to 

eliminate the requirement that the traumatic event be accompanied by particular emotional reactions, 

specifically fear, helplessness, or horror. Changes to the symptom criteria for PTSD included adding three 

new symptoms to the diagnosis. These symptoms, a persistent and distorted sense of blame for the 

trauma or its consequence, persistent negative emotions, and reckless or self-destructive behavior, 

increased the total number of symptoms from 17 to 20. In addition, the descriptions of eight of the original 

17 symptoms were revised or rewritten, with changes ranging from minor to substantial. The symptom 

criteria for PTSD were also rearranged into four symptom clusters instead of the three present in earlier 

versions of the DSM. Effectively, symptoms in the DSM-IV cluster of “Avoidance and numbing” were 

divided into an “Avoidance” cluster and a “Negative alterations in cognition and mood” cluster that 

includes five DSM-IV symptoms and two newly added symptoms. Although the DSM-5 retained the 

diagnostic requirement that symptoms from all clusters be present, the changes in the number of 

symptoms, definitions of symptoms, and specific symptoms included in each cluster effectively changed 

the criteria used to make a diagnosis. 

At the time this CPG was prepared, the full consequences of the changes to the diagnostic criteria were 

not clear. The changes generated considerable controversy and rigorous debate within the clinical and 

research community. A full exploration of these controversies is beyond the scope of this guideline, but 

two issues raised are of particular importance in the application of this guideline. First, there are questions 

about the impact of the diagnostic changes on the actual diagnosis of the disorder, and the potential that 

the new definition excludes people who would have met the previous diagnosis. Second, there are 

questions about the appropriate application of treatments developed and tested using DSM-IV criteria to 

patients diagnosed with the DSM-5 criteria.[4,5] 

With regard to the impact of the changes to the DSM on the diagnosis of PTSD, four logical possibilities 

arise: (1) an individual may meet criteria under both DSM-IV and DSM-5; (2) an individual may not meet 

criteria under either DSM-IV or DSM-5; (3) an individual may meet criteria under DSM-IV but not DSM-5; 

or (4) an individual may meet criteria under DSM-5 but not DSM-IV. Based on the available literature, 

some authors have concluded that a significant number of individuals (upwards of 50%) would be 

diagnosed with PTSD under one set of criteria but not the other (i.e., discordant diagnoses - 3 and 4 

above).[4] Other authors examining the same literature have concluded that the two diagnostic rubrics 

result in much less inconsistency in diagnostic classification (i.e., concordant diagnoses - 1 and 2 above).[5] 

A full understanding of the impact of the changes to DSM criteria for PTSD awaits further study, but it is 

likely that the effect of these changes will depend on factors such as the method of assessment, 

assessment setting, timing of the assessment relative to the trauma, and the nature of the trauma.
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For clinicians, the possibility that changes in the DSM criteria for PTSD could alter the diagnostic 

determination, change a treatment plan, or alter a disability determination raises questions. Indeed, the 

PTSD CPG Work Group was faced with this challenge as it developed this guideline. In an effort to put 

forward a useful guideline based on existing research, the Work Group adopted an approach that balanced 

logic, empirical data, and practicality. 

At the time that this guideline was prepared, both the VA and DoD had adopted the DSM-5 criteria, so 

clinicians are expected to base their diagnosis on these criteria. In contrast, however, all of the clinical 

trials reviewed in the preparation of this guideline utilized the DSM-IV (or earlier) criteria, raising potential 

questions as to the applicability of the present guideline. In situations where the diagnostic determination 

(either presence or absence of PTSD) is consistent under the DSM-IV and DSM-5 criteria, there are no 

particular conflicts. When PTSD is present, one would apply this guideline and when PTSD is clearly absent, 

one would not. Questions arise, however, when PTSD would be diagnosed under one set of criteria but not 

the other, or when significant PTSD symptoms are present but the diagnostic criteria are not met 

(subthreshold PTSD). 

Concerning situations in which diagnoses using the different criteria are discordant or where the DSM-IVbased diagnosis is unknown, the Work Group believes the present guideline reflects the best, empiricallybased treatment recommendations. This can be illustrated by examining three clinical scenarios: two 

involving discordant diagnoses and one involving subthreshold PTSD. 

Scenario 1: In the case of a patient who has been diagnosed with PTSD based on DSM-IV criteria, retains 

symptoms of PTSD, but who does not meet DSM-5 criteria, the present guideline may be used with 

confidence to make treatment decisions because they were developed based on studies that used the 

same DSM-IV criteria. 

Scenario 2: In the case of a patient who has not been previously diagnosed with PTSD based on DSM-IV 

criteria (or the DSM-IV diagnosis is unknown) but does meet DSM-5 criteria, the clinician must make 

treatment decisions although empirical outcome data using DSM-5 criteria are lacking. In this case, the 

present guideline, based on research using DSM-IV criteria, is assumed to provide the best available 

projection of effective treatments for DSM-5 PTSD. 

Scenario 3: A patient who does not meet DSM-5 criteria for PTSD but does have a number of PTSD 

symptoms accompanied by clinically-significant distress or impairment is often referred to as 

“subthreshold PTSD,” although there is no agreed-upon definition of subthreshold PTSD. As there are no 

randomized controlled trials (RCTs) examining treatments specifically for subthreshold PTSD, we are 

unable to make recommendations regarding evidence-based treatments in this situation. Clinicians are 

encouraged to use their clinical judgment in collaboration with the patient to weigh the potential risks and 

benefits of using or withholding an evidence-based PTSD treatment for someone with subthreshold PTSD. 

If additional guidance is needed to make a decision in such cases, clinicians may elect to repeat the 

diagnostic assessment using the DSM-IV criteria. Though impractical in many situations, the additional 

data provided by confirming, or not confirming, a PTSD diagnosis using the earlier criteria would help to 

ensure that these patients benefit from the wealth of treatment evidence derived using the earlier 

diagnostic criteria. 
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E. Epidemiology and Impact

Estimates of the prevalence of PTSD depend on both sample characteristics and study methods. Sample 

characteristics include the population of study (e.g., general population, Veterans, or Service Members; 

U.S. versus other countries; treatment-seeking versus not treatment-seeking). Study methods include the 

sampling strategy and the method of PTSD assessment and diagnosis. In addition, various risk and 

protective factors modify prevalence estimates such as military factors (e.g., service era, branch of service, 

time since deployment, combat exposure), demographic factors (e.g., age, gender, race/ethnicity), and 

type and amount of trauma exposure. 

a. General Population

The Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) study found a 

lifetime PTSD prevalence of 6.4% overall in a sample of over 34,000 U.S. adults.[6] The sample was 

surveyed in 2004-2005 as a representative sample that reflected the population based on characteristics 

including region, age, gender, and race/ethnicity. Lifetime PTSD prevalence was higher in women (8.6%) 

than men (4.1%). The prevalence of lifetime subthreshold partial PTSD was 6.6%. The estimates in the 

NESARC sample are quite similar to the estimates reported by Kessler et al. in the National Comorbidity 

Survey-Replication (NCS-R).[7] Like the NESARC, the NCS-R is based on a nationally -representative sample, 

although the NCS-R data were collected approximately five years earlier. The overall lifetime prevalence of 

PTSD in the NCS-R was 6.8%, with women higher than men in lifetime prevalence (9.7% compared to 5.2%) 

and in current prevalence (3.6% compared to 1.8%). Note that although the prevalence estimates in Wave 

2 of NESARC and in the NCS-R are based on DSM-IV criteria for PTSD, more recent estimates from Wave 3 

of NESARC based on DSM-5 criteria suggest comparable lifetime (6.1%) and current (4.7%) PTSD 

prevalence estimates.[8] 

b. Active Duty U.S. Service Members

In recent years, a number of reviews have examined PTSD prevalence estimates among U.S. Service 

Members deployed to Iraq and/or Afghanistan.[9-12] Many of the studies in the reviews, however, are 

based on data collected relatively early during the wars and may not reflect the dynamic changes in the 

population, such as the cumulative effects of repeated deployments. Richardson et al. reported estimates 

for current PTSD in U.S. Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) Veterans 

ranging from 4% to 17%.[12] Kok et al. reported a weighted post-deployment PTSD prevalence of 13.2% in 

OEF/OIF infantry units, and 6% in the overall population post-deployment.[10] A study by the RAND 

Corporation in 2008 reported that 14% of a representative sample of 1,965 OEF/OIF Veterans interviewed 

by telephone met current criteria for PTSD.[13] A review by Ramchand et al. noted an increased 

prevalence of PTSD in those serving in the Army and Marine Corps as well as among enlisted personnel 

relative to officers.[14] Combat exposure, however, is the strongest predictor of mental health problems 

among those deployed to Iraq and Afghanistan.[14] One study found higher rates of PTSD among National 

Guard members, [15] though in general, similar prevalences have been found by service, branch, or rank 

adjusted for combat exposure.[14] 

Using a random sample of the OEF/OIF military population, two studies based on the Millennium Cohort 

longitudinal cohort study found that 7.3% to 8.3% of participants who reported combat exposure met 

criteria for PTSD.[16,17] The estimates included Veterans who had separated by the time the data were 
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collected, and therefore are not strictly estimates for active duty personnel. However, the Army Study to 

Assess Risk and Resilience in Service Members (ARMYSTARRS), showed a prevalence of 8.6%, consistent 

with the Millennium cohort data.[18] 

c. Users of Care in the Department of Defense Healthcare System

DoD estimates of incidence and prevalence are derived from administrative medical data of active duty 

personnel who receive PTSD-related care within the DoD direct care system. During fiscal year 2015, 

2.2% of the active duty population was estimated to meet criteria for PTSD. Estimated prevalence was 

higher among female Service Members (3.2%) than male Service Members (2.0%) and among those who 

had deployed (3.6%) as compared to those who had not (0.8%).[19] 

d. U.S. Veterans

A precise estimate of the prevalence of PTSD in the current population of U.S. Veterans overall has yet to 

be established. Among non-treatment-seeking Veteran samples, estimates are only slightly higher than in 

the general population (6.4% to 6.8%).[6,7] In a recent survey of a nationally representative U.S. Veteran 

sample, 8% screened positive for lifetime PTSD on the PTSD Checklist (PCL).[20] Current (past year) PTSD 

prevalence was 5%. Lifetime prevalence was higher among female than male Veterans and among 

younger Veterans than older Veterans. Veterans of all ages reported exposure to many potentially 

traumatic events, including combat, and the conditional risk for developing PTSD was high for non-combatrelated events such as sexual or physical assault. 

For various reasons, including barriers to endorsing mental health issues in the military (e.g., stigma, fear, 

job loss), prevalence estimates among active duty U.S. Service Members may not be representative of 

PTSD prevalence estimates among U.S. Veterans.

e. Veteran Service Era

Magruder and Yeager reviewed studies of PTSD prevalence related to deployment status by war era.[21] 

They reported that prevalence of PTSD among OEF/OIF and Operation New Dawn (OND) deployed 

populations ranged from 5% to 20% and among non-deployed, 3% to 9%. The estimated prevalence of 

PTSD among deployed populations to the Gulf War ranged from 2% to 24% and among the non-deployed 

groups from 0.7% to 6%. Among Vietnam War studies, the estimated prevalence of PTSD among deployed 

populations ranged from 9% to 19%. Among the non-deployed Vietnam era comparison groups, estimates 

were 1% to 13%. Despite the heterogeneous results for PTSD prevalence, they noted a 1.5- to 3.5-fold 

increase in PTSD risk with deployment, regardless of war era. The odds of PTSD for deployed versus nondeployed Veterans were lowest among OEF/OIF/OND and highest for Vietnam Veterans. 

The most recognized study of Vietnam-era Veterans is the National Vietnam Veterans Readjustment Study 

(NVVRS) conducted in 1986-1987.[22] Using DSM-III-R PTSD criteria, a lifetime and current prevalence of 

PTSD estimate of 30.9% and 15.2%, respectively, was reported. Approximately 40 years after the Vietnam 

War, a follow-up study of the cohort, the National Vietnam Veterans Longitudinal Study (NVVLS), reported 

a prevalence of current war-zone-related PTSD as 4.5% in men and 6.1% in women based on the Clinician 

Administered PTSD Scale for DSM-5. Prevalence of lifetime war-zone-related PTSD was 17.0% in men and 

15.2% in women.[23] The prevalence of current PTSD from any cause was estimated as 12.2% for male and 

8.5% for female theatre Veterans.[23] 
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The Health of Vietnam-Era Women’s Study examined the prevalence of PTSD in Vietnam-era women 

Veterans.[24] The prevalence of current PTSD according to DSM-5 was 15.9%, 8.1% and 9.1% for the 

Vietnam, near-Vietnam, and U.S. cohorts who served stateside, respectively. The prevalence of lifetime 

PTSD was 20.1%, 11.5%, and 14.1%, respectively. It is not clear why the estimates of current and lifetime 

PTSD are higher in this study than in the NVVLS, but methodologic differences between studies (e.g., use of 

clinician interview in the NVVLS and lay interview in the all-women’s study) may account for the 

difference. One of the most telling findings was that sexual discrimination or harassment, which is not 

thought of as war zone exposure, was higher among deployed women and significantly associated with the 

development of PTSD. 

New research conducted by Magruder et al. has examined the long-term trajectories of PTSD in Vietnamera Veterans and found that while the majority of Veterans remain unaffected by PTSD throughout their 

lives (79% of those with theater service, 91% with non-theater service), a critical minority (10% of theater

Veterans, 4.5% of non-theater Veterans) in 2012 had current PTSD that was either late onset (6.5% 

theater, 3.3% non-theater) or chronic (4% theater, 1% non-theater).[25] The distribution of longitudinal 

patterns was significantly different by theater service and confirms that PTSD remains a critical issue for 

many Vietnam-era Veterans. 

The prevalence of PTSD among surviving Veterans of World War II or the Korean Conflict is unknown, but 

is likely to be lower compared with the prevalence in younger Veterans. The review cited above of 

prevalence across war eras did not include cohorts prior to the Vietnam War.[21] The nationally 

representative sample cited above [20] also did not report prevalence by war era, but did report that 

lifetime and current prevalence were higher in the youngest Veterans (23.4% and 9.1%, respectively, in 

those age 21-29) compared with the oldest Veterans (age 60+, 3.5% and 2.5%, respectively).[20] 

Regardless of the specific estimate, these data indicate that some Veterans continue to experience PTSD 

into old age.

f. Users of Care in the Veterans Health Administration

The VA’s Northeast Program Evaluation Center produces an annual data sheet that provides an overview 

of the PTSD patient population receiving healthcare in the VA. Veterans are defined as meeting a diagnosis 

of PTSD if they had received at least two visits or one inpatient/residential stay with a diagnosis of PTSD in 

the prior year. Of the 5,841,668 total Veterans served, 10.6% (N=619,493) who used VA healthcare in fiscal 

year 2016 were diagnosed with PTSD: 10.2% of men and 15.5% of women.[26] Prevalence data in 2015 

was much higher among those Veterans who served in Iraq and/or Afghanistan: 26.7% overall, and 27.3% 

and 22.5% in men and women, respectively.[27] 

g. Impact

PTSD can affect all aspects of a person’s functioning and well-being. Pietrzak et al. noted PTSD is associated 

with nearly all assessed Axis 1 disorders and lifetime suicide attempts, with magnitudes of associations 

similar to those observed in the NCS-R.[6,7] There are specific increased risks of co-occurring depression 

and SUD.[20] (See Background on Co-occurring Conditions section.) For example, using DSM-5 criteria in 

the U.S. Veteran population, Wisco et al. found that 57% of individuals with past-month PTSD met criteria 

for current major depression, and among those with probable lifetime PTSD, 69% had a lifetime history of 

alcohol use disorder (AUD). PTSD is also associated with impairments in social and occupational 
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functioning and overall quality of life.[6,28,29] In addition, PTSD is associated with poorer perceived 

physical health, increased morbidity, and greater healthcare utilization for physical problems.[30] Findings 

on mortality are mixed, but generally show that PTSD is associated with increased overall mortality and 

mortality due to accidental causes. 

III. About this Clinical Practice Guideline

This guideline represents an important step toward improving the treatment and management of patients 

with PTSD in the VA and DoD. As with other CPGs, however, challenges remain, including evidence gaps, 

the need to develop effective strategies for guideline implementation and to evaluate the effect of 

guideline adherence on clinical outcomes. This guideline is intended for VA and DoD healthcare 

practitioners including primary care physicians, nurse practitioners, physician assistants, psychiatrists, 

psychologists, social workers, nurses, pharmacists, chaplains, addiction counselors, and others involved in 

the care of Service Members or Veterans with PTSD. 

As elaborated in the qualifying statement on page one, this CPG is not intended to serve as a standard of 

care. Standards of care are determined on the basis of all clinical data available for an individual patient

and are subject to change as scientific knowledge and technology advance and patterns evolve. This CPG is 

based on information available by March 2016 and is intended to provide a general guide to best practices. 

The guideline can assist care providers, but the use of a CPG must always be considered as a 

recommendation, within the context of a provider’s clinical judgment and patient values and preferences,

for the care of an individual patient.

A. Methods

The current document is an update to the 2010 PTSD CPG. The methodology used in developing the 2017 

CPG follows the Guideline for Guidelines,[1] an internal document of the VA and DoD EBPWG. The 

Guideline for Guidelines can be downloaded from http://www.healthquality.va.gov/policy/index.asp. This 

document provides information regarding the process of developing guidelines, including the identification 

and assembly of the Guideline Champions (Champions) and other subject matter experts from within the 

VA and DoD, known as the Work Group, and ultimately, the development and submission of a new or

updated PTSD CPG.

The Champions and Work Group for this CPG were charged with developing evidence-based clinical 

practice recommendations and writing and publishing a guideline document to be used by providers 

within the VA/DoD healthcare systems. Specifically, the Champions and Work Group members for this 

guideline were responsible for identifying the key questions (KQs) of the most clinical relevance, 

importance, and interest for the management of patients with PTSD. The Champions and the Work Group 

also provided direction on inclusion and exclusion criteria for the evidence review and assessed the level 

and quality of the evidence. The amount of new scientific evidence that had accumulated since the 

previous version of the CPG was also taken into consideration in the identification of the KQs. In addition, 

the Champions assisted in:

• Identifying appropriate disciplines of individuals to be included as part of the Work Group

• Directing and coordinating the Work Group
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• Participating throughout the guideline development and review processes

The VA Office of Quality, Safety and Value, in collaboration with the Office of Evidence Based Practice, U.S.

Army Medical Command, the proponent for CPGs for the DoD, identified five clinical leaders, Nancy 

Bernardy, PhD, Matthew Friedman, MD, PhD, and Paula Schnurr, PhD, from the VA as well as Charles 

Hoge, MD and David Riggs, PhD from the DoD, as Champions for the 2017 PTSD CPG. 

The Lewin Team, including The Lewin Group, Duty First Consulting, ECRI Institute, and Sigma Health 

Consulting, LLC, was contracted by the VA and DoD to support the development of this CPG and conduct 

the evidence review. The first conference call was held in November 2015, with participation from the 

contracting officer’s representative (COR), leaders from the VA Office of Quality, Safety and Value and the 

DoD Office of Evidence Based Practice, and the Champions. During this call, participants discussed the 

scope of the guideline initiative, the roles and responsibilities of the Champions, the project timeline, and 

the approach for developing and prioritizing specific research questions on which to base a systematic 

review about the management of PTSD. The group also identified a list of clinical specialties and areas of 

expertise that are important and relevant to the management of PTSD, from which Work Group members 

were recruited. The specialties and clinical areas of interest included: ambulatory care, behavioral health, 

clinical pharmacy, clinical neuropsychology, family medicine, nursing, pharmacology, pharmacy, 

psychiatry, and psychology. 

The guideline development process for the 2017 CPG update consisted of the following steps:

1. Formulating and prioritizing evidence KQs

2. Convening a patient focus group

3. Conducting the systematic review

4. Convening a face-to-face meeting with the CPG Champions and Work Group members

5. Drafting and submitting a final CPG on the management of PTSD to the VA/DoD EBPWG

Appendix A provides a detailed description of each of these tasks.

a. Grading Recommendations

The Champions and Work Group used the Grading of Recommendations Assessment, Development and 

Evaluation (GRADE) system to assess the quality of the evidence base and assign a grade for the strength 

for each recommendation. The GRADE system uses the following four domains to assess the strength of 

each recommendation: [31] 

• Balance of desirable and undesirable outcomes

• Confidence in the quality of the evidence

• Patient or provider values and preferences

• Other implications, as appropriate, e.g.,:

 Resource use

 Equity

 Acceptability
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 Feasibility

 Subgroup considerations

Using this system, the Champions and Work Group determined the relative strength of each 

recommendation (Strong or Weak). A strong recommendation indicates that the Work Group is highly 

confident about the balance between desirable and undesirable outcomes. If the Work Group is less 

confident of the balance between desirable and undesirable outcomes, they give a weak recommendation.

They also determined the direction of each recommendation (For or Against). A recommendation for a 

therapy or preventive measure indicates that the desirable consequences outweigh the undesirable 

consequences. A recommendation against a therapy or preventive measure indicates that the undesirable 

consequences outweigh the desirable consequences. 

Occasionally, instances may occur when the Work Group feels there is insufficient evidence to make a 

recommendation for or against a particular therapy or preventive measure. This can occur when there is 

an absence of studies on a particular topic that met evidence review inclusion criteria, studies included in 

the evidence review report conflicting results, or studies included in the evidence review report

inconclusive results regarding the desirable and undesirable outcomes. 

Using these elements, the grade of each recommendation is presented as part of a continuum:

• Strong for (or “We recommend offering this option ...”)

• Weak for (or “We suggest offering this option ...”)

• No recommendation for or against (or “There is insufficient evidence...”)

• Weak against (or “We suggest not offering this option ...”)

• Strong against (or “We recommend against offering this option ...”)

The grade of each recommendation made in the 2017 CPG can be found in the section on 

Recommendations. Additional information regarding the use of the GRADE system can be found in 

Appendix A. 

b. Reconciling 2010 Clinical Practice Guideline Recommendations

Evidence-based CPGs should be current, which typically requires revisions of previous guidelines based on 

new evidence, or as scheduled, subject to time-based expirations.[32] For example, the U.S. Preventive 

Services Task Force (USPSTF) has a process for refining or otherwise updating its recommendations 

pertaining to preventive services.[33] Further, the inclusion criteria for the National Guideline Clearinghouse 

specify that a guideline must have been developed, reviewed, or revised within the past five years. 

The PTSD Guideline Work Group focused largely on developing new and updated recommendations based 

on the evidence review conducted for the priority areas addressed by the KQs. In addition to those new 

and updated recommendations, the Guideline Work Group considered, with a limited review of the 

previous supporting evidence, the current applicability of other recommendations that were included in 

the previous 2010 PTSD CPG, subject to evolving practice in today’s environment. 
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A set of recommendation categories was adapted from those used by the National Institute for Health and 

Care Excellence (NICE).[34,35] These categories, along with their corresponding definitions, were used to 

account for the various ways in which older recommendations could have been updated. In brief, the 

categories took into account whether or not the evidence that related to a recommendation was 

systematically reviewed, the degree to which the recommendation was modified, and the degree to which 

a recommendation is relevant in the current patient care environment and inside the scope of the CPG. 

Additional information regarding these categories and their definitions can be found in Appendix A. The 

categories for the recommendations included in the 2017 version of the guideline can be found in the 

section on Recommendations. The categories for the recommendations from the 2010 PTSD CPG are 

noted in Appendix E: 2010 Recommendation Categorization Table. 

The CPG Work Group recognized the need to accommodate the transition in evidence rating systems from 

the 2010 PTSD CPG to the current CPG. In order to report the strength of all recommendations using a

consistent format (i.e., the GRADE system) the CPG Work Group converted the USPSTF strengths of the

recommendation accompanying the carryover recommendations from the 2010 guideline to the GRADE

system. As such, the CPG Work Group considered the strength of the evidence cited for each 

recommendation in the 2010 PTSD CPG as well as harms and benefits, values and preferences, and other 

implications, where possible. The CPG Work Group referred to the available evidence as summarized in 

the body of the 2010 PTSD CPG and did not re-assess the evidence systematically. In some instances, peerreviewed literature published since the 2010 PTSD CPG was considered along with the evidence base used 

for that CPG. 

Where such newer literature was considered when converting the strength of the recommendation from 

the USPSTF to the GRADE system, it is referenced in the discussion that follows the corresponding 

recommendation, as well as in Appendix D: Evidence Table. 

The CPG Work Group recognizes that, while there are practical reasons for incorporating findings from a 

previous systematic review, previous recommendations,[36] or recent peer-reviewed publications into an 

updated CPG, doing so does not involve an original, comprehensive systematic review and, therefore, may

introduce bias.

c. Peer Review Process

The CPG was developed through an iterative process in which the Work Group produced multiple drafts of 

the CPG. The process for developing the initial draft is described in more detail in Drafting and Submitting

the Final Clinical Practice Guideline.

Once a near-final draft of the guideline was agreed upon by the Champions and Work Group members,

the draft was sent out for peer review and comment. The draft was posted on a wiki website for a

period of 14 business days. The peer reviewers comprised individuals working within the VA and DoD

health systems as well as experts from relevant outside organizations designated by the Work Group

members. Organizations designated by the Work Group to participate in the peer review and that

provided feedback include the following:

• Emory University School of Medicine

• Duke University Medical Center
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• New York University Langone Medical Center

• Medical University of South Carolina

• University of Adelaide

The VA and DoD Leadership reached out to both the internal and external peer reviewers to solicit their 

feedback on the CPG. Reviewers were provided a hyperlink to the wiki website where the draft CPG was 

posted. All reviewer feedback was posted in tabular form on the wiki site, along with the name of the 

reviewer, for transparency. All feedback from the peer reviewers was discussed and considered by the 

Work Group. Modifications made throughout the CPG development process were made in accordance 

with the evidence. 

B. Summary of Patient Focus Group Methods and Findings

When forming guideline recommendations, consideration should be given to the values of those most 

affected by the recommendations: patients. Patients bring perspectives, values, and preferences into their 

healthcare experience that can vary from those of clinicians. These differences can affect decision making 

in various situations, and should thus be highlighted and made explicit due to their potential to influence a 

recommendation’s implementation.[37,38] Focus groups can be used as an efficient method to explore 

ideas and perspectives of a group of individuals with an a priori set of assumptions or hypotheses and 

collect qualitative data on a thoughtfully predetermined set of questions. 

Therefore, as part of the effort to update this CPG, VA and DoD Leadership, along with the PTSD CPG Work 

Group, held a patient focus group prior to finalizing the KQs for the evidence review. The group met on 

January 25, 2016, at Brooke Army Medical Center, San Antonio Military Medical Center, Fort Sam Houston, 

Texas. The aim of the focus group and interview was to further the understanding of the perspectives of 

patients diagnosed with PTSD within the VA and/or DoD healthcare systems. The focus group explored a 

set of topics related to the management of PTSD, including knowledge of PTSD, treatment options, 

delivery of care, and the impact and challenges of living with PTSD. 

It is important to note the focus group was a convenience sample and the Work Group recognizes the 

limitations inherent in the small sample size. Less than 10 people were included in the focus group 

consistent with the requirements of the federal Paperwork Reduction Act, 1980. The Work Group 

acknowledges that the sample of patients included in this focus group is likely not representative of all VA 

and DoD patients diagnosed with PTSD. Further, time limitations for the focus group prevented exhaustive 

exploration of all topics related to PTSD care in the VA and DoD and the patients’ broader experiences with 

their care. Thus, the Work Group made decisions regarding the priority of topics to discuss at the focus 

group. These limitations, as well as others, were considered during the guideline development as the 

information collected from the discussion was being used. Recruitment for participation in the focus group 

was managed by the Champions and VA and DoD Leadership, with assistance from coordinators at the 

facility at which the focus group took place.

The following concepts are ideas and suggestions about aspects of care that are important to patients and

emerged from the discussion. These concepts were important parts of the participants’ care and added to 

the Work Group’s understanding of patient values and perspectives. The Work Group considered the focus 

group feedback while assessing the strength of each recommendation and continued to consider the 
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feedback throughout the PTSD CPG development process. Additional details regarding the patient focus 

group methods and findings can be found in Appendix B: Patient Focus Group Methods and Findings. 

PTSD CPG Focus Group Concepts

A. Using shared decision making, consider treatment options and develop a treatment plan based on patientspecific goals, values, and preferences.

B. Educate patients about treatment options, including benefits and risks, side effects, and expectations.

C. Involve family members in accordance with patient preferences and maintain open, trusting, and respectful

relationships with patients and their families.

D. Take active steps to improve the perception of and stigma surrounding PTSD.

E. Work with appropriate providers to ensure continuity and accessibility of high-quality care within and

between VA and DoD healthcare systems.

C. Conflicts of Interest

At the start of this guideline development process and at other key points throughout, the project team 

was required to submit disclosure statements to reveal any areas of potential conflict of interest (COI) in 

the past 24 months. Verbal affirmations of no COI were used as necessary during meetings throughout the 

guideline development process. The project team was also subject to random web-based surveillance (e.g., 

ProPublica). 

If a project team member reported a COI (actual or potential), then it was reported to the Office of 

Evidence Based Practice. It was also discussed with the PTSD CPG Work Group in tandem with their review

of the evidence and development of recommendations. The Office of Evidence Based Practice and the

PTSD CPG Work Group determined whether or not action, such as restricting participation and/or voting

on sections related to the conflict or removal from the Work Group, was necessary. If it was deemed

necessary, action to mitigate the COI was taken by the Champions and Office of Evidence Based Practice, 

based on the level and extent of involvement. No conflicts of interest were identified for the PTSD CPG 

Work Group members or Champions. Disclosure forms are on file with the Department of Veterans 

Affairs Evidence Based Practice Program office and available upon request.

D. Scope of this Clinical Practice Guideline

Regardless of setting, any patient in the healthcare system should ideally have access to the interventions 

that are recommended in this guideline after taking into consideration the patient’s specific circumstances. 

Guideline recommendations are intended to be patient-centered. Thus, treatment and care should take 

into account a patient’s needs and preferences. Good communication between healthcare professionals 

and the patient is essential and should be supported by evidence-based information tailored to the 

patient’s needs. Use of an empathetic and non-judgmental approach facilitates discussions sensitive to 

gender, culture, ethnic, and other differences. The information that patients are given about treatment 

and care should be culturally appropriate and available to people with limited literacy skills. It should also 

be accessible to people with additional needs such as physical, sensory, or learning disabilities. Family 

involvement should be considered, if appropriate. 

This CPG is designed to assist providers in managing or co-managing patients with PTSD and related 

conditions (e.g., ASD). Moreover, the patient population of interest for this CPG is adults who are eligible 

for care in the VA and DoD healthcare delivery systems. It includes Veterans as well as deployed and non-
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deployed active duty Service Members, Guard, and Reserve. This CPG does not provide recommendations 

for the management of PTSD in children or adolescents. 

The literature review encompassed interventional studies (primarily RCTs) published between March 2009 

and March 2016, and targeted 12 KQs focusing on the means by which the delivery of healthcare could be 

optimized for patients with PTSD. The selected KQs were prioritized from many possible KQs. Due to 

resource constraints, a review of the evidence in all important aspects of care for patients with PTSD was 

not feasible for the update to this CPG. The methodology used in this systematic evidence review differed 

from the methodology used in some other published systematic reviews. The methodology for this 

systematic evidence review relied primarily on existing systematic reviews, supplemented by original 

articles not represented in those reviews and/or published after the existing review. The process for this 

guideline produced comprehensive summaries of the conclusions reached by existing systematic reviews 

or meta-analyses that covered the topics of the KQs. Work Group members pulled the original articles 

cited within the existing systematic reviews when more information was needed about the results of a 

particular trial. Work Group members sometimes identified additional relevant articles not identified in the 

review process or published after March 2016 to supplement the discussion; however, these instances are 

noted in the text and were not considered when determining the strength and direction of the 

recommendations. Although the conclusions reached were mostly consistent with the previous guideline, 

and with other PTSD CPGs, the Work Group acknowledges the limitations of this methodology.

E. Highlighted Features of this Clinical Practice Guideline

The 2017 edition of the VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress 

Disorder and Acute Stress Disorder (2017 PTSD CPG) is the second update to the original CPG. It provides

practice recommendations for the care of populations with PTSD, ASD, and other reactions to trauma 

(ASR/COSR). A particular strength of this CPG is the multidisciplinary stakeholder involvement from its 

inception, ensuring representation from the broad spectrum of clinicians engaged in the treatment and 

management of patients with PTSD and related disorders. 

The framework for recommendations in this CPG considered factors beyond the strength of the evidence, 

including balancing desired outcomes with potential harms of treatment, equity of resource availability, 

and the potential for variation in patient values and preferences. Applicability of the evidence to VA/DoD 

populations was also taken into consideration. A structured algorithm accompanies the guideline to

provide an overview of the recommendations in the context of the flow of patient care and clinician 

decision making and to assist with training providers. The algorithm may be used to help facilitate 

translation of guideline recommendations into effective practice.

F. Patient-centered Care

VA/DoD CPGs encourage clinicians to use a patient-centered care approach that is individualized based on 

patient capabilities, needs, goals, prior treatment experience, and preferences. Whenever possible, all 

patients in the healthcare system should be offered access to evidence-based interventions appropriate to 

that patient. When properly executed, patient-centered care may decrease patient anxiety, increase trust 

in clinicians, [39] and improve treatment adherence.[40] Improved patient-clinician communication 

through patient-centered care can be used to convey openness to discuss any future concerns. 
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As part of the patient-centered care approach, clinicians should review the outcomes of previous selfchange efforts, past treatment experiences, and outcomes (including reasons for treatment dropout) with 

the patient. They should explain treatment options to patients including the benefits of accepting a 

referral to a mental health specialist. The clinician should discuss any concerns the patient has and explore 

any identified treatment barriers. Lastly, the clinician should involve the patient in prioritizing problems to 

be addressed and in setting specific goals regardless of the selected setting or level of care. 

G. Shared Decision Making

Throughout this VA/DoD CPG, the authors encourage clinicians to focus on shared decision making (SDM).

The SDM model was introduced in Crossing the Quality Chasm, an Institute of Medicine (now called the 

National Academy of Medicine) report, in 2001.[41] It is readily apparent that patients with PTSD, together 

with their clinicians, make decisions regarding which care they choose to engage in. However, patients 

require sufficient information and time to be able to make informed decisions. Clinicians must be adept at 

presenting information to their patients regarding individual treatments, expected outcomes, and levels

and/or locations of care. 

H. Background on Co-occurring Conditions with Posttraumatic Stress 

Disorder

The vast majority of patients with PTSD will have one or more co-occurring mental health disorders. 

Comorbid medical and psychiatric conditions are important to recognize because they can modify clinical 

determinations of prognosis, patient or provider treatment priorities, selection of interventions, and the 

setting where PTSD care will be provided. Suicidality in particular should be assessed early on and carefully 

monitored (see Recommendation 4). However, it should be noted that many of the recommended 

treatments (in particular those in Recommendation 11 and Recommendation 17) in this guideline are 

effective for patients with considerable complexity and comorbidity. 

Because of the many potential etiologies of co-occurring conditions, it is generally best to develop a 

collaborative care treatment strategy to address these health concerns simultaneously with PTSD 

symptoms (See Recommendation 2 regarding collaborative care). Some comorbid medical or psychiatric 

conditions may require early specialist mental health consultation in order to assist in determining 

treatment priorities. To improve management of PTSD symptoms when they are complicated by the 

presence of a medical or psychiatric comorbidity, providers may consider the following:

1. Providers should recognize that medical disorders/symptoms, mental health disorders, and

psychosocial problems commonly coexist with PTSD and should assess for them during the

evaluation and treatment of PTSD.
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2. Because of the high prevalence of psychiatric comorbidities in the PTSD population, screening for 

depression and other psychiatric disorders is warranted (see also the VA/DoD CPGs for the 

Management of Major Depressive Disorder [MDD]1 and the Management of Bipolar Disorder2

).

3. Providers should assess and carefully monitor suicide risk (see the VA/DoD CPG for Assessment 

and Management of Patients at Risk for Suicide3

)

4. Patterns of current and past use of substances by persons with trauma histories or PTSD should be 

routinely assessed to identify substance misuse or dependency (alcohol, nicotine, prescribed 

drugs, and illicit drugs) (see also Recommendation 38 on the management of PTSD in the presence 

of co-occurring SUD and the VA/DoD CPG for SUD4). 

5. Pain (acute and chronic) and sleep disturbances should be assessed in all patients with PTSD. See 

Recommendation 39 regarding management of PTSD in the presence of co-occurring sleep 

disorders.

6. Generalized physical and cognitive health symptoms, also attributed to mild traumatic brain injury 

(mTBI) and many other causes, should be assessed and managed in patients with PTSD and cooccurring diagnoses (see VA/DoD CPG for the Management of Concussion/mTBI5 and VA/DoD CPG 

for the Management of Chronic Multisymptom Illness6 [CMI]).

7. Associated high-risk behaviors (e.g., smoking, alcohol/drug use, unsafe weapon storage, 

dangerous driving, unprotected sex, needle sharing, human immunodeficiency virus [HIV],

hepatitis risks) should be assessed in patients with PTSD and addressed in the treatment plan.

8. Providers should consider the existence of comorbid conditions when deciding whether to treat 

patients in the primary care or general mental health setting, or refer them for specialty mental 

healthcare.

9. Patients with complicated comorbidity may be referred to mental health or PTSD specialty care for 

evaluation and diagnosis.

I. Implementation

This CPG and algorithm are designed to be adapted by individual healthcare providers with consideration 

of local needs and resources. The algorithms serve as a tool to prompt providers to consider key decision 

points in the course of an episode of care.

 1 See the VA/DoD Clinical Practice Guideline for Management of Major Depressive Disorder. Available at: 

http://www.healthquality.va.gov/guidelines/mh/mdd/index.asp 2 See the VA/DoD Clinical Practice Guideline for Management of Bipolar Disorder in Adults. Available at: 

http://www.healthquality.va.gov/guidelines/mh/bd/index.asp 3 See the VA/DoD Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide. Available at: 

http://www.healthquality.va.gov/guidelines/mh/srb/index.asp 4 See the VA/DoD Clinical Practice Guideline for Management of Substance Use Disorder. Available at: 

http://www.healthquality.va.gov/guidelines/mh/sud/index.asp 5 See the VA/DoD Clinical Practice Guideline for Management of Concussion/mild Traumatic Brain Injury. Available at: 

http://www.healthquality.va.gov/guidelines/rehab/mtbi/index.asp 6See the VA/DoD Clinical Practice Guideline for Management of Chronic Multisymptom Illness. Available at: 

https://www.healthquality.va.gov/guidelines/mr/cmi/index.asp
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Although this CPG represents the recommended practice on the date of its publication, medical practice is 

evolving and this evolution requires continuous updating based on published information. New technology 

and more research will improve patient care in the future. The CPG can assist in identifying priority areas 

for research and to informing optimal allocation of resources. Future studies examining the results of CPG

implementation may lead to the development of new evidence particularly relevant to clinical practice. 
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IV. Guideline Work Group

Guideline Work Group*

Department of Veterans Affairs Department of Defense

Nancy C. Bernardy, PhD (Champion) Charles W. Hoge, MD (Champion)

Matthew J. Friedman, MD, PhD (Champion) David S. Riggs, PhD (Champion)

Paula P. Schnurr, PhD (Champion) Megan J. Ehret, PharmD, MS, BCPP

Kathleen M. Chard, PhD Maj Joel T. Foster, PhD

Lori Davis, MD COL Shawn F. Kane, MD, FAAFP, FACSM

Bradford Felker, MD Kate McGraw, PhD

Jessica L. Hamblen, PhD CDR Jeffrey Millegan, MD, MPH, FAPA

Matthew Jeffreys, MD Elaine P. Stuffel, BSN, MHA, RN

Sonya Norman, PhD COL Lisa A. Teegarden, PsyD

Mary Jo Pugh, RN, PhD, FACMPH CDR Meena Vythilingam, MD

Sheila A.M. Rauch, PhD, ABPP COL Wendi M. Waits, MD

Todd P. Semla, MS, PharmD, BCPS, FCCP, AGSF Jonathan Wolf, MD

Office of Quality, Safety and Value

Veterans Health Administration

Office of Evidence Based Practice

U.S. Army Medical Command

Eric Rodgers, PhD, FNP, BC

James Sall, PhD, FNP-BC

Rene Sutton, BS, HCA

Corinne K. B. Devlin, MSN, RN, FNP-BC

Elaine P. Stuffel, BSN, MHA, RN

Lewin Group ECRI Institute

Clifford Goodman, PhD

Christine Jones, MS, MPH, PMP

Erin Gardner, BS

Anjali Jain, MD

James Reston, MPH, PhD

Amy Tsou, MD, MSc

Rebecca Rishar, MLIS

Jeff Oristaglio, PhD

Savvas Pavlides, PhD

Sigma Health Consulting, LLC DutyFirst Consulting

Frances Murphy, MD, MPH Anita Ramanathan, BA

Megan McGovern, BA

*Additional contributor contact information is available in Appendix F: Participant List.
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V. Algorithm

This CPG includes an algorithm that is designed to facilitate understanding of the clinical pathway and 

decision making process used in management of PTSD. The use of the algorithm format as a way to 

represent patient management was chosen based on the understanding that such a format may promote 

more efficient diagnostic and therapeutic decision making and has the potential to change patterns of 

resource use. Recognizing that some clinical care processes are non-linear, the algorithm format attempts 

to help the provider to follow a more simplified approach whenever possible in assessing the critical 

information needed at the major decision points in the clinical process, and includes:

• An ordered sequence of steps of care

• Recommended observations and examinations

• Decisions to be considered

• Actions to be taken

A clinical algorithm diagrams a guideline into a step-by-step decision tree. Standardized symbols are used 

to display each step in the algorithm, and arrows connect the numbered boxes indicating the order in 

which the steps should be followed.[42] 
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Module A: Acute Stress Reaction/Disorder 
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Module B: Assessment and Diagnosis of Posttraumatic Stress Disorder
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Module C: Management of Posttraumatic Stress Disorder
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VI. Recommendations

# Recommendation Strength* Category†

A. General Clinical Management

1 We recommend engaging patients in shared decision making (SDM), 

which includes educating patients about effective treatment options.

Strong For Not Reviewed, 

Amended

2 For patients with posttraumatic stress disorder (PTSD) who are treated 

in primary care, we suggest collaborative care interventions that 

facilitate active engagement in evidence-based treatments.

Weak For Reviewed, 

New-replaced

B. Diagnosis and Assessment of PTSD

3 We suggest periodic screening for PTSD using validated measures such 

as the Primary Care PTSD Screen (PC-PTSD) or the PTSD Checklist (PCL).

Weak For Not Reviewed, 

Amended

4 For patients with suspected PTSD, we recommend an appropriate 

diagnostic evaluation that includes determination of DSM criteria, acute 

risk of harm to self or others, functional status, medical history, past 

treatment history, and relevant family history. A structured diagnostic 

interview may be considered.

Strong For Not Reviewed, 

Amended

5 For patients with a diagnosis of PTSD, we suggest using a quantitative 

self-report measure of PTSD severity, such as the PTSD Checklist for 

DSM-5 (PCL-5), in the initial treatment planning and to monitor 

treatment progress.

Weak For Not Reviewed, 

Amended

C. Prevention of PTSD

a. Selective Prevention of PTSD

6 For the selective prevention of PTSD, there is insufficient evidence to 

recommend the use of trauma-focused psychotherapy or 

pharmacotherapy in the immediate post-trauma period.

N/A Reviewed,

New-replaced

b. Indicated Prevention of PTSD and Treatment of ASD

7 For the indicated prevention of PTSD in patients with acute stress 

disorder (ASD), we recommend an individual trauma-focused 

psychotherapy that includes a primary component of exposure and/or 

cognitive restructuring.

Strong For Reviewed, 

New-replaced

8 For the indicated prevention of PTSD in patients with ASD, there is 

insufficient evidence to recommend the use of pharmacotherapy.

N/A Reviewed, 

New-replaced

D. Treatment of PTSD

a. Treatment Selection

9 We recommend individual, manualized trauma-focused psychotherapy 

(see Recommendation 11) over other pharmacologic and nonpharmacologic interventions for the primary treatment of PTSD.

Strong For Reviewed, 

New-added

10 When individual trauma-focused psychotherapy is not readily available 

or not preferred, we recommend pharmacotherapy (see 

Recommendation 17) or individual non-trauma-focused psychotherapy 

(see Recommendation 12). With respect to pharmacotherapy and nontrauma-focused psychotherapy, there is insufficient evidence to 

recommend one over the other.

Strong For Reviewed, 

New-added
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# Recommendation Strength* Category†

b. Psychotherapy

11 For patients with PTSD, we recommend individual, manualized traumafocused psychotherapies that have a primary component of exposure 

and/or cognitive restructuring to include Prolonged Exposure (PE), 

Cognitive Processing Therapy (CPT), Eye Movement Desensitization and 

Reprocessing (EMDR), specific cognitive behavioral therapies for PTSD, 

Brief Eclectic Psychotherapy (BEP), Narrative Exposure Therapy (NET), 

and written narrative exposure.

Strong For Reviewed, 

New-replaced

12 We suggest the following individual, manualized non-trauma-focused 

therapies for patients diagnosed with PTSD: Stress Inoculation Training 

(SIT), Present-Centered Therapy (PCT), and Interpersonal Psychotherapy 

(IPT). 

Weak For Reviewed, 

New-replaced

13 There is insufficient evidence to recommend for or against 

psychotherapies that are not specified in other recommendations, such 

as Dialectical Behavior Therapy (DBT), Skills Training in Affect and 

Interpersonal Regulation (STAIR), Acceptance and Commitment 

Therapy (ACT), Seeking Safety, and supportive counseling.

N/A Reviewed, 

New-replaced

14 There is insufficient evidence to recommend using individual 

components of manualized psychotherapy protocols over or in addition 

to the full therapy protocol. 

N/A Reviewed, 

New-added

15 We suggest manualized group therapy over no treatment. There is 

insufficient evidence to recommend using one type of group therapy 

over any other.

Weak For Reviewed, 

New-replaced

16 There is insufficient evidence to recommend for or against traumafocused or non-trauma-focused couples therapy for the primary 

treatment of PTSD.

N/A Reviewed, 

Amended

c. Pharmacotherapy

17 We recommend sertraline, paroxetine, fluoxetine, or venlafaxine as 

monotherapy for PTSD for patients diagnosed with PTSD who choose not 

to engage in or are unable to access trauma-focused psychotherapy.

Strong For Reviewed, 

New-replaced

18 We suggest nefazodone, imipramine, or phenelzine as monotherapy for 

the treatment of PTSD if recommended pharmacotherapy (see 

Recommendation 17), trauma-focused psychotherapy (see 

Recommendation 11), or non-trauma-focused psychotherapy (see 

Recommendation 12) are ineffective, unavailable, or not in accordance 

with patient preference and tolerance. (NOTE: Nefazodone and 

phenelzine have potentially serious toxicities and should be managed 

carefully.)

Weak For Reviewed, 

New-replaced

19 We suggest against treatment of PTSD with quetiapine, olanzapine, and 

other atypical antipsychotics (except for risperidone, which is a Strong 

Against, see Recommendation 20), citalopram, amitriptyline, 

lamotrigine, or topiramate as monotherapy due to the lack of strong 

evidence for their efficacy and/or known adverse effect profiles and 

associated risks.

Weak Against Reviewed, 

New-replaced

20 We recommend against treating PTSD with divalproex, tiagabine, 

guanfacine, risperidone, benzodiazepines, ketamine, hydrocortisone, or 

D-cycloserine, as monotherapy due to the lack of strong evidence for

their efficacy and/or known adverse effect profiles and associated risks.

Strong Against Reviewed, 

New-replaced

21 We recommend against treating PTSD with cannabis or cannabis 

derivatives due to the lack of evidence for their efficacy, known adverse 

effects, and associated risks. 

Strong Against Reviewed, 

New-added
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# Recommendation Strength* Category†

22 There is insufficient evidence to recommend for or against 

monotherapy or augmentation therapy for the treatment of PTSD with 

eszopiclone, escitalopram, bupropion, desipramine, doxepin, D-serine, 

duloxetine, desvenlafaxine, fluvoxamine, levomilnacipran, mirtazapine, 

nortriptyline, trazodone, vilazodone, vortioxetine, buspirone, 

hydroxyzine, cyproheptadine, zaleplon, and zolpidem.

N/A Reviewed, 

New-replaced

d. Augmentation Therapy

23 We suggest against the use of topiramate, baclofen, or pregabalin as 

augmentation treatment of PTSD due to insufficient data and/or known 

adverse effect profiles and associated risks.

Weak Against Reviewed, 

New-replaced

24 We suggest against combining exposure therapy with D-cycloserine in 

the treatment of PTSD outside of the research setting.

Weak Against Reviewed, 

New-added

25 We recommend against using atypical antipsychotics, benzodiazepines, 

and divalproex as augmentation therapy for the treatment of PTSD due 

to low quality evidence or the absence of studies and their association 

with known adverse effects.

Strong Against Reviewed, 

New-replaced

26 There is insufficient evidence to recommend the combination of 

exposure therapy with hydrocortisone outside of the research setting.

N/A Reviewed, 

New-added

27 There is insufficient evidence to recommend for or against the use of 

mirtazapine in combination with sertraline for the treatment of PTSD.

N/A Reviewed, 

New-replaced

e. Prazosin

28a For global symptoms of PTSD, we suggest against the use of prazosin as 

mono- or augmentation therapy. 

Weak Against Reviewed, 

New-replaced

28b For nightmares associated with PTSD, there is insufficient evidence to 

recommend for or against the use of prazosin as mono- or 

augmentation therapy.

N/A Reviewed, 

New-replaced

f. Combination Therapy

29 In partial- or non-responders to psychotherapy, there is insufficient 

evidence to recommend for or against augmentation with 

pharmacotherapy. 

N/A Reviewed, 

New-replaced

30 In partial- or non-responders to pharmacotherapy, there is insufficient 

evidence to recommend for or against augmentation with 

psychotherapy. 

N/A Reviewed, 

New-replaced

31 There is insufficient evidence to recommend for or against starting 

patients with PTSD on combination pharmacotherapy and 

psychotherapy. 

N/A Reviewed, 

New-added

g. Non-pharmacologic Biological Treatments

32 There is insufficient evidence to recommend for or against the following 

somatic therapies: repetitive transcranial magnetic stimulation (rTMS), 

electroconvulsive therapy (ECT), hyperbaric oxygen therapy (HBOT), 

stellate ganglion block (SGB), or vagal nerve stimulation (VNS).

N/A Reviewed, 

New-replaced

h. Complementary and Integrative Treatments

33 There is insufficient evidence to recommend acupuncture as a primary 

treatment for PTSD.

N/A Reviewed, 

New-replaced

34 There is insufficient evidence to recommend any complementary and 

integrative health (CIH) practice, such as meditation (including 

mindfulness), yoga, and mantram meditation, as a primary treatment for 

PTSD.

N/A Reviewed, 

New-replaced
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# Recommendation Strength* Category†

i. Technology-based Treatment Modalities

35 We suggest internet-based cognitive behavioral therapy (iCBT) with 

feedback provided by a qualified facilitator as an alternative to no 

treatment.

Weak For Reviewed, 

New-replaced

36 We recommend using trauma-focused psychotherapies that have 

demonstrated efficacy using secure video teleconferencing (VTC) 

modality when PTSD treatment is delivered via VTC.

Strong For Reviewed, 

Amended

E. Treatment of PTSD with Co-occurring Conditions

37 We recommend that the presence of co-occurring disorder(s) not 

prevent patients from receiving other VA/DoD guideline-recommended 

treatments for PTSD.

Strong For Reviewed, 

New-added

38 We recommend VA/DoD guideline-recommended treatments for PTSD 

in the presence of co-occurring substance use disorder (SUD).

Strong For Reviewed, 

New-replaced

39 We recommend an independent assessment of co-occurring sleep 

disturbances in patients with PTSD, particularly when sleep problems 

pre-date PTSD onset or remain following successful completion of a 

course of treatment.

Strong For Reviewed, 

New-replaced

40 We recommend Cognitive Behavioral Therapy for Insomnia (CBT-I) for 

insomnia in patients with PTSD unless an underlying medical or 

environmental etiology is identified or severe sleep deprivation 

warrants the immediate use of medication to prevent harm.

Strong For Reviewed, 

Amended

*For additional information, please refer to Grading Recommendations.

†For additional information, please refer to Recommendation Categorization and Appendix E: 2010 Recommendation

Categorization Table.
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A. General Clinical Management

Recommendation

1. We recommend engaging patients in shared decision making (SDM), which includes educating 

patients about effective treatment options.

(Strong For | Not Reviewed, Amended)

Discussion

This 2010 PTSD CPG recommendation was not formally addressed in the systematic evidence review for 

this CPG update. This recommendation has been amended and combines related recommendations from 

the 2010 guideline. SDM has the goal of considering patient preference in treatment decisions to improve 

patient-centered care, decision quality, and treatment outcomes. It often involves educating the patient 

(and family members, as appropriate) on trauma, PTSD and its consequences, and treatment. In SDM, the 

patient and provider together review treatment options and compare the benefits, harms, and risks of 

each with the goal of selecting the option that best meets the patient’s needs.

A systematic review found that the use of SDM with medical patients was associated with improved 

communication, decision satisfaction, and recognition and management of the patient’s problem.[43]

However, the research on SDM for PTSD is minimal. There is one small pilot study that randomized 27 

Veterans with PTSD to a SDM intervention or usual care.[44] Those who participated in the SDM

intervention were more likely to prefer an evidence-based treatment and more likely to receive an 

adequate dose of treatment. 

Much of the SDM research has focused on evaluating decision aids. Decision aids are tools that educate 

patients about treatment options as a way to facilitate SDM for health decisions. A systematic review of 

115 RCTs that compared decision aids to usual care found that participants who received decision aids 

were more likely to select a treatment consistent with their values and were less worried about whether 

they had made the correct decision.[45] There is only one RCT examining a decision aid for PTSD 

treatment.[46] Consistent with the larger literature about decision aids, the 132 Veterans who received 

the decision aid (versus usual care) had higher PTSD knowledge and lower conflict about their treatment 

decision. They were also more likely to select an evidence-based treatment and had better clinical 

outcomes.

The Work Group based its strong recommendation on the substantial literature supporting SDM in other 

conditions. The process of SDM maximizes the likelihood that patient preference is taken into account and 

the benefits outweigh any potential harms. Research should focus on learning more about SDM in the 

context of making PTSD treatment decisions.

Recommendation

2. For patients with posttraumatic stress disorder (PTSD) who are treated in primary care, we suggest 

collaborative care interventions that facilitate active engagement in evidence-based treatments.

(Weak For | Reviewed, New-replaced)
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Discussion

The collaborative care model is an evidence-based approach to integrating physical and behavioral health 

services that is most usually provided within the primary care setting.[47] Collaborative care typically

includes: (1) care coordination and care management, (2) regular/proactive monitoring and treatment to 

achieve outcomes measured using validated clinical rating scales, and (3) regular consultation or referral to 

appropriate specialists for patients who do not show clinical improvement. Many collaborative care 

models generally involve a stepped-care approach to symptom management, using a predetermined 

treatment sequence that starts with simple, low-intensity interventions first. Subsequent treatment steps 

involving increased complexity and intensity are attempted only after initial treatment is unsuccessful. 

Care coordination is an integral component of most collaborative care models. Some models also offer

telehealth or additional care delivery modalities. Studies of collaborative care reviewed by the Work Group 

showed variations related to how interventions were delivered, how components of care were structured, 

and which components of care were delivered. The use of collaborative care interventions that employ or 

facilitate active engagement in evidence-based PTSD treatments in the primary care setting appears to 

increase patient follow-through with treatment, improve patient satisfaction, and potentially reduce

premature termination from treatment when delivered in the primary care setting.[48-54] Due to study 

design differences related to the types of collaborative care programs examined, it is difficult to conduct 

meaningful comparisons across studies; thus, there is a limited body of evidence regarding the 

effectiveness of specific types of collaborative care interventions for PTSD.[48-53]

The six RCTs reviewed included several types of collaborative care interventions conducted in differing 

settings (PTSD care management, coordinated anxiety learning and management, technology-enhanced 

stepped collaborative care, stepped collaborative care, and telemedicine outreach for PTSD). No single 

consistent protocol was used across the six studies. Half of the studies were conducted among military 

personnel or Veterans; the rest were conducted with non-military or non-Veteran populations. One

recently completed study not included in the systematic evidence review for this CPG (due to the search 

date cutoff) is the first published RCT with a military population in a military treatment setting that 

compared this collaborative care model with the usual collaborative care model.[55] The study found that 

a centrally-assisted collaborative telecare with stepped psychosocial management model appeared to 

modestly improve outcomes of PTSD and depression treatment among military personnel attending 

primary care.[55]

Confidence in the quality of evidence for this recommendation was very low to moderate. Among the RCTs 

reviewed, statistically significant findings included increased patient satisfaction using technologyenhanced stepped collaborative care compared to usual care,[49,50] reduction in PTSD symptoms and 

PTSD remission across all models of collaborative care studied,[48] and improvements in PTSD and 

depression when telehealth was used to deliver Cognitive Processing Therapy (CPT) in collaborative 

care.[50] Care management alone did not appear to be effective for PTSD, whereas the stepped care 

aspects of the models evaluated did appear to improve outcomes.[48,49,55]

There were no adverse events reported related to this model of care delivery. Given the apparent 

increased patient follow-through with PTSD treatment and improvement in patient satisfaction correlated 

with the use of the collaborative care model studies reviewed, the potential benefits outweigh risk of 

harm. We also considered the potential increased demands on resources required to deliver collaborative 
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care for PTSD treatment in the primary care setting, which included possible increased staffing to support 

the model, and potential for this model to reduce clinical productivity, if measured by number of provider 

treatment encounters alone. More research is needed on the effect of collaborative care on long-term 

utilization of various healthcare services, on the key components of collaborative care that impact PTSD 

treatment effectiveness, and on the role of technology-assisted interventions in improving the 

effectiveness of collaborative care interventions to treat PTSD.

B. Diagnosis and Assessment of Posttraumatic Stress Disorder

Recommendation

3. We suggest periodic screening for PTSD using validated measures such as the Primary Care PTSD 

Screen (PC-PTSD) or the PTSD Checklist (PCL).

(Weak For | Not Reviewed, Amended)

Discussion

Identification of individuals with PTSD is essential to ensure that they receive appropriate treatment and 

screening is often considered a key step in the diagnostic process. The Work Group did not review 

literature on the benefits of screening for PTSD specifically, and in fact, a recent review of screening 

measures for PTSD that was performed for the VA Evidence-based Synthesis Program noted that no such 

studies exist.[56] Therefore, this recommendation is based in part on evidence supporting the use of 

screening for mental health problems, particularly depression in primary care settings. For example, a 

review of the benefits of depression screening that was conducted by the USPSTF found that screening 

was associated with improvements of 17% to 87% in response and/or remission.[57]

The recommendation is also based on the availability of psychometrically-sound screening measures as 

well as consideration of the relative risks and potential benefits of screening.[58,59] In the VA Evidencebased Synthesis Program review of PTSD screening measures, Spoont et al. mention that inaccurately 

diagnosing PTSD in a patient who does not have PTSD could result in unintended harms to the patient 

from being labeled with a mental disorder and from side effects of treatment.[56] There are also harms to 

the healthcare system from the inefficient use of resources. Spoont et al. reported that the positive 

predictive value—that is, the probability that a person who screens positive has PTSD—was 54% for the 

PC-PTSD (at the recommended cutpoint of 3) and 58% for the PCL (at the recommended cutpoint of 

45).[56] Unfortunately, this means that over 40% of screen positive tests were false positives in the 

validation studies examined. Additionally, positive predictive value is largely a function of prevalence and is 

therefore considerably lower in general population and primary care samples compared with samples 

typically used in validation studies.[60] Spoont et al. also noted that there is potential harm in not

screening, which could prevent individuals with PTSD from being detected and receiving the care they 

need.[56] The risks of screening for PTSD can be minimized and potential benefits maximized by using 

reliable and valid screening measures and by conducting more careful diagnostic evaluation before 

initiating treatment after a positive screen (see Recommendation 4).

Screening for PTSD can be performed in primary and specialty care settings, and both VA and DoD 

mandate screening either in context with combat deployments or in primary care settings. Primary care is 

considered to be an important context for screening because many people with PTSD and other mental 
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disorders first present in primary care and not in specialty mental healthcare settings.[51] This may be 

especially true for patients with concerns about stigma.

One-time screening is not recommended because PTSD is a disorder with a fluctuating course for many 

people. Onset may be delayed, and symptoms may reoccur even after a long period of remission. An 

individual who is symptom-free at one point may be symptomatic at another. There is no evidence to 

suggest how frequently screening should occur. VA recommends annual screening for the first five years 

following separation and then every five years thereafter. DoD recommends routine screening throughout 

deployment cycles.

A variety of measures are available for PTSD screening.[56] Both VA and DoD have relied most heavily on 

the PC-PTSD and PCL for various screening purposes. The PC-PTSD, a four-item questionnaire that is 

generally scored positive if at least three of the four items are endorsed, performs well against both DSMIV and DSM-5 PTSD diagnoses. The PC-PTSD has been revised to include five items in order to reflect 

changes to the PTSD diagnostic criteria in DSM-5.[59] Initial validation of the revised scale, the PC-PTSD-5, 

suggests that a score of three optimizes sensitivity, four optimizes efficiency, and five optimizes specificity. 

At the time of this guideline, VA and DoD are continuing to use the four-item PC-PTSD, which is reasonable 

because the PC-PTSD performs well as a screen for PTSD diagnosed according to DSM-5.[59] Research is 

underway to confirm the optimal cutpoint. The longer 17-item DSM-IV PCL or 20-item DSM-5 PTSD 

Checklist (PCL-5) also can be used for screening.[58] Data on the DSM-IV version indicated that using 

different cutpoints optimized screening depending on prevalence, other sample characteristics, and 

setting.[56,60] Such information is not yet available for the PCL-5, although it is assumed that it will also 

show comparable variation like the previous screen.[60] For the PCL-5, an overall cutpoint of 33 is 

recommended for screening in clinical settings based on two studies conducted with Veterans and Service 

Members whose diagnosis was established by a structured clinical interview.[58] An overall cutpoint of 33 

was found to correlate well with DSM-IV and DSM-5 criteria in an epidemiological study of soldiers based 

on a comparison of PCL and PCL-5 scores, and 38 was determined to be optimally comparable to a higher 

specificity score of 50 on the original PCL widely used as a cutoff in population prevalence studies.[10,61]

No screening measure or cutpoint should be the sole basis for diagnosis (see Recommendation 4).

Recommendation

4. For patients with suspected PTSD, we recommend an appropriate diagnostic evaluation that 

includes determination of DSM criteria, acute risk of harm to self or others, functional status, 

medical history, past treatment history, and relevant family history. A structured diagnostic 

interview may be considered.

(Strong For | Not Reviewed, Amended)

Discussion

PTSD is associated with a range of comorbid psychological conditions, poorer physical health, increased 

treatment utilization, impaired functioning, and reduced quality of life.[29,62,63] (See section on 

Background on Co-occurring Conditions.) Therefore, a comprehensive diagnostic evaluation should include 

all of these factors. Reardon and colleagues provide an excellent overview of the assessment of PTSD and 

its comorbidities in adults.[64]
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The diagnostic criteria for PTSD are listed in Table 2. Further details are available in the DSM-5 manual [2]

and additional guidance about the diagnosis is available in other sources.[65,66]

Diagnosis can be made on the basis of a clinical interview or a structured diagnostic interview such as the 

Clinician-Administered PTSD Scale (CAPS),[67] Posttraumatic Stress Disorder Symptom Scale Interview for 

DSM-5 (PSSI-I),[68] or Structured Clinical Interview for DSM-5 (SCID-5).[69] Structured diagnostic 

interviews can help to enhance the accuracy and completeness of diagnosis. However, the time required 

for structured interviewing may not be available in primary care and routine specialty mental healthcare 

settings. If diagnosis is based on clinical interview in any setting, it can be helpful to administer a selfreport questionnaire such as the PCL-5 along with other routine self-report screening tools, such as the 

Patient Health Questionnaire-9 (PHQ-9) and Alcohol Use Disorders Identification Test-Consumption

(AUDIT-C).[70-72]

Recommendation

5. For patients with a diagnosis of PTSD, we suggest using a quantitative self-report measure of PTSD 

severity, such as the PTSD Checklist for DSM-5 (PCL-5), in the initial treatment planning and to 

monitor treatment progress.

(Weak For | Not Reviewed, Amended)

Discussion

In addition to their utility in screening and diagnosis, brief questionnaires such as the PCL-5 can be used to 

assess symptom severity. The PCL-5 consists of 20 items that reflect the symptoms of the PTSD diagnostic 

criteria. Symptoms are rated on a 5-point scale, ranging from 0=not at all to 4=extremely. The scale takes 

5-10 minutes to complete. The PCL-5 is part of a core set of measures recommended by the Interagency 

Task Force Work Group on Common Mental Health Measures across VA and DoD.[73] The PCL-5 is also the 

measure used for PTSD assessment in VA’s Measurement Based Care Initiative, which is promoting the use 

of measurement-based care in mental health.

There are other well-validated measures that can be used to assess severity of PTSD symptoms. The 

Posttraumatic Diagnostic Scale (PDS) assesses the same DSM-5 criteria and function. For those patients 

who have previously been assessed using the PCL for DSM-IV, continued use of that measure may be 

warranted.

A recent systematic review of RCTs of measurement-based care in mental health found that giving 

providers frequent and timely information about patients’ symptom severity during medication and 

psychotherapy treatment was associated with better patient outcomes.[74] Information about symptom 

severity was not associated with better outcomes if the information was provided in screening only or 

infrequently. Because the time frame captured by these scales is within the past month, providers may 

consider monthly administration as a sufficiently frequent timeframe during an episode of care. However, 

for some treatments (e.g., Prolonged Exposure [PE], CPT), the time frame has been modified to weekly to 

allow for more frequent administrations.

C. Prevention of Posttraumatic Stress Disorder

The Work Group approached prevention of PTSD from the perspective of the Institute of Medicine’s (now 

the National Academy of Medicine) definition of prevention which represents an evolution in thinking 
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beyond primary, secondary, and tertiary prevention.[75] Universal prevention strategies target the general 

population and are not directed at a specific at-risk group. There are currently no recommended strategies 

for universal prevention of PTSD. Selective prevention targets individuals who are at higher than average 

risk for developing PTSD and includes strategies delivered to trauma-exposed individuals who have not yet 

developed symptoms or meet criteria for ASD or PTSD. Indicated prevention includes strategies to prevent 

PTSD in individuals with symptoms of ASD or meet criteria for ASD. Because no key questions were 

included regarding universal prevention of PTSD, we address issues related to selective and indicated 

prevention. 

a. Selective Prevention of Posttraumatic Stress Disorder

Recommendation

6. For the selective prevention of PTSD, there is insufficient evidence to recommend the use of 

trauma-focused psychotherapy or pharmacotherapy in the immediate post-trauma period.

(N/A | Reviewed, New-replaced)

Discussion

Studies examining use of individual trauma-focused psychotherapy in the immediate post-trauma period 

for the selective prevention of PTSD are rare. The seminal single-site study by Rothbaum et al. enrolled 

individuals who presented to an emergency department within 72 hours of a Criterion A trauma and 

randomized them to three one-hour sessions of a modified PE intervention (imaginal exposure to the 

trauma, processing the traumatic material, and in vivo and imaginal exposure homework) spaced one 

week apart or a waitlist group that received assessments, but no treatment.[76] Compared to waitlist 

controls, brief trauma-focused cognitive behavioral therapy (CBT) significantly reduced the severity of PTSD 

symptoms as measured by the PTSD Symptom Scale-Interview Version at four and 12 weeks follow-up.

However, there were no significant differences between treatment and waitlist group in the likelihood of 

developing PTSD at four weeks. The Work Group rated its overall confidence in the existing literature on 

individual trauma-focused psychotherapy in the immediate post-trauma period for prevention of PTSD as 

low based on one single site study with moderate to high risk of bias due to high dropout (>30%) at week 

12 follow-up. While the findings of the Rothbaum et al. study are promising, the Work Group felt there 

was not sufficient evidence to recommend use of individual trauma-focused psychotherapy in the 

immediate post-trauma period to prevent PTSD. 

A systematic review of individual psychological debriefing studies included two blinded RCTs using the 

Critical Incident Stress Debriefing (CISD) strategy in civilian trauma samples.[77] CISD administered 

immediately after trauma exposure did not reduce incidence of PTSD at six-month follow-up compared to 

groups that received no debriefing. In fact, individuals with CISD administered immediately following 

trauma exposure had increased incidence and severity of PTSD at 13-month follow-up.[77]

One study included in the systematic review examined the impact of Battlemind debriefing compared to 

the standard brief on PTSD symptoms in United Kingdom armed forces.[78] Findings from this clusterrandomized trial revealed no significant impact on PTSD symptoms as measured by self-report. This finding 

was consistent with prior studies of Battlemind debriefing in U.S. soldiers that found no effect on PTSD 

compared to a Stress Education control condition except in individuals with high combat exposure.[77]
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A number of studies have examined pharmacologic interventions for the selective prevention of PTSD.[79]

Medication classes that have been evaluated include beta-blockers, benzodiazepines, selective serotonin 

reuptake inhibitors (SSRIs), antiepileptic drugs, and glucocorticoids.

Three RCTs compared the early administration of propranolol to placebo in individuals with trauma 

exposure who were treated in an emergency department.[80-82] Findings indicated no difference in the 

likelihood of developing PTSD between those who received propranolol and controls.[80-83]

A single RCT compared the early administration of temazepam (within three weeks of trauma) [84] and 

gabapentin [82] (within 48 hours of trauma) to placebo in individuals with trauma exposure and similarly 

found no benefit from these medications in the prevention of PTSD. 

Four RCTs compared hydrocortisone to placebo for the prevention of PTSD in a variety of acute inpatient 

medical settings such as intensive care unit, cardiac surgery, emergency room, and trauma center.

Compared to placebo, hydrocortisone administration during life-threatening medical illnesses was 

associated with significantly less PTSD and depression symptoms at three months.[85-88] However, it is 

unclear if these findings can be generalized to non-medical traumatic events. In addition, variable dosing 

regimens across studies and concerns about the safety of high-dose glucocorticoid administration limit the 

utility of hydrocortisone in the selective prevention of PTSD.

The Work Group rated its overall confidence in the existing literature on pharmacotherapy treatment for 

selective prevention of PTSD as low. Fewer than 10 RCTs evaluated five different medication types and 

there was wide variation in the administration and dosage of medications and type of trauma included.

Evidence was insufficient to recommend any pharmacologic intervention in the immediate post-trauma 

period to prevent the development of chronic PTSD.[77,89]

b. Indicated Prevention of Posttraumatic Stress Disorder and Treatment of Acute 

Stress Disorder 

Recommendation

7. For the indicated prevention of PTSD in patients with acute stress disorder (ASD), we recommend 

an individual trauma-focused psychotherapy that includes a primary component of exposure 

and/or cognitive restructuring.

(Strong For | Reviewed, New-replaced)

8. For the indicated prevention of PTSD in patients with ASD, there is insufficient evidence to 

recommend the use of pharmacotherapy.

(N/A | Reviewed, New-replaced)

Discussion

Two systematic reviews confirmed that compared to supportive counseling or waitlist, individuals with ASD 

who received brief individual trauma-focused psychotherapy had significantly reduced PTSD symptom 

severity at follow-up (three to six months).[77,89] However, most studies in the two systematic reviews had 

small sample sizes and methodologic concerns. Three particularly strong studies from an Australian team 

headed by Bryant directly compared brief five to six weeks of trauma-focused CBT to supportive counseling 

in a combined total of 105 civilian survivors of mixed trauma with ASD.[77] Participants with trauma from 
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motor vehicle or industrial accidents and who met criteria for ASD were randomized to brief trauma-focused 

CBT (including education about trauma reactions, progressive muscle relaxation training, imaginal exposure 

to traumatic memories, cognitive restructuring of fear-related beliefs, and graded in-vivo exposure to 

avoided situations) or supportive counseling. Brief trauma-focused CBT significantly reduced clinician-rated 

PTSD severity post-treatment, and the incidence of PTSD at six months. Meta-analysis of 10 published RCTs 

of trauma-focused CBT interventions found a moderate effect size (effect size [ES]=0.54) for preventing PTSD 

diagnosis at three to six months follow-up, small-to-moderate effects with respect to clinician-rated PTSD 

symptom severity at three to six month follow-up (ES=0.45), and small effects at long-term follow-up (>12

months; ES=0.34).[89] The meta-analysis found that dropout rates were similar in both groups, with about 

20% not completing treatment.

The Work Group rated its overall confidence in the existing literature on brief trauma-focused CBT for 

selective prevention of PTSD as moderate. More than 15 RCTs evaluating a variety of trauma-focused CBT

interventions met the threshold for review. Most of these studies were deemed to be of fair to good quality. 

Considering the existing data, the Work Group determined that the benefits far outweigh potential harms.

Two studies examined the efficacy of escitalopram versus placebo for indicated prevention in PTSD.[90,91] A 

study by Suliman et al. randomized individuals who met full DSM-IV criteria or intrusion and hyper-arousal 

criteria for ASD to escitalopram or placebo less than four weeks after the trauma exposure.[91] There was a 

significant reduction in PTSD symptoms for both escitalopram and placebo groups at 24 week follow-up, with 

a significantly greater reduction in CAPS score in the placebo group.[91] A five-armed trial by Shalev et al. 

compared escitalopram to placebo, waitlist, prolonged exposure, and non-trauma-focused CBT in a sample of 

individuals who experienced a life-threatening trauma from terrorist activity, motor vehicle accidents, or 

other accidents, and who met criteria for ASD.[90] Individuals who received prolonged exposure and CBT had 

significantly lower incidence of PTSD at the five-month follow-up compared to individuals who received 

waitlist, escitalopram, or placebo. 

The Work Group rated its overall confidence in the existing literature on pharmacotherapy treatment for 

indicated prevention of PTSD as low. Two RCTs evaluated escitalopram in patients with ASD, or ASD 

symptoms with no evidence of efficacy. One of the trials was small,[91] and the other was considered to have 

low quality due to the fact that participants could decline up to two of the treatments.[90] Thus, evidence 

was insufficient to recommend any pharmacologic interventions for the indicated prevention of PTSD in 

patients with ASD. 

D. Treatment of Posttraumatic Stress Disorder

a. Treatment Selection

Recommendation

9. We recommend individual, manualized trauma-focused psychotherapy (see Recommendation 

11) over other pharmacologic and non-pharmacologic interventions for the primary treatment 

of PTSD.

(Strong For | Reviewed, New-added)
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Discussion

The Work Group’s recommendation to use individual trauma-focused psychotherapy over 

pharmacotherapy reflects the current state of the research into PTSD treatment. Although there are few 

data that reflect direct head-to-head comparisons of trauma-focused psychotherapy and a first-line 

medication for treating PTSD, two recent meta-analyses compared the treatment effects of 

psychotherapies and pharmacotherapies.[92,93] The results of these meta-analyses strongly indicate that 

trauma-focused psychotherapies impart greater change with regard to core PTSD symptoms than 

pharmacotherapies, and that these improvements persist for longer time periods. This appears true even 

when restricting the meta-analyses to studies that utilized “active” treatments such as Present-Centered 

Therapy (PCT) (as opposed to waitlist or treatment as usual) as control groups for psychotherapy studies.

In making this recommendation, the Work Group considered several factors in addition to the apparent 

differences in the magnitude of change associated with the two treatment modalities. First, the risks for 

negative side effects or negative reactions to the treatment are generally greater with pharmacologic 

treatments than with psychotherapies. Second, the positive effects of medication treatment diminish over 

time and are lost when medications are stopped. Third, comments from participants in the focus group 

and a growing body of literature indicate a patient preference for psychotherapy over 

pharmacotherapy.[46,94,95]

Recommendation

10. When individual trauma-focused psychotherapy is not readily available or not preferred, we 

recommend pharmacotherapy (see Recommendation 17) or individual non-trauma-focused 

psychotherapy (see Recommendation 12). With respect to pharmacotherapy and non-traumafocused psychotherapy, there is insufficient evidence to recommend one over the other.

(Strong For | Reviewed, New-added)

Discussion

The Work Group recognizes that individual trauma-focused psychotherapies may not be readily available 

in all settings and that not all patients elect to engage in such treatment. When this is the case, the Work 

Group recommends offering treatment using pharmacologic agents or individual, manualized 

psychotherapy that is not trauma-focused (such as Stress Inoculation Training [SIT], PCT, and Interpersonal 

Psychotherapy [IPT]) (see Recommendation 12). Notably, at the time the recommendations were 

developed, there were no well-designed, well-controlled studies available to the Work Group that directly 

compared the treatment effects of non-trauma-focused psychotherapy and pharmacotherapy. There are 

no empirical data to clearly differentiate pharmacotherapy and non-trauma-focused psychotherapy in 

cases where trauma-focused psychotherapy is unavailable or undesired. However, results of recent metaanalyses suggest that pharmacotherapy or individual non-trauma-focused psychotherapy can help reduce 

PTSD symptoms when used as the primary treatment modality. Therefore, these treatment modalities 

should be considered when individual trauma-focused psychotherapy is not available or when a patient 

declines trauma-focused psychotherapy.[92,93]

The reality is that the growing number of trauma-focused and non-trauma-focused psychotherapies, as 

well as pharmacologic agents to address PTSD, make it practically impossible to directly compare each 

psychotherapy treatment to each pharmacotherapy treatment. Thus, it is likely that decisions between 
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treatment options will continue to rely on clinical judgment and patient preferences, as well as systematic 

reviews of the growing body of well-controlled trials, such as those used in developing the present 

recommendation. However, direct comparisons between select non-trauma-focused psychotherapies and 

select pharmacologic treatments are warranted and will likely prove useful in making clinical decisions 

which should be done in collaboration with the patient.

b. Psychotherapy

Recommendation

11. For patients with PTSD, we recommend individual, manualized trauma-focused psychotherapies

that have a primary component of exposure and/or cognitive restructuring to include Prolonged 

Exposure (PE), Cognitive Processing Therapy (CPT), Eye Movement Desensitization and 

Reprocessing (EMDR), specific cognitive behavioral therapies for PTSD, Brief Eclectic 

Psychotherapy (BEP), Narrative Exposure Therapy (NET), and written narrative exposure.

(Strong For | Reviewed, New-replaced)

Discussion

For this CPG, trauma-focused psychotherapy is defined as any therapy that uses cognitive, emotional, or 

behavioral techniques to facilitate processing a traumatic experience and in which the trauma focus is a 

central component of the therapeutic process.[96] Although a number of theoretical frameworks have 

been cited in support of these treatments, extinction learning and cognitive-behavioral models provide the 

strongest empirical foundation. While trauma-focused psychotherapies differ considerably in their 

approaches and protocols, most often they involve eight to 16 sessions with varying combinations of the 

following core techniques: exposure to traumatic images or memories through narrative or imaginal 

exposure, exposure to avoided or triggering cues in vivo or through visualization, and cognitive 

restructuring techniques focused on enhancing meaning and shifting problematic appraisals stemming 

from the traumatic experience(s).

The trauma-focused psychotherapies with the strongest evidence from clinical trials are PE,[97] CPT,[98]

and EMDR.[99,100] These treatments have been tested in numerous clinical trials, in patients with 

complex presentations and comorbidities, compared to active control conditions, have long-term followup, and have been validated by research teams other than the developers. Other manualized protocols 

that have sufficient evidence to recommend use are: specific cognitive behavioral therapies for PTSD,[101-

109] BEP,[110-112] NET,[113,114] and written narrative exposure.[115,116]

The various psychotherapies differ in the use and delivery of the core trauma-focused techniques. For 

example, PE emphasizes imaginal exposure through repeatedly recounting the traumatic narrative out 

loud (often in present tense, eyes closed, reinforced by being asked to listen to an audio recording of the 

narrative process between treatment sessions). This is combined with in vivo exposure, and emotional 

processing of the narrative experience. CPT, and other trauma-focused cognitive therapies, emphasize 

cognitive restructuring through Socratic dialogue to examine problematic beliefs, emotions, and negative 

appraisals stemming from the event, such as self-blame or mistrust. EMDR incorporates imaginal exposure 

through narration and visualization to process the worst image, emotion, and negative cognition 

associated with the traumatic event, along with a more healthy cognitive reappraisal, with bilateral eye 

movements or other form of bilateral stimulation intended to create a dual awareness environment to 
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facilitate processing and relaxation. BEP has a strong psychodynamic perspective,[110-112,117] but also 

incorporates imaginal exposure, written narrative processes, cognitive restructuring through attention to 

meaning and integration of the experience, relaxation techniques, and a metaphorical ritual closing to 

leave the traumatic event in the past and foster a sense of control. NET relies on imaginal exposure 

through a structured oral life-narrative process that helps patients integrate and find meaning in multiple 

traumatic experiences across their lifespan. Written narrative exposure alone has been shown to be 

effective as a stand-alone and simple way to deliver exposure therapy.[115,116]

This recommendation is based on several comprehensive systematic reviews, as well as other studies, 

and there is high confidence in the evidence overall.[92,93,117,118] Across these trauma-focused 

therapies, benefits clearly outweigh risks in multiple trials. The choice of a specific approach should be 

based on clinical considerations, clinician expertise in one or more of these treatment methods, and 

patient preferences.

There are other psychotherapies that meet the definition of trauma-focused treatment for which there is 

currently insufficient evidence to recommend for or against their use. Future research is needed to explore 

the efficacy of novel, emerging treatments.

Recommendation

12. We suggest the following individual, manualized non-trauma-focused therapies for patients 

diagnosed with PTSD: Stress Inoculation Training (SIT), Present-Centered Therapy (PCT), and 

Interpersonal Psychotherapy (IPT).

(Weak For | Reviewed, New-replaced)

Discussion

Although evidence supports the use of trauma-focused psychotherapies for the treatment of PTSD, access 

to these treatments is not uniform across clinics. In addition, not all patients are willing to participate in 

treatments that may focus on their trauma to any extent. As a result, some practitioners utilize nontrauma-focused therapies. SIT, PCT, and IPT are the non-trauma-focused therapies with the most evidence 

derived from clinical trials that have involved direct comparisons with first-line trauma-focused therapies.

These treatments differ in their focus and techniques, but are similar in that none of them include a direct 

exposure to, or cognitive focus on, the traumatic event(s). SIT is a form of cognitive restructuring targeting 

individual thinking patterns that lead to stress responses in everyday life.[119,120] PCT focuses on current 

problems in a patient’s life that are related to PTSD.[119,121] IPT focuses on the impact that trauma has 

had on an individual’s interpersonal relationships.[122,123]

Evidence for the recommendation supporting non-trauma-focused SIT, PCT and IPT is based largely on two 

comprehensive meta-analyses, as well as other studies.[117,118] Overall, treatment effects for nontrauma-focused therapies are not as large as those seen in trauma-focused therapies, and the limited 

number of studies leads to low confidence in the evidence and weak support for the recommendation. 

However, the evidence shows that these treatments are better than receiving no treatment. A potential 

advantage of non-trauma-focused treatments is that dropout rates are often lower than those of first-line 

trauma-focused therapies.
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Based on CBT's general effectiveness for treating mental health disorders, it may be appropriate to 

consider non-trauma-focused CBT when other psychotherapies for PTSD are not available or when nontrauma-focused CBT would be appropriate based on the patient and therapist's agreed upon treatment 

goals. However, the Work Group could not make a recommendation on this modality because the 

systematic review did not identify any studies of manualized non-trauma-focused CBT for the treatment 

of PTSD.

One limitation of this recommendation is that clinical trials were not specifically designed for individuals 

who opted out of trauma-focused interventions, the target sub-population for this recommendation.

Additionally, these treatments have most often served as an active control condition in clinical trials

involving trauma-focused treatments; therefore, it is unknown to what degree they may differentiate from 

other types of treatment widely used in clinical practice. 

Future trials should focus on the effectiveness of these non-trauma-focused treatments with individuals 

who have refused trauma-focused treatments and on comparing these treatments with less-structured 

supportive counseling used widely in clinical practice. Such trials will establish the magnitude of nontrauma-focused therapy effect against trauma-focused and other approaches.

Recommendation

13. There is insufficient evidence to recommend for or against psychotherapies that are not specified 

in other recommendations, such as Dialectical Behavior Therapy (DBT), Skills Training in Affect and 

Interpersonal Regulation (STAIR), Acceptance and Commitment Therapy (ACT), Seeking Safety, and 

supportive counseling.

(N/A | Reviewed, New-replaced)

Discussion

A wide variety of manualized protocols, including DBT,[124] STAIR, [125] ACT,[126] Seeking Safety,[127]

hypnosis,[128] brief psychodynamic therapy,[129] and supportive counseling,[104,130,131] have all been 

used in the treatment of PTSD. However, further research is needed in order to make a recommendation for 

or against their routine use in patients with PTSD. Some of these treatments have been found to be effective 

for the treatment of other disorders (e.g., ACT for MDD), but do not have evidence of efficacy in patients with 

PTSD. A recent randomized trial of OEF/OID Veterans, 80% of whom had a diagnosis of PTSD, that was not 

included in the systematic evidence review for this guideline, failed to find a difference between ACT and 

Present-Centered Therapy for PTSD and other outcomes.[132] In addition, a systematic review found that 

Seeking Safety was not more effective than treatment as usual for reducing PTSD symptoms in patients with 

PTSD and SUD.[127] STAIR, which was developed to promote the development of skills to enhance 

participation in trauma-focused treatment among patients with PTSD who had experienced childhood 

trauma, has not been studied as a stand-alone treatment for PTSD. The Work Group thought it was not 

possible to make a recommendation for or againstsupportive counseling. Typically, trauma-focused 

treatments are superior to supportive counseling in randomized trials.[105,131] Supportive counseling has 

been shown to be better than waitlist in some trials,[103,104] but the treatment manuals differ so 

substantially (from relatively inactive [104] to very active [103]) that they do not permit a broad 

generalization for this approach. The Work Group also thought it was not possible to make recommendations
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regarding hypnosis and brief psychodynamic therapy given the limited amount and low quality of evidence 

for these approaches in PTSD. 

It must be acknowledged that this recommendation focusing on time-limited approaches may not 

adequately address the problems of severe chronicity or inadequate treatment response that can occur in 

some patients with PTSD, even after successful delivery of one or more courses of trauma-focused 

psychotherapy or other evidence-based treatments. There is no consensus in the literature on how to 

optimally approach the care of these patients. Patient preferences and clinical judgment are important in 

determining the best course of action in such cases.

Recommendation

14. There is insufficient evidence to recommend using individual components of manualized 

psychotherapy protocols over or in addition to the full therapy protocol.

(N/A | Reviewed, New-added)

Discussion

Relatively few studies have examined whether modifying psychotherapy protocols by adding 

components of other effective psychotherapies is beneficial, or conversely, whether the components of 

a multi-component protocol are as effective as the complete protocol. The evidence shows inconsistent 

results and does not support any strong conclusions. In addition, the Work Group was not aware of 

studies that were conducted with Veterans or Service Members. There also is insufficient evidence to 

determine whether the harms and benefits differ for combined or separated treatments relative to the 

original protocols. 

The primary focus of research in this area has been on adding different components to exposure therapy. 

Several studies have examined the potential benefits of adding cognitive restructuring to exposure, with 

two studies finding benefit [106,130] and two studies finding no benefit.[97,108] A systematic review of 

these studies found no added benefit of cognitive restructuring for PTSD symptom severity, loss of PTSD 

diagnosis, and depression symptoms.[118] An additional study examined the benefits of SIT with the 

addition of PE relative to SIT alone or PE alone and found all three treatments superior to waitlist and not 

different from each other.[119]

A dismantling study of CPT, which includes both a written trauma narrative as well as cognitive therapy, 

examined full CPT versus the separate narrative and cognitive components.[116] The cognitive only group 

(known as CPT-C) showed faster improvement during treatment on self-rated PTSD outcomes, but the 

treatments did not differ significantly at post-treatment on clinician-rated PTSD and other outcomes. 

Based on these findings, the CPT protocol has been modified so that the written narrative is optional, and 

the standard protocol (now referred to as CPT) includes the cognitive component only.[133] Although 

there is insufficient evidence to make a general recommendation regarding dismantling psychotherapy 

protocols, both CPT and CPT-C, as well as written narrative exposure, are included in the evidence 

recommendation above for trauma-focused psychotherapies.

If modifications to an established protocol (e.g., PE, CPT, EMDR) are clinically necessary, the modifications 

should be empirically and theoretically guided, and with understanding of the core components of trauma-
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focused psychotherapies considered most therapeutically active. Future research using additive and 

dismantling designs is needed to inform clinical decisions about how to optimize effective treatments.

Recommendation

15. We suggest manualized group therapy over no treatment. There is insufficient evidence to 

recommend using one type of group therapy over any other.

(Weak For | Reviewed, New-replaced)

Discussion

The limited data on the efficacy of group therapy for PTSD indicates that it is not as effective as 

individual therapy. However, some patients with PTSD may prefer manualized group psychotherapy 

over other treatment formats. Unfortunately, there were few studies published through the time period 

of our evidence review that informed whether group psychotherapy is as effective as individual 

psychotherapy. The research has not shown any particular model of manualized trauma-focused or nontrauma-focused group psychotherapy for PTSD to be superior to other active interventions, such as PCT, 

psychoeducation, or treatment as usual. However, group psychotherapy is better than no treatment in 

reducing PTSD symptoms.[134]

One study that was published after the search date cutoff, and was therefore not included in the 

systematic evidence review for this guideline, found that individual CPT was more effective than group CPT 

for reducing PTSD symptoms, although comparably effective for reducing depression and suicidal 

ideation.[135] The Work Group considered this study, and it did not change our recommendation. A metaanalysis of 10 studies comparing group psychotherapy to other active interventions found that no single 

model of group psychotherapy was superior to other group PTSD treatments in reducing PTSD 

symptoms.[134] A variety of different group therapy modalities were examined across the studies, 

including trauma-focused CBT, non-trauma-focused CBT, psychoeducation, and PCT. Additionally, a direct 

head-to-head comparison of group CPT versus group PCT found no significant differences regarding

clinician-rated PTSD outcomes.[136] A meta-analysis of six studies [117] plus one additional study [137]

compared group psychotherapy for PTSD to waitlist or no treatment. Across studies, group treatment for 

PTSD was superior to waitlist (i.e., no treatment). 

The quality of the evidence is low because of the small number of trials comparing time-limited group 

psychotherapies to one another and the minimal research comparing group psychotherapy to individual 

psychotherapy. A trade-off to taking part in group psychotherapy may be that individuals do so at the 

expense of taking part in individual trauma-focused therapy or other treatments that have greater 

empirical support. Patient factors that may warrant consideration include a preference for individual 

trauma-focused psychotherapy, willingness to disclose personal information in group, and potential value 

of group approaches such as the comradery, milieu, and social support. 

Clinical programming that offers group treatment instead of individual treatment may seem like a costefficient way to treat more patients more quickly. However, given the absence of evidence that group 

treatment is as effective as individual trauma-focused psychotherapy, it is not advisable to conclude that 

group treatment is sufficiently cost-effective. The one study comparing group psychotherapy to individual 

psychotherapy suggests that group is less effective for treating PTSD.[135] Research is needed to explore 

the comparative efficacies of different group psychotherapies, including trauma-focused and non-trauma-
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focused CBTs. It is important that studies comparing group psychotherapies to individual psychotherapies 

assess mental health outcomes, dropout rates, and cost-effectiveness.

Recommendation

16. There is insufficient evidence to recommend for or against trauma-focused or non-trauma-focused 

couples therapy for the primary treatment of PTSD. 

(N/A | Reviewed, Amended)

Discussion

In some cases, Veterans may prefer PTSD treatment that includes attention focused on their intimate 

relationships. There are no studies that compare individual trauma-focused treatment for PTSD to a 

couples-based approach. Overall, there is promising but limited evidence in support of trauma-focused 

couples therapy for PTSD.

Two RCTs found that time-limited trauma-focused couples therapy improved PTSD and relationship 

satisfaction compared to a waitlist or PTSD education group.[138,139] In one study, couples were 

randomized to either Cognitive Behavioral Conjoint Therapy (CBCT) or a waitlist.[138] CBCT is a manualized 

treatment for PTSD that is delivered to couples and focuses on reducing avoidance and challenging core 

beliefs that are maintaining PTSD and relationship difficulties. The second study randomized Veterans who 

served in the Iraq or Afghanistan Wars and their partners to either couples therapy or couples-based 

family education.[139] In this study, couples received Structured Approach Therapy, a manualized 

treatment that includes education about PTSD and how it affects relationships, emotion activation, and 

disclosure-based exposures. 

Two studies of different treatments, one waitlist and one psychoeducation comparison, suggest traumafocused couples therapy may reduce PTSD symptoms and improve relationship satisfaction for the 

identified patient.[138,139] However, there is no evidence that the partner benefits from the PTSD 

treatment or that a couples approach improves partner-reported relationship satisfaction. Additionally, 

there are no direct comparisons of individual- versus couples-focused trauma treatment. Given the quality 

of the empirical findings and that some patients may prefer a couples approach, the Work Group 

determined that there was insufficient evidence to recommend for or against trauma-focused couples 

therapy. Research is needed to compare the effectiveness of trauma-focused couples treatment to 

individual trauma-focused psychotherapy.

c. Pharmacotherapy

Recommendation

17. We recommend sertraline, paroxetine, fluoxetine, or venlafaxine as monotherapy for PTSD for 

patients diagnosed with PTSD who choose not to engage in or are unable to access traumafocused psychotherapy.

(Strong For | Reviewed, New-replaced)

Discussion

Results of three systematic reviews support the use of three SSRIs, sertraline, paroxetine, fluoxetine, and 

one serotonin norepinephrine reuptake inhibitor (SNRI), venlafaxine, as monotherapy for the treatment of 
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PTSD.[92,93,140] The most recent meta-analysis included data from over 6,000 participants in 55 

studies.[92] Each of these three meta-analyses concluded that sertraline, paroxetine, fluoxetine, and 

venlafaxine each had stronger evidence to support use in the treatment of PTSD compared to the other 

SSRIs and SNRIs.

The benefits of these medications outweigh the potential harms. The most frequent adverse effects of 

SSRIs include sexual dysfunction, increased sweating, gastrointestinal upset, and drowsiness/fatigue. In 

2004, the Food and Drug Administration (FDA) issued a box warning stating that, compared to placebo, 

antidepressants increase the risk of suicidal thinking and behavior (suicidality) in children, adolescents, and 

young adults; however, there does not appear to be an increase in the risk of suicidality in adults beyond 

age 24 and there may be a reduced risk in adults aged 65 and older. Venlafaxine shares these potential 

harms and can increase blood pressure at higher dosages. Patients taking SSRIs and SNRIs should have 

their dose tapered in order to reduce the chances of precipitating a discontinuation reaction, with the 

exception of fluoxetine (due to its long half-life). Patient preferences and comorbidities should be 

considered when deciding between these agents. Future research priorities should include further 

determination of the role and efficacy of antidepressants for the treatment of PTSD. 

See Table 3 below and Appendix C: Pharmacotherapy Dosing Table for dosing information.
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Table 3. Medication Monotherapy for the Treatment of PTSD by Recommendation and Strength of Evidence

Quality of Evidence* Recommend For Suggest For Suggest Against Recommend Against No Recommendation For or Against

Moderate

Sertraline^

Paroxetine^

Fluoxetine

Venlafaxine

Prazosin (excluding the 

treatment of PTSD 

associated nightmares)

Prazosin for the treatment of PTSD 

associated nightmares

Low Nefazodone ±

Quetiapine

Olanzapine

Citalopram

Amitriptyline

Divalproex

Tiagabine

Guanfacine

Eszopiclone

Very Low Imipramine

Phenelzine±

Lamotrigine

Topiramate

Risperidone

Benzodiazepines

D-cycloserine

Hydrocortisone

Ketamine

Bupropion

Desipramine

D-serine

Escitalopram

Mirtazapine

No Data†

Antidepressants

Doxepin

Duloxetine‡

Desvenlafaxine 

Fluvoxamine‡

Levomilnacipran

Nortriptyline

Trazodone

Vilazodone

Vortioxetine

Anxiolytic/Hypnotics

Buspirone‡

Cyproheptadine

Hydroxyzine

Zaleplon

Zolpidem

*The Work Group determined there was no high quality evidence regarding medication monotherapy

^FDA approved for PTSD

±Serious potential toxicity, should be managed carefully

†No data were captured in the evidence review (based on the criteria outlined in Conducting the Systematic Review) and were not considered in development of this table 

‡Studies of these drugs did not meet the inclusion criteria for the systematic evidence review due to poor quality
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Recommendation

18. We suggest nefazodone, imipramine, or phenelzine as monotherapy for the treatment of PTSD if 

recommended pharmacotherapy (see Recommendation 17), trauma-focused psychotherapy (see 

Recommendation 11), or non-trauma-focused psychotherapy (see Recommendation 12) are 

ineffective, unavailable, or not in accordance with patient preference and tolerance. (NOTE: 

Nefazodone and phenelzine have potentially serious toxicities and should be managed carefully.)

(Weak For | Reviewed, New-replaced)

Discussion

Although additional research on nefazodone, imipramine, and phenelzine has been lacking over the past 

decade, the few previously published placebo-controlled studies demonstrated modest therapeutic effects 

of these medications for the treatment of PTSD. The confidence in the data yielded from these small 

studies is low, but the fact remains that nefazodone significantly improved PTSD symptoms in a Veteran 

population [141] and showed effects equivalent to sertraline in two fair quality trials.[142,143] Recent 

meta-analyses demonstrate that nefazodone has small-to-medium effect sizes.[92,93] One small 

controlled study demonstrated measurable therapeutic effects of imipramine and phenelzine in Vietnam 

combat Veterans.[144]

These medications have fallen out of use by most clinicians due to their unwanted side effect profile, that 

includes, for example, rare cases of liver toxicity caused by nefazodone, anticholinergic, cardiac, and 

sedative effects of imipramine, and risk of hypertensive crisis with phenelzine if the patient does not follow 

a low tyramine diet and avoid contraindicated medications when using monoamine oxidase inhibitors 

(MAOIs). However, with careful monitoring, these medications can be used safely. Patients may prefer one 

of these medications due to their sleep-enhancing effects and reduced sexual side effects, but may feel 

burdened by the need for periodic liver function testing (nefazodone), electrocardiograms (imipramine), or 

dietary/medication restrictions (phenelzine). 

The weak recommendation regarding these medications is due to the limited evidence of their efficacy and 

known adverse effect profiles. Given the lack of evidence-based alternatives to first-line pharmacotherapy 

options, and given the promising results in older small single-site trials, more rigorous research on the 

effectiveness of these three medications, or others in the same classes, is warranted.

Recommendation

19. We suggest against treatment of PTSD with quetiapine, olanzapine, and other atypical 

antipsychotics (except for risperidone, which is a Strong Against, see Recommendation 20), 

citalopram, amitriptyline, lamotrigine, or topiramate as monotherapy due to the lack of strong 

evidence for their efficacy and/or known adverse effect profiles and associated risks.

(Weak Against | Reviewed, New-replaced)

Discussion

We suggest against using quetiapine or olanzapine as monotherapy for the primary treatment of PTSD 

because of low quality evidence and because the harms outweigh the benefit. A study published outside of 

our search timeline and apart from the evidence upon which this recommendation is based, assessed the 
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efficacy of quetiapine as monotherapy for the treatment of PTSD.[145] Despite the moderate effect size 

demonstrated in the quetiapine RCT, the study had a high risk of biasincluding a lack of information 

regarding amount of missing data, analytic method of handling missing data, high attrition, and differential 

dropout; coupled with quetiapine's known adverse effect profile, these factors necessitated a 

recommendation suggesting against the use of quetiapine as monotherapy for the treatment of PTSD. 

(NOTE: The above study was conducted between 2004 and 2008 at two VA medical centers and presented

at two national meetings in 2009; it was not published until December 2016 after closure of the evidence 

review conducted for this CPG. Because of the extensive off-label use of quetiapine to treat PTSD or its 

symptoms in VA, the Work Group felt an obligation to include the study in the guideline.)

Olanzapine has been evaluated in two small studies with participants who had non-combat-related PTSD; 

results were mixed.[146,147] In addition, three meta-analyses reached different conclusions on 

olanzapine’s efficacy ranging from a small effect size to no difference from placebo.[92,93,140]

Antipsychotics can produce metabolic adverse effects (harms) that may exacerbate a patient’s comorbidities 

or result in new medical problems. Metabolic effects, including hyperglycemia, new onset diabetes, weight 

gain and increased lipid concentrations, can occur with all of the atypical antipsychotics. Higher potency 

second generation antipsychotics (SGAs), also have a higher incidence of producing extrapyramidal effects, 

including akathisia and pseudo-parkinsonism, as well as hyperprolactinemia, which can result in sexual 

dysfunction and gynecomastia. All antipsychotics are associated with an increased risk of stroke in elderly 

patients and death in elderly patients with dementia. These and other adverse effects and drug-drug 

interactions limit the acceptability of atypical antipsychotics by patients and healthcare providers. 

Evidence from a recent meta-analysis concluded that citalopram has insufficient evidence and does not 

separate from placebo.[92] Additionally, the potential risk of QT-interval prolongation with doses greater 

than 40 milligrams (mg) per day outweighs the benefits of the medication. One clinical trial of amitriptyline 

demonstrated a positive effect on depression, but no effect on PTSD symptoms.[148]

A recent systematic review that included a meta-analysis did not find a significant effect size for 

topiramate or lamotrigine in the treatment of PTSD.[92] (See Recommendation 38 on PTSD and SUD.) In 

contrast, two previous systematic reviews and meta-analyses concluded that topiramate yielded

moderate-to-large effect sizes as monotherapy.[93,149] Two small 12-week placebo-controlled studies 

were the basis for these meta-analytic findings. In one study, although an improvement in secondary 

outcomes for PTSD was seen for topiramate over placebo, topiramate monotherapy showed no difference 

between groups for the primary outcome of total CAPS scores.[150] In a second study, topiramate was not 

significantly different from placebo, except for the avoidance/numbing symptom cluster in modified 

intention-to-treat analysis and the CAPS-rated PTSD symptoms for the completer-only analysis.[151]

Additionally, rates of remission and change in depression symptoms did not significantly differ between 

groups. There is only one small study to date that indicates lamotrigine leads to some improvement in 

avoidance/numbing and re-experiencing symptoms in patients with PTSD.[152] Further study is warranted 

prior to making recommendations for the use of topiramate or lamotrigine.
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Antiepileptic drugs, including topiramate and lamotrigine, have an FDA warning of an increased risk of 

suicidal thoughts or behaviors. Topiramate is known to cause paresthesias, hyperammonemia, kidney 

stones, and cognitive side effects, including transient impaired learning and memory. Lamotrigine must be 

titrated very slowly and carries a risk of serious rash if dose titration recommendations are not followed 

carefully, especially in combination with valproate.

Recommendation

20. We recommend against treating PTSD with divalproex, tiagabine, guanfacine, risperidone, 

benzodiazepines, ketamine, hydrocortisone, or D-cycloserine, as monotherapy due to the lack of 

strong evidence for their efficacy and/or known adverse effect profiles and associated risks.

(Strong Against | Reviewed, New-replaced)

Discussion

Compared to placebo, divalproex monotherapy,[153] and tiagabine monotherapy [154] were not effective 

in the treatment of PTSD. The divalproex studies were conducted in small samples of Veterans over eight 

to 12 weeks, which reduced the confidence in results of these studies. A 12-week placebo-controlled 

tiagabine study included a much larger PTSD sample from the general population and found no difference 

between groups.[154] A recent meta-analysis also concluded that divalproex and tiagabine were no more

effective in treating PTSD than placebo.[92]

Divalproex requires periodic laboratory testing of liver enzymes and platelets and has significant risks of 

weight gain, hirsutism, polycystic ovarian syndrome, and teratogenicity, which may negatively impact 

patient acceptability and preferences, especially in women of childbearing potential. Tiagabine is generally 

well tolerated and is not associated with significant adverse effects. Neither medication has sexual side 

effects. Antiepileptic drugs, including divalproex and tiagabine, have an FDA box warning for an increased 

risk of suicidal thoughts or behaviors. We therefore recommend against the use divalproex or tiagabine for 

the treatment of PTSD due to the lack of efficacy in the context of significant side effects.

Guanfacine was studied in two small trials.[155,156] No effect was seen on measures of PTSD symptom 

severity for the actively-treated group relative to the placebo group.

We recommend against the use of risperidone as monotherapy for the primary treatment of PTSD due to 

very low quality of evidence and because the potential harms outweigh the benefits. Only two studies of 

risperidone as monotherapy have been conducted; both were in women who were either victims of child 

abuse [157] or sexual assault.[158] Meta-analyses have differed in their effect sizes for risperidone 

monotherapy compared to placebo, with Watts et al. [93] basing theirs (ES=0.95) on one study [157] and 

Lee et al.[92] using both studies (ES=-0.48).[157,158]

We recommend against the use of benzodiazepines for the primary treatment of PTSD due to the lack of 

evidence for effectiveness and because the risks outweigh potential benefits. Historically, 

benzodiazepines, particularly alprazolam and clonazepam, were frequently used as a primary agent or “as 

needed” for the treatment of PTSD despite the lack of evidence of efficacy in RCTs. There was no 

significant difference between alprazolam versus placebo in a small, five-week, randomized controlled 

study in 10 patients with PTSD.[159] The lack of effect on PTSD symptoms was also seen in an RCT of six 

patients who received either placebo or clonazepam.[160] Furthermore, alprazolam administration 30 
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minutes prior to each of five virtual reality exposure sessions reduced the efficacy of exposure therapy and 

was associated with more severe PTSD symptoms at three-month follow-up.[161] A very low quality 

systematic review also concluded that benzodiazepines are ineffective for PTSD treatment, are associated 

with worse overall severity, worse psychotherapy outcomes, aggression, depression, and substance use,

and are relatively contraindicated for patients with PTSD.[162]

Because benzodiazepine use is associated with tolerance and dependence, it can be very difficult to 

discontinue these medications due to significant withdrawal symptoms. Benzodiazepines are also 

relatively contraindicated in patients with history of traumatic brain injury (TBI), sleep apnea, chronic 

obstructive pulmonary disorder (COPD), or who have high rates of comorbid alcohol misuse and SUD, 

particularly Veterans with combat-related PTSD. Furthermore, pre-clinical evidence suggests that 

benzodiazepines may actually interfere with the extinction of fear conditioning and/or potentiate the 

acquisition of fear responses and worsen recovery from trauma.[163,164] We, therefore, recommend 

against the use of benzodiazepines for the primary treatment of PTSD.

Major depression frequently co-occurs with PTSD. Feder et al. evaluated the efficacy of a single 

intravenous (IV) sub-anesthetic dose of ketamine in patients with PTSD since preliminary evidence 

suggests that sub-anesthetic doses of IV ketamine has rapid antidepressant effects in treatment-resistant 

depression. The study compared ketamine versus midazolam in 41 patients with PTSD in a two-week 

crossover, low quality RCT.[165] Ketamine administration significantly reduced self-rated PTSD symptoms 

at 24 hours, but not seven days after the infusion. Furthermore, clinician-rated PTSD symptom severity 

was also not significantly different between subjects given ketamine or midazolam one week after 

administration. Additionally, there was no significant difference between ketamine and midazolam with 

respect to the severity of depressive symptoms. Individuals who received ketamine had greater rates of 

blurred vision, dry mouth, restlessness, nausea and vomiting, headache, and poor coordination compared 

to midazolam.

In the context of limited information on the efficacy of ketamine in PTSD combined with its significant side 

effects and potential for abuse, we recommend against the use of ketamine for the primary treatment of 

PTSD in a clinical setting. Future, well-designed studies could help shed light on the efficacy of ketamine on 

clinician-rated PTSD and depressive symptoms.

There is no evidence for the efficacy of hydrocortisone in the primary treatment of PTSD. In a 

randomized, double-blind, placebo-controlled, crossover pilot study evaluating hydrocortisone’s effect 

on automatic memory retrieval in 30 inpatients with PTSD, investigators found no differences between 

10 mg and 30 mg hydrocortisone compared to placebo in outcomes for overall PTSD or in intrusions, 

avoidance, or hyperarousal using the Impact of Event Scale - Revised. Subjects were taking a variety of 

psychotropic medications including tricyclic antidepressants (TCAs), SNRIs, SSRIs, antipsychotics, and 

anticonvulsants.[166]

Recommendation

21. We recommend against treating PTSD with cannabis or cannabis derivatives due to the lack of 

evidence for their efficacy, known adverse effects, and associated risks.

(Strong Against | Reviewed, New-added)
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Discussion

Preliminary evidence that natural and synthetic cannabinoids could improve PTSD symptoms, particularly 

nightmares, is offset by the significant side effects including tolerance, dependence, withdrawal syndrome, 

psychosis, cognitive deficits, and respiratory symptoms if smoked. A recent systematic review concluded 

that the quality of two retrospective and four prospective studies assessing the use of medical marijuana 

to treat PTSD was very low.[167] The lack of well-designed RCTs evaluating the efficacy of cannabinoids in 

large samples of patients with PTSD, together with its serious side effects, does not support the use of 

natural or synthetic cannabinoids as a treatment for PTSD. Additionally, these findings are consistent with 

the reviews by Steenkamp et al. and Belendiuk et al.,[168,169] as well as the VA Evidence-based Synthesis 

Program review of cannabinoids for the treatment of PTSD.[170]

Recommendation

22. There is insufficient evidence to recommend for or against monotherapy or augmentation 

therapy for the treatment of PTSD with eszopiclone, escitalopram, bupropion, desipramine, 

doxepin, D-serine, duloxetine, desvenlafaxine, fluvoxamine, levomilnacipran, mirtazapine, 

nortriptyline, trazodone, vilazodone, vortioxetine, buspirone, hydroxyzine, cyproheptadine, 

zaleplon, and zolpidem.

(N/A | Reviewed, New-replaced)

Discussion

Medications listed in this recommendation are based on the following criteria: absence of studies, studies 

reported conflicting results, or studies reporting inconclusive results. As of yet, there are no RCTs that 

would support the use of any of the above agents as monotherapy. Escitalopram, duloxetine, 

desvenlafaxine, levomilnacipran, vilazodone, vortioxetine, and fluvoxamine have not been studied 

sufficiently to warrant a recommendation. 

Currently, there is no evidence for the efficacy of bupropion in the treatment of core symptoms of 

PTSD.[171] However, we recognize that bupropion may be prescribed to manage antidepressant-induced 

sexual dysfunction, concurrent attention deficit disorder, or smoking cessation in patients with a diagnosis 

of PTSD.

Two single-site RCTs with mirtazapine monotherapy versus placebo have been published. Three systematic 

reviews of these findings have concluded that mirtazapine monotherapy is ineffective and that there was a 

high risk of bias in both RCTs.[92,93,140] The first study randomized 26 participants to mirtazapine or 

placebo and found mixed results depending on the outcome measure.[172] Although response rates were 

significantly greater for mirtazapine (65%) than placebo (22%) and drug performed better than placebo on 

one secondary PTSD scale; there was no difference found on the primary PTSD outcome. In the second 

study, 100 participants were openly randomized to mirtazapine or sertraline and both medications were 

found to be effective in reducing PTSD measures, with no differences between groups.[173] Therefore, in 

view of mixed results in two methodologically flawed single-site studies, and since the benefits are 

outweighed by associated risks, there is insufficient evidence to recommend for or against mirtazapine 

monotherapy for PTSD.
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One randomized, double-blind, placebo-controlled crossover study assessed the effects of three weeks of 

eszopiclone and three weeks of placebo interspersed with one week of washout in 24 patients with PTSD 

and insomnia who were receiving psychotherapy or antidepressants for more than one month.[174] 

Eszopiclone significantly improved PTSD symptoms and sleep latency however, the total duration of sleep 

was not significantly different between patients who were randomized to eszopiclone or placebo.[174] 

Since the quality of this single study using eszopiclone was low and the reductions in PTSD symptoms were 

only weakly positive, there is insufficient evidence to recommend for or against the use of eszopiclone for 

the primary treatment of PTSD.

There is no evidence for the efficacy of D-serine in the primary treatment of PTSD. In a six-week doubleblind, placebo-controlled, crossover pilot study of D-serine as monotherapy or add-on to a variety of 

psychotropic medications (including TCAs, SSRIs, benzodiazepines, and antipsychotics) in 22 outpatients, 

investigators found a significant reduction in anxiety symptoms and self-reported PTSD scale with Dserine compared to placebo, but only a trend towards improvements in clinician-rated PTSD symptoms 

using the CAPS.[175] 

Given the significant burden of sleep difficulties, relative balance between risks and benefits, and the 

utility of non-benzodiazepine sedatives/hypnotics in patients with SUD, future studies should evaluate 

whether primary treatment of insomnia with non-benzodiazepine sedatives/hypnotics can reliably 

decrease PTSD symptoms. See Recommendation 40 for additional information on insomnia. 

d. Augmentation Therapy

Table 4. Medication Augmentation and Combination* Pharmacotherapy for the Treatment of 

PTSD by Recommendation and Strength of Evidence

Quality of 

Evidence±

Recommend 

For

Suggest 

For Suggest Against

Recommend 

Against

No Recommendation 

For or Against

Moderate

Prazosin

(excluding the 

treatment of 

PTSD associated 

nightmares)

Risperidone

Prazosin for the 

treatment of PTSD 

associated nightmares

Low Topiramate Divalproex

Olanzapine Hydrocortisone

Very Low

Baclofen

Pregabalin 

D-cycloserine†

Mirtazapine and 

Sertraline^

No data‡ Other atypical 

antipsychotics Any drug not listed

*Combination means treatments are started simultaneously; augmentation means one treatment is started after another 

treatment (all treatments are augmentation unless otherwise noted) 

±The Work Group determined there was no high quality evidence regarding medication augmentation and combination therapy

†Outside of a research setting 

^Combination treatment

‡No data were captured in the evidence review (based on the criteria outlined in Conducting the Systematic Review) and were not 

considered in development of this table
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Recommendation

23. We suggest against the use of topiramate, baclofen, or pregabalin as augmentation treatment of 

PTSD due to insufficient data and/or known adverse effect profiles and associated risks.

(Weak Against | Reviewed, New-replaced)

Discussion

In a study of Veterans with PTSD, topiramate augmentation (of antipsychotics, SSRIs and TCAs, 

benzodiazepines, and anticonvulsants) did not show a significant difference from placebo in change in 

PTSD symptoms.[176]

The few published clinical trials with pregabalin and baclofen were small, single-site studies for which the 

risk of bias was high. Other systematic reviews reached the same conclusion and did not include either 

baclofen or pregabalin in their final analyses.[92,93,140] In view of inconclusive evidence regarding 

efficacy and clear evidence regarding adverse effects, we suggest against the use of pregabalin or baclofen

augmentation for the treatment of PTSD.

In the only published RCT of baclofen, combat Veterans were randomized to receive medication or 

placebo as an augmentation agent to citalopram in an eight-week study.[177] Published data only included 

results for a fraction of those who completed the study. This evidence was considered at very high risk of 

bias and insufficient to suggest augmentation with baclofen as a treatment for PTSD.

The single published RCT of pregabalin was also an augmentation trial in which 37 soldiers with PTSD, all 

receiving citalopram or sertraline plus sodium valproate, were randomized to receive either pregabalin or 

placebo for six weeks.[178] Reduction of scores on the PCL was significantly greater for the pregabalin than 

for the placebo augmentation group. Although encouraging, this study had substantial methodological and 

bias concerns, including not reporting the dropout rate, methods of allocation concealment and 

randomization, and not employing an intention-to-treat analysis, that render these findings insufficient to 

suggest pregabalin as a treatment augmentation for PTSD.

Recommendation

24. We suggest against combining exposure therapy with D-cycloserine in the treatment of PTSD 

outside of the research setting.

(Weak Against | Reviewed, New-added)

Discussion

Combination of exposure therapy with D-cycloserine has not shown consistent benefit for reduction of 

overall PTSD symptoms based on five studies.[179] While D-cycloserine is inexpensive, the side effect 

profile is low, and has very good acceptability compared to placebo, one study found lower efficacy of

exposure therapy on improving outcomes in combination with D-cycloserine.[179] The lack of overall 

benefit, low number of randomized trials, and the barriers to implementation suggest that the current 

state of literature does not support D-cycloserine for combination with exposure therapy. However, some 

studies have demonstrated that certain subgroups of patients may benefit from D-cycloserine

combination.[161] Additional research on the more precise identification of patient subtypes, proper Dcycloserine dose, timing of D-cycloserine administration, and other factors related to D-cycloserine use is 

warranted. Studies with more precise methodologies are recommended to clarify potential efficacy.
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Recommendation

25. We recommend against using atypical antipsychotics, benzodiazepines, and divalproex as

augmentation therapy for the treatment of PTSD due to low quality evidence or the absence of 

studies and their association with known adverse effects.

(Strong Against | Reviewed, New-replaced)

Discussion

Risperidone and olanzapine are the only atypical antipsychotics to have been studied as augmentation 

treatment for PTSD. Although researchers found some benefit of SSRI augmentation with olanzapine in 19 

Veterans with chronic military-related PTSD compared to placebo, [180] the effect did not achieve 

statistical significance in a meta-analysis.[92]

Risperidone has been studied in Veterans as an augmentation strategy to antidepressant 

treatment.[92,93] Two meta-analyses have included studies of risperidone as monotherapy or as 

treatment augmentation (four trials, N=419).[92,93] The effect sizes were small and any statistically 

significant improvements were not clinically significant.

VA Cooperative Study #504 [181] randomized 247 Veterans with military-related PTSD deemed resistant to 

antidepressants to either risperidone augmentation or placebo treatment. After six months, the changes 

from baseline in CAPS scores were not significant between the two treatment arms. Changes in CAPS 

subscale scores for re-experiencing and hyperarousal were statistically significant favoring risperidone, but 

the differences were not considered clinically important. No difference was found in the symptom scales 

for anxiety, depression, positive or negative symptoms, sleep, or quality of life. The authors concluded that 

compared to placebo, risperidone did not reduce PTSD symptoms. This is the largest clinical trial of an 

atypical antipsychotic as a treatment of PTSD to date.

Atypical antipsychotics, other than risperidone and olanzapine, have not been studied as augmentation 

therapy for PTSD. Since the risks of these medications outweigh the unknown benefits, we recommend 

against augmentation using atypical antipsychotics. 

We recommend against the use of benzodiazepines due to the lack of evidence for effectiveness and 

because the risks outweigh potential benefits. Historically, benzodiazepines, particularly alprazolam and 

clonazepam, were frequently used as a primary agent or “as needed” for the treatment of PTSD despite 

the lack of evidence of efficacy in RCTs. Please see Recommendation 20 for additional information. 

Because benzodiazepine use is associated with tolerance and dependence, it can be very difficult to 

discontinue these medications due to significant withdrawal symptoms. Benzodiazepines are also 

relatively contraindicated in patients with a history of TBI, sleep apnea, COPD, or who have high rates of 

comorbid alcohol misuse and SUD, particularly Veterans with combat-related PTSD. Furthermore, preclinical evidence suggests that benzodiazepines may actually interfere with the extinction of fear 

conditioning and/or potentiate the acquisition of fear responses and worsen recovery from 

trauma.[163,164] We, therefore, recommend against the use of benzodiazepines, even as augmenting 

agents, in the treatment of PTSD.
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A single-site, double-blind study randomized 29 Veterans to divalproex or placebo augmentation of 

antidepressants (SSRIs, nefazodone, mirtazapine, bupropion, trazodone, and TCAs).[182] No significant 

differences in mean change in CAPS total or sub-scores were found except for a decrease in 

avoidance/numbing scores in the placebo arm.

Recommendation

26. There is insufficient evidence to recommend the combination of exposure therapy with 

hydrocortisone outside of the research setting.

(N/A | Reviewed, New-added)

Discussion

One small RCT examined whether hydrocortisone enhances the efficacy of exposure therapy in reducing 

PTSD symptoms.[183] Although this study demonstrated effective combination and noted no side effects 

of the medication, replication would be necessary to improve confidence in these results. Barriers to 

implementation include the requirement for a clinician trained in exposure therapy and a prescribing 

provider to synchronize their efforts. Additional research into identification of certain subtypes of patients, 

proper hydrocortisone dose, timing of administration, and other factors is warranted. Studies with more 

precise combination methodologies may demonstrate different results.

Recommendation

27. There is insufficient evidence to recommend for or against the use of mirtazapine in combination 

with sertraline for the treatment of PTSD.

(N/A | Reviewed, New-replaced)

Discussion

In the only RCT of combination pharmacotherapy, 36 civilian adults were randomized to sertraline plus 

mirtazapine (started simultaneously) versus sertraline plus placebo. Treatment groups did not differ in the 

change in CAPS over 24 weeks.[184] There was a significantly greater reduction of depressive symptoms as 

well as a greater PTSD remission rate in the combined treatment group (39%) compared to sertraline plus 

placebo (11%). Based on these methodologically challenged results, we suggest additional research 

regarding the combination of sertraline with mirtazapine for PTSD treatment be conducted.

e. Prazosin

Recommendation

28a. For global symptoms of PTSD, we suggest against the use of prazosin as mono- or augmentation 

therapy.

(Weak Against | Reviewed, New-replaced)

28b. For nightmares associated with PTSD, there is insufficient evidence to recommend for or against 

the use of prazosin as mono- or augmentation therapy.

(N/A | Reviewed, New-replaced)
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Discussion

Four small, published trials of variable quality met the threshold for review.[185-188] These trials 

contained a total of 167 subjects, all of whom were Veterans or active duty Service Members. Most of 

these trials had promising results, particularly for nightmares. However, in a much larger, well-designed VA 

Cooperative multi-site trial with 304 subjects, prazosin failed to separate from placebo in the treatment of 

both global symptoms of PTSD and nightmares.[189] Interestingly, this study had not been published at 

the time of our review, three years after its completion. Nonetheless, we believed it was important to 

include in our analysis due to its significance and availability in the public domain (www.clinicaltrials.gov, 

identifier NCT00532493).

The quality of the four published trials was rated as moderate, based on small-to-medium sample sizes 

(10-67 subjects per trial), notable design flaws, and the potential for bias. For example, three of the four 

published trials (along with the VA Cooperative Study) were conducted by the same investigator.[185-

187,189] In the fourth published study, only 58% of the subjects met DSM-IV criteria for PTSD.[188] All of 

these trials also included a mixture of subjects taking prazosin either as monotherapy or to augment 

existing psychotropic medications, which compromised the Work Group’s ability to make separate 

recommendations for prazosin as mono- and augmentation pharmacotherapy. The quality of the VA 

Cooperative Study could not be fully rated as it was unpublished. However, the study design was 

impressive and VA Cooperative Studies are well-known for scientific excellence and methodological rigor. 

Several systematic reviews and meta-analyses, none of which reviewed the VA Cooperative Study, have 

reached differing conclusions regarding the benefit of prazosin for treating PTSD. Lee et al. concluded 

that prazosin was beneficial at 14-27 weeks as an augmentation medication for the treatment of the 

global symptoms of PTSD, based on three of the four aforementioned trials.[92] However, Jonas et al. 

concluded there was insufficient evidence to determine prazosin’s efficacy for the global symptoms of 

PTSD based on two trials.[149] A third, poor quality meta-analysis concluded that prazosin improved 

sleep quality, nightmares, PTSD symptoms, and global change based on six trials producing medium to 

large effect sizes.[190]

Global Posttraumatic Stress Disorder Symptoms

We suggest against prazosin as monotherapy or augmentation therapy for global symptoms of PTSD, 

based on lack of demonstrated efficacy. Two of the three published studies reviewed by the work group, 

which had 10 and 67 subjects respectively, did find a statistically significant reduction in overall CAPS 

scores in their prazosin arms compared to controls.[185,187] However, in the third study there was no 

difference in total CAPS scores.[186] Additionally, in the VA Cooperative Study, which had nearly four 

times as many subjects, there was no difference in the total CAPS and Clinical Global Impression of Change 

Scale (CGIC) scores between the prazosin and placebo arms.[189] The VA study demonstrated a placebo 

effect that appeared larger than that seen in the other trials.

Nightmares and Sleep Quality

Despite the fact that prazosin has been used for managing PTSD-associated nightmares in recent years, we 

found insufficient evidence to recommend for or against the use of prazosin as mono- or augmentation 

therapy for nightmares or sleep disturbance associated with PTSD. Specifically, positive results in nearly all 
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of the smaller studies were contradicted by negative results in the much larger and stronger VA 

Cooperative Study. In three of the four smaller trials, prazosin significantly decreased recurrent distressing 

dreams.[185-187] Additionally, in three of the four smaller trials, prazosin significantly improved sleep 

quality.[186-188] However, in the VA Cooperative Study, there was no difference between prazosin and 

placebo on recurrent distressing dreams or sleep quality.[189] As mentioned above, the VA study 

demonstrated a placebo effect that appeared larger than that seen in the other trials.

We recognize that these recommendations constitute a significant reversal of prazosin’s role in the current 

management of PTSD. We are recommending neither for nor against the continuation of prazosin in 

patients who believe it to be beneficial; the decision to stop or continue prazosin should be individualized 

and made using SDM. If patients and/or providers decide to discontinue prazosin, we suggest a slow taper 

of the dose, while monitoring for symptom worsening or reappearance. Prazosin may need to be 

continued or restarted in some patients.

f. Combination Therapy

Recommendations

29. In partial- or non-responders to psychotherapy, there is insufficient evidence to recommend for or 

against augmentation with pharmacotherapy.

(N/A | Reviewed, New-replaced)

30. In partial- or non-responders to pharmacotherapy, there is insufficient evidence to recommend for 

or against augmentation with psychotherapy.

(N/A | Reviewed, New-replaced)

31. There is insufficient evidence to recommend for or against starting patients with PTSD on 

combination pharmacotherapy and psychotherapy.

(N/A | Reviewed, New-added)

Discussion

Although many patients show clinical improvement in response to recommended evidence-based 

psychotherapies and/or pharmacotherapies, a sizable proportion of patients are partial- or nonresponders. Determining what to do for these patients is a clinically important question, yet the limited 

evidence available is insufficient to guide clinical decision making. Only a few studies have examined the 

benefits of administering medication and psychotherapy to either augment a single initial modality 

following inadequate response, or as a combination at the outset of therapy.

A single study that examined the benefits of sertraline versus placebo for patients following partial 

response to PE found no added benefit of sertraline augmentation.[191] A study that examined the 

benefits of PE following eight weeks of treatment with sertraline (versus placebo) found no added benefit 

of PE augmentation, although post-hoc analysis found that PE (versus continued sertraline monotherapy) 

improved response among partial responders.[192]

Two studies examined the combination of PE and paroxetine as an initial approach to treatment. In the 

first, patients who received PE and paroxetine had better outcomes relative to those who received PE and 

placebo, which suggests that combination treatment is better.[193] In the second, which was based only 
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on self-reported patient outcomes, patients who received paroxetine and PE did not have better outcomes 

relative to those who received PE or paroxetine as monotherapy.[194]

None of the studies on augmentation or combination therapy included Veterans or Service Members.

Research in these populations is needed to inform clinical decision making. In the absence of evidence to 

guide decision making, clinicians treating partial- or non-responders should rely on their clinical judgment, 

use an SDM approach, and take patient preferences into consideration.

g. Non-pharmacologic Biological Treatments

Recommendation

32. There is insufficient evidence to recommend for or against the following somatic therapies: 

repetitive transcranial magnetic stimulation (rTMS), electroconvulsive therapy (ECT), hyperbaric 

oxygen therapy (HBOT), stellate ganglion block (SGB), or vagal nerve stimulation (VNS).

(N/A | Reviewed, New-replaced)

Discussion

Although there is a great deal of interest in rTMS for the treatment of PTSD, data supporting its use is not 

robust. There are a limited number of trials and a lack of uniformity among studies in terms of location, 

frequency, and intensity of treatment. A 2014 systematic review identified three RCTs examining the 

efficacy of rTMS applied to the right dorsolateral prefrontal cortex (DLPFC) for the treatment of PTSD.[195]

All three identified RCTs utilized a sham-controlled double-blind design with a clinician-administered 

outcome metric. Further examination of the individual studies revealed some variability in study design 

and inconsistency in treatment parameters. For example, Cohen et al. conducted a three-armed study 

comparing 1 hertz (Hz) or 10 Hz to sham control.[196] The results demonstrated statistically significant 

improvement for 10 Hz treatment over either sham or 1 Hz. In this trial, low frequency (1 Hz) rTMS failed 

to separate from sham control. However, the study was limited due to questionable blinding and 

completers-only data analysis. Watts et al. enrolled 20 subjects randomized into groups for 10 sessions of 

rTMS targeting the right DLPFC with either 1 Hz treatment or sham control.[197] At two-month follow-up, 

subjects treated with 1 Hz treatment still had significant improvement over sham control. Boggio et al. also 

conducted a three-armed study with a total of 30 patients; however patients were randomized to 20 Hz

sequences to either right or left DLPFC or sham.[198] Both active controls treatment groups showed 

statistically significant improvement in clinician-administered scales before and after treatment (but no 

difference between treatment groups and control), with a larger effect size in the right DLPFC group.[198]

Despite the findings of improvement on clinician-administered scales with rTMS targeting the right DLPFC, 

there are limitations to the quality of the evidence.[196-198] All three studies used different protocols in 

terms of frequency of magnetic pulses (20 Hz versus 10 Hz versus 1 Hz). High frequency treatment was 

effective in both studies where it was included, but in one of the three studies low frequency (1 Hz) rTMS 

failed to separate from control. As a result, the indicated settings for treatment are unclear. Given the limited 

number of studies demonstrating efficacy of rTMS for PTSD treatment and the lack of clinical guidance as to 

location, frequency of dose (Hz), and duration of treatment, we cannot recommend for or against rTMS until 

additional research has addressed these matters.
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There is considerable interest in alternatives to either psychotherapy or pharmacology for the primary 

treatment of PTSD; however there is currently insufficient evidence to recommend the majority of somatic 

therapies, including ECT, HBOT, SGB, or VNS. Although there are published case reports supporting the 

utility of ECT [199] and VNS, [200] there is a lack of published randomized studies.

There is no conclusive evidence that HBOT is effective for treating PTSD. There have been no RCTs or 

uncontrolled trials specifically focused on patients with PTSD, and there is disagreement about what 

constitutes an adequate sham treatment. In a DoD study, 72 soldiers with TBI (66% with PTSD) were 

randomized to standard care (78%), HBOT (54%), or sham HBOT (64%).[201] Baseline scores on the PCL 

were less severe than in all-PTSD studies, likely because not everyone had PTSD. Scores were still in the 

severe range. Based on the evidence to date, and the practical and cost concerns, it does not appear that 

HBOT is a promising treatment for further study. 

In addition to small open label trials, SGB has been studied in an open label trial of 166 Service Members

followed for up to six months following the procedure.[202] Although the study showed significant 

reduction in overall PTSD scores, it is limited by its open label design, lack of clinician-administered 

outcome measures, and completers-only analysis. In a double-blinded RCT using a clinician-administered 

outcome scale, SGB failed to separate from sham control.[203] Based upon a lack of high quality RCTs 

supporting the efficacy of ECT, HBOT, SGB, or VNS, the Work Group is unable to recommend the use for 

the primary treatment of PTSD.

h. Complementary and Integrative Treatments

Recommendation

33. There is insufficient evidence to recommend acupuncture as a primary treatment for PTSD.

(N/A | Reviewed, New-replaced)

Discussion

The available evidence on acupuncture for the treatment of PTSD is limited. Two low quality RCTs 

comparing a course of acupuncture to control conditions demonstrated significantly decreased PTSD 

symptom severity in the acupuncture groups.[204,205] However, neither trial involved a sham control, so 

a placebo effect cannot be ruled out as an explanation for any positive outcomes. In the first study, 

Hollifield et al. found that both acupuncture and CBT were effective compared to a waitlist control. 

Although equivalence or non-inferiority of acupuncture relative to CBT was not tested, the effects 

appeared similar in both treatments.[204] Engel et al. compared acupuncture in conjunction with usual 

care to usual care alone and found improvement in PTSD symptoms (based on clinician-rated CAPS scores), 

depressive symptoms, pain, and overall quality of life in the acupuncture group.[205] No adverse events 

were reported, although the dropout rate was greater in the acupuncture condition. It should be noted 

that almost 40% of participants in this study had no medications or counseling, so almost half of the usual 

care group was effectively a waitlist control group. Finally, a variant of acupuncture called acupoint 

stimulation, when combined with CBT, was found to be more effective than CBT alone.[206] Since this is a 

different modality that lacked a sham control condition, the evidence for acupoint stimulation is 

inconclusive and more research is warranted.
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Our overall confidence in the available literature is low. Even though the evidence is trending positively for 

the use of acupuncture, based on the lack of sham control and other study limitations, the Work Group’s 

assessment was that the current available evidence was still insufficient to recommend acupuncture as a 

primary treatment modality for PTSD. Safety data suggest that acupuncture is not associated with any 

serious adverse events, but some participants reported minor/moderate needle pain, superficial bleeding, 

and hematoma. There is also an insufficient number of staff trained in acupuncture within the VA and DoD 

healthcare systems to be able to offer it widely. In addition, some patients may not feel comfortable with 

the procedure, as suggested by the disproportionately high dropout rate in the acupuncture arm of the 

Engel et al. study.[205] Practitioners should consider factors such as patient preference and treatment 

availability when determining complementary and integrative health treatment options.

Recommendation

34. There is insufficient evidence to recommend any complementary and integrative health (CIH) 

practice, such as meditation (including mindfulness), yoga, and mantram meditation, as a primary 

treatment for PTSD.

(N/A | Reviewed, New-replaced)

Discussion

The Work Group acknowledges the widespread use of CIH practices as part of the treatment of individuals 

with PTSD in the DoD and VA healthcare systems. It is important to clarify that we are not recommending 

against the treatments but rather are saying that, at this time, the research does not support the use of 

any CIH practice for the primary treatment of PTSD. 

Two systematic reviews formed the evidence base to determine which CIH treatments are safe and 

effective for adults diagnosed with PTSD.[207,208] One systematic review focused on physical activity and 

exercise,[208] whereas the other summarized the CIH literature more broadly, but included study designs 

other than RCTs and participants who did not meet the diagnostic threshold for PTSD.[207] Both reviews 

highlighted the need for improved CIH clinical trial methods, more rigorous reporting, and additional RCTs 

of CIH interventions. Further research also should focus on analyzing treatment adherence to identify the 

minimum frequency or duration of practice required for maximum meditation effectiveness.

There were more clinical trials available for meditation than for any other CIH modality. Meditation is a 

mind-body technique that refers to a broad variety of practices with the general goal of training the mind 

through regulation of attention and/or emotion to affect functions, symptoms, and state of being. Ten 

RCTs were reviewed, including five that were specific to mindfulness practices. Grading the body of 

evidence for meditation overall was complicated by the heterogeneity of the types of meditation that have 

been assessed. Five RCTs were also specific to mindfulness-based stress reduction (MBSR). MBSR is a 

manualized protocol that includes didactic training and formal practice in three meditation techniques: 

body scan, sitting meditation, and mindful yoga. Meditation offered as augmentation to treatment as 

usual was compared to treatment as usual plus waitlist controls in one of these studies. Studies examining 

MBSR in group format did not find it to be superior to PCT for clinician-rated CAPS PTSD symptoms [209] or 

to treatment as usual for self-reported PCL PTSD symptoms.[210] Meditation is promising and may provide 

a safe, self-administered, and inexpensive intervention for PTSD. Unfortunately, the current research 
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clearly does not establish its efficacy. Additional high quality trials with adequate power, active control 

conditions, and longer follow-up periods are needed. 

Three studies tested the effects of yoga.[211-213] All included a gentle form of yoga that focused on 

breathing and meditation and one was trauma-informed yoga. In one study that included patients with 

subthreshold PTSD, the yoga group participated in twelve 75-minute sessions of Kripalu yoga (weekly for 

12 weeks, or twice weekly for six weeks) while controls had weekly group meetings over 12 weeks to 

complete assessment surveys.[211] The second study evaluated yoga as an augmentation to ongoing 

supportive psychotherapy.[213] Patients in the yoga group had hour-long weekly trauma-informed yoga 

sessions for 10 weeks, while controls had 10 weeks of women’s health education. Quiones et al.

randomized individuals with PTSD to Satyananda yoga versus controls.[212] The yoga group participated in 

twice weekly sessions of yoga for 16 weeks while controls received usual care. The meta-analysis of these 

RCTs found that compared to control groups, the yoga interventions reduced PTSD symptoms. No major 

adverse events were reported in the yoga interventions. However, the Mitchell et al. study was limited by

lack of a control treatment and use of self-rated PTSD measures [211] and the Quiones et al. study was 

limited by a lack of intention-to-treat analysis, use of self-rated PTSD measures, and lack of blinding of 

outcome assessors.[212] Thus, our overall confidence in the available literature is low.

One systematic review [207] and one RCT [214] compared mantram meditation to waitlist or treatment as 

usual for PTSD symptoms. The systematic review described a single RCT [215] that randomized 33 patients 

with PTSD to mantram meditation versus waitlist. Mantram meditation was delivered in 90-minute weekly 

sessions for six weeks. A second RCT randomized 146 Veterans with military-related PTSD to mantram 

meditation plus treatment as usual or treatment as usual alone.[214] The mantram intervention consisted 

of six 90-minute weekly group sessions. This study found that compared to treatment as usual, mantram 

meditation was associated with reductions in PTSD symptoms as measured by the CAPS, a dropout rate of 

only 7%, and no reported adverse events. The quality of evidence for the efficacy of mantram was graded 

as low due to serious limitations and imprecision in effect estimates.

A number of other CIH modalities were reviewed, including various forms of exercise, natural products

such as gingko biloba, and recreational therapies (e.g., sailing), but none were found to have sufficient 

evidence to support any recommendations regarding their use.[207] Although there is much interest in the 

area of animal assisted therapy, no studies evaluating the use of interventions with animals, such as 

equine therapy or canine therapy, met the threshold for inclusion in the review. At this time, there is no 

evidence to support their use for the primary treatment of PTSD.

Overall, the Work Group recognizes that CIH practices are increasingly offered as part of the treatment of 

PTSD. These practices hold promise as interventions to improve wellness and promote recovery.

Meditation interventions in particular offered as augmentation treatments to treatment as usual—

including yoga, MBSR, and mantram repetition—statistically significantly reduced PTSD symptoms 

compared with all comparators across all sources of trauma. However, at this time there are methodologic 

concerns that make it difficult to recommend any specific type of meditation. Research is needed to 

provide more information not only about meditation but other types of CIH as well for the primary and 

augmentation treatment of PTSD.
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i. Technology-based Treatment Modalities

Recommendation

35. We suggest internet-based cognitive behavioral therapy (iCBT) with feedback provided by a 

qualified facilitator as an alternative to no treatment.

(Weak For | Reviewed, New-replaced)

Discussion

Several studies have shown beneficial effects of supported iCBT for PTSD symptoms. In each case, support 

was provided by a qualified facilitator (e.g., care manager, trained peer, therapist) as described in the 

summary of the studies below.

Three trials utilized therapist support in combination with the internet-based interventions. In a small pilot 

RCT of 42 individuals, preliminary evidence supported a significant improvement on self-reported PTSD 

symptoms for therapist-supported iCBT versus waitlist control, although the between-group effect size 

was small (ES=0.47). Study limitations included a lack of clinician and patient blinding and a small sample 

size.[216] In a larger study by the same author, 125 individuals were randomized to eight weeks of iCBT 

with and without exposure components. There was no waitlist comparison or comparison with another 

treatment. Both groups had significant reductions in clinician-rated PTSD symptoms but there was no 

between group difference. Study limitations included a lack of assessor blinding and verification of 

adherence to the treatment protocols, among others.[217] A third study randomized 62 individuals to 

either iCBT versus delayed treatment group and found significant reductions in clinician-rated PTSD 

favoring iCBT. The therapist provided guidance and support in the iCBT condition whereas study personnel 

had weekly contact to answer general questions in the delayed treatment control condition. Study 

limitations included a lack of screening for comorbidities, the validity of using the CAPS over the phone, 

and the sample being drawn from the community.[218]

One larger study examined peer support in 303 Veterans that were randomized to either an iCBT 

intervention or treatment as usual. The iCBT intervention group demonstrated significantly better 

improvement in self-reported PTSD symptoms. Support for the iCBT was provided by Veteran peers rather 

than a therapist. Study limitations included an inability to track treatment fidelity, levels of distress (which 

were measured as mild-to-moderate in degree), and levels of PTSD at the end of the study which 

potentially could benefit from further treatment.[219]

Some studies have pointed out the particular utility of web-based interventions in certain settings. In a 

study of 159 patients randomized to either iCBT or to waitlist control, there was significant improvement 

in the treatment group versus the control group, with effects sustained at three-month follow-up as 

measured by the PDS.[220]

A small pilot study demonstrated the feasibility of using iCBT in primary care with Veterans.[221]

Treatment in primary care may be associated with less stigma than a mental health appointment, making 

the use of iCBT in primary care an attractive option for those refusing a mental health referral. In a study of 

80 Veterans randomized to either iCBT versus optimized usual care in a primary care setting, the iCBT 

group demonstrated significantly better outcomes on the PTSD Checklist – Civilian Version (PCL-C) than 
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optimized usual care, which consisted of care management, feedback to the primary care provider, and 

training on the management of PTSD in primary care settings. A registered nurse provided support to the 

study participants. Study limitations included a small sample size and the inability to measure treatment 

adherence.[222]

While there are several limitations to these studies, the Work Group suggests the use of supported iCBT 

along with the qualifications stated below: 

• Clinicians should carefully review the content of any web-based materials to ensure their 

accuracy and ethical application before recommending their use to patients.

• Web-based approaches may be used when face-to-face interventions are not feasible (e.g., 

geography limits access to other forms of treatment) or when patients decline more traditional 

mental health interventions. 

• Providers should regularly encourage patients to complete the intervention and endeavor to 

maintain and strengthen the therapeutic relationship, build patient rapport, stress practice and 

assignment completion, and ensure adequacy of safety protocols. Availability of telephone 

contact for initial assessment or other reasons (e.g., emergencies, suicidality/homicidality, or 

follow-up of specific problems) should be considered.

• Providers using technology-assisted interventions should take steps to ensure that their work 

complies with the regulations and procedures of the organization in which they are employed, 

legal standards, and the ethical standards of their professions. Patient confidentiality and safety 

should be monitored closely.

These interventions may be suggested for patients who refuse other treatment interventions. However, 

the Work Group’s confidence in the quality of evidence for iCBT is low. Moreover, iCBT is not as well 

supported by the scientific literature as primary treatments for PTSD. The benefits appear to only slightly 

outweigh the harms. We also recognize that these studies provided oversight to the participants through 

qualified facilitators familiar with the treatment protocols. There were concerns that unsupervised iCBT 

or supervision by a peer not adequately trained to deal with a mental health crisis could be a potential 

harm. Also, there are potential barriers, including knowledge and/or availability of technology, technical 

support, and cost, which might prevent some individuals from using these approaches. 

The Work Group also recognized many potential advantages of iCBT, including increased access to services 

and reduced stigma in seeking services. These interventions are convenient and can be completed on the 

patient’s own schedule. Participation in supervised iCBT programs could be potentially very helpful to 

those in remote areas, locations where other services are not readily available, or when irregular hours 

preclude conventional clinical care. This is a promising area of research and more studies are needed 

before internet-based interventions can be strongly recommended. Some potential areas of research 

include human factors in using the technology, monitoring adherence, comparison to in-person PTSD 

treatments, and studies looking at the types of interventions and their mechanisms of action.
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Recommendation

36. We recommend using trauma-focused psychotherapies that have demonstrated efficacy using 

secure video teleconferencing (VTC) modality when PTSD treatment is delivered via VTC.

(Strong For | Reviewed, Amended)

Discussion

An initial study in 2009 demonstrated the non-inferiority of VTC to in-person treatment of anger 

management in combat Veterans with PTSD.[223] Since then, additional studies have been completed that 

support the delivery of exposure therapies, anger treatment, and CPT through VTC, strengthening the 

support for the use of this modality in the delivery of care.[224-227]

Two studies demonstrated the non-inferiority of delivering exposure therapies for Veterans with PTSD 

through VTC to the home. In a study of 232 Veterans randomized to eight sessions of a combined 

behavioral activation and therapeutic exposure treatment delivered either in-person or through homebased VTC, both modalities of treatment produced significant improvements in symptoms. The delivery of 

the intervention through VTC was non-inferior to the in-person delivery of the treatment, meaning that it 

was shown to be just as good as the standard delivery mechanism.[227] In another study of 52 Veterans 

receiving eight to 12 sessions of PE either in-person or through home-based VTC, there was a significant 

reduction in symptoms for both groups, and the outcomes were non-inferior for the VTC group versus the 

in-person treatment group.[224]

Both individual and group CPT are effective when delivered through VTC. In a study of 126 women with 

PTSD (including 21 Veterans) receiving individual CPT once to twice weekly for 12 sessions, there was no 

difference between the in-person delivery of CPT and delivery by VTC, with significant symptom 

improvements in both groups.[225] An additional study of 125 male Veterans randomized to group CPT-C 

provided either in-person or through VTC demonstrated significant symptom reduction in both groups, 

with the treatment outcomes in the VTC group being non-inferior to the in-person treatment group.[226]

Another study demonstrated a trend suggesting that delivery of individual CPT to Veterans through VTC 

was non-inferior to in-person treatment, but the study was underpowered to make any definitive 

conclusions.[227]

The Work Group has updated and built upon the recommendations from the 2010 PTSD CPG based upon 

these new studies as described above. Although there are fewer studies examining the delivery of 

evidence-based treatments through VTC than those delivered in-person, there appears to be similar 

efficacy for VTC interventions as compared to the in-person delivery of services.

• VTC interventions are encouraged when: in-person interventions are not feasible due to 

geographic distance between patient and provider or other barriers to patient access (e.g., 

agoraphobia, physical disability), the patient would benefit from more frequent contact than is 

feasible with face-to-face sessions, or the patient declines in-person treatment.

• Providers using VTC interventions should endeavor to maintain and strengthen the therapeutic 

relationship, build patient rapport, stress practice and assignment completion, and ensure 

adequacy of safety protocols using similar techniques as they do in-person.
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• Providers using VTC should take steps to ensure that their work complies with the regulations 

and procedures of the organization in which they are employed, legal standards, and the ethical 

standards of their professions. Patient confidentiality and safety should be monitored closely.

The Work Group’s confidence in the quality of evidence is moderate. However, there are some concerns 

associated with treatment delivery through VTC such as technical support, computer literacy, and human 

factors in using technology. Potential advantages include increased access and decreased stigma. Further 

research is needed to address these questions.

Although this recommendation is specific to the delivery of trauma-focused therapies tested in VTC 

settings, the Work Group recognizes that VTC policies across the VA and DoD take a broad interpretation 

of the literature in making the assumption that any evidence-based outpatient modality being delivered in 

a face-to-face clinical setting may be considered for VTC delivery. This recommendation should not be 

interpreted to imply that modalities that have not been specifically tested through VTC are precluded from 

consideration based upon factors such as research literature outside the scope of this guideline, clinical 

judgment, SDM, availability of treatment modalities, and others. However, because the recommendations 

in this guideline are based on empirical evidence, the PTSD Work Group limited the recommendation to 

those treatments that have demonstrated efficacy.

E. Treatment of Posttraumatic Stress Disorder with Co-occurring Conditions

Recommendation

37. We recommend that the presence of co-occurring disorder(s) not prevent patients from receiving 

other VA/DoD guideline-recommended treatments for PTSD.

(Strong For | Reviewed, New-added)

Discussion

Treatment studies of PTSD with various co-occurring disorders have shown that individuals with comorbid 

conditions can tolerate and benefit from evidence-based individual trauma-focused PTSD treatment, such 

as PE and CPT. RCTs using various methods rated as fair quality are consistent with these findings. For 

adults diagnosed with PTSD, treatment safety and effectiveness does not appear to be altered by the 

presence of comorbidities. 

Based on a systematic review of 14 RCTs, the Work Group concluded that the presence of an SUD should 

not prevent concurrent treatment with evidence-based, trauma-focused therapy for PTSD.[127] A more 

detailed review of PTSD and co-occurring SUD is provided in Recommendation 38. Similarly, a detailed 

review of PTSD and co-occurring sleep disturbances is provided in Recommendation 39 and 

Recommendation 40. RCTs have found good tolerance and efficacy for various trauma-focused PTSD 

treatments in patients with comorbid psychotic disorders,[228] personality disorders,[122] severe mental 

illness,[229] dissociation,[230,231] anger,[232] suicidal ideation,[233] and depression.[232] One RCT 

addressed the issue of the safety of delivering imaginal exposure to patients with PTSD resulting from a 

cardiovascular event and found no evidence of adverse outcomes from the treatment.[234] The findings 

from this study suggest that cardiovascular patients should not be prevented from receiving evidencebased PTSD treatments because of safety concerns. 
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We did not find any studies meeting the threshold for review that examined the common comorbidities of 

TBI or pain. Well-designed trials looking at the treatment of PTSD and comorbidities, including individuals 

with multiple co-occurring conditions, are needed. Studies that also examine the patterns and predictors 

of PTSD and co-occurring condition change are needed to help determine if changes occur concurrently or 

if changes primarily by PTSD symptoms influence subsequent co-occurring disorder change. However, 

based on this evidence review, individuals with comorbid disorders should not be excluded from evidencebased treatment for PTSD.

Recommendation

38. We recommend VA/DoD guideline-recommended treatments for PTSD in the presence of cooccurring substance use disorder (SUD).

(Strong For | Reviewed, New-replaced)

Discussion

Among Veterans with PTSD, rates of problematic drinking range from 12% to 48%.[235] Among Veterans 

with an SUD, rates of PTSD range from 63% to 76%.[236] Whether or not PTSD and SUDs may be treated 

concurrently, or if one (typically SUD) must be stabilized prior to treating the other, has historically been a 

topic of debate among clinicians, primarily due to concerns that individuals with SUDs may not be able to 

tolerate trauma-focused PTSD treatment.[127] Recent research, however, has shown that patients with 

PTSD and SUD (including nicotine use disorder) can both tolerate and benefit from concurrent treatment 

for both conditions, even in the most severe cases.[237]

A 2015 systematic review of 14 controlled trials in individuals with co-occurring PTSD and SUD found that 

trauma-focused therapies including exposure and cognitive restructuring, when delivered together with 

SUD interventions, were more likely than SUD treatment alone or treatment as usual to improve PTSD 

symptoms.[127] Several of these therapies also showed benefit in improving SUD symptoms after five to 

seven months.[127]

Non-trauma-focused PTSD therapies (e.g., Seeking Safety), when delivered together with an SUD therapy, 

did not improve PTSD symptoms in individuals with SUDs more than SUD treatment alone or treatment as 

usual. Evidence of improvement in SUD symptoms is mixed.[127,238,239] Thus, the Work Group does not 

recommend non-trauma-focused therapies such as Seeking Safety for the treatment of PTSD in the 

context of co-occurring SUD. 

Likewise, medication trials of topiramate (up to 300 mg daily) [240] and prazosin (16 mg daily in divided 

doses) [241] in patients with comorbid PTSD and AUD failed to demonstrate efficacy in improving the 

primary symptoms of PTSD, although both medications reduced percent drinking days. In another study, 

desipramine outperformed paroxetine in reducing drinking days, although both showed some benefit on 

both drinking and core PTSD symptoms. Interestingly, in the same study, the addition of naltrexone had no 

effect on outcomes.[242] Combining medication and psychotherapy, however, may be a potentially 

effective strategy for PTSD and SUD. In one study, adding PE to naltrexone reduced drinking more at six

months following treatment completion than naltrexone alone.[237]

The Work Group rated its overall confidence in the literature on treating PTSD and SUDs concurrently as 

moderate. A number of RCTs evaluating both pharmacotherapy and psychotherapy interventions met the 
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threshold for review. Most were deemed to be of fair to good quality. In general, the risks of traumafocused psychotherapies are limited. Patient factors that may warrant consideration include possible 

denial of their SUD, reluctance to stop using a substance perceived as beneficial for coping with PTSD 

symptoms, and ambivalence about engaging in treatment for either PTSD or SUDs. Concurrent treatment 

of PTSD and SUDs also presumes that sufficient resources (e.g., programs, therapists) exist to treat both 

simultaneously and that providers are skilled in the management of co-occurring disorders. More research 

is needed to explore the comparative efficacies of different trauma-focused psychotherapies in this 

population, whether or not different approaches are needed for different substances or patterns of use, 

and how to improve treatment completion rates.

Recommendation

39. We recommend an independent assessment of co-occurring sleep disturbances in patients with 

PTSD, particularly when sleep problems pre-date PTSD onset or remain following successful 

completion of a course of treatment.

(Strong For | Reviewed, New-replaced)

40. We recommend Cognitive Behavioral Therapy for Insomnia (CBT-I) for insomnia in patients with

PTSD unless an underlying medical or environmental etiology is identified or severe sleep 

deprivation warrants the immediate use of medication to prevent harm.

(Strong For | Reviewed, Amended)

Discussion

Sleep disturbance is found in 90-100% of Veterans with PTSD.[243,244] Some types of sleep 

disturbance, such as anxiety about falling asleep due to nightmares, are fairly unique to PTSD. Others, 

including obstructive sleep apnea, restless leg syndrome, and early morning awakening may occur in 

patients with PTSD, but are likely to have an alternative etiology and should be considered as cooccurring disorders. Sleep disturbances often do not improve after otherwise effective first-line PTSD 

treatments.[245,246] It is thus important to examine potential causes of sleep disturbance 

independently of PTSD, particularly with respect to underlying medical, dietary, and environmental 

etiologies. A discussion of primary treatments for co-occurring sleep disturbances is beyond the scope of 

this guideline; interested clinicians may wish to review the CPG on Chronic Insomnia Disorder published 

by the American College of Physicians in 2016.[247]

Few studies have explicitly evaluated the treatment of sleep disturbance in patients with PTSD. Among 11 

studies examined in a 2016 systematic review by Ho et al.,[248] low-to-moderate quality evidence favored 

the use of CBT-I with and without the addition of Imagery Rehearsal Therapy (IRT) or Exposure, Relaxation, 

and Rescripting Therapy (ERRT) in patients with PTSD and sleep disturbance. One RCT found that CBT-I 

improved sleep in Veterans with PTSD; importantly, the gains were still seen at six months posttreatment.[249] CBT-I has also been recommended by the American College of Physicians as the initial 

treatment for chronic insomnia [247] and web-based CBT-I applications have also shown significant 

benefit.[250,251] Medication should be considered a second-line intervention at this time following an 

unsuccessful course of CBT-I treatment, and should include an SDM discussion regarding the harms and 

benefits of the medication. 
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Treating nightmares is an integral part of treating sleep disturbance in PTSD. However, the data are 

somewhat inconclusive regarding the best choice of intervention. Initial studies of IRT in civilian 

populations were positive,[252,253] but a subsequent, higher-quality trial evaluating the use of IRT in 

Veterans showed no benefit for nightmare frequency, sleep quality, or PTSD symptoms.[254] Another 

trial examining the use of IRT administered with CBT-I in Veterans found both objective and subjective 

improvements in sleep quality, PTSD symptoms, and depression.[255] The study, however, had a waitlist 

control and lacked a comparison group without the adjunctive IRT, so it is difficult to determine the 

mechanism of change. Some participants reported difficulty engaging in imagery techniques (a finding 

noted in several IRT studies), but the protocol overall was acceptable to Veterans and had reasonably 

high completion rates. Ho et al. assessed the evidence of benefit for ERRT in treating nightmares as 

being of moderate quality.[248] However, the evidence for ERRT is inconclusive at this time. The two 

ERRT studies examined by Ho et al. enrolled primarily Caucasian women, had treatment groups 

numbering fewer than 25 subjects each, did not require a diagnosis of PTSD, and did not include any 

physiological indices of sleep functioning.[256,257] For information regarding the use of prazosin for 

nightmares, see section on Prazosin. 

The Work Group’s overall confidence in the literature on sleep disturbances co-occurring with PTSD is low. 

However, the risks of treating sleep problems with a discussion of good sleep habits and psychotherapy 

are very low and patient buy-in is generally quite high due to the potential benefits of sleep on overall 

health and well-being. At this time, CBT-I continues to offer the strongest evidence and greatest promise. 

It is a particularly attractive modality because training is widely available in the VA and DoD, it can be 

delivered in individual or group format, and it requires only a few sessions. Future research should explore 

the best sequence of treating PTSD and co-occurring sleep disturbance. It should also examine the relative 

efficacy of effective PTSD treatment versus treatment as usual plus CBT-I in populations with PTSD. 

Additionally, we need studies evaluating whether or not there is a difference in treating sleep disturbance 

as an independent condition versus treating it as a component of PTSD. Finally, it may be determined that 

proactive management of sleep disturbances in Veterans has value in preventing PTSD; more research is 

needed to explore this possibility.
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VII. Knowledge Gaps and Recommended Research

During the development of the 2017 version of the PTSD CPG, the Work Group identified a number of 

areas for which future research should be conducted. These included, but are not limited to, the following:

A. Shared Decision Making and Collaborative Care

• SDM in the context of making treatment decisions for PTSD

• The effect of collaborative care on long-term utilization of effective PTSD treatment and other 

healthcare services 

• Key components of SDM and collaborative care that impact PTSD treatment effectiveness

• The role of technology-assisted interventions in improving the effectiveness of collaborative 

care to treat PTSD

B. Treatments for Acute Stress Disorder and Preventing Posttraumatic Stress 

Disorder

• Studies examining the efficacy and safety of pharmacotherapy and psychotherapy treatments 

for ASD

• Studies examining the efficacy, safety, and cost effectiveness of pharmacotherapy and 

psychotherapy treatments to prevent PTSD

C. Treatments for Posttraumatic Stress Disorder

• Issues of access and how to improve access, including accessibility and treatment retention

 Studies examining how treatment completion rates can be improved

 Studies to improve treatment motivation and treatment engagement

 Studies examining the role of treatment choice in retention and the effectiveness of 

treatment

 Studies examining models of implementation of effective treatments including costs, 

value, and feasibility

 Studies examining novel implementation approaches of effective interventions, such as 

telehealth, web-based, and primary-care-based models of care

• Comparative efficacy and effectiveness of established treatments

 Comparative studies of different methods of treatment provisions including couples, 

family, group, and individually provided interventions

 Direct comparisons between established treatments, including psychotherapies and 

pharmacologic treatments 

 Examine treatment approaches for refractory PTSD and sequencing of treatments 

following partial response
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 Studies including outcomes beyond symptoms such as comorbid conditions, health 

outcomes, biomarkers, and cost-effectiveness

 More rigorous research on the effectiveness of pharmacotherapy options 

 Examination of treatment dosing and duration and the impact on outcomes

 Further investigation of the use of topiramate, prazosin, ketamine and novel therapies 

in patients with PTSD

• Studies examining treatment effectiveness in different patient populations

 Studies informing the selection of treatments for specific patient populations, including 

men and women, various ethnic and racial groups, and various war cohort and trauma 

exposure groups

 Examine the influence of service connection, disability, and the process of evaluation on 

treatment choice, retention, and response in the short and long-term

 Examination of the effectiveness of practice-based variations/modifications to 

established psychotherapy protocols to include variations in length, frequency, and 

number of sessions as well as variations in specific techniques resulting from specific 

patient population or logistical considerations

• Augmentation of established treatments with other treatment options and/or novel approaches

 Investigation of factors related to D-cycloserine and hydrocortisone use such as 

identification of efficacy, patient subtypes, proper dosing, and timing of dose 

administration 

 Examination of the impact of combining two or more established treatments for PTSD or 

augmenting an established treatment with a novel treatment

• Clinical trials testing emerging, novel treatments to improve the range of options available to 

patients 

• Research to establish mechanisms of PTSD development and effective treatments to directly 

inform treatment development and improvement

 Research examining the use of additive and/or dismantling designs to investigate 

creating more effective treatments

 Studies to bring order/parsimony to treatment decision making and development

 Examination of treatment impact beyond mental health symptoms to larger biological 

systems 

 Optimize treatment outcomes through mechanism-based treatment modifications

 Research to better match patients to treatments based on biological or other factors

• Studies examining methods of training and dissemination of effective treatments

 Best ways to disseminate effective treatments broadly while maintaining fidelity
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D. Non-Pharmacologic Biological Treatments for Posttraumatic Stress 

Disorder

• Studies examining the efficacy of rTMS for PTSD treatment, including studies to identify 

parameters of effective treatment such as the location and frequency of dose, and duration of 

treatment

• Studies of acupuncture involving a sham control to examine relationship between placebo effect 

and improved outcomes

• Adequately powered, actively controlled trials with sufficient follow-up periods for meditation 

and other types of CIH practices 

E. Technology-based Treatments for Posttraumatic Stress Disorder

• Studies examining internet-based interventions including the human factors involved in using 

the technology, monitoring adherence, comparison to in-person PTSD treatments, and types of 

interventions offered

• Factors that affect treatment delivery through VTC such as technical support, computer literacy, 

and human factors in using technology

• Studies examining modified or novel treatment protocols that take advantage of technologybased delivery of care

• Examine potential advantages to technology-based modalities such as increased access and 

decreased stigma

F. Treatments for Posttraumatic Stress Disorder with Comorbidities and Cooccurring Conditions

• Trials examining the concurrent treatment of PTSD and comorbidities, including individuals with 

multiple co-occurring conditions

• Studies that examine the patterns and predictors of changes in PTSD symptoms in relation to cooccurring conditions 

• Investigation of whether the improvement of PTSD symptoms influences co-occurring 

conditions and/or if improvements to co-occurring conditions influence PTSD symptoms

• Comparative efficacies of different trauma-focused psychotherapies in populations with cooccurring conditions

• Studies determining the optimal sequence of treating PTSD and co-occurring sleep disturbance, 

including evaluating whether or not there is a difference in treating sleep disturbance as an 

independent condition versus treating it as a component of PTSD

• Proactive management of sleep disturbances in Veterans and its role in prevention of PTSD

• Relative efficacy of PTSD treatment versus treatment as usual with CBT-I

• Studies addressing PTSD among older Veterans with dementia and other conditions

• Studies addressing PTSD in the context of advanced illness/end-of-life care
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Appendix A: Evidence Review Methodology

A. Developing the Scope and Key Questions

The CPG Champions, along with the Work Group, were tasked with identifying KQs to guide the systematic 

review of the literature on PTSD. These questions, which were developed in consultation with the Lewin 

team, addressed clinical topics of the highest priority for the VA and DoD populations. The KQs follow the 

population, intervention, comparison, outcome, timing and setting (PICOTS) framework for evidence 

questions, as established by the Agency for Healthcare Research and Quality (AHRQ). Table A-1 provides a 

brief overview of the PICOTS typology.

Table A-1. PICOTS [258]

P

Patients, 

Population, or 

Problem

A description of the patients of interest. It includes the condition(s), populations or subpopulations, disease severity or stage, co-occurring conditions, and other patient 

characteristics or demographics.

I Intervention or 

Exposure

Refers to the specific treatments or approaches used with the patient or population. It 

includes doses, frequency, methods of administering treatments, etc.

C Comparison

Describes the interventions or care that is being compared with the intervention(s) of 

interest described above. It includes alternatives such as placebo, drugs, surgery, lifestyle 

changes, standard of care, etc.

O Outcome

Describes the specific results of interest. Outcomes can include short, intermediate, and 

long-term outcomes, or specific results such as quality of life, complications, mortality, 

morbidity, etc.

(T) Timing, if 

applicable

Describes the duration of time that is of interest for the particular patient intervention and 

outcome, benefit, or harm to occur (or not occur).

(S) Setting, if

applicable

Describes the setting or context of interest. Setting can be a location (such as primary, 

specialty, or inpatient care).

The Champions, Work Group, and evidence review team carried out several iterations of this process, each 

time narrowing the scope of the CPG and the literature review by prioritizing the topics of interest. Due to 

resource constraints, all developed KQs were not able to be included in the systematic evidence review.

Thus, the Champions and Work Group determined which questions were of highest priority, and those 

were included in the review. Table A-2 contains the final set of KQs used to guide the systematic review for 

this CPG. 

a. Population(s)

• Adults 18 years or older with PTSD or ASD treated in any VA/DoD clinical setting

b. Interventions

• Key Question 1: Drug classes

 SSRIs

 SNRIs

 TCAs

 MAOIs

 Other antidepressants
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 Mood stabilizer/anticonvulsants

 Antipsychotics 

 Benzodiazepines (anti-anxiety, sedative/hypnotics)

 Non-benzodiazepine sedative/hypnotics

 Antianxiety, non-benzodiazepines

 Peripheral alpha-1 antagonists

 Other sympatholytics

 Beta-blockers

 Psychostimulants

 Steroids

 Cannabinoids

 Other

• Key Question 2: Trauma-focused psychotherapies—therapies that include consciously recalling 

or activating the traumatic memory either as part (or all) of the presumed therapeutic 

mechanism or to provide material for other therapeutic techniques (e.g., cognitive 

restructuring, relaxation, imagery substitution)

 PE Therapy

 CPT

 EMDR

 Narrative therapy

 Written exposure therapy

 Accelerated Resolution Therapy

 Trauma-focused CBT

 Cognitive therapy

 Virtual reality exposure

 IRT

 CBCT

 Mindfulness-based exposure therapy

 Emotional Freedom Technique/Thought Field Therapy

 BEP

 Non-trauma-focused psychotherapies

 PCT

 Problem-solving therapy
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 SIT

 Mindfulness therapies

 MBSR

 Family therapy

 Behavioral activation

 IPT

 Emotionally Focused Couples Therapy

 ACT

 Relaxation

 Supportive counseling

 Brief psychodynamic therapy

 Neurolinguistic programming (NLP)

 Seeking Safety

• Key Question 3: Non-pharmacologic biological treatments

 SGB

 HBOT

 ECT

 TMS

• Key Question 4: Complementary and integrative treatments 

 Mind-body practices

 Acupuncture

 Mindfulness (stand-alone)

 Meditation

 Relaxation

 Mantram

 Natural products

 Animal-assisted therapy

 Creative therapy (e.g., music, art, drama therapy) 

 Recreational therapy (e.g., exercise, fishing)

 Progressive muscle relaxation

• Key Question 5: See list of interventions for KQ 1 and 2 

• Key Question 6: See list of interventions for KQ 1 and 2
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• Key Question 7: Group psychotherapy

 CBT (trauma-focused psychotherapy or non- trauma-focused psychotherapy) 

 Psychodynamic, supportive, or peer group psychotherapy

• Key Question 8: Collaborative care, integrated care

 Mental health integration (e.g., primary care mental health integration [PCMHI]) 

 Embedded behavioral health 

 Care management models

 Stepped care

• Key Question 9: Technology-based modalities 

 Telehealth 

 Virtual reality 

 VTC

 Telephone based or web-based tools 

 Mobile apps

• Key Question 10: Any intervention in KQ 1–5 

• Key Question 11: Any intervention in KQ 1–5 in patients with PTSD with co-morbidity

• Key Question 12: Peer support

c. Outcomes

• Primary outcomes

 Improvement in global PTSD severity based on CAPS or other validated structured 

clinical interviews

 Adverse events

 Retention/dropout rate

 Loss of diagnosis/remission

• Secondary outcomes

 Self-reported PTSD

 Specific symptom improvement (e.g., sleep, anger/aggression)

 Comorbid symptoms (e.g., depression, anxiety, SUD, pain, physical symptoms, sleep, 

aggression, post-concussive symptoms)

 Quality of life 

 Functional status

 Patient satisfaction 
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B. Conducting the Systematic Review

Extensive literature searches identified 1,667 citations potentially addressing the KQs of interest to this 

evidence review. Of those, 367 were excluded upon title review for clearly not meeting inclusion criteria 

(e.g., not pertinent to the topic, not published in English, published prior to study inclusion publication 

date, or not a full-length article). Overall, 1,300 abstracts were reviewed with 666 of those being excluded 

for the following reasons: not a systematic review or clinical study, did not address a KQ of interest to this 

review, did not enroll a population of interest, or published prior to January 2009. A total of 634 full-length 

articles were reviewed. Of those, 347 were excluded at a first pass review for the following: not addressing 

a KQ of interest, not enrolling the population of interest, not meeting inclusion criteria for clinical study or 

systematic review, not meeting inclusion criteria for any KQ, or being a duplicate. A total of 287 full-length 

articles were thought to address one or more KQs and were further reviewed. Of these, 150 were 

ultimately excluded. Reasons for their exclusion are presented in Figure A-1 below. 

Overall, 122 studies (in 133 publications) addressed one or more of the KQs and were considered as 

evidence in this review. Table A-2 indicates the number of studies that addressed each of the questions. 
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Figure A-1. Study Flow Diagram

Abbreviations: CS: comparative study; KQ: key question; PTSD: posttraumatic stress disorder; SR: systematic review

, 

150 Citations Excluded at 2nd Pass Full Article Level

38 SR superseded by or overlaps with an included SR

32 SR with methodological or other issues or 

narrative review

27 Study appears in included SR

16 No PTSD diagnosis or <80% of patients with PTSD 

diagnosis

37 Other 

150 Citations Excluded at 2nd Pass Full Article Level

38 SR superseded by or overlaps with an included SR

32 SR with methodological or other issues or 

narrative review

27 Study appears in included SR

16 No PTSD diagnosis or <80% of patients with PTSD 

diagnosis

37 Other 

367 Citations Excluded at the Title Level

Citations excluded at this level were off-topic, not 

published in English, or published prior to

inclusion date

367 Citations Excluded at the Title Level

Citations excluded at this level were off-topic, not 

published in English, or published prior to

inclusion date

1,667 Citations Identified by Searches

1,300 Abstracts 

Reviewed

1,300 Abstracts 

Reviewed

666 Citations Excluded at the Abstract Level

Citations excluded at this level were not SR or CS, 

clearly did not address a KQ, did not report on an 

outcome of interest, or were outside cutoff 

publication dates

666 Citations Excluded at the Abstract Level

Citations excluded at this level were not SR or CS, 

clearly did not address a KQ, did not report on an 

outcome of interest, or were outside cutoff 

publication dates

287 Articles 

Reviewed

122 Included Studies (in 133 publications)

 347 Citations Excluded at 1st Pass Full Article Level

Articles excluded at this level did not: address a key 

question of interest, enroll the population of interest, 

meet inclusion criteria for clinical study or systematic 

review, meet inclusion criteria for any key question, 

or were a duplicate.

 347 Citations Excluded at 1st Pass Full Article Level

Articles excluded at this level did not: address a key 

question of interest, enroll the population of interest, 

meet inclusion criteria for clinical study or systematic 

review, meet inclusion criteria for any key question, 

or were a duplicate.

634 Full-length Articles Reviewed
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Table A-2. Evidence Base for KQs

Question 

Number Question

Number of Studies &

Type of Studies

1

For adults diagnosed with PTSD, what is the effectiveness and safety of 

pharmacotherapy treatments to improve PTSD symptoms?

a. Are there specific medications within certain classes (e.g., sertraline 

within SSRI category) that have evidence of greater efficacy and safety 

than other medications within the same class?

6 SRs and 7 RCTs

2

For adults diagnosed with PTSD, what is the effectiveness and safety of 

psychotherapy treatments to improve PTSD symptoms?

a. Do any individual non-trauma-focused therapies (e.g., PCT, IPT, SIT) 

demonstrate equivalent or nearly equivalent efficacy to trauma-focused 

therapies?

b. For the therapies that are effective, is the efficacy of the components of 

psychotherapies equivalent to the full therapy protocol or components 

of combined protocols?

c. What is the safety and effectiveness of brief interventions to be 

delivered in primary care or any setting where full interventions are not 

feasible for improving PTSD symptoms?

d. What is the role of peer support in treatment outcomes?

3 SRs (in 4 publications) 

and 19 RCTs (in 21 

publications)

3

For adults diagnosed with PTSD, what is the effectiveness and safety of nonpharmacologic biological treatments, such as stellate ganglion block, 

hyperbaric oxygen, ECT, or transcranial magnetic stimulation to improve 

PTSD symptoms?

1 SR and 1 RCT

4

For adults diagnosed with PTSD, are complementary and integrative 

treatments such as mind-body practices, natural products, animal-assisted 

therapy, and creative therapy, safe and effective either as primary 

treatments or adjunctive to standard treatments?

2 SRs and 6 RCTs

5

For adults diagnosed with PTSD, what combined treatment approaches are 

safe and effective in enhancing treatment response?

a. Combination of two or more medication monotherapies

b. Augmenting psychotherapy or medication treatment to enhance 

outcomes

c. Combination of psychotherapy with medication

2 SRs and 11 RCTs

6

What is the comparative effectiveness of medication and psychotherapy 

overall, and within specific classes (e.g., medication versus psychotherapy), 

for SSRIs versus trauma-focused psychotherapy?

1 SR and 2 RCTs

7

For adults diagnosed with PTSD, what is the effectiveness and safety of CBT 

(trauma-focused psychotherapy or non-trauma-focused psychotherapy), 

psychodynamic therapy, supportive psychotherapy, or peer psychotherapy 

treatments delivered in a group therapy setting?

a. What is the effectiveness of group therapy versus individual therapy 

setting?

b. Non-specific group interventions (adjunctively?)

2 SRs and 7 RCTs (in 8 

publications)

8 For adults diagnosed with PTSD, what is the effectiveness and safety of 

collaborative care interventions?

6 RCTs
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Question 

Number Question

Number of Studies &

Type of Studies

9

What is the effectiveness and safety of treatment delivered via technology 

based modalities?

a. What is the comparative effectiveness of treatment delivered by a 

therapist or licensed health professional via technology based 

modalities versus in-person?

b. What is the comparative effectiveness of treatment delivered via videoteleconferencing based modalities versus telephone based modalities?

19 RCTs

10 What treatments are safe and effective for acute stress disorder or acute 

stress reaction?

3 SRs (in 4 publications) 

and 2 RCTs

11

For adults diagnosed with PTSD, is treatment safety and effectiveness 

altered by presence of comorbidities?

3 SRs, 20 RCTs or 

secondary analyses of 

RCTs (in 26 publications) 

and 2 retrospective 

cohort studies

12

What is the safety and effectiveness of peer support approaches?

a. Stand-alone

b. Adjunct therapy

No studies identified

Total Evidence Base 122 studies (in 133 

publications)

Abbreviations: CBT: cognitive behavioral therapy; ECT: electroconvulsive therapy; IPT: Interpersonal psychotherapy; PCT: presentcentered therapy; PTSD: posttraumatic stress disorder; RCT: randomized controlled trial; SIT: Stress Inoculation Training; SSRI: 

serotonin reuptake inhibitors; SR: systematic review

a. Criteria for Study Inclusion/Exclusion

i. General Criteria

 Clinical studies or systematic reviews published on or after January 1, 2009 to March 

2016. If multiple systematic reviews address a KQ, we selected the most recent and/or 

comprehensive review. Systematic reviews were supplemented with clinical studies 

published subsequent to the systematic review.

 Studies must be published in English.

 Publication must be a full clinical study or systematic review; abstracts alone were not 

included. Similarly, letters, editorials, and other publications that were not full-length 

clinical studies were not be accepted as evidence. 

 Study must have enrolled at least 20 patients (10 per study group) unless otherwise 

noted (see Key Question Specific Criteria below)

 Study must have reported on an outcome of interest. 

 Study must have enrolled a patient population in which at least 80% of patients were 

diagnosed with PTSD (or ASD for KQ 10) and were age 18 years or older. If the 

percentage is less than 80%, then data must have been reported separately for this 

patient subgroup.
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ii. Key Question Specific Criteria

 For KQs 1–10 and 12, acceptable study designs included systematic reviews of RCTs and

individual RCTs not evaluated in systematic reviews. If no relevant studies with these 

designs were found for a given KQ or sub-question, prospective nonrandomized 

comparative studies were evaluated for inclusion.

 For KQ 11, acceptable study designs included systematic reviews, RCTs, or prospective 

cohort studies that statistically compared outcomes for patients with PTSD and a cooccurring medical or mental health condition to patients with PTSD and no additional 

medical or mental health condition. Large retrospective database studies (200 patients 

minimum) that performed multivariate statistical analyses of the effect of co-occurring 

conditions on patient outcomes were also acceptable. 

b. Literature Search Strategy

Information regarding the bibliographic databases, date limits, and platform/provider can be found in 

Table A-3, below. Additional information on the search strategies, including topic-specific search terms and 

search strategies can be found in Appendix G: Literature Review Search Terms and Strategy. 

Table A-3. Bibliographic Database Information 

Name Date Limits Platform/Provider

Bibliographic Databases 

The Cochrane Database of Systematic Reviews (Cochrane 

Reviews) 2009 to February 2, 2016 Wiley

EMBASE (Excerpta Medica) 2009 to March 3, 2016 Elsevier

Health Technology Assessment Database (HTA) 2009 to February 2, 2016 Wiley

MEDLINE/PreMEDLINE 2009 to March 3, 2016 Elsevier

PILOTS: Published International Literature On Traumatic Stress 2009 to March 9, 2016 ProQuest

PsycINFO 2009 to March 3, 2016 OVIDSP

PubMed (In-process and Publisher records) 2009 to March 3, 2016 NLM

Gray Literature Resources 

The Evidence-based Synthesis Program (ESP) Reports 2009 to March 16, 2016 VA

C. Convening the Face-to-face Meeting

In consultation with the COR, the Champions, and the Work Group, the Lewin Team convened a three and 

a half day face-to-face meeting of the CPG Champions and Work Group members on August 29-September 

1, 2016. These experts were gathered to develop and draft the clinical recommendations for an update to 

the 2010 PTSD CPG. Lewin presented findings from the evidence review of KQs 1-12 in order to facilitate 

and inform the process. 

Under the direction of the Champions, the Work Group members were charged with interpreting the 

results of the evidence review, and asked to categorize and carry forward recommendations from the 

2010 PTSD CPG, modifying the recommendations as necessary. The members also developed new clinical 

practice recommendations not presented in the 2010 PTSD CPG, based on the 2016 evidence review. The 

subject matter experts were divided into three smaller subgroups at this meeting. 
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As the Work Group members drafted clinical practice recommendations, they also assigned a grade for 

each recommendation based on a modified GRADE and USPSTF methodology. Each recommendation was 

graded by assessing the quality of the overall evidence base, the associated benefits and harms, the 

variation in values and preferences, and other implications of the recommendation.

In addition to developing recommendations during the face-to-face meeting, the Work Group members 

also revised the 2010 PTSD CPG algorithms to reflect the new and amended recommendations. They 

discussed the available evidence as well as changes in clinical practice since 2010, as necessary, to update 

the algorithms.

D. Grading Recommendations

This CPG uses the GRADE methodology to assess the quality of the evidence base and assign a grade for 

the strength for each recommendation. The GRADE system uses the following four domains to assess the 

strength of each recommendation: [31]

• Balance of desirable and undesirable outcomes 

• Confidence in the quality of the evidence 

• Values and preferences

• Other implications, as appropriate, e.g.,:

 Resource use

 Equity

 Acceptability

 Feasibility

 Subgroup considerations

The following sections further describe each domain. 

Balance of desirable and undesirable outcomes refers to the size of anticipated benefits (e.g., increased 

longevity, reduction in morbid event, resolution of symptoms, improved quality of life, decreased 

resource use) and harms (e.g., decreased longevity, immediate serious complications, adverse event, 

impaired quality of life, increased resource use, inconvenience/hassle) relative to each other. This 

domain is based on the understanding that the majority of clinicians will offer patients therapeutic or 

preventive measures as long as the advantages of the intervention exceed the risks and adverse effects. 

The certainty or uncertainty of the clinician about the risk-benefit balance will greatly influence the 

strength of the recommendation.

Some of the discussion questions that fall under this domain include:

• Given the best estimate of typical values and preferences, are you confident that the benefits 

outweigh the harms and burden or vice versa?

• Are the desirable anticipated effects large?

• Are the undesirable anticipated effects small?
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• Are the desirable effects large relative to undesirable effects?

Confidence in the quality of the evidence reflects the quality of the evidence base and the certainty in 

that evidence. This second domain reflects the methodological quality of the studies for each outcome 

variable. In general, the strength of recommendation follows the level of evidence, but not always, as 

other domains may increase or decrease the strength. The evidence review used for the development of 

recommendations for PTSD, conducted by ECRI, assessed the confidence in the quality of the evidence 

base and assigned a rate of “High,” “Moderate,” “Low,” or “Very Low.”

The elements that go into the confidence in the quality of the evidence include: 

• Is there high or moderate quality evidence that answers this question?

• What is the overall certainty of this evidence?

Values and preferences is an overarching term that includes patients’ perspectives, beliefs, expectations, 

and goals for health and life. More precisely, it refers to the processes that individuals use in considering 

the potential benefits, harms, costs, limitations, and inconvenience of the therapeutic or preventive 

measures in relation to one another. For some, the term “values” has the closest connotation to these 

processes. For others, the connotation of “preferences” best captures the notion of choice. In general, 

values and preferences increase the strength of the recommendation when there is high concordance and 

decrease it when there is great variability. In a situation in which the balance of benefits and risks are 

uncertain, eliciting the values and preferences of patients and empowering them and their surrogates to 

make decisions consistent with their goals of care becomes even more important. A recommendation can 

be described as having “similar values,” “some variation,” or “large variation” in typical values and 

preferences between patients and the larger populations of interest.

Some of the discussion questions that fall under the purview of values and preferences include:

• Are you confident about the typical values and preferences and are they similar across the 

target population?

• What are the patient’s values and preferences? 

• Are the assumed or identified relative values similar across the target population?

Other implications consider the practicality of the recommendation, including resources use, equity, 

acceptability, feasibility and subgroup considerations. Resource use is related to the uncertainty around 

the cost-effectiveness of a therapeutic or preventive measure. For example statin use in the frail elderly 

and others with multiple co-occurring conditions may not be effective and depending on the societal 

benchmark for willingness to pay, may not be a good use of resources. Equity, acceptability, feasibility, and 

subgroup considerations require similar judgments around the practically of the recommendation.

The framework in Table A-4 was used by the Work Group to guide discussions on each domain.
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Table A-4. Evidence to Recommendation Framework

Decision Domain Judgment

Balance of desirable and undesirable outcomes

 Given the best estimate of typical values and preferences, are you 

confident that the benefits outweigh the harms and burden or vice 

versa?

 Are the desirable anticipated effects large? 

 Are the undesirable anticipated effects small?

 Are the desirable effects large relative to undesirable effects?

Benefits outweigh harms/burden

Benefits slightly outweigh harms/burden

Benefits and harms/burden are balanced

Harms/burden slightly outweigh benefits

Harms/burden outweigh benefits

Confidence in the quality of the evidence

 Is there high or moderate quality evidence that answers this 

question?

 What is the overall certainty of this evidence?

High

Moderate

Low

Very low

Values and preferences

 Are you confident about the typical values and preferences and are 

they similar across the target population?

 What are the patient’s values and preferences? 

 Are the assumed or identified relative values similar across the 

target population?

Similar values

Some variation

Large variation

Other implications (e.g., resource use, equity, acceptability, feasibility, subgroup considerations)

 Are the resources worth the expected net benefit from the 

recommendation?

 What are the costs per resource unit?

 Is this intervention generally available?

 Is this intervention and its effects worth withdrawing or not 

allocating resources from other interventions? 

 Is there lots of variability in resource requirements across settings?

Various considerations

The strength of a recommendation is defined as the extent to which one can be confident that the 

desirable effects of an intervention outweigh its undesirable effects and is based on the framework above, 

which combines the four domains.[31] GRADE methodology does not allow for recommendations to be 

made based on expert opinion alone. While strong recommendations are usually based on high or 

moderate confidence in the estimates of effect (quality of the evidence) there may be instances where 

strong recommendations are warranted even when the quality of evidence is low.[259] In these types of 

instances where the balance of desirable and undesirable outcomes and values and preferences played 

large roles in determining the strength of a recommendation, this is explained in the discussion section for 

the recommendation.

The GRADE of a recommendation is based on the following elements:

• Four decision domains used to determine the strength and direction (described above)

• Relative strength (Strong or Weak)

• Direction (For or Against)
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The relative strength of the recommendation is based on a binary scale, “Strong” or “Weak.” A strong 

recommendation indicates that the Work Group is highly confident that desirable outcomes outweigh 

undesirable outcomes. If the Work Group is less confident of the balance between desirable and 

undesirable outcomes, they present a weak recommendation.

Similarly, a recommendation for a therapy or preventive measure indicates that the desirable 

consequences outweigh the undesirable consequences. A recommendation against a therapy or 

preventive measure indicates that the undesirable consequences outweigh the desirable consequences.

Occasionally, instances may occur when the Work Group feels there is insufficient evidence to make a 

recommendation for or against a particular therapy or preventive measure. This can occur when there is 

an absence of studies on a particular topic that met evidence review inclusion criteria, studies included in 

the evidence review report conflicting results, or studies included in the evidence review report

inconclusive results regarding the desirable and undesirable outcomes.

Using these elements, the grade of each recommendation is presented as part of a continuum:

• Strong For (or “We recommend offering this option ...”)

• Weak For (or “We suggest offering this option ...”)

• No recommendation for or against (or “There is insufficient evidence...”)

• Weak Against (or “We suggest not offering this option ...”)

• Strong Against (or “We recommend against offering this option ...”)

Note that weak (For or Against) recommendations may also be termed “Conditional,” “Discretionary,” or 

“Qualified.” Recommendations may be conditional based upon patient values and preferences, the 

resources available, or the setting in which the intervention will be implemented. Recommendations may 

be at the discretion of the patient and clinician or they may be qualified with an explanation about the 

issues that would lead decisions to vary.

E. Recommendation Categorization

a. Recommendation Categories and Definitions

For use in the 2017 PTSD CPG, a set of recommendation categories was adapted from those used by the 

United Kingdom National Institute for Health and Clinical Excellence (NICE).[34,35] These categories, along 

with their corresponding definitions, were used to account for the various ways in which 

recommendations could have been updated from the 2010 PTSD CPG. The categories and definitions can 

be found in Table A-5.
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Table A-5. Recommendation Categories and Definitions 

Evidence

Reviewed*

Recommendation

Category* Definition*

Reviewed

New-added New recommendation following review of the evidence

New-replaced Recommendation from previous CPG that has been carried over to the 

updated CPG that has been changed following review of the evidence

Not changed

Recommendation from previous CPG that has been carried forward to the 

updated CPG where the evidence has been reviewed but the 

recommendation is not changed

Amended

Recommendation from the previous CPG that has been carried forward to 

the updated CPG where the evidence has been reviewed and a minor 

amendment has been made

Deleted Recommendation from the previous CPG that has been removed based on 

review of the evidence

Not 

reviewed

Not changed Recommendation from previous CPG that has been carried forward to the 

updated CPG, but for which the evidence has not been reviewed

Amended

Recommendation from the previous CPG that has been carried forward to 

the updated CPG where the evidence has not been reviewed and a minor 

amendment has been made

Deleted Recommendation from the previous CPG that has been removed because it 

was deemed out of scope for the updated CPG

Abbreviation: CPG: clinical practice guideline 

*Adapted from the NICE guideline manual (2012) [34] and Garcia et al. (2014) [35]

b. Categorizing Recommendations with an Updated Review of the Evidence

Recommendations were first categorized by whether or not they were based on an updated review of the 

evidence. If evidence had been reviewed, recommendations were categorized as “New-added,” “Newreplaced,” “Not changed,” “Amended,” or “Deleted.” 

“Reviewed, New-added” recommendations were original, new recommendations that were not in the 

2010 PTSD CPG. “Reviewed, New-replaced” recommendations were in the previous version of the 

guideline, but were modified to align with the updated review of the evidence. These recommendations 

could have also included clinically-significant changes to the previous version. Recommendations 

categorized as “Reviewed, Not changed” were carried forward from the previous version of the CPG 

unchanged. 

To maintain consistency between 2010 recommendations, which were developed using the USPSTF 

methodology, and 2017 recommendations, which were developed using the GRADE methodology, it was 

necessary to modify the 2010 recommendations to include verbiage to signify the strength of the 

recommendation (e.g., “We recommend,” “We suggest”). Because the 2010 recommendations inherently 

needed to be modified at least slightly to include this language, the “Not changed” category was not used. 

For recommendations carried forward to the updated CPG with review of the evidence and slightly 

modified wording, the “Reviewed, Amended” recommendation category was used. This allowed for the 

wording of the recommendation to reflect GRADE methodology as well as for any other non-substantive 

(i.e., not clinically meaningful) language changes deemed necessary. The evidence used to support these 
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recommendations was carried forward from the previous version of the CPG and/or was identified in the 

evidence review for the update. 

Recommendations could have also been designated “Reviewed, Deleted.” These were recommendations 

from the previous version of the CPG that were not brought forward to the updated guideline after review 

of the evidence. This occurred if the evidence supporting the recommendations was out of date, to the 

extent that there was no longer any basis to recommend a particular course of care and/or new evidence 

suggests a shift in care, rendering recommendations in the previous version of the guideline obsolete.

c. Categorizing Recommendations without an Updated Review of the Evidence

There also were cases in which it was necessary to carry forward recommendations from the previous 

version of the CPG without a systematic review of the evidence. Due to time and budget constraints, the 

update of the PTSD CPG could not review all available evidence on management of PTSD, but instead 

focused its KQs on areas of new or updated scientific research or areas that were not previously covered in 

the CPG. 

For areas of research that have not changed, and for which recommendations made in the previous 

version of the guideline were still relevant, recommendations could have been carried forward to the 

updated guideline without an updated systematic review of the evidence. The support for these 

recommendations in the updated CPG was thus also carried forward from the previous version of the CPG. 

These recommendations were categorized as “Not reviewed.” If evidence had not been reviewed, 

recommendations could have been categorized as “Not changed,” Amended,” or “Deleted.” 

“Not reviewed, Not changed” recommendations refer to recommendations from the previous version of 

the PTSD CPG that were carried forward unchanged to the updated version. The category of “Not 

reviewed, Amended” was used to designate recommendations which were modified from the 2010 CPG 

with the updated GRADE language, as explained above. 

Recommendations could also have been categorized as “Not reviewed, Deleted” if they were determined 

to be out of scope. A recommendation was out of scope if it pertained to a topic (e.g., population, care 

setting, treatment, condition) outside of the scope for the updated CPG as defined by the Work Group. 

The categories for the recommendations included in the 2017 version of the guideline are noted in the 

Recommendations. Recommendations 1, 3, 4, and 5 were carried forward from the 2010 PTSD CPG using 

this method. The categories for the recommendations from the 2010 PTSD CPG are noted in Appendix E:

2010 Recommendation Categorization Table. 

F. Drafting and Submitting the Final Clinical Practice Guideline

Following the face-to-face meeting held August 29-September 1, 2016, the Champions and Work Group 

members were given writing assignments to craft discussion sections to support each of the new 

recommendations and/or to update discussion sections from the 2010 PTSD CPG to support the amended

“carried forward” recommendations. The Work Group also considered tables, appendices, and other 

sections from the 2010 PTSD CPG for inclusion in the update. During this time, the Champions and Work 

Group also made additional revisions to the algorithms, as necessary. 
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After developing the initial draft of the updated CPG, an iterative review process was used to solicit 

feedback on and make revisions to the CPG. Once they were developed, the first two drafts of the CPG 

were posted on a wiki website for a period of 14-20 business days for internal review and comment by the 

Work Group. All feedback submitted during each review period was reviewed and discussed by the Work 

Group and appropriate revisions were made to the CPG. 

Draft 3 of the CPG was made available for peer review and comment. This process is described in the 

section titled Peer Review Process. Following the Draft 3 peer review and comment period, a second faceto-face meeting was convened on March 28-29, 2017, to discuss the feedback received and revise the CPG. 

After revisions were made based on the feedback received during the peer review and comment period, 

the Champions presented the CPG to the EBPWG for their approval. Changes were made based on 

feedback from the EBPWG and the guideline was finalized.

The Work Group also produced a set of guideline toolkit materials which included a provider summary, 

pocket cards, and a patient summary. The final 2017 PTSD CPG was submitted to the EBPWG in May 2017.
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Appendix B: Patient Focus Group Methods and Findings

A. Methods

As part of the effort to update this CPG, the VA and DoD Leadership held a patient focus group on January 

25, 2016, in San Antonio, Texas. The aim of the focus group was to further the understanding of the 

perspective of patients receiving treatment for PTSD within the VA and/or DoD healthcare systems, as 

patients are most affected by the recommendations put forth in the CPG. The focus group explored 

patient perspectives on a set of topics related to the management of PTSD in the VA and DoD healthcare 

systems, including patients’ knowledge of PTSD treatment options, views on the delivery of care, and the 

impact of PTSD and the challenges it poses.

Participants for the focus group were recruited by VA and DoD Leadership as well as by the PTSD CPG 

Champions. Patient focus group participants were not designed to be a representative sample of VA and 

DoD patients who have experienced PTSD. However, recruitment focused on eliciting a range of 

perspectives likely to be relevant and informative in the guideline development process. Patients were not 

incentivized for their participation or reimbursed for travel expenses.

The PTSD CPG Champions and Work Group, with support from Lewin, developed a set of questions to help 

guide the focus group. The focus group facilitator led the discussion using the previously prepared 

questions as a general guide to elicit the most important information from the patients regarding their 

experiences and views about their treatment and overall care. Given the limited time and the range of 

interests of the focus group participants, not all of the listed questions were addressed. Audio and visual 

recording equipment was used to record the session. The recording was for internal use only and was 

distributed to the PTSD Champions and guideline development team. The video was used to document the 

discussion and synthesize the information. 

Ten patients participated in the focus group, however, only nine participants were present at any given 

time. Seven participants had received care in the DoD healthcare system and three received care in VA 

facilities. However, at the time of the focus group, the majority of the participants that were receiving care 

in the DoD healthcare system were either receiving treatment in Warrior Transition Units (WTUs) or were 

in the process of retiring.

B. Patient Focus Group Findings

a. Using SDM, consider treatment options and develop a treatment plan based on 

patient-specific goals, values, and preferences

 Use SDM to develop an individualized treatment plan; discuss pros and cons (e.g., 

benefits, risks, side effects) of each treatment option in conjunction with each patient’s 

goals, priorities, values, and preferences.

 Consider intensive outpatient programs or cognitive behavioral therapy when 

determining a treatment plan with the patient. 

 Discuss pharmacologic options in depth with the patient, including their willingness to 

take medications and their preferences for adjunctive therapies.
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 Consider that patients may prefer group-based outpatient therapies as opposed to 

individual-based treatment or inpatient treatment.

b. Educate patients about treatment options, including benefits and risks, side 

effects, and expectations

 Clinicians should be proactive and responsive in providing necessary clinical information 

in a manner comprehensible to patients and family members; acknowledge that 

patients will seek and acquire information from other sources (especially the Internet) 

and encourage patients to proactively seek information from reliable sources.

 When prescribing pharmacologic therapy, provide in-depth and patient-specific 

education on medication (e.g., side effects, dosing, and safety) during medical visits in 

conjunction with distributing or otherwise enabling access to educational materials.

c. Involve family members in accordance with patient preferences and maintain 

open, trusting, and respectful relationships with patients and their families

 Foster family involvement in SDM and patient support in accordance with patient 

preferences and in a way that is beneficial to the patient.

 Always treat patients and family members with respect.

 Include family members early in treatment discussions, especially regarding what to 

expect during and after completing treatment.

 Build and maintain trust, respect, and support with the patient and their family.

d. Take active steps to improve the perception of and stigma surrounding PTSD

 Encourage a culture shift surrounding PTSD within the VA and DoD systems; patients 

often “hide” PTSD while on active duty to comply with “readiness” standards.

 Provide education to patients and have preemptive discussions with Service Members

before deployment addressing the prevalence of PTSD and available treatments.

 Consider and offer settings to obtain care that encourage receptiveness to care and 

respect the privacy of the patient. 

e. Work with appropriate providers to ensure continuity and accessibility of highquality care within and between healthcare systems

 Consult with other providers (e.g., psychiatrists, social workers) and patient advocates 

as appropriate, especially when patients express the need for more information or other 

clinical support.

 Provide seamless transitions for pharmacologic treatment, psychotherapy, and other 

care management within and between VA, DoD, and any other healthcare systems.

Patients should not have to encounter abrupt changes in treatment regimens moving 

from one system to another or have to “start all over” when moving to another system.

 Increase the number of psychiatrists, social workers, and other health providers 

available to patients with PTSD; inability to locate an available provider may create 

interruptions in high-quality care.
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Appendix C: Pharmacotherapy Dosing Table

Therapeutic Category Initial Dose Dose Range Clinical Considerations: Comorbidities and Safety

Antidepressants

Monotherapy

 Fluoxetine* 

 Paroxetine* 

 Sertraline* 

 Venlafaxine* 

10-20 mg daily

10-20 mg daily

25-60 mg daily

IR: 25 mg 2 or 3 times a day

XR: 37.5 mg once daily

20-80 mg daily

20-50 mg daily

50-200 mg daily

75-375 mg in 2-3 divided doses

75-225 mg once daily

 Avoid abrupt discontinuation; withdrawal symptoms 

with sudden discontinuation of SSRIs and SNRIs, 

paroxetine and venlafaxine in particular

 Paroxetine and sertraline have FDA label indications 

for treating PTSD

 Common adverse effects of the SSRIs and SNRIs 

include nausea, headache, diarrhea, anxiety, 

nervousness, sexual dysfunction, agitation, dizziness, 

hyponatremia or SIADH, and serotonin syndrome

 Venlafaxine can elevate blood pressure; caution 

advised with patients with hypertension

 Nefazodone± 25–100 mg 2 times daily 150-600 mg in 2 divided doses  Nefazodone is associated with life-threatening hepatic 

failure; monitor for signs and symptoms including 

LFTs; avoid if active liver disease; do not re-challenge 

 Nefazodone is subject to many drug interactions, 

particularly those involving CYP3A4 and glycoprotein

 Imipramine± 25-75 mg daily 100-300 mg in 1 or 2 divided doses  Avoid TCAs within three months of an acute MI

 TCAs are relatively contraindicated in patients with 

coronary artery disease or prostatic enlargement

 TCAs side effects include dry mouth, dry eyes, 

constipation, orthostatic hypotension, tachycardia, 

ventricular arrhythmias, weight gain, and drowsiness 

Photosensitivity may occur

 Phenelzine± 15 mg 3 times daily 15 mg daily; 90 mg in divided doses  Phenelzine considerations include drug-drug and drugfood interactions, risk of hypertensive crisis, 

hypotension, and anticholinergic effects

Abbreviations: FDA: Food and Drug Administration; IR: immediate release; LFT: liver function tests; mg: milligram; MI: myocardial infarction; PTSD: posttraumatic stress disorder; 

SIADH: syndrome of inappropriate anti-diuretic hormone; SIT: Stress Inoculation Training; SNRI: serotonin-norepinephrine reuptake inhibitor; SSRI: serotonin reuptake inhibitors; 

TCA: tricyclic antidepressant; XR: extended release 

*Strong For recommendation

±Weak For recommendation
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Appendix D: Evidence Table

Recommendation 2010 Grade1 Evidence2

Strength of 

Recommendation3

Recommendation 

Category4

1. We recommend engaging patients in shared decision

making (SDM), which includes educating patients about

effective treatment options.

None Additional References:

[43-46] 

Strong For Not Reviewed, 

Amended

2. For patients with posttraumatic stress disorder (PTSD)

who are treated in primary care, we suggest collaborative 

care interventions that facilitate active engagement in

evidence-based treatments.

None [48-54] 

Additional References:

[47,55] 

Weak For Reviewed, Newreplaced

3. We suggest periodic screening for PTSD using validated

measures such as the Primary Care PTSD Screen (PC-PTSD)

or the PTSD Checklist (PCL).

B, I [60]

Additional References:

[10,51,56-59] 

Weak For Not Reviewed, 

Amended

4. For patients with suspected PTSD, we recommend an

appropriate diagnostic evaluation that includes 

determination of DSM criteria, acute risk of harm to self or

others, functional status, medical history, past treatment

history, and relevant family history. A structured

diagnostic interview may be considered.

B, I [70-72]

Additional References:

[2,29,61-69] 

Strong For Not Reviewed, 

Amended

1 The 2010 VA/DoD PTSD CPG used the USPSTF evidence grading system (http://www.uspreventiveservicestaskforce.org). Inclusion of more than one 2010 Grade indicates that more 

than one 2010 CPG recommendation is covered under the 2017 recommendation. The strength of recommendations were rated as follows: A- a strong recommendation that the 

clinicians provide the intervention to eligible patients; B- a recommendation that clinicians provide (the service) to eligible patients; C- no recommendation for or against the 

routine provision of the intervention is made; D- recommendation is made against routinely providing the intervention; I- the conclusion is that the evidence is insufficient to 

recommend for or against routinely providing the intervention. “None” indicates that the 2017 PTSD CPG recommendation replaced or amended a 2010 PTSD CPG 

recommendation for which there was no grade. “N/A” indicates that the 2017 PTSD CPG recommendation was a new recommendation, and therefore does not have an 

associated 2010 Grade. 2 The evidence column indicates studies that support each recommendation. For new recommendations, developed by the 2017 guideline Work Group, the literature cited 

corresponds directly to the 2016 evidence review. For recommendations that have been carried over from the 2010 VA/DoD PTSD CPG, slight modifications were made to the 

language in order to better reflect the current evidence and/or the change in grading system used for assigning the strength of each recommendation (USPSTF to GRADE). For 

these “modified” recommendations, the evidence column indicates “additional evidence,” which can refer to either 1) studies that support the recommendation and which were 

identified through the 2016 evidence review, or 2) relevant studies that support the recommendation, but which were not systematically identified through a literature review. 3 Refer to the Grading Recommendations section for more information on how the strength of the recommendation was determined using GRADE methodology. 4 Refer to the Recommendation Categorization section for more information on the description of the categorization process and the definition of each category.
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Recommendation 2010 Grade1 Evidence2

Strength of 

Recommendation3

Recommendation 

Category4

5. For patients with a diagnosis of PTSD, we suggest using a

quantitative self-report measure of PTSD severity, such as 

the PTSD Checklist for DSM-5 (PCL-5), in the initial

treatment planning and to monitor treatment progress.

None Additional References:

[73,74] 

Weak For Not Reviewed, 

Amended

6. For the selective prevention of PTSD, there is insufficient

evidence to recommend the use of trauma-focused

psychotherapy or pharmacotherapy in the immediate 

post-trauma period.

D, I [76-91] N/A Reviewed, Newreplaced

7. For the indicated prevention of PTSD in patients with

acute stress disorder (ASD), we recommend an individual

trauma-focused psychotherapy that includes a primary

component of exposure and/or cognitive restructuring.

A, D, I [77,89] Strong For Reviewed, Newreplaced

8. For the indicated prevention of PTSD in patients with ASD,

there is insufficient evidence to recommend the use of 

pharmacotherapy.

D, I [77,89-91] N/A Reviewed, Newreplaced

9. We recommend individual, manualized trauma-focused

psychotherapy (see Recommendation 11) over other

pharmacologic and non-pharmacologic interventions for

the primary treatment of PTSD.

N/A [92,93]

Additional References:

[46,94,95] 

Strong For Reviewed, New-added

10. When individual trauma-focused psychotherapy is not

readily available or not preferred, we recommend

pharmacotherapy (see Recommendation 17) or individual

non-trauma-focused psychotherapy (see

Recommendation 12). With respect to pharmacotherapy

and non-trauma-focused psychotherapy, there is 

insufficient evidence to recommend one over the other.

N/A [92,93] Strong For Reviewed, New-added

11. For patients with PTSD, we recommend individual,

manualized trauma-focused psychotherapies that have a

primary component of exposure and/or cognitive

restructuring to include Prolonged Exposure (PE),

Cognitive Processing Therapy (CPT), Eye Movement

Desensitization and Reprocessing (EMDR), specific

cognitive behavioral therapies for PTSD, Brief Eclectic

Psychotherapy (BEP), Narrative Exposure Therapy (NET),

and written narrative exposure.

A [92,93,97-118]

Additional References:

[96] 

Strong For Reviewed, Newreplaced
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Recommendation 2010 Grade1 Evidence2

Strength of 

Recommendation3

Recommendation 

Category4

12. We suggest the following individual, manualized nontrauma-focused therapies for patients diagnosed with

PTSD: Stress Inoculation Training (SIT), Present-Centered

Therapy (PCT), and Interpersonal Psychotherapy (IPT).

A [117-119,121-123]

Additional References:

[120] 

Weak For Reviewed, Newreplaced

13. There is insufficient evidence to recommend for or against

psychotherapies that are not specified in other

recommendations, such as Dialectical Behavior Therapy

(DBT), Skills Training in Affect and Interpersonal Regulation

(STAIR), Acceptance and Commitment Therapy (ACT),

Seeking Safety, and supportive counseling.

None [103-105,124,125,128-132] 

Additional References:

[126,127] 

N/A Reviewed, Newreplaced

14. There is insufficient evidence to recommend using

individual components of manualized psychotherapy

protocols over or in addition to the full therapy protocol.

N/A [97,106,108,116,118,119,130] 

Additional References:

[133] 

N/A Reviewed, New-added

15. We suggest manualized group therapy over no treatment.

There is insufficient evidence to recommend using one

type of group therapy over any other.

C, I [117,134,136,137] 

Additional References:

[135] 

Weak For Reviewed, Newreplaced

16. There is insufficient evidence to recommend for or against

trauma-focused or non-trauma-focused couples therapy

for the primary treatment of PTSD.

I [138,139] N/A Reviewed, Amended

17. We recommend sertraline, paroxetine, fluoxetine, or

venlafaxine as monotherapy for PTSD for patients 

diagnosed with PTSD who choose not to engage in or are 

unable to access trauma-focused psychotherapy.

A [92,93,140] Strong For Reviewed, Newreplaced

18. We suggest nefazodone, imipramine, or phenelzine as

monotherapy for the treatment of PTSD if recommended

pharmacotherapy (see Recommendation 17), traumafocused psychotherapy (see Recommendation 11), or

non-trauma-focused psychotherapy (see

Recommendation 12) are ineffective, unavailable, or not

in accordance with patient preference and tolerance.

(NOTE: Nefazodone and phenelzine have potentially

serious toxicities and should be managed carefully.)

B [92,93,141-144] Weak For Reviewed, Newreplaced
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Recommendation 2010 Grade1 Evidence2

Strength of 

Recommendation3

Recommendation 

Category4

19. We suggest against treatment of PTSD with quetiapine,

olanzapine, and other atypical antipsychotics (except for

risperidone, which is a Strong Against, see

Recommendation 20), citalopram, amitriptyline,

lamotrigine, or topiramate as monotherapy due to the 

lack of strong evidence for their efficacy and/or known

adverse effect profiles and associated risks.

D [92,93,140,146-152]

Additional References:

[145] 

Weak Against Reviewed, Newreplaced

20. We recommend against treating PTSD with divalproex,

tiagabine, guanfacine, risperidone, benzodiazepines,

ketamine, hydrocortisone, or D-cycloserine, as 

monotherapy due to the lack of strong evidence for their

efficacy and/or known adverse effect profiles and

associated risks.

D, I [92,93,153-158,160-166] Strong Against Reviewed, Newreplaced

21. We recommend against treating PTSD with cannabis or

cannabis derivatives due to the lack of evidence for their

efficacy, known adverse effects, and associated risks.

N/A Additional References:

[167-170] 

Strong Against Reviewed, New-added

22. There is insufficient evidence to recommend for or against

monotherapy or augmentation therapy for the treatment

of PTSD with eszopiclone, escitalopram, bupropion,

desipramine, doxepin, D-serine, duloxetine,

desvenlafaxine, fluvoxamine, levomilnacipran,

mirtazapine, nortriptyline, trazodone, vilazodone,

vortioxetine, buspirone, hydroxyzine, cyproheptadine,

zaleplon, and zolpidem.

I [92,93,140,171-175] N/A Reviewed, Newreplaced

23. We suggest against the use of topiramate, baclofen, or

pregabalin as augmentation treatment of PTSD due to

insufficient data and/or known adverse effect profiles and

associated risks.

D [92,93,140,177,178]

Additional References:

[176] 

Weak Against Reviewed, Newreplaced

24. We suggest against combining exposure therapy with Dcycloserine in the treatment of PTSD outside of the

research setting.

N/A [161,179] Weak Against Reviewed, New-added

25. We recommend against using atypical antipsychotics,

benzodiazepines, and divalproex as augmentation therapy

for the treatment of PTSD due to low quality evidence or

the absence of studies and their association with known

adverse effects.

D, I [92,93,163,164,180,182] 

Additional References:

[181] 

Strong Against Reviewed, Newreplaced
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June 2017 Page 102 of 200

Recommendation 2010 Grade1 Evidence2

Strength of 

Recommendation3

Recommendation 

Category4

26. There is insufficient evidence to recommend the 

combination of exposure therapy with hydrocortisone 

outside of the research setting.

N/A [183] N/A Reviewed, New-added

27. There is insufficient evidence to recommend for or against

the use of mirtazapine in combination with sertraline for

the treatment of PTSD.

B [184] N/A Reviewed, Newreplaced

28a. For global symptoms of PTSD, we suggest against the use 

of prazosin as mono- or augmentation therapy.

I [92,149,185-188,190]

Additional References:

[189] 

Weak Against Reviewed, Newreplaced

28b. For nightmares associated with PTSD, there is insufficient 

evidence to recommend for or against the use of prazosin 

as mono- or augmentation therapy.

B [92,149,185-188,190] 

Additional References:

[189] 

N/A Reviewed, Newreplaced

29. In partial- or non-responders to psychotherapy, there is 

insufficient evidence to recommend for or against

augmentation with pharmacotherapy.

None [191-194] N/A Reviewed, Newreplaced

30. In partial- or non-responders to pharmacotherapy, there is 

insufficient evidence to recommend for or against

augmentation with psychotherapy.

None [191-194] N/A Reviewed, Newreplaced

31. There is insufficient evidence to recommend for or against

starting patients with PTSD on combination

pharmacotherapy and psychotherapy.

N/A [191-194] N/A Reviewed, New-added

32. There is insufficient evidence to recommend for or against

the following somatic therapies: repetitive transcranial

magnetic stimulation (rTMS), electroconvulsive therapy

(ECT), hyperbaric oxygen therapy (HBOT), stellate ganglion

block (SGB), or vagal nerve stimulation (VNS).

B, D [195-198] 

Additional References:

[199-203] 

N/A Reviewed, Newreplaced

33. There is insufficient evidence to recommend acupuncture

as a primary treatment for PTSD.

B [204-206] N/A Reviewed, Newreplaced

34. There is insufficient evidence to recommend any

complementary and integrative health (CIH) practice, such

as meditation (including mindfulness), yoga, and mantram

meditation, as a primary treatment for PTSD.

C, I [207-215] N/A Reviewed, Newreplaced
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June 2017 Page 103 of 200

Recommendation 2010 Grade1 Evidence2

Strength of 

Recommendation3

Recommendation 

Category4

35. We suggest internet-based cognitive behavioral therapy

(iCBT) with feedback provided by a qualified facilitator as 

an alternative to no treatment.

C, I [216-222] Weak For Reviewed, Newreplaced

36. We recommend using trauma-focused psychotherapies 

that have demonstrated efficacy using secure video

teleconferencing (VTC) modality when PTSD treatment is 

delivered via VTC.

C, I [223-227] Strong For Reviewed, Amended

37. We recommend that the presence of co-occurring

disorder(s) not prevent patients from receiving other

VA/DoD guideline-recommended treatments for PTSD.

N/A [122,127,228-232,234] Strong For Reviewed, New-added

38. We recommend VA/DoD guideline-recommended

treatments for PTSD in the presence of co-occurring

substance use disorder (SUD).

I [127,237-242] 

Additional References:

[235,236] 

Strong For Reviewed, Newreplaced

39. We recommend an independent assessment of cooccurring sleep disturbances in patients with PTSD,

particularly when sleep problems pre-date PTSD onset or

remain following successful completion of a course of

treatment.

None [248-251,254-257]

Additional References:

[243-247,252,253] 

Strong For Reviewed, Newreplaced

40. We recommend Cognitive Behavioral Therapy for

Insomnia (CBT-I) for insomnia in patients with PTSD unless 

an underlying medical or environmental etiology is 

identified or severe sleep deprivation warrants the

immediate use of medication to prevent harm.

None [248-251,254-257] 

Additional References:

[243-247,252,253] 

Strong For Reviewed, Amended
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Appendix E: 2010 Recommendation Categorization Table 2010 Module1 2010 Section 2010 Number

2010 Recommendation Text2

2010 Grade3

Category4 2017 Recommendation5

CORE 1 A In high-risk occupations, for which the probability of trauma 

exposure is moderate or high, efforts should be undertaken to 

increase the psychological resilience of workers to the negative 

effects of trauma exposure

None Not reviewed, Deleted

CORE 2 B Persons exposed to trauma should be assessed for the type, 

frequency, nature, and severity of the trauma. [B]

a. Assessment should include a broad range of potential trauma

exposures in addition to the index trauma.

b. Trauma Exposure Assessment Instruments may assist in

evaluating the nature and severity of the exposure.

c. Assessment of existing social supports and ongoing stressors is

important.

B Not reviewed, Amended Recommendation 3

CORE 3 C All new patients should be screened for symptoms of PTSD initially 

and then on an annual basis or more frequently if clinically indicated 

due to clinical suspicion, recent trauma exposure (e.g., major 

disaster), or history of PTSD. [B]

B Not reviewed, Amended Recommendation 3

CORE 3 C Patients should be screened for symptoms of PTSD using paper-andpencil or computer-based screening tools. [B]B Not reviewed, Amended Recommendation 3

1 The first three columns indicate the location of each recommendation within the 2010 PTSD CPG.

2 The 2010 Recommendation Text column contains the wording of each recommendation from the 2010 PTSD CPG. 

3 The 2010 VA/DoD PTSD CPG used the U.S. Preventive Services Task Force (USPSTF) evidence grading system. http://www.uspreventiveservicestaskforce.org The strength of 

recommendations were rated as follows: A- a strong recommendation that the clinicians provide the intervention to eligible patients; B- a recommendation that clinicians provide 

(the service) to eligible patients; C- no recommendation for or against the routine provision of the intervention is made; D- recommendation is made against routinely providing 

the intervention; I- the conclusion is that the evidence is insufficient to recommend for or against routinely providing the intervention. “None” indicates there was no grade 

assigned to the recommendation in the 2010 PTSD CPG. 4 The Category column indicates the way in which each 2010 PTSD CPG recommendation was updated. 

5 For recommendations that were carried forward to the 2010 PTSD CPG, this column indicates the new recommendation(s) to which they correspond.
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2010 Recommendation Text

2010 Grade 

Category

2017 

Recommendation

CORE 3 C There is insufficient evidence to recommend one PTSD screening tool versus 

another. However, the following screening tools have been validated and 

should be considered for use. For example: (See Appendix C)

 Primary Care PTSD Screen (PC-PTSD)

 PTSD Brief Screen

 Short Screening Scale for DSM IV PTSD.

 PTSD Checklist (PCL)

I Not reviewed, Amended Recommendation 3

CORE 3 C There is insufficient evidence to recommend special screening for members of 

any cultural or racial group or gender. [I]

I Not reviewed, Deleted

CORE 3 D Individuals who are presumed to have symptoms of PTSD or who are positive 

for PTSD on the initial screening should receive a more detailed assessment of 

their symptoms.

None Not reviewed, Amended Recommendation 4

CORE 3 D Useful symptom-related information may include details, such as time of onset, 

frequency, course, severity, level of distress, and degree of functional 

impairment.

None Not reviewed, Deleted

CORE 3 D The elapsed time since the exposure to trauma should be considered when 

assessing the risk of developing PTSD and determining the diagnosis and 

appropriate intervention.

None Not reviewed, Deleted

CORE 3 E Pre- and post-trauma education should include helping the asymptomatic 

trauma survivor or responder understand that the acute stress reactions of 

other people are common and probably transient and do not indicate personal 

failure or weakness, mental illness, or health problems.

None Not reviewed, Deleted

CORE 3 E Education should include sufficient review of the many ways that posttraumatic problems can present, including symptoms in the ASD/PTSD 

spectrum, behavioral problems with family and friends, occupational problems, 

and the potential impact of alcohol or other substance misuse/abuse.

None Not reviewed, Deleted

CORE 3 E Education should also include positive messages by identifying and encouraging 

positive ways of coping, describing simple strategies to resolve or cope with 

developing symptoms and problems, and setting expectations for mastery 

and/or recovery.

None Not reviewed, Deleted

CORE 3 E Provide contact information, should post-traumatic symptoms emerge later. None Not reviewed, Deleted
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Category

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CORE 3 E Routine debriefing or formal psychotherapy is not beneficial for asymptomatic 

individuals and may be harmful. [D]

D Not reviewed, Deleted

A 1 B Identification of a patient with ASR symptoms is based on observation of 

behavior and function; there is insufficient evidence to recommend a specific 

screening tool.

None Not reviewed, Deleted

A 1 B Individuals exhibiting the following responses to trauma should be screened for 

ASR:

a. Physical: exhaustion, hyperarousal, somatic complaints (GI, GU, MS, CV, 

Resp, NS), or symptoms of conversion disorder

b. Emotional: anxiety, depression, guilt/hopelessness

c. Cognitive/mental: amnestic or dissociative symptoms, hypervigilance, 

paranoia, intrusive re-experiencing

d. Behavioral: avoidance, problematic substance use.

None Not reviewed, Deleted

A 1 B Individuals who experience ASR should receive a comprehensive assessment of 

their symptoms to include details about the time of onset, frequency, course, 

severity, level of distress, functional impairment, and other relevant 

information.

None Not reviewed, Deleted

A 1 B Assess for capability to perform routine functions. None Not reviewed, Deleted

A 1 B Assess service member’s functional status, to include:

a. Any changes in productivity

b. Co-worker or supervisor reports of recent changes in appearance, quality of 

work, or relationships

c. Any tardiness/unreliability, loss of motivation, or loss of interest

d. Forgetful or easily distracted

e. Screening for substance use.

None Not reviewed, Deleted

A 1 B Document symptoms of COSR and obtain collateral information from unit 

leaders, coworkers, or peers about stressors, function, medical history, and 

absence or impairment in operation or mission.

None Not reviewed, Deleted

A 1 B Consider the service member’s role and functional capabilities and the 

complexity and importance of his/her job.

None Not reviewed, Deleted
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A 1 C Address acute medical/behavioral issues to preserve life and avoid further harm 

by:

a. Providing appropriate medical/surgical care or referring to stabilize

b. Evaluating the use of prescribed medications

c. Preventing possible biological or chemical agent exposure

d. Managing substance intoxication or withdrawal

e. Stopping self-injury or mutilation

f. Addressing inability to care for oneself.

None Not reviewed, Deleted

A 1 C Arrange a safe, private, and comfortable environment for continuation of the 

evaluation:

a. Assess danger to self or others (e.g., suicidal, or homicidal behavior)

b. Establish a working treatment alliance with the patient

c. Maintain a supportive, non-blaming, non-judgmental stance throughout the 

evaluation

d. Assist with the removal of any ongoing exposure to stimuli associated with 

the traumatic event

e. Minimize further traumas that may arise from the initial traumatic event

f. Assess and optimize social supports

g. Secure any weapons and explosives.

None Not reviewed, Deleted

A 1 C Legal mandates should be followed:

a. Reporting of violence, assault

b. Confidentiality for the patient

c. Mandatory testing

d. Attending to chain of evidence in criminal cases (e.g., rape, evaluation)

e. Involuntary Commitment procedures if needed.

None Not reviewed, Deleted
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A 1 C Carefully consider the following potential interventions to secure safety:

a. Find safe accommodation and protect against further trauma

b. Voluntary admission if suicidal

c. Restraint/seclusion only if less restrictive measures are ineffective

d. Provide medications managing specific symptoms as needed (e.g., sleep, 

pain).

None Not reviewed, Deleted

A 1 C Educate and “normalize” observed psychological reactions to the chain of 

command.

None Not reviewed, Deleted

A 1 C Evacuate to next level of care if unmanageable, if existing resources are 

unavailable, or if reaction is outside of the scope of expertise of the care 

provider.

None Not reviewed, Deleted

A 1 D Acute intervention should ensure that the following needs are met:

a. Safety/security/survival

b. Food, hydration, clothing, hygiene, and shelter

c. Sleep

d. Medications (i.e., replace medications destroyed/lost)

e. Education as to current status

f. Communication with family, friends, and community

g. Protection from ongoing threats/toxins/harm. If indicated, reduce use of 

alcohol, tobacco, caffeine, and illicit psychoactive substances.

None Not reviewed, Deleted

A 1 D Provide Psychological First Aid to:

a. Protect survivors from further harm

b. Reduce physiological arousal

c. Mobilize support for those who are most distressed

d. Keep families together and facilitate reunion with loved ones

e. Provide information and foster communication and education

f. Use effective risk communication techniques.

None Not reviewed, Deleted

A 1 D Treat according to member’s prior role and not as a “patient.” None Not reviewed, Deleted
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Recommendation

A 1 D Assure or provide the following, as needed:

a. Reunion or ongoing contact with group/unit

b. Promote continuity with established relationships (e.g., primary group)

c. Respite from intense stress

d. Comfortable environment (e.g., thermal comfort)

e. Consider psychoeducation and discussion in a group format

f. Assign job tasks and recreational activities that will restore focus and 

confidence and reinforce teamwork (limited duty).

None Not reviewed, Deleted

A 1 E Acutely traumatized people, who meet the criteria for diagnosis of ASD, and 

those with significant levels of post-trauma symptoms after at least two weeks 

post-trauma, as well as those who are incapacitated by acute psychological or 

physical symptoms, should receive further assessment and early intervention to 

prevent PTSD.

None Not reviewed, Amended Recommendation 4

A 1 E Trauma survivors, who present with symptoms that do not meet the diagnostic 

threshold for ASD, or those who have recovered from the trauma and currently 

show no symptoms, should be monitored and may benefit from follow-up and 

provision of ongoing counseling or symptomatic treatment.

None Not reviewed, Deleted

A 1 E Service members with COSR who do not respond to initial supportive 

interventions may warrant referral or evacuation.

None Not reviewed, Deleted

A 1 F Medical status should be obtained for all persons presenting with symptoms to 

include:

a. History, physical examination, and a neurological examination

b. Use of prescribed medications, mood or mind-altering substances, and 

possible biological or chemical agent exposure

c. A mini-mental status examination (MMSE) to assess cognitive function if 

indicated.

None Not reviewed, Deleted
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A 1 F The history and physical examination findings should lead the provider to other 

assessments as clinically indicated. Based on the clinical presentation, 

assessment may include:

a. Screen for toxicology if the symptom presentation indicates

b. Radiological assessment of patients with focal neurological findings or 

possible head injury

c. Appropriate laboratory studies to rule out medical disorders that may cause 

symptoms of acute stress reactions (e.g., complete blood count [CBC], 

chemistry profile, thyroid studies, HCG, EKG, EEG).

None Not reviewed, Deleted

A 1 F A focused psychosocial assessment should be performed to include assessment 

of active stressors, losses, current social supports, and basic needs (e.g., 

housing, food, and financial resources).

None Not reviewed, Deleted

A 1 F A brief assessment of function should be completed to evaluate: 1) objectively 

impaired function based on general appearance and behavior; 2) subjectively 

impaired function; 3) baseline level of function (LOF) vs. current LOF; and 4) 

family and relationship functioning.

None Not reviewed, Deleted

A 1 G Assess patients for pre-existing psychiatric conditions to identify high-risk 

individuals and groups.

None Not reviewed, Deleted

A 1 G Assure access and adherence to medications that the patient is currently taking. None Not reviewed, Deleted

A 1 G Refer patients with pre-existing psychiatric conditions to mental health 

specialty when indicated or emergency hospitalization if needed.

None Not reviewed, Deleted
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A 1 H Trauma survivors who exhibit symptoms or functional impairment should be 

screened for the following risk factors for developing ASD/PTSD:

Pre-traumatic factors

1. Ongoing life stress

2. Lack of social support

3. Young age at time of trauma

4. Pre-existing psychiatric disorders, or substance misuse

5. History of traumatic events (e.g., MVA)

6. History of post-traumatic stress disorder (PTSD).

7. Other pre-traumatic factors, including: female gender, low socioeconomic 

status, lower level of education, lower level of intelligence, race (Hispanic, 

African-American, American Indian, and Pacific Islander), reported abuse in 

childhood, report of other previous traumatization, report of other adverse 

childhood factors, family history of psychiatric disorders, and poor training 

or preparation for the traumatic event.

Peri-traumatic or trauma-related factors 

1. Severe trauma

2. Physical injury to self or others

3. Type of trauma (combat, interpersonal traumas such as killing another 

person, torture, rape, or assault convey high risk of PTSD)

4. High perceived threat to life of self or others

5. Community (mass) trauma

6. Other peri-traumatic factors, including: history of peri-traumatic dissociation.

Post-traumatic factors

1. Ongoing life stress

2. Lack of positive social support

3. Bereavement or traumatic grief

4. Major loss of resources

5. Negative social support (shaming or blaming environment)

6. Poor coping skills

7. Other post-traumatic factors, including: children at home and a distressed 

spouse.

None Not reviewed, Deleted
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Recommendation

A 2 I All survivors should be given educational information to help normalize 

common reactions to trauma, improve coping, enhance self-care, facilitate 

recognition of significant problems, and increase knowledge of and access to 

services. Such information can be delivered in many ways, including public 

media, community education activities, and written materials.

None Not reviewed, Deleted

A 2 J Continue providing psychoeducation and normalization. None Not reviewed, Deleted

A 2 J Treatment should be initiated after education, normalization, and Psychological 

First Aid has been provided and after basic needs following the trauma have 

been made available.

None Not reviewed, Deleted

A 2 J There is insufficient evidence to recommend for or against the use of 

Psychological First Aid to address symptoms beyond 4 days following trauma. [I]

I Not reviewed, Deleted

A 2 J Survivors who present symptoms that do not meet the diagnostic threshold of 

ASD or PTSD should be monitored and may benefit from follow-up and 

provision of ongoing counseling or symptomatic treatment.

None Not reviewed, Deleted

A 2 J Recommend monitoring for development of PTSD using validated symptom 

measures (e.g., PTSD Checklist, other screening tools for ASD/PTSD).

None Not reviewed, Amended Recommendation 3
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Recommendation

A 2 J Psychotherapy:

a. Consider early brief intervention (4 to 5 sessions) of cognitive-based therapy 

(CBT) that includes exposure-based therapy, alone or combined with a 

component of cognitive re-structuring therapy for patients with significant 

early symptom levels, especially those meeting diagnostic criteria for ASD. [A]

b. Routine formal psychotherapy intervention for asymptomatic individuals is 

not beneficial and may be harmful. [D]

c. Strongly recommend against individual Psychological Debriefing as a viable 

means of reducing acute stress disorder (ASD) or progression to posttraumatic stress disorder (PTSD). [D]

d. The evidence does not support a single session group Psychological 

Debriefing as a viable means of reducing acute stress disorder (ASD) or 

progression to post-traumatic stress disorder, but there is no evidence of 

harm (Note: this is not a recommendation pertaining to Operational 

Debriefing). [D]

e. Groups may be effective vehicles for providing trauma-related education, 

training in coping skills, and increasing social support, especially in the 

context of multiple group sessions. [I]

f. Group participation should be voluntary.

A, D, I Reviewed, NewreplacedRecommendation 7

A 2 J Pharmacotherapy:

a. There is no evidence to support a recommendation for use of a 

pharmacological agent to prevent the development of ASD or PTSD. [I]

b. Strongly recommend against the use of benzodiazepines to prevent the 

development of ASD or PTSD [D]

D, I Reviewed, NewreplacedRecommendation 6

Recommendation 8

A 2 K Symptom-specific treatment should be provided after education, normalization, 

and basic needs are met.

None Not reviewed, Deleted

A 2 K Consider a short course of medication (less than 6 days), targeted for specific 

symptoms in patients post-trauma

a. Sleep disturbance/insomnia

b. Management of pain

c. Irritation/excessive arousal/anger.

None Reviewed, Deleted
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Recommendation

A 2 K Provide non-pharmacological intervention to address specific symptoms 

(e.g., relaxation, breathing techniques, avoiding caffeine) to address both 

general recovery and specific symptoms (sleep disturbance, pain, hyperarousal, 

or anger).

None Reviewed, Deleted

A 2 L1 Ensure patient access to spiritual care when sought. None Not reviewed, Deleted

A 2 L1 Assess for spiritual needs. None Not reviewed, Deleted

A 2 L1 Provide opportunities for grieving for losses (providing space and opportunities 

for prayers, mantras, rites, and rituals and end-of-life care, as determined 

important by the patient).

None Not reviewed, Deleted

A 2 L2 Immediately after trauma exposure, preserve an interpersonal safety zone 

protecting basic personal space (e.g., privacy, quiet, personal effects).

None Not reviewed, Deleted

A 2 L2 As part of Psychological First Aid, reconnect trauma survivors with previously 

supportive relationships (e.g., family, friends, unit members) and link with 

additional sources of interpersonal support.

None Not reviewed, Deleted

A 2 L2 Assess for impact of PTSD on social functioning. None Not reviewed, Deleted

A 2 L2 Facilitate access to social support and provide assistance in improving social 

functioning, as indicated.

None Not reviewed, Deleted

A 3 M Assessment of the response to the acute intervention should include an 

evaluation for the following risk factors:

a. Persistent or worsening traumatic stress symptoms (e.g., dissociation, panic, 

autonomic arousal, cognitive impairment)

b. Significant functional impairments (e.g., role/work, relationships)

c. Dangerousness (suicidal or violent ideation, plan, and/or intent)

d. Severe psychiatric co-morbidity (e.g., psychotic spectrum disorder, 

substance use disorder or abuse)

e. Maladaptive coping strategies (e.g., pattern of impulsivity, social 

withdrawal, or other reactions under stress)

f. New or evolving psychosocial stressors

g. Poor social supports.

None Not reviewed, Deleted
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Recommendation

A 3 M Follow-up after acute intervention to determine patient status should include 

the following:

a. Patient does not improve or status worsens – continue management of PTSD 

(See Module B) in consultation or referral to PTSD specialty care or mental 

health provider. Recommend involvement of the primary care provider in the 

treatment. Patients with multiple problems may benefit from a multidisciplinary approach to include occupational therapy, spiritual counseling, 

recreation therapy, social work, psychology, and/or psychiatry.

b. Patient demonstrates partial improvement (e.g., less arousal, but no 

improvement in sleep) – consider augmentation or adjustment of the acute 

intervention and follow up within 2 weeks.

c. Patient recovers from acute symptoms – provide education about acute 

stress reaction and contact information with instructions for available 

follow-up if needed.

None Not reviewed, Deleted

A 4 N Individuals who fail to respond to early interventions should be referred for 

PTSD treatment when they have:

a. Worsening of stress-related symptoms

b. High potential or new-onset potential for dangerousness

c. Development of ASD/PTSD

d. Maladaptive coping with stress (e.g., social withdrawal, alcohol use)

e. Exacerbation of pre-existing psychiatric conditions

f. Deterioration in function

g. New onset stressors

h. Poor social supports.

None Not reviewed, Deleted

A 4 N Primary Care provider should consider initiating therapy pending referral or if 

the patient is reluctant or unable to obtain specialty services.

None Not reviewed, Deleted

A 4 N Primary Care provider should continue evaluating and treating co-morbid 

physical illnesses and addressing any other health concerns, as well as 

educating and validating the patient regarding his/her illness.

None Not reviewed, Deleted
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Recommendation

A 4 O Follow-up should be offered to individuals who request it or to those at high 

risk of developing adjustment difficulties following exposure to major incidents 

and disasters, including individuals who:

a. Have acute stress disorder or other clinically significant symptoms stemming 

from the trauma

b. Are bereaved

c. Have a pre-existing psychiatric disorder

d. Require medical or surgical attention

e. Were exposed to a major incident or disaster that was particularly intense 

and of long duration.

None Not reviewed, Deleted

A 4 O Primary Care providers should follow-up with patients about issues related to 

trauma in an ongoing way. Patients with initial sub-threshold presentation are 

at increased risk of developing PTSD and may need symptom-specific 

management.

None Not reviewed, Deleted

B 1 A Patients who are presumed to have symptoms of PTSD or who are positive for 

PTSD on the initial screening should receive a thorough assessment of their 

symptoms that includes details such as time of onset, frequency, course, severity, 

level of distress, functional impairment, and other relevant information to guide 

accurate diagnosis and appropriate clinical decision- making.

None Not reviewed, Amended Recommendation 4

B 1 A Consider use of a validated, self-administered checklist to ensure systematic, 

standardized, and efficient review of the patient’s symptoms and history of 

trauma exposure. Routine ongoing use of these checklists may allow assessment 

of treatment response and patient progress (see Appendix C: PCL-C).

None Not reviewed, Amended Recommendation 5

B 1 A Diagnosis of PTSD should be obtained based on a comprehensive clinical 

interview that assesses all the symptoms that characterize PTSD. Structured 

diagnostic interviews, such as the Clinician-Administered PTSD scale (CAPS), 

may be considered.

None Not reviewed, Amended Recommendation 4
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B 1 B Assessment of the trauma exposure experience should include:

a. History of exposure to traumatic event(s)

b. Nature of the trauma

c. Severity of the trauma

d. Duration and frequency of the trauma

e. Age at time of trauma

f. Patient’s reactions during and immediately following trauma exposure (e.g., 

helplessness, horror, and fear)

g. Existence of multiple traumas.

None Not reviewed, Deleted

B 1 B If trauma exposure is recent (<1 month), particular attention should be given to 

the following:

a. Exposure to/Environment of trauma

b. Ongoing traumatic event exposure

c. Exposure, perhaps ongoing, to environmental toxins

d. Ongoing perceived threat.

None Not reviewed, Deleted

B 1 B When assessing trauma exposure, the clinician must consider the patient’s 

ability to tolerate the recounting of traumatic material, since it may increase 

distress and/or exacerbate PTSD symptoms.

None Not reviewed, Deleted

B 1 C All patients with PTSD should be assessed for safety and dangerousness, 

including current risk to self or others, as well as historical patterns of risk:

a. Suicidal or homicidal ideation, intent (plan), means (e.g., weapon, excess 

medications), history (e.g. violence or suicide attempts), behaviors (e.g., 

aggression, impulsivity), co-morbidities (substance abuse, medical 

conditions) [B]

b. Family and social environment – including domestic or family violence, risks 

to the family [B]

c. Ongoing health risks or risk-taking behavior [B]

d. Medical/psychiatric co-morbidities or unstable medical conditions [B]

e. Potential to jeopardize mission in an operational environment. [I]

B, I Not reviewed, Amended Recommendation 4
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B 1 D All patients should have a thorough assessment of medical and psychiatric 

history, with particular attention paid to the following:

a. Baseline functional status

b. Baseline mental status

c. Medical history: to include any injury (e.g., mild-TBI)

d. Medications: to include medication allergies and sensitivities; prescription 

medications; herbal or nutritional supplements; and over-the- counter 

(OTC) medications (caffeine, energy drinks or use of other substances)

e. Past psychiatric history: to include prior treatment for mental health and 

substance use disorder, and past hospitalization for depression or suicidality

f. Current life stressors.

None Not reviewed, Deleted

B 1 D All patients should have a thorough physical examination. On physical 

examination, particular attention should be paid to the neurological exam and 

stigmata of physical/sexual abuse, self-mutilation, or medical illness. Note 

distress caused by, or avoidance of, diagnostic tests/examination procedures.

None Not reviewed, Deleted
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B 1 D All patients, particularly the elderly, should have a Mental Status Examination 

(MSE) to include assessment of the following:

a. Appearance and behavior

b. Language/speech

c. Thought process (loose associations, ruminations, obsessions) and content 

(delusions, illusions and hallucinations)

d. Mood (subjective)

e. Affect (to include intensity, range, and appropriateness to situation and 

ideation)

f. Level of Consciousness (LOC)

g. Cognitive function

h. All patients should have routine laboratory tests as clinically

indicated, such as TSH, Complete Metabolic Panel, Hepatitis, HIV,

and HCG (for females). Also consider CBC, UA, Tox/EtoH panel, and other tests

i. Other assessments may be considered (radiology studies, ECG, and EEG), as 

clinically indicated

j. All patients should have a narrative summary of psychosocial assessments 

to include work/school, family, relationships, housing,

legal, financial, unit/community involvement, and recreation, as

clinically appropriate.

None Not reviewed, Deleted

B 1 E Assessment of function should be obtained through a comprehensive narrative 

assessment, and the use of standardized, targeted, and validated instruments 

designed to assess family/relationship, work/school, and/or social functioning.

None Not reviewed, Amended Recommendation 4

B 1 E The determination of when to return to work/duty should take into 

consideration the complexity and importance of the patient’s job role and 

functional capabilities.

None Not reviewed, Deleted

B 1 E The continuing presence of symptoms of PTSD should not be considered in 

itself as sufficient justification for preventing a return to work/duty.

None Not reviewed, Deleted

B 1 F Patients should be assessed for risk factors for developing PTSD. Special attention 

should be given to post-traumatic factors (i.e., social support, ongoing stressors, 

and functional incapacity) that may be modified by intervention.

None Not reviewed, Deleted
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B 1 F When evaluating risk factors for PTSD, the clinician should keep in mind that 

PTSD is defined as occurring only after four weeks have elapsed following a 

traumatic event. PTSD symptoms, however, may not appear until a 

considerable time has passed—sometimes surfacing years later.

None Not reviewed, Deleted

B 2 G A diagnosis of stress-related disorder consistent with the DSM IV criteria for 

PTSD should be formulated before initiating treatment.

None Not reviewed, Deleted

B 2 G Diagnosis of PTSD should be obtained based on a comprehensive clinical 

interview that assesses all the symptoms that characterize PTSD. Structured 

diagnostic interviews, such as the Clinician-Administered PTSD scale (CAPS), 

may be considered.

None Reviewed, Amended Recommendation 4

B 2 G When a diagnostic work up cannot be completed, primary care providers 

should consider initiating treatment or referral based on a working diagnosis of

stress-related disorder.

None Not reviewed, Deleted

B 2 G Patients with difficult or complicated presentation of the psychiatric component 

should be referred to PTSD specialty care for diagnosis and treatment.

None Not reviewed, Deleted

B 2 G Patients with partial or sub-threshold PTSD should be carefully monitored for 

deterioration of symptoms.

None Not reviewed, Deleted

B 2 H Providers should recognize that medical disorders/symptoms, mental health 

disorders, and psychosocial problems commonly coexist with PTSD and should 

screen for them during the evaluation and treatment of PTSD.

None Not reviewed, Deleted

B 2 H Because of the high prevalence of psychiatric co-morbidities in the PTSD 

population, screening for depression and other psychiatric disorders is 

warranted (see also VA/DoD Clinical Practice Guidelines for the Management of 

Major Depressive Disorder [MDD] and for Bipolar Disorder).

None Not reviewed, Deleted

B 2 H Patterns of current and past use of substance by persons with trauma histories 

or PTSD should be routinely assessed to identify substance misuse or 

dependency (alcohol, nicotine, prescribed drugs, and illicit drugs) (see also 

VA/DoD Clinical Practice Guideline for Substance Use Disorders).

None Not reviewed, Deleted

B 2 H Pain (acute and chronic) and sleep disturbances should be assessed in all 

patients with PTSD.

None Not reviewed, Deleted
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B 2 H Generalized physical and cognitive health symptoms - also attributed to 

concussion/mild traumatic brain injury (mTBI) and many other causes - should 

be assessed and managed in patients with PTSD and co-occurring diagnosis of 

mTBI (see also VA/DoD CPG for Concussion/mild-TBI, and the CPG for PostDeployment Health).

None Not reviewed, Deleted

B 2 H Associated high-risk behaviors (e.g., smoking, alcohol/drug abuse, unsafe 

weapon storage, dangerous driving, HIV and hepatitis risks) should be assessed 

in patients with PTSD.

None Not reviewed, Deleted

B 2 H Providers should consider the existence of co-morbid conditions when deciding 

whether to treat patients in the primary care setting or refer them for specialty 

mental healthcare (See Annotation J).

None Not reviewed, Deleted

B 2 H Patients with complicated co-morbidity may be referred to mental health or 

PTSD specialty care for evaluation and diagnosis (see Annotation J).

None Not reviewed, Deleted

B 2 I Trauma survivors and their families should be educated about PTSD symptoms, 

other potential consequences of exposure to traumatic stress, practical ways of 

coping with traumatic stress symptoms, co-morbidity with other medical health 

concerns, processes of recovery from PTSD, and the nature of treatments. [C]

C Not reviewed, Deleted

B 2 I Providers should explain to all patients with PTSD the range of available and 

effective options for PTSD treatment.

None Not reviewed, Deleted

B 2 I Patient preferences along with provider recommendations should drive the 

selection of treatment interventions in a shared and informed decision-making 

process.

None Not reviewed, Deleted

B 2 J1 PTSD and co-morbid mental health conditions should be treated concurrently 

for all conditions through an integrated treatment approach, which considers 

patient preferences, provider experience, severity of the conditions, and the 

availability of resources.

None Reviewed, Deleted

B 2 J1 Patients with PTSD and severe co-morbid mental health conditions should be 

treated either through referral or in consultation with a provider that is 

experienced in treating the co-morbid conditions.

None Reviewed, Deleted
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B 2 J1 Because of the profound social impairment of PTSD (caused, for example, by the 

patient’s anger and avoidance symptoms), close friends and family members in 

the patient’s immediate daily environment (e.g., parents, spouse, or children) 

should be provided with education and advised to consider assistance from 

specialty care, both for individual treatment and couples/family treatment.

None Not reviewed, Deleted

B 2 J1 Factors to consider when determining the optimal setting for treatment 

include:

a. Severity of the PTSD or co-occurring disorders

b. Local availability of service options (specialized PTSD programs, evidencebased treatments, behavioral health specialty care, primary care, integrated 

care for co-occurring disorders, Vet Centers, other)

c. Level of provider comfort and experience in treating psychiatric comorbidities

d. Patient preferences

e. The need to maintain a coordinated continuum of care for chronic comorbidities

f. Availability of resources and time to offer treatment.

None Not reviewed, Deleted
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B 2 J1 Considerations related to possible referral:

Complicated severe PTSD: Some patients with PTSD have complicated, 

challenging presentations. These patients warrant referral to specialty PTSD 

care that includes access to cognitive-behavioral evidence-based treatments 

(see Module I-2: Treatment for PTSD).

Co-occurring major depressive disorder (MDD) in the absence of significant 

suicidality, panic, or generalized anxiety often shows reduction in intensity 

when the PTSD is treated. Depression of mild severity may not require referral 

to specialty care or additional treatments outside those targeting PTSD. Patients 

should be carefully monitored for changes in symptoms. A reduction of PTSD 

symptoms that is not accompanied by reduction of symptoms in depression or 

anxiety would justify a more formally targeted treatment (refer to the VA/DoD 

guideline for MDD).

Co-occurring mild to moderate disorders, such as substance use, pain disorders, 

and sleep problems, can frequently be effectively treated in the context of PTSD 

treatment and do not require a referral to specialty care. Consultation, to 

integrate adjunctive interventions, may be considered (see the respective 

VA/DoD CPGs).

Co-occurring severe psychiatric disorders, while not precluding concurrent PTSD 

treatment, typically justify referral to specialty care for evaluation and 

treatment. These disorders may include: Severe Major Depression or Major 

Depression with suicidality, Unstable Bipolar Disorder, Severe Personality 

Disorders, Psychotic Disorders, Significant TBI, and Severe Substance Use 

Disorder (SUD) or substance abuse of such intensity that PTSD treatment 

components are likely to be difficult to implement.

Persistent Post-Concussion Symptoms in patients who present with PTSD and a 

history of concussion/mTBI may be best managed within either primary care or 

polytrauma rehab settings that utilize a multidisciplinary team approach. 

Providers should recognize that mTBI/concussion is one of numerous possible 

etiologies of co-morbid post-deployment symptoms occurring in Veterans and 

Service Members with PTSD, and it is often difficult to precisely attribute 

symptoms to concussive events that occurred months or years earlier. From a 

treatment standpoint, physical or cognitive symptoms, such as headaches or 

memory problems, or other persistent post-concussive symptoms should be 

treated symptomatically whether or not concussion/mTBI is thought to be one 

of the causal factors. Clinicians should not get caught up in debating causation 

but maintain focus on identifying and treating the symptoms that are 

contributing to the most impairment. There is no evidence to support 

withholding PTSD treatments while addressing post-concussive symptoms.

None Not reviewed, Deleted

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B 2 J2 All patients diagnosed with PTSD should receive comprehensive assessment for 

SUD, including nicotine dependence (as recommended by the separate Clinical 

Practice Guideline).

None Not reviewed, Deleted

B 2 J2 Recommend and offer cessation treatment to patients with nicotine 

dependence. [A]

A Reviewed, Deleted

B 2 J2 Patients with SUD and PTSD should be educated about the relationships 

between PTSD and substance abuse. The patient’s prior treatment experience 

and preference should be considered since no single intervention approach for 

the co- morbidity has yet emerged as the treatment of choice.

None Not reviewed, Deleted

B 2 J2 Treat other concurrent Substance Use Disorders consistent with VA/DoD clinical 

practice guidelines including concurrent pharmacotherapy:

a. Addiction-focused pharmacotherapy should be discussed, considered,

available and offered, if indicated, for all patients with alcohol dependence

and/or opioid dependence.

b. Once initiated, addiction-focused pharmacotherapy should be monitored for

adherence and treatment response.

None Reviewed, NewreplacedRecommendation 38 

B 2 J2 Provide multiple services in the most accessible setting to promote engagement 

and coordination of care for both conditions. [I]

I Not reviewed, Deleted

B 2 J2 Reassess response to treatment for SUD periodically and systematically, using 

standardized and valid self-report instrument(s) and laboratory tests. Indicators 

of SUD treatment response include ongoing substance use, craving, side effects 

of medication, emerging symptoms, etc.

None Not reviewed, Deleted

B 2 J2 There is insufficient evidence to recommend for or against any specific 

psychosocial approach to addressing PTSD that is co-morbid with SUD. [I]

I Reviewed, NewreplacedRecommendation 38 
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B 2 J3 Primary care providers should routinely provide the following services for all 

patients with trauma-related disorders, especially those who are reluctant to 

seek specialty mental healthcare:

 Education about the disorder and importance of not letting stigma and 

barriers to care interfere with specialty treatment if needed

 Provision of evidence-based treatment within the primary Care or through 

referral

 Regular follow-up and monitoring of symptoms

 Regular follow-up and monitoring of co-morbid health concerns.

None Not reviewed, Deleted

B 2 J3 Primary care providers should consider consultation with mental health 

providers for patients with PTSD who warrant a mental health referral but 

refuse it or seem reluctant to talk to a mental health provider.

None Not reviewed, Deleted

B 2 J3 Primary care providers should take leadership in providing a collaborative multidisciplinary treatment approach. Team members may include the primary care 

providers, mental health specialists, other medical specialists (e.g., neurology, 

pain management), chaplains, pastors, social workers, occupational or 

recreational therapists, Vet Center staff members, staff of family support 

centers, exceptional family member programs, VA benefits counselors, 

vocational rehabilitation specialists, peer counselors, and others.

None Reviewed, NewreplacedRecommendation 2

B 2 J3 When an integrated behavioral health clinician is available (e.g., collaborative 

care model, or Post-Deployment Care clinics) evidence-based treatment should 

be provided.

None Reviewed, NewreplacedRecommendation 2

B 2 J3 Primary care providers should continue to be involved in the treatment of 

patients with acute or chronic stress disorders. All patients with PTSD should have 

a specific primary care provider assigned to coordinate their overall healthcare.

None Not reviewed, Deleted

B 3 K A supportive and collaborative treatment relationship or therapeutic alliance 

should be developed and maintained with patients with PTSD.

None Not reviewed, Deleted

B 3 K Evidence-based psychotherapy and/or evidence-based pharmacotherapy are 

recommended as first-line treatment options.

None Reviewed, Deleted

B 3 K Specialized PTSD psychotherapies may be augmented by additional problemspecific methods/services and pharmacotherapy.None Reviewed, NewreplacedRecommendation 29 
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B 3 K Consider referral for alternative care modalities (Complementary Alternative 

Medicine) for patient symptoms, consistent with available resources and 

resonant with patient belief systems. [See Module I-2]

None Reviewed, Deleted

B 3 K Patients with PTSD who are experiencing clinically significant symptoms, 

including chronic pain, insomnia, anxiety, should receive symptom-specific 

management interventions. [See Module I-3]

None Not reviewed, Deleted

B 3 K Management of PTSD or related symptoms may be initiated based on a 

presumptive diagnosis of PTSD. Long-term pharmacotherapy will be 

coordinated with other intervention.

None Reviewed, Deleted

B 4 N At a minimum, providers should perform a brief PTSD symptom assessment at 

each treatment visit. The use of a validated PTSD symptom measure, such as 

the PTSD Checklist, should be considered (see Appendix C).

None Not reviewed, Deleted

B 4 N Comprehensive re-assessment and evaluation of treatment progress should be 

conducted at least every 90 days, perhaps with greater frequency for those in 

active treatment, and should include a measure of PTSD symptomatology 

(e.g., PCL) and strongly consider a measure of Depression symptomatology 

(e.g., PHQ9).

None Not reviewed, Deleted

B 4 N Other specific areas of treatment focus (e.g., substance abuse) should also be 

reevaluated and measured by standardized measures of outcome.

None Not reviewed, Deleted

B 4 N Assessment of functional impairment should also be made, at a minimum, by 

asking patients to rate to what extent their symptoms make it difficult to 

engage in vocational, parental, spousal, familial, or other roles.

None Not reviewed, Deleted

B 4 N Consider continued assessment of:

 Patient preferences

 Treatment adherence

 Adverse treatment effects.

None Not reviewed, Deleted
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B 4 O If patient does not improve or status worsens, consider one of the following 

treatment modification options:

a. Continue application of the same modality at intensified dose and/or

frequency

b. Change to a different treatment modality

c. Apply adjunctive therapies

d. Consider a referral to adjunctive services for treatment of co-morbid

disorders or behavioral abnormalities (e.g., homelessness, domestic

violence, or aggressive behavior).

e. For patient with severe symptoms or coexisting psychiatric problems 

consider referrals to:

• Specialized PTSD programs

• Specialized programs for coexisting problems and conditions

• Partial psychiatric hospitalization or “day treatment” programs

• Inpatient psychiatric hospitalization.

None Reviewed, NewreplacedRecommendation 29

Recommendation 30
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B 4 O If patient demonstrates partial (insufficient) remission, consider one of the 

following treatment modification options:

a. Before making any therapeutic change, ensure that “treatment nonresponse” is not due to one or more of the following: not keeping

psychotherapy appointments, not doing prescribed homework, not taking

prescribed medications, still using alcohol or illicit substances, still suffering

from ongoing insomnia or chronic pain, not experiencing any new 

psychosocial stressors, the original assessment did not overlook a comorbid medical or psychiatric condition

b. Continue the present treatment modality to allow sufficient time for full

response

c. Continue application of the same modality at intensified dose and/or 

frequency

d. Change to a different treatment modality

e. Apply adjunctive therapies

f. Increase level of care (e.g., referral facility, partial hospitalization, inpatient

hospitalization, residential care)

g. Consider a referral to adjunctive services for treatment of co-morbid disorders 

or behavioral abnormalities (e.g., homelessness or domestic violence).

None Reviewed, NewreplacedRecommendation 29

Recommendation 30

B 4 O If patient demonstrates improved symptoms and functioning but requires 

maintenance treatment:

a. Continue current course of treatment

b. Consider stepping down the type, frequency, or dose of therapy

c. Consider:

• Transition from intensive psychotherapy to case management contacts

• Transition from individual to group treatment modalities

• Transition to as-needed treatment

d. Discuss patient status and need for monitoring with the primary care provider

e. Consider a referral to adjunctive services for treatment of co-morbid disorders 

or behavioral abnormalities (e.g., homelessness or domestic violence).

None Not reviewed, Deleted
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B 4 O If patient demonstrates remission from symptoms and there are no indications 

for further therapy:

a. Discontinue treatment

b. Educate the patient about indications for and route of future care access

c. Monitor by primary care for relapse/exacerbation.

None Not reviewed, Deleted

B 4 O Evaluate psychosocial function and refer for psychosocial rehabilitation, as 

indicated. Available resources include, but are not limited to: chaplains, pastors, 

Family Support Centers, Exceptional Family Member Programs, VA benefits 

counselors, occupational or recreational therapists, Vet Centers, and peersupport groups (see Module I-2 D: Psychosocial Rehabilitation).

None Not reviewed, Deleted

B 4 O Provide case management, as indicated, to address high utilization of medical 

resources.

None Reviewed, Deleted

I 1 - Continue providing psychoeducation and normalization. None Not reviewed, Deleted

I 1 - Treatment should be initiated after education, normalization, and Psychological 

First Aid has been provided and after basic needs following the trauma have 

been made available.

None Not reviewed, Deleted

I 1 - There is insufficient evidence to recommend for or against the use of 

Psychological First Aid to address symptoms beyond 4 days following trauma. [I]

I Not reviewed, Deleted

I 1 - Survivors who present with symptoms that do not meet the diagnostic 

threshold of ASD or PTSD should be monitored and may benefit from follow-up 

and provision of ongoing counseling or symptomatic treatment.

None Not reviewed, Deleted

I 1 - Recommend monitoring for development of PTSD using validated symptom 

measures (e.g., PTSD Checklist, other screening tools for ASD/PTSD).

None Not reviewed, Deleted
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I 1 - Psychotherapy:

a. Consider early brief intervention (4 to 5 sessions) of cognitive-based therapy 

(CBT) that includes exposure-based therapy, alone or combined with a 

component of cognitive re-structuring therapy for patients with significant 

early symptom levels, especially those meeting diagnostic criteria for ASD. [A]

b. Routine formal psychotherapy intervention for asymptomatic

individuals is not beneficial and may be harmful. [D]

c. Strongly recommend against individual Psychological Debriefing as a viable 

means of reducing acute stress disorder (ASD) or progression to posttraumatic stress disorder (PTSD). [D]

d. The evidence does not support a single session group Psychological 

Debriefing as a viable means of reducing acute stress disorder (ASD) or 

progression to post-traumatic stress disorder, but there is no evidence of 

harm (Note: this is not a recommendation pertaining to Operational 

Debriefing). [D]

e. Groups may be effective vehicles for providing trauma-related education, 

training in coping skills, and increasing social support, especially in the 

context of multiple group sessions. [I]

f. Group participation should be voluntary.

A, D, I Reviewed, NewreplacedRecommendation 7

I 1 - Pharmacotherapy:

a. There is no evidence to support a recommendation for use of a 

pharmacological agent to prevent the development of ASDor PTSD. [I]

b. Strongly recommend against the use of benzodiazepines to prevent the 

development of ASD or PTSD [D]

D, I Reviewed, NewreplacedRecommendation 6

Recommendation 8

I 2 A Providers should explain to all patients with PTSD the range of available and 

effective therapeutic options for PTSD.

None Not reviewed, Amended Recommendation 1

I 2 A Patient education is recommended as an element of treatment of PTSD for all 

patients and the family members. [C]

C Not reviewed, Deleted

I 2 A Patient and provider preferences should drive the selection of evidence-based 

psychotherapy and/or evidence-based pharmacotherapy as the first line 

treatment.

None Not reviewed, Amended Recommendation 1
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I 2 A Psychotherapies should be provided by practitioners who have been trained in 

the particular method of treatment.

None Reviewed, Deleted

I 2 A A collaborative care approach to therapy administration, with care

management, may be considered, although supportive evidence is lacking 

specifically for PTSD.

None Reviewed, Amended Recommendation 2

I 2 B Strongly recommend that patients who are diagnosed with PTSD should be 

offered one of the evidence-based trauma-focused psychotherapeutic 

interventions that include components of exposure and/or cognitive 

restructuring; or stress inoculation training. [A]

The choice of a specific approach should be based on the severity of the 

symptoms, clinician expertise in one or more of these treatment methods and 

patient preference, and may include an exposure-based therapy 

(e.g., Prolonged Exposure), a cognitive-based therapy (e.g., Cognitive Processing 

Therapy), Stress management therapy (e.g., SIT) or Eye Movement 

Desensitization and Reprocessing (EMDR).

A Reviewed, NewreplacedRecommendation 11

Recommendation 12 

I 2 B Relaxation techniques should be considered as a component of treatment 

approaches for ASD or PTSD in alleviating symptoms associated with 

physiological hyper-reactivity. [C]

C Reviewed, Deleted

I 2 B Imagery Rehearsal Therapy [IRT] can be considered for treatment of nightmares 

and sleep disruption. [C]

C Reviewed, Deleted

I 2 B Brief Psychodynamic Therapy can be considered for patients with PTSD. [C] C Reviewed, Deleted

I 2 B Hypnotic Techniques can be considered, especially for symptoms associated 

with PTSD, such as pain, anxiety, dissociation, and nightmares, for which 

hypnosis has been successfully used. [C]

C Not reviewed, Deleted

I 2 B There is insufficient evidence to recommend for or against Dialectical 

Behavioral Therapy (DBT) as first-line treatment for PTSD [I]

 Dialectical Behavioral Therapy can be considered for patients with a 

borderline personality disorder typified by parasuicidal behaviors. [B]

B, I Reviewed, Deleted

I 2 B There is insufficient evidence to recommend for or against Family or Couples 

Therapy as first-line treatment for PTSD; Family or Couples therapy may be 

considered in managing PTSD-related family disruption or conflict, increasing 

support, or improving communication. [I]

I Reviewed, Amended Recommendation 16
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I 2 B Group Therapy may be considered for treatment of PTSD [C]

 There is insufficient evidence to favor any particular type of group therapy 

over other types

 Patients being considered for group therapy should exhibit acceptance for 

the rationale for trauma work, and willingness to self-disclose in a group.

C, I Reviewed, NewreplacedRecommendation 15

I 2 B Consider augmenting with other effective evidence-based interventions for 

patients who do not respond to a single approach.

None Reviewed, NewreplacedRecommendation 29

Recommendation 30

I 2 B Supportive psychotherapy is not considered to be effective for the treatment of 

PTSD. However, multiple studies have shown that supportive interventions are 

significantly more helpful than no treatment, and they may be helpful in 

preventing relapse in patients who have reasonable control over their 

symptoms and are not in severe and acute distress.

None Reviewed, NewreplacedRecommendation 13 

I 2 B Telemedicine interventions that involve person-to-person individual treatment 

sessions appear to have similar efficacy and satisfaction clinically as a direct 

face-to-face interaction, though data are much more limited than for face-toface encounters. [C]

a. Telemedicine interventions are recommended when face-to-face 

interventions are not feasible due to geographic distance between patient 

and provider or other barriers to patient access (e.g., agoraphobia, physical 

disability); when the patient would benefit from more frequent contact than 

is feasible with face-to-face sessions; or when the patient declines more 

traditional mental health interventions.

b. Providers using telemedicine interventions should endeavor to maintain and 

strengthen the therapeutic relationship, build patient rapport, stress 

practice and assignment completion, and ensure adequacy of safety 

protocols using similar techniques as they do in a face-to-face session.

c. Providers using technology-assisted interventions should take steps to 

ensure that their work complies with the regulations and procedures of the 

organization in which they are employed, legal standards, and the ethical 

standards of their professions. Patient confidentiality and safety should be 

monitored closely.

C Reviewed, Amended Recommendation 35 

Recommendation 36 
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I 2 B There is insufficient evidence to recommend for or against Web-based 

interventions as a stand-alone intervention or as an alternative to standard 

mental health treatment for PTSD. [I] If used:

a. Clinicians should carefully review the content of any web-based materials to 

ensure their accuracy and ethical application before recommending use to 

patients.

b. Web-based approach may be used where face-to-face interventions are not 

feasible (e.g., geography limits access to other forms of treatment) or when 

patients decline more traditional mental health interventions. It has also 

been suggested that web-based interventions may provide more 

confidentiality than more traditional approaches.

c. Providers should regularly encourage patients to complete the intervention 

and endeavor to maintain and strengthen the therapeutic relationship, build 

patient rapport, stress practice and assignment completion, and ensure 

adequacy of safety protocols. Availability of telephone contact for initial 

assessment or other reasons (e.g. emergencies, suicidality/homicidality, or 

follow-up of specific problems) should be considered.

d. Providers using technology-assisted interventions should take steps to 

ensure that their work complies with the regulations and procedures of the 

organization in which they are employed, legal standards, and the ethical 

standards of their professions. Patient confidentiality and safety should be 

monitored closely.

I Reviewed, NewreplacedRecommendation 35

Recommendation 36 

I 2 C Risks and benefits of long-term pharmacotherapy should be discussed prior to 

starting medication and should be a continued discussion item during treatment.

None Reviewed, Deleted

I 2 C Monotherapy therapeutic trial should be optimized before proceeding to 

subsequent strategies by monitoring outcomes, maximizing dosage (medication 

or psychotherapy), and allowing sufficient response time (for at least 8 weeks). [C]

C Reviewed, Deleted

I 2 C If there is some response and patient is tolerating the drug, continue for at least 

another 4 weeks.

None Reviewed, Deleted

I 2 C If the drug is not tolerated, discontinue the current agent and switch to another 

effective medication.

None Reviewed, Deleted
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 134 of 200 2010 Module 2010 Section 2010 Number

2010 Recommendation Text

2010 Grade 

Category

2017 

Recommendation

I 2 C If no improvement is observed at 8 weeks consider:

a. Increasing the dose of the initial drug to maximum tolerated

b. Discontinuing the current agent and switching to another effective 

medication

None Reviewed, Deleted

I 2 C Recommend assessment of adherence to medication at each visit. None Reviewed, Deleted

I 2 C Recommend assessment of side effects and management to minimize or 

alleviate adverse effects.

None Reviewed, Deleted

I 2 C Assess for treatment burden (e.g., medication adverse effects, attending 

appointments) after initiating or changing treatment when the patient is nonadherent to treatment or when the patient is not responding to treatment.

None Reviewed, Deleted

I 2 C Since PTSD is a chronic disorder, responders to pharmacotherapy may need to 

continue medication indefinitely; however, it is recommended that 

maintenance treatment should be periodically reassessed.

None Reviewed, Deleted

I 2 C Providers should give simple educational messages regarding antidepressant use 

(e.g., take daily, understand gradual nature of benefits, continue even when 

feeling better, medication may cause some transient side effects, along with 

specific instructions on how to address issues or concerns, and when to contact 

the provider) in order to increase adherence to treatment in the acute phase. [B]

B Reviewed, Deleted

I 2 C Strongly recommend that patients diagnosed with PTSD should be offered 

selective serotonin reuptake inhibitors (SSRIs), for which fluoxetine, paroxetine, 

or sertraline have the strongest support, or serotonin norepinephrine reuptake 

inhibitors (SNRIs), for which venlafaxine has the strongest support, for the 

treatment of PTSD. [A]

A Reviewed, NewreplacedRecommendation 17

I 2 C Recommend mirtazapine, nefazodone, tricyclic antidepressants (TCAs), 

amitriptyline and imipramine, or monoamine oxidase inhibitors (phenelzine) for 

the treatments for PTSD. [B]

B Reviewed, NewreplacedRecommendation 18 

Recommendation 19

Recommendation 20

Recommendation 22 

I 2 C Recommend against the use of guanfacine, anticonvulsants (tiagabine, 

topiramate, or valproate) as monotherapy in the management of PTSD. [D]

D Reviewed, NewreplacedRecommendation 19

Recommendation 20
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 135 of 200 2010 Module 2010 Section 2010 Number

2010 Recommendation Text

2010 Grade 

Category

2017 

Recommendation

I 2 C The 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]

I Reviewed, NewreplacedRecommendation 22

I 2 C There is evidence against the use of benzodiazepines in the management of 

PTSD. [D]

D Reviewed, Amended Recommendation 20

I 2 C There is insufficient evidence to support the use of prazosin as monotherapy in 

the management of PTSD. [I]

I Reviewed, NewreplacedRecommendation 

28a 

I 2 C Recommend against the use of risperidone as adjunctive therapy [D]. There is 

insufficient evidence to recommend the use of any other atypical antipsychotic 

for treatment of PTSD. [I]

D, I Reviewed, NewreplacedRecommendation 20

Recommendation 22 

Recommendation 25 

I 2 C Recommend adjunctive treatment with prazosin for sleep/nightmares. [B] B Reviewed, NewreplacedRecommendation 

28b 

I 2 C There is insufficient evidence to recommend a sympatholytic or an 

anticonvulsant as an adjunctive therapy for the treatment of PTSD. [I]

I Reviewed, Deleted

I 2 D Consider psychosocial rehabilitation techniques once the client and clinician 

identify the following kinds of problems associated with the diagnosis of PTSD: 

persistent high-risk behaviors, lack of self-care/independent living skills, 

homelessness, interactions with a family that does not understand PTSD, 

socially inactive, unemployed, and encounters with barriers to various forms of 

treatment/rehabilitation services.

None Not reviewed, Deleted

I 2 D Patient and clinician should determine whether such problems are associated 

with core symptoms of PTSD and, if so, ensure that rehabilitation techniques 

are used as a contextual vehicle for alleviating PTSD symptoms.

None Not reviewed, Deleted

I 2 D Psychosocial rehabilitation should occur concurrently or shortly after a course 

of treatment for PTSD, since psychosocial rehabilitation is not trauma-focused.

None Not reviewed, Deleted

I 2 E There is insufficient evidence to recommend the use of any of the Biomedical 

Somatic Therapies for first-line treatment of PTSD. [D]

D Reviewed, NewreplacedRecommendation 32 

I 2 E ECT and rTMS may be considered as an alternative in chronic, severe, 

medication- and psychotherapy-resistant PTSD. [B]

B Reviewed, NewreplacedRecommendation 32

I 2 E2 Acupuncture may be considered as treatment for patients with PTSD. [B] B Reviewed, Amended Recommendation 33 
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 136 of 200 2010 Module 2010 Section 2010 Number

2010 Recommendation Text

2010 Grade 

Category

2017 

Recommendation

I 2 F There is insufficient evidence to recommend CAM approaches as first line 

treatments for PTSD. [I]

I Reviewed, NewreplacedRecommendation 34

I 2 F CAM approaches that facilitate a relaxation response (e.g. mindfulness, yoga, 

acupuncture, massage, and others) may be considered for adjunctive treatment 

of hyperarousal symptoms, although there is no evidence that these are more 

effective than standard stress inoculation techniques. [I]

I Reviewed, NewreplacedRecommendation 34 

I 2 F CAM approaches may be considered as adjunctive approaches to address some 

co- morbid conditions (e.g. acupuncture for pain). [C]

C Reviewed, NewreplacedRecommendation 34

I 2 F CAM may facilitate engagement in medical care and may be considered in some 

patients who refuse evidence-based treatments. However, providers should 

discuss the evidence for effectiveness and risk-benefits of different options, and 

ensure that the patient is appropriately informed.

None Reviewed, Deleted

I 3 A Encourage patients to practice good sleep hygiene, including:

 Restricting the night-time sleep period to about eight hours

 Waking at a regular time

 Arising from bed at a regular time

 Avoiding going to bed too early

 Avoiding alcohol

 Avoiding stimulants, caffeinated beverages, power/energy drinks, nicotine, 

and over-the-counter medications

 Avoiding stimulating activities, light, noise, and temperature extremes 

before bedtime (e.g., exercise, video games, T.V.) or in the sleeping area

 Reducing (to less than 30 minutes), or abolishing, daytime naps

 Practicing relaxation techniques

 Engaging in moderate exercise, but not immediately before bedtime

None Not reviewed, Deleted

I 3 A Offer Cognitive Behavioral Therapy for Insomnia, which may include:

 Educating about proper sleep habits and sleep needs

 Correcting false and unrealistic beliefs/concerns about sleep

 Identifying and addressing anxious, automatic thoughts which disrupt sleep

None Reviewed, Amended Recommendation 40

I 3 A Consider adjunctive therapy for nightmares using prazosin. [B] B Reviewed, NewreplacedRecommendation 

28b 
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 137 of 200 2010 Module 2010 Section 2010 Number

2010 Recommendation Text

2010 Grade 

Category

2017 

Recommendation

I 3 A Any significant change in sleep patterns should trigger clinical reassessment in 

order to rule out worsening or new onset of co-morbid conditions

None Reviewed, Deleted

I 3 A Monitor symptoms to assess improvement or deterioration and reassess 

accordingly.

None Not reviewed, Deleted

I 3 A Explore cause(s) for insomnia, including co-morbid conditions. None Reviewed, NewreplacedRecommendation 39 

I 3 A Begin treatment for insomnia with non-pharmacological treatments, including 

sleep hygiene and cognitive behavioral treatment (see recommendation for 

Sleep Disturbances).

None Reviewed, NewreplacedRecommendation 40

I 3 A The selection of sleep agents for the treatment of insomnia in PTSD patients 

may be impacted by other treatment decisions (e.g., medications already 

prescribed for the treatment of PTSD, depression, TBI, pain, or concurrent 

substance abuse/withdrawal) and social/environmental/logistical concerns 

associated with deployment.

a. Trazodone may be helpful in management of insomnia and may also 

supplement the action of other antidepressants.

b. Hypnotics are a second-line approach to the management of insomnia and 

should only be used for short periods of time. Should hypnotic therapy be 

indicated, the newer generation of non-benzodiazepines (e.g., zolpidem, 

eszopiclone, ramelteon) may have a safety advantage by virtue of their 

shorter half-life and lower risk of dependency. Patients should be warned of 

and monitored for the possibility of acute confusional states/bizarre sleep 

behaviors associated with hypnotic use.

Benzodiazepines can be effective in chronic insomnia but may have 

significant adverse effects (confusion, sedation, intoxication) and significant 

risk of dependency.

c. Atypical antipsychotics should be avoided due to potential adverse effects 

but may be of value when agitation or other symptoms are severe. 

d. If nightmares remain severe, consider adjunctive treatment with prazosin [B]

e. If symptoms persist or worsen, refer for evaluation and treatment of insomnia

B, 

None

Reviewed, Deleted

I 3 B Recommend pain assessment using a ‘0 to 10’ scale. None Not reviewed, Deleted
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 138 of 200 2010 Module 2010 Section 2010 Number

2010 Recommendation Text

2010 Grade 

Category

2017 

Recommendation

I 3 B Obtain a thorough biopsychosocial history and assess for other medical and 

psychiatric problems, including risk assessment for suicidal and homicidal 

ideation and misuse of substances, such as drugs or alcohol and over-thecounter and prescription drugs or narcotics.

None Not reviewed, Deleted

I 3 B Assessment should include questions about the nature of the pain and likely 

etiology (i.e., musculoskeletal and neuropathic), locations, quality, quantity, 

triggers, intensity, and duration of the pain, as well as aggravating and 

relieving factors.

None Not reviewed, Deleted

I 3 B Assessment should include evaluation of the impact of pain on function and 

activities, pain-related disability, or interference with daily activities.

None Not reviewed, Deleted

I 3 B Assessment should include the identification of avoidance behaviors that 

contribute to emotional distress and/or impaired functioning.

None Not reviewed, Amended Recommendation 4

I 3 B Management of pain should be multidisciplinary, addressing the physical, social, 

psychological, and spiritual components of pain in an individualized treatment 

plan that is tailored to the type of pain. [C]

C Reviewed, Deleted

I 3 B Selection of treatment options should balance the benefits of pain control with 

possible adverse effects (especially sedating medications) on the individual’s 

ability to participate in, and benefit from, PTSD treatment. [I]

I Not reviewed, Deleted

I 3 B Musculoskeletal pain syndromes can respond to correcting the underlying 

condition and treatment with non-steroidal anti-inflammatory drugs (NSAIDs).

None Not reviewed, Deleted

I 3 B When appropriate, recommend use of non-pharmacological modalities for pain 

control, such as biofeedback, massage, imaging therapy, physical therapy, and 

complementary alternative modalities (yoga, meditation, acupuncture). [C]

C Not reviewed, Deleted

I 3 B Centrally acting medications should be used in caution in patients with PTSD, as 

they may cause confusion and deterioration of cognitive performance and 

interfere with the recovery process.

a. If required, lower doses of opioid therapy or other centrally acting 

analgesics should be used for short duration with transition to the use of 

NSAIDs. [C]

C Not reviewed, Deleted
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 139 of 200 2010 Module 2010 Section 2010 Number

2010 Recommendation Text

2010 Grade 

Category

2017 

Recommendation

I 3 B Consider offering Cognitive Behavioral Therapy, which may include:

a. Encouraging increasing activity by setting goals

b. Correcting false and unrealistic beliefs/concerns about pain

c. Teaching cognitive and behavioral coping skills (e.g., activity pacing)

d. Practicing and consolidation of coping skills and reinforcement of use

None Not reviewed, Deleted

I 3 C Assess the nature of symptoms, severity, and dangerousness. Consider using 

standardized Anger Scales, such as Spielberger’s State-Trait Anger Expression 

Inventory, to quantify.

None Not reviewed, Deleted

I 3 C Explore for cause of symptoms and follow-up to monitor change. None Not reviewed, Deleted

I 3 C Consider referral to specialty care for counseling or for marital or family 

counseling as indicated. Offer referral for:

a. Anger Management therapy

b. Training in exercise and relaxation techniques

None Not reviewed, Deleted

I 3 C Promote participation in enjoyable activities - especially with family/ loved ones. None Not reviewed, Deleted

I 3 C Promote sleep and relaxation. None Not reviewed, Deleted

I 3 C Avoid stimulants and other substances (caffeine, alcohol). None Not reviewed, Deleted

I 3 C Address pain (see pain management). None Not reviewed, Deleted

I 3 C Avoid benzodiazepines. None Reviewed, Amended Recommendation 20

I 3 C Consider SSRIs/SNRIs

a. If not responding to SSRIs/SNRIs and other non-pharmacological 

interventions, consider low-dose anti-adrenergics or low-dose atypical 

antipsychotics (risperidone, quetiapine).

b. If not responding or worsening, refer to specialty care. 

None Reviewed, NewreplacedRecommendation 17 
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 140 of 200

Appendix F: Participant List

Nancy C. Bernardy, PhD (Champion) 

Director, PTSD Mentoring Program 

Associate Director for Clinical Networking, VA National 

Center for PTSD

Associate Professor of Psychiatry

Geisel School of Medicine at Dartmouth

White River Jct, VT

Kathleen M. Chard, PhD 

Associate Chief of Staff for Research

Director, Trauma Recovery Center 

Cincinnati VA Medical Center

Professor of Psychiatry and Behavioral Neuroscience 

University of Cincinnati 

Cincinnati, OH

Lori Davis, MD 

Associate Chief of Staff for Research and Development

Tuscaloosa VA Medical Center

Clinical Professor of Psychiatry 

The University of Alabama at Birmingham

Tuscaloosa, AL

Megan J. Ehret, PharmD, MS, BCPP 

Behavioral Health Clinical Pharmacy Specialist

Fort Belvoir Community Hospital

Fort Belvoir, VA

Bradford Felker, MD

Director, Telemental Health Program

VA Puget Sound Health Care System

Professor, Department of Psychiatry and Behavioral 

Sciences 

University of Washington

Seattle, WA

Joel T. Foster, PhD 

Maj, USAF, BSC

Psychologist 

Chief, Air Force Deployment Mental Health

Defense Health Agency Headquarters

Falls Church, VA

Matthew J. Friedman, MD, PhD (Champion)

Senior Advisor, VA National Center for PTSD 

Professor of Psychiatry 

Geisel School of Medicine at Dartmouth 

White River Jct, VT

Jessica Hamblen, PhD

Acting Deputy Executive Director, VA National Center for 

PTSD

Associate Professor, Department of Psychiatry 

Geisel School of Medicine at Dartmouth

White River Jct, VT

Charles W. Hoge, MD (Champion) 

Senior Scientist, Walter Reed Army Institute of Research

Neuropsychiatry Consultant, Office of the Army Surgeon 

General

Attending Psychiatrist, Walter Reed National Military 

Medical Center

Bethesda, MD

Matthew Jeffreys, MD

Telehealth Psychiatrist

VA Texas Valley Coastal Bend Healthcare System

Associate Professor of Psychiatry 

University of Texas Health Science Center

San Antonio, TX

Shawn F. Kane, MD, FAAFP, FACSM 

COL, MC, MFS, DMO

Commander, Special Warfare Medical Group (Airborne) 

Dean, Joint Special Operations Medical Training Center

Family Medicine Consultant to The Surgeon General

United States Army Special Operations Command

Fort Bragg, NC

Kate McGraw, PhD

Interim Director, Deployment Health Clinical Center

Defense Centers of Excellence for Psychological Health 

and Traumatic Brain Injury

Silver Spring, MD
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 141 of 200

Jeffrey Millegan, MD, MPH, FAPA

CDR MC USN

Director, Naval Center for Combat & Operational Stress 

Control

Bureau of Medicine and Surgery (M3)

San Diego, CA

Sonya Norman, PhD

Director, PTSD Consultation Program 

VA National Center for PTSD

VA San Diego Healthcare System

Professor, University California San Diego School of 

Medicine

San Diego, CA

Mary Jo Pugh, RN, PhD, FACMPH

National Quality Assurance Director, VA Epilepsy 

Centers of Excellence

Research Health Scientist, Veterans Evidence-based 

Research, Dissemination, and Implementation Center

Professor, Department of Epidemiology and Biostatistics

Co-Director, Research to Advance Community Health 

(ReACH) Center 

University of Texas Health Science Center

San Antonio, TX

Sheila A.M. Rauch, PhD, ABPP

Director, Mental Health Research and Program 

Evaluation

Atlanta VAMC Clinical Director, Emory Healthcare 

Veterans Program 

Associate Professor of Psychiatry and Behavioral 

Sciences

Emory University School of Medicine

Atlanta, GA

David S. Riggs, PhD (Champion)

Professor and Chair, Department of Medical and Clinical 

Psychology

Executive Director, Center for Deployment Psychology

Uniformed Services University of the Health Sciences

Bethesda, MD

Todd P. Semla, MS, PharmD, BCPS, FCCP, AGSF

National PBM Clinical Pharmacy Program Manager

Mental Health & Geriatrics

National Pharmacy Benefits Management Services

US Department of Veterans Affairs

Feinberg School of Medicine 

Northwestern University

Chicago, IL

Paula P. Schnurr, PhD (Champion)

Executive Director, VA National Center for PTSD 

Research Professor of Psychiatry

Geisel School of Medicine at Dartmouth

White River Jct, VT 

Elaine P. Stuffel, BSN, MHA, RN

Chronic Disease Clinical Practice Guideline Coordinator, 

Office of Evidence Based Practice

US Army Medical Command 

Quality Management Division

Fort Sam Houston, TX

Lisa A. Teegarden, PsyD

COL, MS, USA

Director for Behavioral Health

Walter Reed National Military Medical Center

Bethesda, MD

Meena Vythilingam, MD

CDR, USPHS

Deputy Director of Psychological Health

Head Quarters Marine Corps, Health Services

Arlington, VA

Wendi M. Waits, MD

COL, MC, USA

Chief, Adolescent Inpatient Behavioral Health

Fort Belvoir Community Hospital

Fort Belvoir, VA

Jonathan Wolf, MD 

Psychiatrist 

National Intrepid Center of Excellence

Bethesda, MD
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 142 of 200

Appendix G: Literature Review Search Terms and Strategy

A. Topic-specific Search Terms

The search strategies employed combinations of free-text keywords as well as controlled vocabulary terms 

including (but not limited to) the following concepts. Strategies for each bibliographic database follow this 

table.

EMTREE, Medical Subject Headings (MeSH), PsycInfo, and Keywords 

Concept Controlled Vocabulary Keywords 

Acute Stress 

Disorders/Reactions & PTSD

Embase (EMTREE)

'acute stress disorder'/de

‘posttraumatic stress disorder’/de

Medline (MeSH)

Combat Disorders/

Stress Disorders, Post-Traumatic/

Stress Disorders, Traumatic, Acute/

PsycINFO

Acute Stress Disorder/

Posttraumatic Stress Disorder/

Stress Reactions/

acute stress disorder*

acute stress reaction*

“Combat and operational stress reaction”

“combat disorder”

“combat disorders”

“combat fatigue”

“combat stress”

“post-traumatic neurosis”

“post-traumatic psychic”

“post-traumatic psychoses”

“post-traumatic psychosis”

“post-traumatic stress”

“post-traumatic syndrome”

“post-traumatic syndromes”

“posttraumatic neurosis”

“posttraumatic psychic”

“posttraumatic psychoses”

“posttraumatic psychosis”

“posttraumatic stress”

“posttraumatic syndrome”

“posttraumatic syndromes”

PTSD

“stress disorder”

“stress disorders”

“trauma syndrome”

“trauma syndromes”

“traumatic stress”

“war neuroses”

“war neurosis”
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 143 of 200

Concept Controlled Vocabulary Keywords 

Biological Treatments Embase (EMTREE)

'electroconvulsive therapy'/de

'hyperbaric oxygen'/de 

'stellate ganglion block'/de

'transcranial magnetic stimulation'/de

Medline (MeSH)

Electroconvulsive Therapy/

Hyperbaric Oxygenation/

Transcranial Magnetic Stimulation/ 

PsycINFO

Electroconvulsive Shock Therapy/ 

Transcranial Magnetic Stimulation/

convulsive therapy

ECS

ECT

electric shock therapy

electroconvulsive therapy

electroconvulsant therapy

electroconvulsive shock therapy

electroconvulsive treatment

electroshock therapy

electroshock treatment

“high pressure o”

“high pressure oxygen”

hyperbaric medicine

hyperbaric o2

hyperbaric oxygen therapy

hyperbaric oxygenation

hyperbaric oxygen

shock therapy

stellate ganglion block

stellate ganglion blockade

stellate ganglion blocking

rTMS

TMS

transcranial magnetic stimulation
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 144 of 200

Concept Controlled Vocabulary Keywords 

CAM Embase (EMTREE) 

'acupuncture'/exp 

'alternative medicine'/exp 

'animal assisted therapy'/exp 

'art therapy'/de 

'dance therapy'/de 

'diet supplementation'/de 

'exercise'/exp 

'herbal medicine'/de 

'homeopathic agent'/de 

'integrative medicine'/de 

'meditation'/de 

'mindfulness'/de 

'music therapy'/de 

'phytotherapy'/de 

‘Psychodrama’/de 

'recreational therapy'/de 

'Tai Chi'/de 

'transcendental meditation'/de 

'yoga'/de 

Medline (MeSH) 

Acupuncture/ 

Acupuncture Therapy/ 

Animal Assisted Therapy/ 

Art Therapy/ 

Dance Therapy/ 

Dietary Supplements/ 

exp Exercise/ 

Herbal Medicine/ 

Homeopathy/ 

Integrative Medicine/ 

Meditation/ 

exp Mind-Body Therapies/ 

Music Therapy/ 

Plants, Medicinal/ 

Psychodrama/ 

Recreation Therapy/ 

Relaxation/ 

Relaxation Therapy/ 

Tai Ji/ 

yoga/ 

PsycINFO 

Acupuncture/ 

exp Alternative Medicine/ Art 

Therapy/ 

Animal Assisted Therapy/ exp 

Creative Arts Therapy/ Dietary 

Supplements/ 

exp Exercise/ 

acupuncture

alternative medicine

animal-assisted therapy

art therapy

complementary medicine

creative arts therapy

dance therapy

dietary supplements

drama therapy

exercise

fishing

herbs

herbal

Homeopath*

integrative medicine

mantram

meditation

mind-body 

mindfulness

Movement Therapy

music therapy

phytotherapy

progressive muscle relaxation

Psychodrama

recreational therapy

relaxation

Tai Chi

Tai Ji

yoga
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June 2017 Page 145 of 200

Concept Controlled Vocabulary Keywords 

Holistic Health/

Martial Arts/

exp "medicinal herbs and plants"/ 

Mind Body Therapy/ 

Mindfulness/ 

Meditation/

Movement Therapy/ 

Music Therapy/

Progressive Relaxation Therapy/ 

Psychodrama/ 

Recreation Therapy/ 

Relaxation/

Relaxation Therapy/ 

Yoga/

Collaborative Care Embase (EMTREE)

'integrated health care system'/de

Medline (MeSH)

Delivery of Health Care, Integrated/

CALM

Care management

Collaborative care

Collaborative mental health

“Coordinated Anxiety Learning and Management”

Coordinated care

Embedded behavioral health

IMPACT

Integrated mental health

Mental health integration

PCMHI

“Primary Care Mental Health Integration”

“Re-Engineering Systems of Primary Care Treatment 

in the Military”

“re-engineering systems for the primary care 

treatment of PTSD”

“RESPECT MIL”

“RESPECT PTSD”

Stepped care

“Stepped Enhancement of PTSD Services Using 

Primary Care”

“STEPS UP”

TIDES

“Translating Initiatives for Depression into Effective 

Solutions”
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 146 of 200

Concept Controlled Vocabulary Keywords 

Group / Peer Support Embase (EMTREE)

'group therapy'/de

'peer group'/de

'social support'/de

Medline (MeSH)

Exp Peer Group/

Exp Psychotherapy, Group/

Exp Self-Help Groups/ 

Social Support/

PsycINFO

Exp Encounter Group Therapy/

Group Counseling/

Group Intervention/

Exp Group Psychotherapy/

Peer Counseling/

Peer Relations/

Peers/

Social Group Work/

Social Support/

Support Groups/

Supportive Psychotherapy/

community therapy

community treatment

encounter group

group psychotherapy

Group setting

Group therapy

group treatment

peer group

Peer support

Self-help

Support group

Supportive Psychotherapy

Supportive therapy

Pharmacotherapy – Alpha 

Adrenergic Antagonists

Embase (EMTREE)

'alpha adrenergic receptor blocking 

agent'/mj

Medline (MeSH)

exp Adrenergic alpha-Antagonists/ 

Doxazosin/ 

Prazosin/ 

Sympatholytics/

PsycINFO

Adrenergic Blocking Drugs/ 

adrenergic alpha-Antagonist*

adrenergic receptor block*

alpha adrenergic antagonist*

alpha block*

antiadrenergic*

doxazosin

prazosin

sympatholytic*

terazosin
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 147 of 200

Concept Controlled Vocabulary Keywords 

Pharmacotherapy –

Antidepressants

Embase (EMTREE)

'antidepressant agent'/exp/mj

‘serotonin noradrenalin reuptake 

inhibitor’/exp/mj

'serotonin uptake inhibitor'/exp/mj

'tricyclic antidepressant agent'/exp/mj

'triple reuptake inhibitor'/exp/mj

Medline (MeSH)

amitriptyline/

amoxapine/

exp Antidepressive Agents/

Antidepressive Agents, Tricyclic/

citalopram/

clomipramine/

desipramine/

Desvenlafaxine Succinate/

doxepin/

Duloxetine Hydrochloride/

fluoxetine/

fluvoxamine/

imipramine/

maprotiline/

nortriptyline/

paroxetine/

protriptyline/

Serotonin and Noradrenaline Reuptake 

Inhibitors/

exp serotonin uptake inhibitors/

sertraline/

trazodone/

trimipramine/

Venlafaxine Hydrochloride/

Vilazodone Hydrochloride/

PsycINFO

exp Antidepressant Drugs/

exp Serotonin Norepinephrine 

Reuptake Inhibitors/

exp Serotonin Reuptake Inhibitors/

exp Tricyclic Antidepressant Drugs/ 

amitriptyline

amoxapine

bupropion

anti-depressant*

antidepressant*

citalopram

clomipramine

desipramine

desvenlafaxine

doxepin 

duloxetine

escitalopram

fluoxetine

fluvoxamine

hydroxizine

imipramine

levomilnacipran

maprotiline

milnacipran

mirtazapine

nefazodone

nortriptyline

paroxetine

protriptyline

selective serotonin reuptake inhibitor*

serotonin–noradrenaline reuptake inhibitor*

Serotonin–norepinephrine reuptake inhibitor*

sertraline

SNRI*

SSRI*

trazodone

tricyclic antidepressant*

trimipramine

venlafaxine

vilazodone

vortioxetine
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June 2017 Page 148 of 200

Concept Controlled Vocabulary Keywords 

Pharmacotherapy – 

Antipsychotics

Embase (EMTREE)

'neuroleptic agent'/mj

Medline (MeSH)

Antipsychotic Agents/

chlorpromazine/ 

fluphenazine/ 

haloperidol/ 

loxapine/ 

perphenazine/ 

pimozide/ 

thioridazine/ 

thiothixene/

trifluoperazine/ 

PsycINFO

exp Neuroleptic Drugs/

anti-psychotic*

antipsychotic*

chlorpromazine

fluphenazine 

haloperidol

loxapine

neuroleptic

perphenazine

pimozide

thioridazine

thiothixene

trifluoperazine
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 149 of 200

Concept Controlled Vocabulary Keywords 

Pharmacotherapy – Atypical 

antipsychotics

EMBASE (EMTREE)

‘atypical antipsychotic agent’/de

MEDLINE(MeSH)

Antipsychotic Agents/

aripiprazole/

clozapine/ 

lurasidone hydrochloride/

paliperidone palmitate/

quetiapine fumarate/

risperidone/

PsycINFO

aripiprazole/

exp Neuroleptic Drugs/

aripiprazole

asenapine

atypical antipsychotic*

brexpiprazole

cariprazine

clozapine

iloperidone

lurasidone

olanzapine

paliperidone

quetiapine

risperidone

ziprasidone

Pharmacotherapy - 

Benzodiazepines

Embase (EMTREE)

'benzodiazepine derivative'/exp 

Medline (MeSH)

alprazolam/

exp benzodiazepines/ 

Clorazepate Dipotassium/

diazepam/

estazolam/

flurazepam/

lorazepam/

midazolam/

oxazepam/

temazepam/

triazolam/ 

PsycINFO

exp Benzodiazepines/ 

Alprazolam

benzodiazepine*

benzodiazepinone*

chlordiazepoxide

clonazepam

clorazepate

diazepam

estazolam

flurazepam

lorazepam

midazolam

oxazepam

quazepam

temazepam

triazolam

Pharmacotherapy - 

Cannabinoids 

Embase (EMTREE)

'cannabidiol'/de

'cannabinoid'/exp/mj

'cannabis'/de

'dronabinol'/de

'medical cannabis'/de

'tetrahydrocannabinol'/de

Medline (MeSH)

Cannabidiol/

Exp Cannabinoids/

Cannabis/

Dronabinol/

Medical Marijuana/

PsycINFO

Exp Cannabinoids/

Exp Cannabis/

Marijuana/

Tetrahydrocannabinol/

Cannabidiol

Cannabinoid*

CBD

Dronabinol 

Marijuana 

Tetrahydrocannabinol

THC
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 150 of 200

Concept Controlled Vocabulary Keywords 

Pharmacotherapy - General Embase (EMTREE)

'drug therapy'/de/mj

Medline (MeSH)

Drug Therapy/

dt.fs

PsycINFO

exp Drug Therapy/

drug therap*

drug treatment*

pharmacological

pharmaco-therap*

pharmacotherap*

Pharmacotherapy –

Monoamine oxidase inhibitor 

(MAOIs)

EMBASE (EMTREE)

‘monoamine oxidase inhibitor’/de

MEDLINE (MeSH)

Isocarboxazid/

Monoamine Oxidase Inhibitors/

phenelzine/

selegiline/

tranylcypromine/

PsycINFO

exp Monoamine Oxidase Inhibitors/

isocarboxazid

monoamine oxidase inhibitor*

MAO

MAOI*

“MAO inhibitor”

“MAO inhibitors”

monoamine oxidase A inhibitor

monoamine oxidase B inhibitor

phenelzine

selegiline

tranylcypromine

Pharmacotherapy – Mood 

Stabilizers

Embase (EMTREE)

'anticonvulsive agent'/de

Medline (MeSH)

carbamazepine/

clonidine/

lithium/

pregabalin/

valproic acid/

PsycINFO

anticonvulsive drugs/

Carbamazepine/

exp Lithium/

Mood Stabilizers/

Valproic Acid/

anticonvuls*

carbamazepine

divalproex

gabapentin

lamotrigine

lithium

mood stabilizer*

oxcarbazepine

pregabalin

tiagabine

topiramate

valproate

valproic acid

Pharmacotherapy - Other Medline (MeSH)

ketamine/

propranolol/

Propranolol

“D-cycloserine”

ketamine
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 151 of 200

Concept Controlled Vocabulary Keywords 

Pharmacotherapy -

Psychostimulants

Embase (EMTREE)

'3,4 

methylenedioxymethamphetamine'/de

'amphetamine plus 

dexamphetamine'/de

'amphetamine'/de

'atomoxetine'/de

'dexamphetamine'/de

'dexmethylphenidate'/de

'lisdexamfetamine'/de

'methamphetamine'/de

'methylphenidate'/de

'psychostimulant agent'/exp/mj

Medline (MeSH)

N-Methyl-3,4-

methylenedioxyamphetamine/

Exp Amphetamine/ 

Atomoxetine Hydrochloride/

Dexmethylphenidate Hydrochloride/

Dextroamphetamine/

Methamphetamine/

Methylphenidate/

PsycINFO

Amphetamine/

Atomoxetine/ 

cns stimulating drugs/

Dextroamphetamine/

Methamphetamine/

Methylenedioxymethamphetamine/

Methylphenidate/

“3,4-methylenedioxymethamphetamine"

Adderall

Amphetamine

Armodafanil

Atomoxetine

Dexmethylphenidate

Dextroamphetamine

Lisdexamphetamine

MDMA

Methamphetamine

Methylphenidate

Modafanil

Psychostimulant*

Pharmacotherapy - Sedatives Embase (EMTREE)

'hypnotic sedative agent'/exp/mj

'sedative agent'/de/mj

Medline (MeSH)

anti-anxiety agents/

buspirone/

diphenhydramine/

eszopiclone/

guanfacine/

Hypnotics and Sedatives/

PsycINFO

exp sedatives/

anti-anxiety

antianxiety 

buspirone

clonidine

diphenhydramine

eszopiclone

guanfacine

hydroxizine

hypnotic*

ramelteon

sedative*

suvorexant

tasimelteon

zaleplon

zolpidem

zopiclone
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 152 of 200

Concept Controlled Vocabulary Keywords 

Pharmacotherapy - Steroids Embase (EMTREE)

'hydrocortisone'/de

'mifepristone'/de

'prasterone'/de

'steroid'/exp/mj

Medline (MeSH)

Exp Dehydroepiandrosterone/

Hydrocortisone/

Mifepristone/

Steroids/

PsycINFO

Hydrocortisone/

Steroids/

Dehydroepiandrosterone

DHEA

Hydrocortisone

Mifepristone 

Steroid*
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 153 of 200

Concept Controlled Vocabulary Keywords 

Psychotherapy - Brief Medline (MeSH)

Psychotherapy, Brief/

PsycINFO

Brief Psychotherapy/

Brief CBT

Brief counsel*

Brief intervention*

Brief Psychotherap*

Brief therap*

Brief treatment*

Short term CBT

Short term counsel*

Short term intervention*

Short term Psychotherap*

Short term therap*

Short term treatment*

Time limited CBT

Time limited counsel*

Time limited intervention*

Time limited Psychotherap*

Time limited therap*

Time limited treatment*
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 154 of 200

Concept Controlled Vocabulary Keywords 

Psychotherapy - Non-Traumafocused 

Embase (EMTREE)

'acceptance and commitment 

therapy'/mj

'family therapy'/mj

'marital therapy'/mj

'mindfulness'/mj

'psychodynamic psychotherapy'/mj

psychotherapy/exp/mj

Medline (MeSH)

Acceptance and Commitment Therapy/

Family Therapy/

exp Mind-Body Therapies/

mindfulness/

Neurolinguistic Programming/

exp psychotherapy/

Psychotherapy, Psychodynamic/

px.fs

Relaxation Therapy/

exp Socioenvironmental Therapy/

th.fs

PsycINFO

Acceptance and Commitment Therapy/

Brief Psychotherapy/ 

exp Cognitive Behavior Therapy/

Cognitive Therapy/

Conjoint Therapy/

Couples Therapy/

Emotion Focused Therapy/

exp Family Therapy/

Interpersonal Psychotherapy/

exp Marriage Counseling/

Meditation/

mindfulness/

Neurolinguistic Programming/

exp Psychoanalysis/

Psychodynamic Psychotherapy/

Psychotherapy/

Relaxation/

exp Relaxation Therapy/

acceptance and commitment therapy

behavioral activation

couples therapy

emotion focused couples therapy

family therapy

interpersonal therapy

IPT

marital therapy

marriage therapy

meditation

mindfulness

Neurolinguistic programming

PCT

Present Centered Therapy

Problem Solving Therapy

Psychoanalysis

psychodynamic*

psychotherap*

relaxation

Seeking Safety

SIT

Socioenvironmental Therapy

Stress Inoculation Therapy

supportive counseling
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 155 of 200

Concept Controlled Vocabulary Keywords 

Psychotherapy – Traumafocused

Embase (EMTREE)

'behavior therapy'/exp 

'cognitive therapy'/exp

'narrative therapy'/de

‘virtual reality exposure therapy’/de

Medline (MeSH)

exp Cognitive Therapy/

Eye Movement Desensitization 

Reprocessing/ 

Virtual Reality Exposure Therapy/ 

PsycINFO

exp Behavior Therapy/ 

exp Cognitive Behavior Therapy/

Cognitive Therapy/

Eclectic Psychotherapy/

exp Exposure Therapy/ 

Eye Movement Desensitization 

Therapy/ 

Virtual Reality/

Accelerated Resolution Therapy

ART

behavior therapy

behaviour therapy

BEP-TG

brief eclectic psychotherapy

CBCT

CBT

“cognitive behavioral conjoint therapy”

cognitive behavioral therapy

Cognitive Processing Therapy

cognitive therapy

Ehlers[tiab]

EMDR

emotional freedom technique*

exposure therapy

Eye Movement Desensitization

imagery rehearsal therapy

Mindfulness based exposure therapy

Narrative Therapy

Prolonged Exposure Therapy

thought field therapy

“trauma focused”

virtual reality exposure

Written Exposure Therapy 
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 156 of 200

Concept Controlled Vocabulary Keywords 

Technology Embase (EMTREE)

'mobile application'/de

'mobile phone'/exp

'telecommunication'/exp

'teleconference'/de

'teleconsultation'/de

'telehealth'/exp

'telemedicine'/exp

'telephone'/de

'telepsychiatry'/de

'virtual reality'/de

Medline (MeSH)

Exp Cell Phones/

Remote Consultation/

Smartphone/

exp Telemedicine/

exp Telephone/

PsycINFO

Cellular Phones/

Exp Mobile Devices/

Teleconferencing/

telemedicine/

exp Telephone Systems/

Virtual Reality/

“clinical video teleconferencing”

CVT

Ehealth

e-health

mobile device*

Mobile phone*

Mobile application*

Mobile app*

Smartphone*

Tele-communication*

Tele-conferenc*

Tele-health*

Tele-medicine

Tele-monitor*

Tele-psych*

Telecommunication*

Teleconferenc* 

Teleconsultation*

Telehealth*

Telemedicine 

Telemonitor*

Telephone

Telepsych*

telephone care management

video conferenc*

Video tele-conferencing

Video teleconferencing

Virtual reality

B. Search Strategies

MEDLINE/PSYCINFO (presented in OVID syntax) 

Set 

Number Concept Search statement

1 PTSD *Posttraumatic Stress Disorder/ or *Combat Disorders/ or *Stress Disorders, PostTraumatic/ or *Acute Stress Disorder/ OR *Stress Reactions/ OR * Stress Disorders, 

Traumatic, Acute/ OR ((combat or war) adj2 (disorder* or fatigue or neuros* stress*)).ti,ab. 

or (("post-traumatic" or posttraumatic) adj2 (neurosis or psych* or stress* or 

syndrome*)).ti,ab. or PTSD.ti,ab. or (stress* adj2 (disorder* or reaction*)).ti,ab. or 

(trauma* adj2 (stress or syndrome*)).ti,ab.

2 Pharmacotherapy – 

General

dt.fs or exp Drug Therapy/ OR (drug* ADJ2 (therap* OR treatment*)).ti,ab. or 

pharmacological.ti,ab. or pharmaco-therap*.ti,ab. or pharmacotherap*.ti,ab.

3 Pharmacotherapy –

Alpha Adrenergic 

Antagonists

exp Adrenergic alpha-Antagonists/ or Sympatholytics/ or Adrenergic Blocking Drugs/ or 

Doxazosin/ or Prazosin/ or (adrenergic alpha-Antagonist* or adrenergic receptor block* or 

alpha adrenergic antagonist* or alpha block* or antiadrenergic* or doxazosin or prazosin 

or sympatholytic* or terazosin).ti,ab. 
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 157 of 200

Set 

Number Concept Search statement

4 Pharmacotherapy –

Antipsychotics

Antipsychotic Agents/ OR chlorpromazine/ OR fluphenazine/ OR haloperidol/ OR loxapine/

OR perphenazine/ OR pimozide/ OR thioridazine/ OR thiothixene/ OR trifluoperazine/ OR 

exp Neuroleptic Drugs/ OR (anti-psychotic* OR antipsychotic* OR chlorpromazine OR 

fluphenazine OR haloperidol OR loxapine OR neuroleptic OR perphenazine OR pimozide OR 

thioridazine OR thiothixene OR trifluoperazine).ti,ab.

5 Pharmacotherapy –

Atypical antipsychotics

Antipsychotic Agents/ OR aripiprazole/ OR clozapine/ OR lurasidone hydrochloride/ OR 

paliperidone palmitate/ OR quetiapine fumarate/ OR risperidone/ OR aripiprazole/ OR exp 

Neuroleptic Drugs/ OR (aripiprazole OR asenapine OR brexpiprazole OR cariprazine OR

clozapine OR iloperidone OR lurasidone OR olanzapine OR paliperidone OR quetiapine OR 

risperidone OR ziprasidone).ti,ab. 

6 Pharmacotherapy –

Benzodiazepines

alprazolam/ OR exp benzodiazepines/ OR Clorazepate Dipotassium/ OR diazepam/ OR 

estazolam/ OR flurazepam/ OR lorazepam/ OR midazolam/ OR oxazepam/ OR temazepam/ 

OR triazolam/ OR exp Benzodiazepines/ OR (Alprazolam OR benzodiazepine* OR 

benzodiazepinone* OR chlordiazepoxide OR clonazepam OR clorazepate OR diazepam OR 

estazolam OR flurazepam OR lorazepam OR midazolam OR oxazepam OR quazepam OR 

temazepam OR triazolam).ti,ab.

7 Pharmacotherapy –

MAOIs

Isocarboxazid/ OR Monoamine Oxidase Inhibitors/ OR phenelzine/ OR selegiline/ OR 

tranylcypromine/ OR exp Monoamine Oxidase Inhibitors/ OR (monoamine oxidase 

inhibitor* or ((MAO* OR “monoamine oxidase”) ADJ2 inhibitor*) or MAOI* or 

isocarboxazid OR phenelzine OR selegiline OR tranylcypromine).ti,ab.

8 Pharmacotherapy –

Mood Stablizers

carbamazepine/ OR clonidine/ OR lithium/ OR pregabalin/ OR valproic acid/ OR 

anticonvulsive drugs/ OR Carbamazepine/ OR exp Lithium/ OR Mood Stabilizers/ OR 

Valproic Acid/ OR (anticonvuls* OR carbamazepine OR divalproex OR gabapentin OR 

lamotrigine OR lithium OR (mood ADJ2 stabiliz*) OR oxcarbazepine OR pregabalin OR 

tiagabine OR topiramate OR valproate OR valproic acid).ti,ab.

9 Pharmacotherapy –

Sedatives

anti-anxiety agents/ OR buspirone/ OR diphenhydramine/ OR eszopiclone/ OR guanfacine/ 

OR Hypnotics and Sedatives/ OR exp sedatives/ OR (buspirone OR clonidine OR 

diphenhydramine OR eszopiclone OR guanfacine OR hydroxizine OR hypnotic* OR 

ramelteon OR sedative* OR suvorexant OR tasimelteon OR zaleplon OR zolpidem OR 

zopiclone).ti,ab.

10 Pharmacotherapy –

Antidepressants

amitriptyline/ OR amoxapine/ OR exp Antidepressive Agents/ OR Antidepressive Agents, 

Tricyclic/ OR citalopram/ OR clomipramine/ OR desipramine/ OR Desvenlafaxine Succinate/ 

OR doxepin/ OR Duloxetine Hydrochloride/ OR fluoxetine/ OR fluvoxamine/ OR 

imipramine/ OR maprotiline/ OR nortriptyline/ OR paroxetine/ OR protriptyline/ OR 

Serotonin and Noradrenaline Reuptake Inhibitors/ OR exp serotonin uptake inhibitors/ OR 

sertraline/ OR trazodone/ OR trimipramine/ OR Venlafaxine Hydrochloride/ OR Vilazodone 

Hydrochloride/ OR exp Antidepressant Drugs/ OR exp Serotonin Norepinephrine Reuptake 

Inhibitors/ OR exp Serotonin Reuptake Inhibitors/ OR exp Tricyclic Antidepressant Drugs/

OR (amitriptyline OR amoxapine OR bupropion OR anti-depressant* OR antidepressant* 

OR citalopram OR clomipramine OR desipramine OR desvenlafaxine OR doxepin OR 

duloxetine OR escitalopram OR fluoxetine OR fluvoxamine OR hydroxizine OR imipramine 

OR levomilnacipran OR maprotiline OR milnacipran OR mirtazapine OR nefazodone OR 

nortriptyline OR paroxetine OR protriptyline OR selective serotonin reuptake inhibitor* OR 

serotonin noradrenaline reuptake inhibitor* OR Serotonin norepinephrine reuptake 

inhibitor* OR sertraline OR SNRI* OR SSRI* OR trazodone OR tricyclic antidepressant* OR 

trimipramine OR venlafaxine OR vilazodone OR vortioxetine).ti,ab.

11 Pharmacotherapy –

Psychostimulants

*N-Methyl-3,4-methylenedioxyamphetamine/ OR *Amphetamine/ OR *Atomoxetine 

Hydrochloride/ OR *Dexmethylphenidate Hydrochloride/ OR *Dextroamphetamine/ OR 

*Methamphetamine/ OR *Methylphenidate/ OR *Amphetamine/ OR *Atomoxetine/ OR 

*cns stimulating drugs/ OR *Dextroamphetamine/ OR *Methamphetamine/ OR 

*Methylenedioxymethamphetamine/ OR *Methylphenidate/ OR (“3,4-

methylenedioxymethamphetamine" OR Adderall OR Amphetamine OR Armodafanil OR 

Atomoxetine OR Dexmethylphenidate OR Dextroamphetamine OR Lisdexamphetamine OR 

MDMA OR Methamphetamine OR Methylphenidate OR Modafanil OR 

Psychostimulant*).ti,ab.
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 158 of 200

Set 

Number Concept Search statement

12 Pharmacotherapy – 

Steroids

exp Dehydroepiandrosterone/ or *Hydrocortisone/ or *Mifepristone/ or *Steroids/ or 

*Hydrocortisone/ or *Steroids/ or (Dehydroepiandrosterone or DHEA or Hydrocortisone or 

Mifepristone or Steroid*).ti,ab.

13 Pharmacotherapy – 

Cannabinoids

*Cannabidiol/ OR Exp Cannabinoids/ OR *Cannabis/ OR *Dronabinol/ OR *Medical 

Marijuana/ OR Exp Cannabinoids/ OR Exp Cannabis/ OR *Marijuana/ OR 

*Tetrahydrocannabinol/ OR (Cannabidiol OR Cannabinoid* OR CBD OR Dronabinol OR 

Marijuana OR Tetrahydrocannabinol OR THC).ti,ab.

14 Pharmacotherapy –

Other

ketamine/ OR propranolol/ OR (propranolol OR “D-cycloserine” OR ketamine).ti,ab.

15 Combine 

Pharmacotherapies

Or/2-14

16 Combine PTSD & 

Pharmacotherapies

1 and 15

17 English Language limit 16 to english language

18 Human limit 17 to human

19 Date limit 18 to yr="2009 -Current"

20 Humans limit 19 to humans [Limit not valid in PsycINFO; records were retained]

21 Systematic Reviews 20 and (research synthesis or pooled or systematic review/ or meta analysis/ or metaanalysis/ or ((evidence base$ or methodol$ or systematic or quantitative$ or studies or 

search$).mp. and (review/ or review.pt. or literature review/)))

22 RCTs 20 and ((Randomized controlled trials or random allocation or double-blind method or 

single-blind method or placebos or cross-over studies).de. or placebo$.mp. or 

random$.ti,ab. or crossover$.mp. or cross over.mp. or ((singl$ or doubl$ or tripl$ or trebl$) 

and (blind$ or mask$ or sham$)).mp. or latin square.mp. or ISRTCN or ACTRN$ or (NCT$ 

not NCT) or (clinical trials/ and random$.ti,ab.))

23 Combine Systematic 

Reviews & RCTs

21 or 22

24 Remove Selected 

Publication Types

23 not (letter/ or editorial/ or news/ or comment/ or case report or case reports/ or note/ 

or conference paper/ or (letter or editorial or news or comment or case reports or 

conference abstract$).pt.)

25 Deduplication remove duplicates from 24

Set 

Number Concept Search statement

1 PTSD *Posttraumatic Stress Disorder/ or *Combat Disorders/ or *Stress Disorders, PostTraumatic/ or *Acute Stress Disorder/ OR *Stress Reactions/ OR * Stress Disorders, 

Traumatic, Acute/ OR ((combat or war) adj2 (disorder* or fatigue or neuros* stress*)).ti,ab. 

or (("post-traumatic" or posttraumatic) adj2 (neurosis or psych* or stress* or 

syndrome*)).ti,ab. or PTSD.ti,ab. or (stress* adj2 (disorder* or reaction*)).ti,ab. or 

(trauma* adj2 (stress or syndrome*)).ti,ab.

2 Psychotherapy – 

Trauma-Focused

exp Cognitive Therapy/ OR Eye Movement Desensitization Reprocessing/ OR Virtual Reality 

Exposure Therapy/ OR exp Behavior Therapy/ OR exp Cognitive Behavior Therapy/ OR 

Cognitive Therapy/ OR Eclectic Psychotherapy/ OR exp Exposure Therapy/ OR Eye 

Movement Desensitization Therapy/ OR Virtual Reality/ OR (Accelerated Resolution 

Therapy OR ART OR (Behavior* ADJ2 therap*) OR (behaviour* ADJ2 therap*) OR BEP-TG 

OR Brief eclectic psychotherapy OR CBCT OR CBT OR cognitive behavioral conjoint therapy 

OR cognitive behavioral therapy OR Cognitive Processing Therapy OR (cognitive ADJ2 

therap*) OR Ehlers OR EMDR OR emotional freedom OR exposure therapy OR Eye 

Movement Desensitization OR imagery rehearsal OR Mindfulness OR Narrative Therapy OR 

Prolonged Exposure Therapy OR thought field therapy OR trauma focused OR virtual reality 

exposure OR Written Exposure Therapy).ti,ab.
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 159 of 200

Set 

Number Concept Search statement

3 Psychotherapy – 

Non-trauma-focused

Acceptance and Commitment Therapy/ OR Family Therapy/ OR exp Mind-Body Therapies/ 

OR mindfulness/ OR Neurolinguistic Programming/ OR exp psychotherapy/ OR 

Psychotherapy, Psychodynamic/ OR px.fs OR Relaxation Therapy/ OR exp Socioenvironmental 

Therapy/ OR th.fs OR Acceptance and Commitment Therapy/ OR Brief Psychotherapy/ OR 

exp Cognitive Behavior Therapy/ OR Cognitive Therapy/ OR Conjoint Therapy/ OR Couples 

Therapy/ OR Emotion Focused Therapy/ OR exp Family Therapy/ OR Interpersonal 

Psychotherapy/ OR exp Marriage Counseling/ OR Meditation/ OR mindfulness/ OR 

Neurolinguistic Programming/ OR exp Psychoanalysis/ OR Psychodynamic Psychotherapy/ OR 

Psychotherapy/ OR Relaxation/ OR exp Relaxation Therapy/ OR (acceptance and commitment 

therapy OR behavioral activation OR couples therapy OR emotion focused couples therapy 

OR family therapy OR interpersonal therapy OR IPT OR marital therapy OR marriage therapy 

OR meditation OR mindfulness OR Neurolinguistic programming OR PCT OR Present Centered 

Therapy OR Problem Solving Therapy OR Psychoanalysis OR psychodynamic* OR 

psychotherap* OR relaxation OR Seeking Safety OR SIT OR Socioenvironmental Therapy OR 

Stress Inoculation Therapy OR supportive counseling).ti,ab.

4 Combine 

Psychotherapies

2 or 3

5 PTSD & 

Psychotherapies

1 and 4

6 Remove Publication 

Types & Non-Adult 

Subjects

5 not ((authored book or autobiography or biography or book or case reports or comment or 

conference* or dissertation abstract edited book or editorial or encyclopedia or lectures or 

letter or news or note or proceeding or video-audio media or webcasts).pt. or (bibliography 

or chapter or column/opinion or comment/reply or dissertation or editorial or encyclopedia 

entry or letter or obituary or review-book).dt. or (adolescen* or antenatal or babies or baby 

or birth or child* or infan* or kid or kids or neonat* or newborn* or paediatric* or pediatric* 

or perinatal or prenatal or teen* or toddler* or young* or youth*).ti.)

7 Systematic Reviews 6 and (research synthesis or pooled or systematic review/ or meta analysis/ or metaanalysis/ or ((evidence base$ or methodol$ or systematic or quantitative$ or studies or 

search$).mp. and (review/ or review.pt. or literature review/)))

8 RCTs 6 and ((Randomized controlled trials or random allocation or double-blind method or 

single-blind method or placebos or cross-over studies).de. or placebo$.mp. or 

random$.ti,ab. or crossover$.mp. or cross over.mp. or ((singl$ or doubl$ or tripl$ or trebl$) 

and (blind$ or mask$ or sham$)).mp. or latin square.mp. or ISRTCN or ACTRN$ or (NCT$ 

not NCT) or (clinical trials/ and random$.ti,ab.))

9 Combine SRs & RCTs 7 or 8

10 English limit 9 to english language

11 Date limit 10 to yr="2009 - 2016"

Set 

Number Concept Search statement

1 PTSD *Posttraumatic Stress Disorder/ or *Combat Disorders/ or *Stress Disorders, PostTraumatic/ or *Acute Stress Disorder/ OR *Stress Reactions/ OR * Stress Disorders, 

Traumatic, Acute/ OR ((combat or war) adj2 (disorder* or fatigue or neuros* stress*)).ti,ab. 

or (("post-traumatic" or posttraumatic) adj2 (neurosis or psych* or stress* or 

syndrome*)).ti,ab. or PTSD.ti,ab. or (stress* adj2 (disorder* or reaction*)).ti,ab. or (trauma* 

adj2 (stress or syndrome*)).ti,ab.

2 Interventions Electroconvulsive Therapy/ OR Hyperbaric Oxygenation/ OR Transcranial Magnetic 

Stimulation/ OR Electroconvulsive OR Shock Therapy/ OR Transcranial Magnetic 

Stimulation/ OR (((convulsive or "electric shock" or electroconvuls* or electroshock or 

shock) adj2 (therap* or treatment*)) or (ECS or ECT or rTMS or TMS or "transcranial 

magnetic stimulation") or (("high pressure" or hyperbaric) adj2 (o or oxygen or 

oxygenation)) or ("stellate ganglion" adj2 block*)).ti,ab.

3 Combine 1 and 2
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 160 of 200

Set 

Number Concept Search statement

4 Systematic Reviews 3 and (research synthesis or pooled or systematic review/ or meta analysis/ or metaanalysis/ or ((evidence base$ or methodol$ or systematic or quantitative$ or studies or 

search$).mp. and (review/ or review.pt. or literature review/)))

5 RCTs 3 and ((Randomized controlled trials or random allocation or double-blind method or singleblind method or placebos or cross-over studies).de. or placebo$.mp. or random$.ti,ab. or 

crossover$.mp. or cross over.mp. or ((singl$ or doubl$ or tripl$ or trebl$) and (blind$ or 

mask$ or sham$)).mp. or latin square.mp. or ISRTCN or ACTRN$ or (NCT$ not NCT) or 

(clinical trials/ and random$.ti,ab.))

6 Combine 4 or 5

7 Remove Selected 

Publication Types

6 not ((authored book or autobiography or biography or book or case reports or comment or 

conference* or dissertation abstract edited book or editorial or encyclopedia or lectures or 

letter or news or note or proceeding or video-audio media or webcasts).pt. or (bibliography or 

chapter or column/opinion or comment/reply or dissertation or editorial or encyclopedia entry 

or letter or obituary or review-book).dt. or (adolescen* or antenatal or babies or baby or birth 

or child* or infan* or kid or kids or neonat* or newborn* or paediatric* or pediatric* or 

perinatal or prenatal or teen* or toddler* or young* or youth*).ti.)

8 Deduplication remove duplicates from 7
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 161 of 200

Set 

Number Concept Search statement

1 PTSD *Posttraumatic Stress Disorder/ or *Combat Disorders/ or *Stress Disorders, PostTraumatic/ or *Acute Stress Disorder/ OR *Stress Reactions/ OR * Stress Disorders, 

Traumatic, Acute/ OR ((combat or war) adj2 (disorder* or fatigue or neuros* 

stress*)).ti,ab. or (("post-traumatic" or posttraumatic) adj2 (neurosis or psych* or stress* 

or syndrome*)).ti,ab. or PTSD.ti,ab. or (stress* adj2 (disorder* or reaction*)).ti,ab. or 

(trauma* adj2 (stress or syndrome*)).ti,ab.

2 CAM Interventions – 

Controlled Vocabulary 

Acupuncture/ OR Acupuncture Therapy/ OR Animal Assisted Therapy/ OR Art Therapy/

OR Dance Therapy/ OR Dietary Supplements/ OR exp Exercise/ OR Herbal Medicine/ OR 

Homeopathy/ OR Integrative Medicine/ OR Meditation/ OR exp Mind-Body Therapies/

OR Music Therapy/ OR Plants, Medicinal/ OR Psychodrama/ OR Recreation Therapy/ OR 

Relaxation/ OR Relaxation Therapy/ OR Tai Ji/ OR yoga/ OR Acupuncture/ OR exp 

Alternative Medicine/ OR Art Therapy/ OR Animal Assisted Therapy/ OR exp Creative 

Arts Therapy/ OR Dietary Supplements/ OR exp Exercise/ OR Holistic Health/ OR Martial 

Arts/ OR exp "medicinal herbs and plants"/ OR Mind Body Therapy/ OR Mindfulness/ OR 

Meditation/ OR Movement Therapy/ OR Music Therapy/ OR Progressive Relaxation 

Therapy/ OR Psychodrama/ OR Recreation Therapy/ OR Relaxation/ OR Relaxation 

Therapy/ OR Yoga/

3 CAM Interventions – 

Keywords/

Phrases

Acupuncture.ti,ab. OR ((“animal assisted” OR art OR “creative art” OR “creative arts” OR 

dance OR drama OR movement OR music OR recreational) ADJ2 therap*).ti,ab. OR 

((alternative OR complementary OR integrative) ADJ2 medicine).ti,ab. OR (dietary ADJ2 

supplement*).ti,ab. OR exercise.ti,ab. OR fishing.ti,ab. OR herbs.ti,ab. OR herbal.ti,ab. OR 

Homeopath*.ti,ab. OR mantram.ti,ab. OR meditation.ti,ab. OR meditate*.ti,ab. OR mindbody.ti,ab. OR mindfulness.ti,ab. OR phytotherapy.ti,ab. OR “progressive muscle 

relaxation”.ti,ab. OR Psychodrama.ti,ab. OR relaxation.ti,ab. OR “Tai Chi”.ti,ab. OR “Tai 

Ji”.ti,ab. OR Yoga.ti,ab.

4 Combine Interventions 2 or 3

5 Combine PTSD & 

Intervention

1 and 4

6 Systematic Reviews 5 and (research synthesis or pooled or systematic review/ or meta analysis/ or metaanalysis/ or ((evidence base$ or methodol$ or systematic or quantitative$ or studies or 

search$).mp. and (review/ or review.pt. or literature review/)))

7 RCTs 5 and ((Randomized controlled trials or random allocation or double-blind method or 

single-blind method or placebos or cross-over studies).de. or placebo$.mp. or 

random$.ti,ab. or crossover$.mp. or cross over.mp. or ((singl$ or doubl$ or tripl$ or 

trebl$) and (blind$ or mask$ or sham$)).mp. or latin square.mp. or ISRTCN or ACTRN$ or 

(NCT$ not NCT) or (clinical trials/ and random$.ti,ab.))

8 Combine 6 or 7

9 Remove Selected 

Publication Types

8 not ((authored book or autobiography or biography or book or case reports or 

comment or conference* or dissertation abstract edited book or editorial or 

encyclopedia or lectures or letter or news or note or proceeding or video-audio media or 

webcasts).pt. or (bibliography or chapter or column/opinion or comment/reply or 

dissertation or editorial or encyclopedia entry or letter or obituary or review-book).dt. or 

(adolescen* or antenatal or babies or baby or birth or child* or infan* or kid or kids or 

neonat* or newborn* or paediatric* or pediatric* or perinatal or prenatal or teen* or 

toddler* or young* or youth*).ti.)

10 Deduplication remove duplicates from 9

11 English limit 10 to english language

12 Human limit 11 to human

13 Date limit 12 to yr="2009 - 2016"

14 Humans limit 13 to humans [Limit not valid in PsycINFO; records were retained]
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 162 of 200

Set 

Number Concept Search statement

1 PTSD *Posttraumatic Stress Disorder/ or *Combat Disorders/ or *Stress Disorders, PostTraumatic/ or *Acute Stress Disorder/ OR *Stress Reactions/ OR * Stress Disorders, 

Traumatic, Acute/ OR ((combat or war) adj2 (disorder* or fatigue or neuros* stress*)).ti,ab. 

or (("post-traumatic" or posttraumatic) adj2 (neurosis or psych* or stress* or 

syndrome*)).ti,ab. or PTSD.ti,ab. or (stress* adj2 (disorder* or reaction*)).ti,ab. or 

(trauma* adj2 (stress or syndrome*)).ti,ab.

2 Group/Peer 

Interventions

Exp Peer Group/ OR Exp Psychotherapy, Group/ OR Exp Self-Help Groups/ OR *Social 

Support/ OR Exp Encounter Group Therapy/ OR *Group Counseling/ OR *Group 

Intervention/ OR Exp Group Psychotherapy/ OR *Peer Counseling/ OR *Peer Relations/ OR 

Peers/ OR *Social Group Work/ OR *Social Support/ OR *Support Groups/ OR *Supportive 

Psychotherapy/ OR ((community OR group* OR peer* OR “self-help” OR support*) ADJ2 

(group* OR psychotherap* OR setting OR support* OR therap* OR treatment*)).ti,ab. OR 

“encounter group”.ti,ab.

3 Combine PTSD & 

Interventions

1 and 2

4 Systematic Reviews 3 and (research synthesis or pooled or systematic review/ or meta analysis/ or metaanalysis/ or ((evidence base$ or methodol$ or systematic or quantitative$ or studies or 

search$).mp. and (review/ or review.pt. or literature review/)))

5 RCTs 3 and ((Randomized controlled trials or random allocation or double-blind method or 

single-blind method or placebos or cross-over studies).de. or placebo$.mp. or 

random$.ti,ab. or crossover$.mp. or cross over.mp. or ((singl$ or doubl$ or tripl$ or trebl$) 

and (blind$ or mask$ or sham$)).mp. or latin square.mp. or ISRTCN or ACTRN$ or (NCT$ 

not NCT) or (clinical trials/ and random$.ti,ab.))

6 Combine 4 or 5

7 Remove Selected 

Publication Types

6 not ((authored book or autobiography or biography or book or case reports or comment or 

conference* or dissertation abstract edited book or editorial or encyclopedia or lectures or 

letter or news or note or proceeding or video-audio media or webcasts).pt. or (bibliography or 

chapter or column/opinion or comment/reply or dissertation or editorial or encyclopedia 

entry or letter or obituary or review-book).dt. or (adolescen* or antenatal or babies or baby 

or birth or child* or infan* or kid or kids or neonat* or newborn* or paediatric* or pediatric* 

or perinatal or prenatal or teen* or toddler* or young* or youth*).ti.)

8 Deduplication remove duplicates from 7

9 English limit 8 to english language

10 Human limit 9 to human 

11 Date limit 10 to yr="2009 - 2016"

12 Humans limit 11 to humans [Limit not valid in PsycINFO; records were retained]
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 163 of 200

Set 

Number Concept Search statement

1 PTSD *Posttraumatic Stress Disorder/ or *Combat Disorders/ or *Stress Disorders, PostTraumatic/ or *Acute Stress Disorder/ OR *Stress Reactions/ OR * Stress Disorders, 

Traumatic, Acute/ OR ((combat or war) adj2 (disorder* or fatigue or neuros* 

stress*)).ti,ab. or (("post-traumatic" or posttraumatic) adj2 (neurosis or psych* or stress* 

or syndrome*)).ti,ab. or PTSD.ti,ab. or (stress* adj2 (disorder* or reaction*)).ti,ab. or 

(trauma* adj2 (stress or syndrome*)).ti,ab.

2 Collaborative Care Delivery of Health Care, Integrated/ OR (“Care management” OR “Collaborative care” OR 

“Coordinated Anxiety Learning and Management” OR “Coordinated care” OR 

“Embedded behavioral health” OR “Mental health integration” OR PCMHI OR “Primary 

Care Mental Health Integration” OR “Re-Engineering Systems of Primary Care Treatment 

in the Military” OR “re-engineering systemsfor the primary care treatment of PTSD” OR 

“RESPECT MIL” OR “RESPECT PTSD” OR “Stepped care” OR “STepped Enhancement of 

PTSD Services Using Primary Care” OR “STEPS UP” OR TIDES OR “Translating Initiatives 

for Depression into Effective Solutions”).ti,ab.

3 Combine PTSD & 

Collaborative Care

1 and 2

4 Systematic Reviews 3 and (research synthesis or pooled or systematic review/ or meta analysis/ or metaanalysis/ or ((evidence base$ or methodol$ or systematic or quantitative$ or studies or 

search$).mp. and (review/ or review.pt. or literature review/)))

5 RCTs 3 and ((Randomized controlled trials or random allocation or double-blind method or 

single-blind method or placebos or cross-over studies).de. or placebo$.mp. or 

random$.ti,ab. or crossover$.mp. or cross over.mp. or ((singl$ or doubl$ or tripl$ or 

trebl$) and (blind$ or mask$ or sham$)).mp. or latin square.mp. or ISRTCN or ACTRN$ or 

(NCT$ not NCT) or (clinical trials/ and random$.ti,ab.))

6 Combine 4 or 5

7 Remove Selected 

Publication Types

6 not ((authored book or autobiography or biography or book or case reports or 

comment or conference* or dissertation abstract edited book or editorial or 

encyclopedia or lectures or letter or news or note or proceeding or video-audio media or 

webcasts).pt. or (bibliography or chapter or column/opinion or comment/reply or 

dissertation or editorial or encyclopedia entry or letter or obituary or review-book).dt. or 

(adolescen* or antenatal or babies or baby or birth or child* or infan* or kid or kids or 

neonat* or newborn* or paediatric* or pediatric* or perinatal or prenatal or teen* or 

toddler* or young* or youth*).ti.)

8 Deduplication remove duplicates from 7

9 English limit 8 to english language

10 Human limit 9 to human

11 Date limit 10 to yr="2009 - 2016"

12 Humans limit 11 to humans [Limit not valid in PsycINFO; records were retained]
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 164 of 200

Set 

Number Concept Search statement

1 PTSD *Posttraumatic Stress Disorder/ or *Combat Disorders/ or *Stress Disorders, PostTraumatic/ or *Acute Stress Disorder/ OR *Stress Reactions/ OR * Stress Disorders, 

Traumatic, Acute/ OR ((combat or war) adj2 (disorder* or fatigue or neuros* stress*)).ti,ab. 

or (("post-traumatic" or posttraumatic) adj2 (neurosis or psych* or stress* or 

syndrome*)).ti,ab. or PTSD.ti,ab. or (stress* adj2 (disorder* or reaction*)).ti,ab. or (trauma* 

adj2 (stress or syndrome*)).ti,ab.

2 Technologies Exp Cell Phones/ OR Remote Consultation/ OR Smartphone/ OR exp Telemedicine/ OR exp 

Telephone/ OR Cellular Phones/ OR Exp Mobile Devices/ OR Teleconferencing/ OR 

telemedicine/ OR exp Telephone Systems/ OR Virtual Reality/ OR ("clinical video 

teleconferencing" or CVT or Ehealth or "e-health" or (mobile adj2 (application* or app or 

apps or device* or phone*)) or Smartphone* or Tele-communication* or Tele-conferenc* or 

Tele-health* or Tele-medicine or Tele-monitor* or Tele-psych* or Telecommunication* or 

Teleconferenc* or Teleconsultation* or Telehealth* or Telemedicine or Telemonitor* or 

Telephone or Telepsych* or "telephone care management" or (video adj2 (conferenc* or 

tele-conferenc* or teleconference*)) or Virtual reality).ti,ab.

3 Combine PTSD & 

Technologies

1 and 2

4 Systematic Reviews 3 and (research synthesis or pooled or systematic review/ or meta analysis/ or metaanalysis/ or ((evidence base$ or methodol$ or systematic or quantitative$ or studies or 

search$).mp. and (review/ or review.pt. or literature review/)))

5 RCTs 3 and ((Randomized controlled trials or random allocation or double-blind method or singleblind method or placebos or cross-over studies).de. or placebo$.mp. or random$.ti,ab. or 

crossover$.mp. or cross over.mp. or ((singl$ or doubl$ or tripl$ or trebl$) and (blind$ or 

mask$ or sham$)).mp. or latin square.mp. or ISRTCN or ACTRN$ or (NCT$ not NCT) or 

(clinical trials/ and random$.ti,ab.))

6 Combine 4 or 5

7 Remove Selected 

Publication Types

6 not ((authored book or autobiography or biography or book or case reports or comment 

or conference* or dissertation abstract edited book or editorial or encyclopedia or lectures 

or letter or news or note or proceeding or video-audio media or webcasts).pt. or 

(bibliography or chapter or column/opinion or comment/reply or dissertation or editorial or 

encyclopedia entry or letter or obituary or review-book).dt. or (adolescen* or antenatal or 

babies or baby or birth or child* or infan* or kid or kids or neonat* or newborn* or 

paediatric* or pediatric* or perinatal or prenatal or teen* or toddler* or young* or 

youth*).ti.)

8 Deduplication remove duplicates from 7

9 English limit 8 to english language

10 Human limit 9 to human

11 Date limit 10 to yr="2009 - 2016"

12 Humans limit 11 to humans [Limit not valid in PsycINFO; records were retained]

Set 

Number Concept Search statement

1 PTSD *Posttraumatic Stress Disorder/ or *Combat Disorders/ or *Stress Disorders, PostTraumatic/ or *Acute Stress Disorder/ OR *Stress Reactions/ OR * Stress Disorders, 

Traumatic, Acute/ OR ((combat or war) adj2 (disorder* or fatigue or neuros* 

stress*)).ti,ab. or (("post-traumatic" or posttraumatic) adj2 (neurosis or psych* or stress* 

or syndrome*)).ti,ab. or PTSD.ti,ab. or (stress* adj2 (disorder* or reaction*)).ti,ab. or 

(trauma* adj2 (stress or syndrome*)).ti,ab.

2 Brief Psychotherapy, Brief/ or Brief Psychotherapy/ or ((brief or "short term" or "time limited") 

adj2 (CBT or intervention* or psychotherap* or therap* or counsel* or treatment*)).ti,ab.

3 Combine PTSD & Brief 1 and 2
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 165 of 200

Set 

Number Concept Search statement

4 Remove Publication 

Types & Non-Adult 

Subjects

3 not ((authored book or autobiography or biography or book or case reports or comment 

or conference* or dissertation abstract edited book or editorial or encyclopedia or 

lectures or letter or news or note or proceeding or video-audio media or webcasts).pt. or 

(bibliography or chapter or column/opinion or comment/reply or dissertation or editorial 

or encyclopedia entry or letter or obituary or review-book).dt. or (adolescen* or antenatal 

or babies or baby or birth or child* or infan* or kid or kids or neonat* or newborn* or 

paediatric* or pediatric* or perinatal or prenatal or teen* or toddler* or young* or 

youth*).ti.)

5 Systematic Reviews 4 and (research synthesis or pooled or systematic review/ or meta analysis/ or metaanalysis/ or ((evidence base$ or methodol$ or systematic or quantitative$ or studies or 

search$).mp. and (review/ or review.pt. or literature review/)))

6 RCTs 4 and ((Randomized controlled trials or random allocation or double-blind method or 

single-blind method or placebos or cross-over studies).de. or placebo$.mp. or 

random$.ti,ab. or crossover$.mp. or cross over.mp. or ((singl$ or doubl$ or tripl$ or 

trebl$) and (blind$ or mask$ or sham$)).mp. or latin square.mp. or ISRTCN or ACTRN$ or 

(NCT$ not NCT) or (clinical trials/ and random$.ti,ab.))

7 Combine SRs & RCTs 5 or 6

8 English limit 7 to english language

9 Human limit 8 to human

10 Date limit 9 to yr="2009 - 2016"

11 Humans limit 10 to humans [Limit not valid in PsycINFO; records were retained]

12 Dedupe remove duplicates from 11

OVID syntax: 

$ or * = truncation character (wildcard)

ADJn = search terms within a specified number (n) of words from each other in any order

/ = search as a subject heading (note that terms preceded by an asterisk are searched as a major subject headings)

exp = “explodes” controlled vocabulary term (e.g., expands search to all more specific related terms in the vocabulary’s 

hierarchy)

.de. = limit controlled vocabulary heading

.fs. = floating subheading

.hw. = limit to heading word

.md. = type of methodology (PsycINFO)

.mp. = combined search fields (default if no fields are specified)

.pt. = publication type 

.ti. = limit to title 

.tw. = limit to title and abstract fields 
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 166 of 200

Embase/MEDLINE

Set 

Number Concept Search statement

1 PTSD 'posttraumatic stress disorder'/mj OR 'acute stress disorder'/mj OR 'acute stress 

disorder':ab,ti OR 'acute stress disorders':ab,ti OR 'acute stress reaction':ab,ti OR 'acute 

stress reactions':ab,ti OR 'combat and operational stress reaction':ab,ti OR 'combat 

disorder':ab,ti OR 'combat disorders':ab,ti OR 'combat fatigue':ab,ti OR 'combat stress':ab,ti 

OR 'post-traumatic neurosis':ab,ti OR 'post-traumatic neuroses':ab,ti OR 'post-traumatic 

psychoses':ab,ti OR 'post-traumatic psychosis':ab,ti OR 'post-traumatic stress':ab,ti OR 

'post-traumatic syndrome':ab,ti OR 'post-traumatic syndromes':ab,ti OR 'posttraumatic 

neurosis':ab,ti OR 'posttraumatic neuroses':ab,ti OR 'posttraumatic psychoses':ab,ti OR 

'posttraumatic psychosis':ab,ti OR 'posttraumatic stress':ab,ti OR 'posttraumatic 

syndrome':ab,ti OR 'posttraumatic syndromes':ab,ti OR ptsd:ab,ti OR 'stress disorder':ab,ti 

OR 'stress disorders':ab,ti OR 'trauma syndrome':ab,ti OR 'trauma syndromes':ab,ti OR 

'traumatic stress':ab,ti OR 'war neuroses':ab,ti OR 'war neurosis':ab,ti

2 Pharmacotherapy –

General

'drug therapy'/exp OR ((drug* OR pharma*) NEAR/2 (therap* OR treatment*)) OR 

pharmacological OR “pharmaco-therapy” OR “pharmaco-therapies” OR pharmacotherap*

3 Pharmacotherapy –

Alpha Adrenergic 

Antagonists

'alpha adrenergic receptor blocking agent'/mj OR antiadrenergic* OR doxazosin OR 

prazosin OR terazosin OR ((adrenergic OR alpha*) NEAR/2 (antagonist* OR block*))

4 Pharmacotherapy –

Antipsychotics

'neuroleptic agent'/exp OR 'anti psychotic' OR 'anti psychotics' OR antipsychotic* OR 

chlorpromazine OR fluphenazine OR haloperidol OR loxapine OR neuroleptic OR 

perphenazine OR pimozide OR thioridazine OR thiothixene OR trifluoperazine

5 Pharmacotherapy –

Atypical antipsychotics

‘atypical antipsychotic agent’/mj OR aripiprazole OR asenapine OR brexpiprazole OR 

clozapine OR iloperidone OR lurasidone OR olanzapine OR paliperidone OR quetiapine OR 

risperidone OR ziprasidone

6 Pharmacotherapy -

Benzodiazepines

'benzodiazepine derivative'/mj OR Alprazolam OR benzodiazepine* OR benzodiazepinone* 

OR chlordiazepoxide OR clonazepam OR clorazepate OR diazepam OR estazolam OR 

flurazepam OR lorazepam OR midazolam OR oxazepam OR quazepam OR temazepam OR 

triazolam

7 Pharmacotherapy -

MAOIs

‘monoamine oxidase inhibitor’/mj OR ((MAO* OR “monoamine oxidase”) NEAR/2 inhibit*) 

OR isocarboxazid OR monoamine oxidase A inhibitor OR monoamine oxidase B inhibitor OR 

phenelzine OR selegiline OR tranylcypromine

8 Pharmacotherapy –

Mood Stablizers

'anticonvulsive agent'/mj OR anticonvuls* OR carbamazepine OR divalproex OR gabapentin 

OR lamotrigine OR lithium OR mood stabilizer* OR oxcarbazepine OR pregabalin OR 

tiagabine OR topiramate OR valproate OR valproic acid

9 Pharmacotherapy -

Sedatives

'hypnotic sedative agent'/mj OR 'sedative agent'/mj OR anti-anxiety OR antianxiety OR 

buspirone OR clonidine OR diphenhydramine OR eszopiclone OR guanfacine OR 

hydroxizine OR hypnotic* OR ramelteon OR sedative* OR suvorexant OR tasimelteon OR 

zaleplon OR zolpidem OR zopiclone

10 Pharmacotherapy -

Antidepressants

'antidepressant agent'/exp/mj OR 'serotonin noradrenalin reuptake inhibitor'/exp/mj OR 

'serotonin uptake inhibitor'/exp/mj OR 'tricyclic antidepressant agent'/exp/mj OR 'triple 

reuptake inhibitor'/exp/mj OR amitriptyline OR amoxapine OR bupropion OR 'antidepressant' OR 'anti-depressants' OR antidepressant* OR citalopram OR clomipramine OR 

desipramine OR desvenlafaxine OR doxepin OR duloxetine OR escitalopram OR fluoxetine OR 

fluvoxamine OR hydroxizine OR imipramine OR levomilnacipran OR maprotiline OR 

milnacipran OR mirtazapine OR nefazodone OR nortriptyline OR paroxetine OR protriptyline 

OR 'selective serotonin reuptake inhibitor' OR 'selective serotonin reuptake inhibitors' OR 

'serotonin noradrenaline reuptake inhibitor' OR 'serotonin noradrenaline reuptake inhibitors' 

OR 'serotonin norepinephrine reuptake inhibitor' OR 'serotonin norepinephrine reuptake 

inhibitors' OR sertraline OR snri* OR ssri* OR trazodone OR trimipramine OR venlafaxine OR 

vilazodone OR vortioxetine OR tricyclic NEAR/2 antidepressant*

11 Pharmacotherapy –

Other

propranolol OR “D-cycloserine” OR ketamine

12 Combine 

Pharmacotherapies

#2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 167 of 200

Set 

Number Concept Search statement

13 Combine PTSD & 

Pharmacotherapies

#1 AND #12

14 Systematic Reviews & 

Meta Analyses

#13 AND ([cochrane review]/lim OR [systematic review]/lim OR [meta analysis]/lim OR 

'meta analysis'/de OR 'meta analysis (topic)'/de OR 'systematic review'/de OR 'systematic 

review (topic)'/de OR (systematic* NEAR/2 review*):ab,ti OR metaanaly*:ab,ti OR 'meta 

analysis':ab,ti OR 'meta analyses':ab,ti OR search*:ab)

15 RCTs #13 AND ('randomized controlled trial'/de OR 'randomized controlled trial (topic)'/de OR 

random*:ab,ti OR nct*)

16 Systematic Reviews & 

RCTs 

#14 OR #15

17 Humans, English, & 

Date Limits

#14 OR #15 AND [humans]/lim AND [english]/lim AND [2009-2016]/py

18 Remove Selected 

Publication Types

#17 NOT ('conference abstract'/it OR 'conference paper'/it OR

'editorial'/it OR 'letter'/it OR 'note'/it OR 'short survey'/it)

19 Embase Only Records #18 AND [embase]/lim NOT [medline]/lim

Set 

Number Concept Search statement

1 PTSD 'posttraumatic stress disorder'/mj OR 'acute stress disorder'/mj OR 'acute stress 

disorder':ab,ti OR 'acute stress disorders':ab,ti OR 'acute stress reaction':ab,ti OR 'acute 

stress reactions':ab,ti OR 'combat and operational stress reaction':ab,ti OR 'combat 

disorder':ab,ti OR 'combat disorders':ab,ti OR 'combat fatigue':ab,ti OR 'combat stress':ab,ti 

OR 'post-traumatic neurosis':ab,ti OR 'post-traumatic neuroses':ab,ti OR 'post-traumatic 

psychoses':ab,ti OR 'post-traumatic psychosis':ab,ti OR 'post-traumatic stress':ab,ti OR 

'post-traumatic syndrome':ab,ti OR 'post-traumatic syndromes':ab,ti OR 'posttraumatic 

neurosis':ab,ti OR 'posttraumatic neuroses':ab,ti OR 'posttraumatic psychoses':ab,ti OR 

'posttraumatic psychosis':ab,ti OR 'posttraumatic stress':ab,ti OR 'posttraumatic 

syndrome':ab,ti OR 'posttraumatic syndromes':ab,ti OR ptsd:ab,ti OR 'stress disorder':ab,ti 

OR 'stress disorders':ab,ti OR 'trauma syndrome':ab,ti OR 'trauma syndromes':ab,ti OR 

'traumatic stress':ab,ti OR 'war neuroses':ab,ti OR 'war neurosis':ab,ti

2 Antipsychotic Cariprazine:ti,ab

3 Psychostimulants '3,4 methylenedioxymethamphetamine'/mj OR 'amphetamine plus dexamphetamine'/mj 

OR 'amphetamine'/mj OR 'atomoxetine'/mj OR 'dexamphetamine'/mj OR 

'dexmethylphenidate'/mj OR 'lisdexamfetamine'/mj OR 'methamphetamine'/mj OR 

'methylphenidate'/mj OR 'psychostimulant agent'/exp/mj OR “3,4-

methylenedioxymethamphetamine":ti,ab OR Adderall:ti,ab OR Amphetamine:ti,ab OR 

Armodafanil:ti,ab OR Atomoxetine:ti,ab OR Dexmethylphenidate:ti,ab OR 

Dextroamphetamine:ti,ab OR Lisdexamphetamine:ti,ab OR MDMA:ti,ab OR 

Methamphetamine:ti,ab OR Methylphenidate:ti,ab OR Modafanil:ti,ab OR 

Psychostimulant*:ti,ab

4 Steroids 'hydrocortisone'/mj OR 'mifepristone'/mj OR 'prasterone'/mj OR 'steroid'/exp/mj OR 

Dehydroepiandrosterone:ti,ab OR DHEA:ti,ab OR Hydrocortisone:ti,ab OR 

Mifepristone:ti,ab OR Steroid*:ti,ab

5 Cannabinoids 'cannabidiol'/mj OR 'cannabinoid'/exp/mj OR 'cannabis'/mj OR 'dronabinol'/mj OR 'medical 

cannabis'/mj OR 'tetrahydrocannabinol'/mj OR Cannabidiol;ti,ab OR Cannabinoid*:ti,ab OR 

CBD:ti,ab OR Dronabinol:ti,ab OR Marijuana:ti,ab OR Tetrahydrocannabinol:ti,ab OR 

THC:ti,ab

6 Other 'cycloserine'/mj OR “D-cycloserine”:ti,ab

7 Combine 

Pharmacotherapies

#2 OR #3 OR #4 OR #5 OR #6

8 Combine PTSD & 

Pharmacotherapies

#1 AND #7
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 168 of 200

Set 

Number Concept Search statement

9 Systematic Reviews & 

Meta Analyses

#8 AND ([cochrane review]/lim OR [systematic review]/lim OR [meta analysis]/lim OR 

'meta analysis'/de OR 'meta analysis (topic)'/de OR 'systematic review'/de OR 'systematic 

review (topic)'/de OR (systematic* NEAR/2 review*):ab,ti OR metaanaly*:ab,ti OR 'meta 

analysis':ab,ti OR 'meta analyses':ab,ti OR search*:ab)

10 RCTs #8 AND ('randomized controlled trial'/de OR 'randomized controlled trial (topic)'/de OR 

random*:ab,ti OR nct*)

11 Systematic Reviews & 

RCTs 

#9 OR #10

12 Humans, English, & 

Date Limits

#9 OR #10 AND [humans]/lim AND [english]/lim AND [2009-2016]/py

13 Remove Selected 

Publication Types

#12 NOT ('conference abstract'/it OR 'conference paper'/it OR

'editorial'/it OR 'letter'/it OR 'note'/it OR 'short survey'/it)

14 Embase Only Records #13 AND [embase]/lim NOT [medline]/lim

15 Remove Non-Adult 

Abstracts

#14 NOT (adolescen*:ti OR antenatal:ti OR babies:ti OR baby:ti OR birth:ti OR child*:ti OR 

infan*:ti OR kid:ti OR kids:ti OR neonat*:ti OR newborn*:ti OR paediatric*:ti OR 

pediatric*:ti OR perinatal:ti OR prenatal:ti OR teen*:ti OR toddler*:ti OR young*:ti OR 

youth*:ti)

Set 

Number Concept Search statement

1 PTSD 'posttraumatic stress disorder'/mj OR 'acute stress disorder'/mj OR 'acute stress 

disorder':ab,ti OR 'acute stress disorders':ab,ti OR 'acute stress reaction':ab,ti OR 'acute 

stress reactions':ab,ti OR 'combat and operational stress reaction':ab,ti OR 'combat 

disorder':ab,ti OR 'combat disorders':ab,ti OR 'combat fatigue':ab,ti OR 'combat stress':ab,ti 

OR 'post-traumatic neurosis':ab,ti OR 'post-traumatic neuroses':ab,ti OR 'post-traumatic 

psychoses':ab,ti OR 'post-traumatic psychosis':ab,ti OR 'post-traumatic stress':ab,ti OR 

'post-traumatic syndrome':ab,ti OR 'post-traumatic syndromes':ab,ti OR 'posttraumatic 

neurosis':ab,ti OR 'posttraumatic neuroses':ab,ti OR 'posttraumatic psychoses':ab,ti OR 

'posttraumatic psychosis':ab,ti OR 'posttraumatic stress':ab,ti OR 'posttraumatic 

syndrome':ab,ti OR 'posttraumatic syndromes':ab,ti OR ptsd:ab,ti OR 'stress disorder':ab,ti 

OR 'stress disorders':ab,ti OR 'trauma syndrome':ab,ti OR 'trauma syndromes':ab,ti OR 

'traumatic stress':ab,ti OR 'war neuroses':ab,ti OR 'war neurosis':ab,ti

2 Brief Therapies ((Brief OR “short term” OR “time limited”) NEAR/2 (CBT OR counsel* OR intervention* OR 

therap* OR treatment*)):ti,ab

3 Combine PTSD & Brief 

Interventions

#1 AND #2

4 Systematic Reviews & 

Meta Analyses

#3 AND ([cochrane review]/lim OR [systematic review]/lim OR [meta analysis]/lim OR 

'meta analysis'/de OR 'meta analysis (topic)'/de OR 'systematic review'/de OR 'systematic 

review (topic)'/de OR (systematic* NEAR/2 review*):ab,ti OR metaanaly*:ab,ti OR 'meta 

analysis':ab,ti OR 'meta analyses':ab,ti OR search*:ab)

5 RCTs #3 AND ('randomized controlled trial'/de OR 'randomized controlled trial (topic)'/de OR 

random*:ab,ti OR nct*)

6 Combine #4 OR #5

7 Humans, English, & 

Date Limits

#6 AND [humans]/lim AND [english]/lim AND [2009-2016]/py

8 Remove Selected 

Publication Types

#7 NOT ('conference abstract'/it OR 'conference paper'/it OR

'editorial'/it OR 'letter'/it OR 'note'/it OR 'short survey'/it)

9 Embase Only Records #8 AND [embase]/lim NOT [medline]/lim
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 169 of 200

Set 

Number Concept Search statement

10 Remove Non-Adult 

Citations

#9 NOT (adolescen*:ti OR antenatal:ti OR babies:ti OR baby:ti OR birth:ti OR child*:ti OR 

infan*:ti OR kid:ti OR kids:ti OR

neonat*:ti OR newborn*:ti OR paediatric*:ti OR pediatric*:ti OR

perinatal:ti OR prenatal:ti OR teen*:ti OR toddler*:ti OR

young*:ti OR youth*:ti)

Set 

Number Concept Search statement

1 PTSD 'posttraumatic stress disorder'/mj OR 'acute stress disorder'/mj OR 'acute stress 

disorder':ab,ti OR 'acute stress disorders':ab,ti OR 'acute stress reaction':ab,ti OR 'acute 

stress reactions':ab,ti OR 'combat and operational stress reaction':ab,ti OR 'combat 

disorder':ab,ti OR 'combat disorders':ab,ti OR 'combat fatigue':ab,ti OR 'combat stress':ab,ti 

OR 'post-traumatic neurosis':ab,ti OR 'post-traumatic neuroses':ab,ti OR 'post-traumatic 

psychoses':ab,ti OR 'post-traumatic psychosis':ab,ti OR 'post-traumatic stress':ab,ti OR 

'post-traumatic syndrome':ab,ti OR 'post-traumatic syndromes':ab,ti OR 'posttraumatic 

neurosis':ab,ti OR 'posttraumatic neuroses':ab,ti OR 'posttraumatic psychoses':ab,ti OR 

'posttraumatic psychosis':ab,ti OR 'posttraumatic stress':ab,ti OR 'posttraumatic 

syndrome':ab,ti OR 'posttraumatic syndromes':ab,ti OR ptsd:ab,ti OR 'stress disorder':ab,ti 

OR 'stress disorders':ab,ti OR 'trauma syndrome':ab,ti OR 'trauma syndromes':ab,ti OR 

'traumatic stress':ab,ti OR 'war neuroses':ab,ti OR 'war neurosis':ab,ti

2 Psychotherapy –

Trauma-focused

'behavior therapy'/exp OR 'cognitive therapy'/exp OR 'narrative therapy'/mj OR 'virtual 

reality exposure therapy'/mj OR 'accelerated resolution therapy':ab,ti OR art:ab,ti OR 

“behavior therapy”:ti,ab OR “behaviour therap”:ti,ab OR “behavioral therapy”:ti,ab OR 

“behavioural therapy”:ti,ab OR 'bep tg':ab,ti OR cbct:ab,ti OR cbt:ab,ti OR 'cognitive 

behavioral conjoint therapy':ab,ti OR 'cognitive behavioral therapy':ab,ti OR 'cognitive 

behavioural therapy':ab,ti OR 'cognitive processing therapy':ab,ti OR 'cognitive 

therapy':ab,ti OR eclectic:ab,ti OR ehlers:ab,ti OR emdr:ab,ti OR 'emotional freedom':ab,ti 

OR 'exposure therapy':ab,ti OR 'eye movement desensitization':ab,ti OR 'imagery rehearsal 

therapy':ab,ti OR 'implosive therapy':ab,ti OR mindfulness:ab,ti OR 'narrative therapy':ab,ti 

OR 'prolonged exposure therapy':ab,ti OR 'thought field therapy':ab,ti OR 'trauma 

focused':ab,ti OR 'virtual reality':ab,ti OR 'written exposure therapy':ab,ti

3 Psychotherapy – 

Non-trauma-focused

'acceptance and commitment therapy'/exp OR 'family therapy'/exp OR 'marital 

therapy'/exp OR 'mindfulness'/exp OR 'psychodynamic psychotherapy'/exp OR 

psychotherapy/exp OR “acceptance and commitment therapy”:ti,ab OR ACT:ti,ab OR 

“behavioral activation”:ti,ab OR “behavioural activation”:ti,ab OR “couples 

counseling”:ti,ab OR “couples therapy”:ti,ab OR “emotion focused couples therapy”:ti,ab 

OR “family therapy”:ti,ab OR “interpersonal therapy”:ti,ab OR IPT:ti,ab OR “marital 

therapy”:ti,ab OR “marriage therapy”:ti,ab OR Mindfulness:ti,ab OR “Neurolinguistic 

programming”:ti,ab OR PCT:ti,ab OR “Present Centered Therapy”:ti,ab OR “Problem 

Solving Therapy”:ti,ab OR Psychoanalysis:ti,ab OR psychodynamic*:ti,ab OR 

psychotherap*:ti,ab OR relaxation:ti,ab OR “Seeking Safety”:ti,ab OR SIT:ti,ab OR 

“Socioenvironmental Therapy”:ti,ab OR “Stress Inoculation Therapy”:ti,ab OR 

“supportive counseling”:ti,ab

4 Combine 

Psychotherapies

#2 or #3

5 PTSD & 

Psychotherapies

#1 AND #4

6 Systematic Reviews & 

Meta Analyses

#5 AND ([cochrane review]/lim OR [systematic review]/lim OR [meta analysis]/lim OR 

'meta analysis'/de OR 'meta analysis (topic)'/de OR 'systematic review'/de OR 

'systematic review (topic)'/de OR (systematic* NEAR/2 review*):ab,ti OR 

metaanaly*:ab,ti OR 'meta analysis':ab,ti OR 'meta analyses':ab,ti OR search*:ab)

7 RCTs #5 AND ('randomized controlled trial'/de OR 'randomized controlled trial (topic)'/de OR 

random*:ab,ti OR nct*)

8 Combine #6 OR #7
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 170 of 200

Set 

Number Concept Search statement

9 Humans, English, & 

Date Limits

#8 AND [humans]/lim AND [english]/lim AND [2009-2016]/py

10 Remove Selected 

Publication Types

#9 NOT ('conference abstract'/it OR 'conference paper'/it OR

'editorial'/it OR 'letter'/it OR 'note'/it OR 'short survey'/it)

11 Embase Only Records #10 AND [embase]/lim NOT [medline]/lim

Set 

Number Concept Search statement

1 PTSD 'posttraumatic stress disorder'/mj OR 'acute stress disorder'/mj OR 'acute stress 

disorder':ab,ti OR 'acute stress disorders':ab,ti OR 'acute stress reaction':ab,ti OR 'acute 

stress reactions':ab,ti OR 'combat and operational stress reaction':ab,ti OR 'combat 

disorder':ab,ti OR 'combat disorders':ab,ti OR 'combat fatigue':ab,ti OR 'combat stress':ab,ti 

OR 'post-traumatic neurosis':ab,ti OR 'post-traumatic neuroses':ab,ti OR 'post-traumatic 

psychoses':ab,ti OR 'post-traumatic psychosis':ab,ti OR 'post-traumatic stress':ab,ti OR 

'post-traumatic syndrome':ab,ti OR 'post-traumatic syndromes':ab,ti OR 'posttraumatic 

neurosis':ab,ti OR 'posttraumatic neuroses':ab,ti OR 'posttraumatic psychoses':ab,ti OR 

'posttraumatic psychosis':ab,ti OR 'posttraumatic stress':ab,ti OR 'posttraumatic 

syndrome':ab,ti OR 'posttraumatic syndromes':ab,ti OR ptsd:ab,ti OR 'stress disorder':ab,ti 

OR 'stress disorders':ab,ti OR 'trauma syndrome':ab,ti OR 'trauma syndromes':ab,ti OR 

'traumatic stress':ab,ti OR 'war neuroses':ab,ti OR 'war neurosis':ab,ti

2 Interventions 'electroconvulsive therapy'/de OR 'hyperbaric oxygen'/de OR 'stellate ganglion block'/de 

OR 'transcranial magnetic stimulation'/de OR “convulsive therapy”:ti,ab OR ECS:ti,ab OR 

ECT:ti,ab OR “electric shock therapy”:ti,ab OR “electroconvulsive therapy”:ti,ab OR 

“electroconvulsant therapy”:ti,ab OR “electroconvulsive shock therapy”:ti,ab OR 

“electroconvulsive treatment”:ti,ab OR “electroshock therapy”:ti,ab OR “electroshock 

treatment”:ti,ab OR “high pressure o”:ti,ab OR “high pressure oxygen”:ti,ab OR “hyperbaric 

medicine”:ti,ab OR “hyperbaric o2”:ti,ab OR “hyperbaric oxygen therapy”:ti,ab OR 

“hyperbaric oxygenation”:ti,ab OR “hyperbaric oxygen”:ti,ab OR “shock therapy”:ti,ab OR 

“stellate ganglion block”:ti,ab OR “stellate ganglion blockade”:ti,ab OR “stellate ganglion 

blocking”:ti,ab OR rTMS:ti,ab OR TMS:ti,ab OR “transcranial magnetic stimulation”:ti,ab

3 Combine #1 AND #2

4 Systematic Reviews & 

Meta Analyses

#3 AND ([cochrane review]/lim OR [systematic review]/lim OR [meta analysis]/lim OR 

'meta analysis'/de OR 'meta analysis (topic)'/de OR 'systematic review'/de OR 'systematic 

review (topic)'/de OR (systematic* NEAR/2 review*):ab,ti OR metaanaly*:ab,ti OR 'meta 

analysis':ab,ti OR 'meta analyses':ab,ti OR search*:ab)

5 RCTs #3 AND ('randomized controlled trial'/de OR 'randomized controlled trial (topic)'/de OR 

random*:ab,ti OR nct*)

6 Combine #4 or #5

7 Humans, English, & 

Date Limits

#6 AND [humans]/lim AND [english]/lim AND [2009-2016]/py

8 Remove Selected 

Publication Types

#7 NOT ('conference abstract'/it OR 'conference paper'/it OR

'editorial'/it OR 'letter'/it OR 'note'/it OR 'short survey'/it)

9 Embase Only Records #8 AND [embase]/lim NOT [medline]/lim
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 171 of 200

Set 

Number Concept Search statement

1 PTSD 'posttraumatic stress disorder'/mj OR 'acute stress disorder'/mj OR 'acute stress 

disorder':ab,ti OR 'acute stress disorders':ab,ti OR 'acute stress reaction':ab,ti OR 'acute 

stress reactions':ab,ti OR 'combat and operational stress reaction':ab,ti OR 'combat 

disorder':ab,ti OR 'combat disorders':ab,ti OR 'combat fatigue':ab,ti OR 'combat stress':ab,ti 

OR 'post-traumatic neurosis':ab,ti OR 'post-traumatic neuroses':ab,ti OR 'post-traumatic 

psychoses':ab,ti OR 'post-traumatic psychosis':ab,ti OR 'post-traumatic stress':ab,ti OR 

'post-traumatic syndrome':ab,ti OR 'post-traumatic syndromes':ab,ti OR 'posttraumatic 

neurosis':ab,ti OR 'posttraumatic neuroses':ab,ti OR 'posttraumatic psychoses':ab,ti OR 

'posttraumatic psychosis':ab,ti OR 'posttraumatic stress':ab,ti OR 'posttraumatic 

syndrome':ab,ti OR 'posttraumatic syndromes':ab,ti OR ptsd:ab,ti OR 'stress disorder':ab,ti 

OR 'stress disorders':ab,ti OR 'trauma syndrome':ab,ti OR 'trauma syndromes':ab,ti OR 

'traumatic stress':ab,ti OR 'war neuroses':ab,ti OR 'war neurosis':ab,ti

2 CAM Controlled 

vocabulary

'acupuncture'/exp OR 'alternative medicine'/exp OR 'animal assisted therapy'/exp OR 'art 

therapy'/de OR 'dance therapy'/de OR 'diet supplementation'/de OR 'exercise'/exp OR 

'herbal medicine'/de OR 'homeopathic agent'/de OR 'integrative medicine'/de OR 

'meditation'/de OR 'mindfulness'/de OR 'music therapy'/de OR 'phytotherapy'/de OR 

'psychodrama'/de OR 'recreational therapy'/de OR 'tai chi'/de OR 'transcendental 

meditation'/de OR 'yoga'/de

3 CAM Keywords / 

Phrases

Acupuncture:ti,ab OR ((“animal assisted” OR art OR “creative art”

OR “creative arts” OR dance OR drama OR movement OR music

OR recreational) NEAR/2 therap*):ti,ab OR ((alternative OR

complementary OR integrative) NEAR/2 medicine):ti,ab OR (dietary

NEAR/2 supplement*):ti,ab OR exercise:ti,ab OR fishing:ti,ab OR

herbs:ti,ab OR herbal:ti,ab OR Homeopath*:ti,ab OR

mantram:ti,ab OR meditation:ti,ab OR meditate*:ti,ab OR mindbody:ti,ab OR “mind 

body”:ti,ab OR mindfulness:ti,ab OR phytotherapy:ti,ab OR

“progressive muscle relaxation”:ti,ab OR Psychodrama:ti,ab OR

relaxation:ti,ab OR “Tai Chi”:ti,ab OR “Tai Ji”:ti,ab OR Yoga:ti,ab

4 Combine Interventions #2 or #3

5 Combine PTSD & 

Interventions

#1 and #4

6 Systematic Reviews & 

Meta Analyses

#5 AND ([cochrane review]/lim OR [systematic review]/lim OR [meta analysis]/lim OR 

'meta analysis'/de OR 'meta analysis (topic)'/de OR 'systematic review'/de OR 'systematic 

review (topic)'/de OR (systematic* NEAR/2 review*):ab,ti OR metaanaly*:ab,ti OR 'meta 

analysis':ab,ti OR 'meta analyses':ab,ti OR search*:ab)

7 RCTs #5 AND ('randomized controlled trial'/de OR 'randomized controlled trial (topic)'/de OR 

random*:ab,ti OR nct*)

8 Combine SRs & RCTs #6 or #7

9 Humans, English, & 

Date Limits

#8 AND [humans]/lim AND [english]/lim AND [2009-2016]/py

10 Remove Selected 

Publication Types

#9 NOT ('conference abstract'/it OR 'conference paper'/it OR

'editorial'/it OR 'letter'/it OR 'note'/it OR 'short survey'/it)

11 Remove Out of Scope 

Ages

#10 NOT (adolescen*:ti OR antenatal:ti OR babies:ti OR baby:ti OR birth:ti OR child*:ti OR 

infan*:ti OR kid:ti OR kids:ti OR neonat*:ti OR newborn*:ti OR paediatric*:ti OR 

pediatric*:ti OR perinatal:ti OR prenatal:ti OR teen*:ti OR toddler*:ti OR young*:ti OR 

youth*:ti)

12 Embase Only Records #11 AND [embase]/lim NOT [medline]/lim
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 172 of 200

Set 

Number Concept Search statement

1 PTSD 'posttraumatic stress disorder'/mj OR 'acute stress disorder'/de OR 'acute stress 

disorder':ab,ti OR 'acute stress disorders':ab,ti OR 'acute stress reaction':ab,ti OR 'acute 

stress reactions':ab,ti OR 'combat and operational stress reaction':ab,ti OR 'combat 

disorder':ab,ti OR 'combat disorders':ab,ti OR 'combat fatigue':ab,ti OR 'combat stress':ab,ti 

OR 'post-traumatic neurosis':ab,ti OR 'post-traumatic neuroses':ab,ti OR 'post-traumatic 

psychoses':ab,ti OR 'post-traumatic psychosis':ab,ti OR 'post-traumatic stress':ab,ti OR 

'post-traumatic syndrome':ab,ti OR 'post-traumatic syndromes':ab,ti OR 'posttraumatic 

neurosis':ab,ti OR 'posttraumatic neuroses':ab,ti OR 'posttraumatic psychoses':ab,ti OR 

'posttraumatic psychosis':ab,ti OR 'posttraumatic stress':ab,ti OR 'posttraumatic 

syndrome':ab,ti OR 'posttraumatic syndromes':ab,ti OR ptsd:ab,ti OR 'stress disorder':ab,ti 

OR 'stress disorders':ab,ti OR 'trauma syndrome':ab,ti OR 'trauma syndromes':ab,ti OR 

'traumatic stress':ab,ti OR 'war neuroses':ab,ti OR 'war neurosis':ab,ti

2 Group/Peer 

Interventions

'group therapy'/mj OR 'peer group'/mj OR 'social support'/mj OR “community 

therapy”:ti,ab OR “community treatment”:ti,ab OR “encounter group”:ti,ab OR “group 

psychotherapy”:ti,ab OR “Group setting”:ti,ab OR “Group therapy”:ti,ab OR “group 

treatment”:ti,ab OR “peer group”:ti,ab OR “peer groups”:ti,ab OR “Peer support”:ti,ab OR 

“Self-help”:ti,ab OR “Support group”:ti,ab OR “Support groups”:ti,ab OR “Supportive 

Psychotherapy”:ti,ab OR “supportive psychotherapies”:ti,ab OR “Supportive therapy”:ti,ab 

OR “supportive therapies”:ti,ab

3 Combine PTSD & 

Interventions

#1 AND #2

4 Systematic Reviews & 

Meta Analyses

#3 AND ([cochrane review]/lim OR [systematic review]/lim OR [meta analysis]/lim OR 

'meta analysis'/de OR 'meta analysis (topic)'/de OR 'systematic review'/de OR 'systematic 

review (topic)'/de OR (systematic* NEAR/2 review*):ab,ti OR metaanaly*:ab,ti OR 'meta 

analysis':ab,ti OR 'meta analyses':ab,ti OR search*:ab)

5 RCTs #3 AND ('randomized controlled trial'/de OR 'randomized controlled trial (topic)'/de OR 

random*:ab,ti OR nct*)

6 Combine SRs & RCTs #4 OR #5

7 Humans, English, & 

Date Limits

#6 AND [humans]/lim AND [english]/lim AND [2009-2016]/py

8 Remove Selected 

Publication Types

#7 NOT ('conference abstract'/it OR 'conference paper'/it OR

'editorial'/it OR 'letter'/it OR 'note'/it OR 'short survey'/it)

9 Embase Only Records #8 AND [embase]/lim NOT [medline]/lim

10 Remove non-Adult 

Abstracts

#9 NOT (adolescen*:ti OR antenatal:ti OR babies:ti OR baby:ti OR birth:ti OR child*:ti OR 

infan*:ti OR kid:ti OR kids:ti OR neonat*:ti OR newborn*:ti OR paediatric*:ti OR 

pediatric*:ti OR perinatal:ti OR prenatal:ti OR teen*:ti OR toddler*:ti OR young*:ti OR 

youth*:ti)

Set 

Number Concept Search statement

1 PTSD 'posttraumatic stress disorder'/mj OR 'acute stress disorder'/mj OR 'acute stress 

disorder':ab,ti OR 'acute stress disorders':ab,ti OR 'acute stress reaction':ab,ti OR 'acute 

stress reactions':ab,ti OR 'combat and operational stress reaction':ab,ti OR 'combat 

disorder':ab,ti OR 'combat disorders':ab,ti OR 'combat fatigue':ab,ti OR 'combat 

stress':ab,ti OR 'post-traumatic neurosis':ab,ti OR 'post-traumatic neuroses':ab,ti OR 

'post-traumatic psychoses':ab,ti OR 'post-traumatic psychosis':ab,ti OR 'post-traumatic 

stress':ab,ti OR 'post-traumatic syndrome':ab,ti OR 'post-traumatic syndromes':ab,ti OR 

'posttraumatic neurosis':ab,ti OR 'posttraumatic neuroses':ab,ti OR 'posttraumatic 

psychoses':ab,ti OR 'posttraumatic psychosis':ab,ti OR 'posttraumatic stress':ab,ti OR 

'posttraumatic syndrome':ab,ti OR 'posttraumatic syndromes':ab,ti OR ptsd:ab,ti OR 

'stress disorder':ab,ti OR 'stress disorders':ab,ti OR 'trauma syndrome':ab,ti OR 'trauma 

syndromes':ab,ti OR 'traumatic stress':ab,ti OR 'war neuroses':ab,ti OR 'war 

neurosis':ab,ti
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 173 of 200

Set 

Number Concept Search statement

2 Collaborative Care 

Interventions

'integrated health care system'/mj OR “Care management”:ti,ab OR “Collaborative 

care”:ti,ab OR “Coordinated Anxiety Learning and Management”:ti,ab OR “Coordinated 

care”:ti,ab OR “Embedded behavioral health”:ti,ab OR “Mental health integration”:ti,ab 

OR PCMHI:ti,ab OR “Primary Care Mental Health Integration”:ti,ab OR “Re-Engineering 

Systems of Primary Care Treatment in the Military”:ti,ab OR “re-engineering systems for 

the primary care treatment of PTSD”:ti,ab OR “RESPECT MIL”:ti,ab OR “RESPECT 

PTSD”:ti,ab OR “Stepped care”:ti,ab OR “STepped Enhancement of PTSD Services Using 

Primary Care”:ti,ab OR “STEPS UP”:ti,ab OR TIDES:ti,ab OR “Translating Initiatives for 

Depression into Effective Solutions”:ti,ab

3 Combine PTSD & 

Collaborative Care

#1 AND #2

4 Remove Non-Adult 

Citations

#3 NOT (adolescen*:ti OR antenatal:ti OR babies:ti OR baby:ti OR birth:ti OR child*:ti OR 

infan*:ti OR kid:ti OR kids:ti OR

neonat*:ti OR newborn*:ti OR paediatric*:ti OR pediatric*:ti OR

perinatal:ti OR prenatal:ti OR teen*:ti OR toddler*:ti OR

young*:ti OR youth*:ti)

5 Systematic Reviews & 

Meta Analyses

#4 AND ([cochrane review]/lim OR [systematic review]/lim OR [meta analysis]/lim OR 

'meta analysis'/de OR 'meta analysis (topic)'/de OR 'systematic review'/de OR 'systematic 

review (topic)'/de OR (systematic* NEAR/2 review*):ab,ti OR metaanaly*:ab,ti OR 'meta 

analysis':ab,ti OR 'meta analyses':ab,ti OR search*:ab)

6 RCTs #4 AND ('randomized controlled trial'/de OR 'randomized controlled trial (topic)'/de OR 

random*:ab,ti OR nct*)

7 Combine SRs & RCTs #5 OR #6

8 Humans, English, & 

Date Limits

#7 AND [humans]/lim AND [english]/lim AND [2009-2016]/py

9 Remove Selected 

Publication Types

#8 NOT ('conference abstract'/it OR 'conference paper'/it OR

'editorial'/it OR 'letter'/it OR 'note'/it OR 'short survey'/it)

10 Embase Only Records #9 AND [embase]/lim NOT [medline]/lim

Set 

Number Concept Search statement

1 PTSD 'posttraumatic stress disorder'/mj OR 'acute stress disorder'/mj OR 'acute stress 

disorder':ab,ti OR 'acute stress disorders':ab,ti OR 'acute stress reaction':ab,ti OR 'acute 

stress reactions':ab,ti OR 'combat and operational stress reaction':ab,ti OR 'combat 

disorder':ab,ti OR 'combat disorders':ab,ti OR 'combat fatigue':ab,ti OR 'combat stress':ab,ti 

OR 'post-traumatic neurosis':ab,ti OR 'post-traumatic neuroses':ab,ti OR 'post-traumatic 

psychoses':ab,ti OR 'post-traumatic psychosis':ab,ti OR 'post-traumatic stress':ab,ti OR 

'post-traumatic syndrome':ab,ti OR 'post-traumatic syndromes':ab,ti OR 'posttraumatic 

neurosis':ab,ti OR 'posttraumatic neuroses':ab,ti OR 'posttraumatic psychoses':ab,ti OR 

'posttraumatic psychosis':ab,ti OR 'posttraumatic stress':ab,ti OR 'posttraumatic 

syndrome':ab,ti OR 'posttraumatic syndromes':ab,ti OR ptsd:ab,ti OR 'stress disorder':ab,ti 

OR 'stress disorders':ab,ti OR 'trauma syndrome':ab,ti OR 'trauma syndromes':ab,ti OR 

'traumatic stress':ab,ti OR 'war neuroses':ab,ti OR 'war neurosis':ab,ti
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 174 of 200

Set 

Number Concept Search statement

2 Technologies 'mobile application'/de OR 'mobile phone'/exp OR 'telecommunication'/exp OR 

'teleconference'/de OR 'teleconsultation'/de OR 'telehealth'/exp OR 'telemedicine'/exp OR 

'telephone'/de OR 'telepsychiatry'/de OR 'virtual reality'/de OR 'clinical video 

teleconferencing':ab,ti OR cvt:ab,ti OR ehealth:ab,ti OR 'e-health':ab,ti OR 

smartphone*:ab,ti OR 'tele communication*':ab,ti OR 'tele conferenc*':ab,ti OR 'tele 

health*':ab,ti OR 'tele medicine':ab,ti OR 'tele monitor*':ab,ti OR 'tele psych*':ab,ti OR 

telecommunication*:ab,ti OR teleconferenc*:ab,ti OR teleconsultation*:ab,ti OR 

telehealth*:ab,ti OR telemedicine:ab,ti OR telemonitor*:ab,ti OR telephone:ab,ti OR 

telepsych*:ab,ti OR 'telephone care management':ab,ti OR (video NEAR/2 (conferenc* OR 

'tele conferenc*' OR teleconference*)):ab,ti OR (mobile NEAR/2 (application* OR app OR 

apps OR device* OR phone*)):ab,ti

3 Combine PTSD & 

Technologies

#1 AND #2

4 Remove non-Adult 

Abstracts

#3 NOT (adolescen*:ti OR antenatal:ti OR babies:ti OR baby:ti OR birth:ti OR child*:ti OR 

infan*:ti OR kid:ti OR kids:ti OR

neonat*:ti OR newborn*:ti OR paediatric*:ti OR pediatric*:ti OR

perinatal:ti OR prenatal:ti OR teen*:ti OR toddler*:ti OR

young*:ti OR youth*:ti)

5 Systematic Reviews & 

Meta Analyses

#4 AND ([cochrane review]/lim OR [systematic review]/lim OR [meta analysis]/lim OR 

'meta analysis'/de OR 'meta analysis (topic)'/de OR 'systematic review'/de OR 'systematic 

review (topic)'/de OR (systematic* NEAR/2 review*):ab,ti OR metaanaly*:ab,ti OR 'meta 

analysis':ab,ti OR 'meta analyses':ab,ti OR search*:ab)

6 RCTs #4 AND ('randomized controlled trial'/de OR 'randomized controlled trial (topic)'/de OR 

random*:ab,ti OR nct*)

7 Combine SRs & RCTs #5 OR #6

8 Humans, English, &

Date Limits

#7 AND [humans]/lim AND [english]/lim AND [2009-2016]/py

9 Remove Selected 

Publication Types

#8 NOT ('conference abstract'/it OR 'conference paper'/it OR

'editorial'/it OR 'letter'/it OR 'note'/it OR 'short survey'/it)

10 Embase Only Records #9 AND [embase]/lim NOT [medline]/lim

EMBASE.com Syntax: 

* = truncation character (wildcard)

NEAR/n = search terms within a specified number (n) of words from each other in any order

NEXT/n = search terms within a specified number (n) of words from each other in the order specified

/ = search as a subject heading

exp = “explodes” controlled vocabulary term (e.g., expands search to all more specific related terms in the vocabulary’s 

hierarchy)

mj = denotes a term that has been searched as a major subject heading

:de = search in the descriptors field (controlled terms and keywords)

:lnk = floating subheading

:it,pt. = source item or publication type 

:ti. = limit to title 

:ti,ab. = limit to title and abstract fields
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 175 of 200

PUBMED (In-Process, Publisher, PubMed Not Medline) 

Set 

Number Concept Search statement

1 PTSD “acute stress disorder”[tiab] OR “acute stress disorders”[tiab] OR “acute stress 

reaction”[tiab] OR “acute stress reactions”[tiab] OR “combat and operational stress 

reaction”[tiab] OR “combat disorder”[tiab] OR “combat disorders”[tiab] OR “combat 

fatigue”[tiab] OR “combat stress”[tiab] OR “post-traumatic neurosis”[tiab] OR “posttraumatic neuroses”[tiab] OR “post-traumatic psychoses”[tiab] OR “post-traumatic 

psychosis”[tiab] OR “post-traumatic stress”[tiab] OR “post-traumatic syndrome”[tiab] OR 

“post-traumatic syndromes”[tiab] OR “posttraumatic neurosis”[tiab] OR “posttraumatic 

neuroses”[tiab] OR “posttraumatic psychoses”[tiab] OR “posttraumatic psychosis”[tiab] OR 

“posttraumatic stress”[tiab] OR “posttraumatic syndrome”[tiab] OR “posttraumatic 

syndromes”[tiab] OR ptsd OR “stress disorder”[tiab] OR “stress disorders”[tiab] OR 

“trauma syndrome”[tiab] OR “trauma syndromes”[tiab] OR “traumatic stress”[tiab] OR 

“war neuroses”[tiab] OR “war neurosis”[tiab]

2 Pharmacotherapy –

General

((drug*[tiab] OR pharma*[tiab]) AND (therap*[tiab] OR treatment*[tiab])) OR 

pharmacological[tiab] OR “pharmaco-therapy”[tiab] OR “pharmaco-therapies”[tiab] OR 

pharmacotherap*[tiab]

3 Pharmacotherapy –

Alpha Adrenergic 

Antagonists

antiadrenergic*[tiab] OR doxazosin[tiab] OR prazosin[tiab] OR sympatholytic*[tiab] OR 

terazosin[tiab] OR ((adrenergic[tiab] OR alpha*[tiab]) AND (antagonist*[tiab] OR 

block*[tiab]))

4 Pharmacotherapy –

Antipsychotics

“anti psychotic”[tiab] OR “anti psychotics”[tiab] OR antipsychotic*[tiab] OR 

chlorpromazine[tiab] OR fluphenazine[tiab] OR haloperidol[tiab] OR loxapine[tiab] OR 

neuroleptic[tiab] OR perphenazine[tiab] OR pimozide[tiab] OR thioridazine[tiab] OR 

thiothixene[tiab] OR trifluoperazine[tiab]

5 Pharmacotherapy –

Atypical antipsychotics

aripiprazole[tiab] OR asenapine[tiab] OR brexpiprazole[tiab] OR clozapine[tiab] OR 

iloperidone[tiab] OR lurasidone[tiab] OR olanzapine[tiab] OR paliperidone[tiab] OR 

quetiapine[tiab] OR risperidone[tiab] OR ziprasidone[tiab]

6 Pharmacotherapy -

Benzodiazepines

Alprazolam[tiab] OR benzodiazepine*[tiab] OR benzodiazepinone*[tiab] OR 

chlordiazepoxide[tiab] OR clonazepam[tiab] OR clorazepate[tiab] OR diazepam[tiab] OR 

estazolam[tiab] OR flurazepam[tiab] OR lorazepam[tiab] OR midazolam[tiab] OR 

oxazepam[tiab] OR quazepam[tiab] OR temazepam[tiab] OR triazolam[tiab]

7 Pharmacotherapy -

MAOIs

((MAO*[tiab] OR “monoamine oxidase” [tiab]) AND inhibit*[tiab]) OR isocarboxazid[tiab]

OR monoamine oxidase A inhibitor OR monoamine oxidase B inhibitor[tiab] OR 

phenelzine[tiab] OR selegiline[tiab] OR tranylcypromine[tiab] OR MAOI*[tiab]

8 Pharmacotherapy –

Mood Stablizers

'anticonvulsive agent'/mj OR anticonvuls* OR carbamazepine OR divalproex OR gabapentin 

OR lamotrigine OR lithium OR mood stabilizer* OR oxcarbazepine OR pregabalin OR 

tiagabine OR topiramate OR valproate OR valproic acid

9 Pharmacotherapy -

Sedatives

buspirone[tiab] OR clonidine[tiab] OR diphenhydramine[tiab] OR eszopiclone[tiab] OR 

guanfacine[tiab] OR hydroxyzine[tiab] OR hypnotic*[tiab] OR ramelteon[tiab] OR 

sedative*[tiab] OR suvorexant[tiab] OR tasimelteon[tiab] OR zaleplon[tiab] OR 

zolpidem[tiab] OR zopiclone[tiab]

10 Pharmacotherapy -

Antidepressants

amitriptyline[tiab] OR amoxapine[tiab] OR bupropion[tiab] OR “anti-depressant” [tiab] OR 

“anti-depressants” [tiab] OR antidepressant*[tiab] OR citalopram[tiab] OR 

clomipramine[tiab] OR desipramine[tiab] OR desvenlafaxine[tiab] OR doxepin[tiab] OR 

duloxetine[tiab] OR escitalopram[tiab] OR fluoxetine[tiab] OR fluvoxamine[tiab] OR 

hydroxizine[tiab] OR imipramine[tiab] OR levomilnacipran[tiab] OR maprotiline[tiab] OR 

milnacipran[tiab] OR mirtazapine[tiab] OR nefazodone[tiab] OR nortriptyline[tiab] OR 

paroxetine[tiab] OR protriptyline[tiab] OR “selective serotonin reuptake inhibitor”[tiab] OR 

“selective serotonin reuptake inhibitors”[tiab] OR “serotonin noradrenaline reuptake 

inhibitor”[tiab] OR “serotonin noradrenaline reuptake inhibitors”[tiab] OR “serotonin 

norepinephrine reuptake inhibitor”[tiab] OR “serotonin norepinephrine reuptake 

inhibitors”[tiab] OR sertraline[tiab] OR snri*[tiab] OR ssri*[tiab] OR trazodone[tiab] OR 

trimipramine[tiab] OR venlafaxine[tiab] OR vilazodone[tiab] OR vortioxetine[tiab] OR 

(tricyclic[tiab] AND antidepressant*[tiab])

11 Pharmacotherapy –

Other

propranolol[tiab] OR “D-cyclcerine”[tiab] OR ketamine[tiab]
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 176 of 200

Set 

Number Concept Search statement

12 Combine 

Pharmacotherapies

#2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11

13 Combine PTSD & 

Pharmacotherapies

#1 AND #12

14 Systematic Reviews & 

Meta Analyses

#13 AND (Cochrane[tiab] OR (systematic*[tiab] AND review*[tiab]) OR metaanaly*[tiab] 

OR “meta analysis”[tiab] OR “meta analyses”[tiab] OR search*[ab])

15 RCTs #13 AND (random*[tiab] OR nct*[tiab])

16 Systematic Reviews & 

RCTs 

#14 OR #15

17 In-Process Subsets (#16 AND (inprocess[sb] OR publisher[sb] OR pubmednotmedline[sb]))

18 Limits Filters activated: Publication date from 2009/01/01 to 2016/12/31, English

Set 

Number Concept Search statement

1 PTSD “acute stress disorder”[tiab] OR “acute stress disorders”[tiab] OR “acute stress 

reaction”[tiab] OR “acute stress reactions”[tiab] OR “combat and operational stress 

reaction”[tiab] OR “combat disorder”[tiab] OR “combat disorders”[tiab] OR “combat 

fatigue”[tiab] OR “combat stress”[tiab] OR “post-traumatic neurosis”[tiab] OR “posttraumatic neuroses”[tiab] OR “post-traumatic psychoses”[tiab] OR “post-traumatic 

psychosis”[tiab] OR “post-traumatic stress”[tiab] OR “post-traumatic syndrome”[tiab] OR 

“post-traumatic syndromes”[tiab] OR “posttraumatic neurosis”[tiab] OR “posttraumatic 

neuroses”[tiab] OR “posttraumatic psychoses”[tiab] OR “posttraumatic psychosis”[tiab]

OR “posttraumatic stress”[tiab] OR “posttraumatic syndrome”[tiab] OR “posttraumatic 

syndromes”[tiab] OR ptsd OR “stress disorder”[tiab] OR “stress disorders”[tiab] OR 

“trauma syndrome”[tiab] OR “trauma syndromes”[tiab] OR “traumatic stress”[tiab] OR 

“war neuroses”[tiab] OR “war neurosis”[tiab] 

2 Antipychotic Cariprazine[tiab]

3 Psychostimulants “3,4-methylenedioxymethamphetamine"[tiab] OR Adderall[tiab] OR Amphetamine[tiab] 

OR Armodafanil[tiab] OR Atomoxetine[tiab] OR Dexamphetamine[tiab] OR 

Dexmethylphenidate[tiab] OR Dextroamphetamine[tiab] OR Lisdexamphetamine[tiab] 

OR MDMA[tiab] OR Methamphetamine[tiab] OR Methylphenidate[tiab] OR 

Modafanil[tiab] OR Psychostimulant*[tiab]

4 Steroids Dehydroepiandrosterone[tiab] OR DHEA[tiab] OR Hydrocortisone[tiab] OR 

Mifepristone[tiab] OR Steroid*[tiab]

5 Cannabinoids Cannabidiol[tiab] OR Cannabinoid*[tiab] OR CBD[tiab] OR Dronabinol[tiab] OR 

Marijuana[tiab] OR Tetrahydrocannabinol[tiab] OR THC[tiab]

6 Other “D-cycloserine”[tiab]

7 Combine 

Pharmacotherapies

#2 OR #3 OR #4 OR #5 OR #6

8 Combine PTSD & 

Pharmacotherapies

#1 And #7

9 Systematic Reviews & 

Meta Analyses

#8 AND (Cochrane[tiab] OR (systematic*[tiab] AND review*[tiab]) OR metaanaly*[tiab] 

OR “meta analysis”[tiab] OR “meta analyses”[tiab] OR search*[ab])

10 RCTs #8 AND (random*[tiab] OR nct*[tiab])

11 Systematic Reviews & 

RCTs 

#8 OR #10

12 In-Process Subsets (#11 AND (inprocess[sb] OR publisher[sb] OR pubmednotmedline[sb]))

13 Remove Non-Adult 

Abstracts

#12 NOT (adolescen*[ti] OR antenatal[ti] OR babies[ti] OR baby[ti] OR birth[ti] OR 

child*[ti] OR infan*[ti] OR kid[ti] OR kids[ti] OR neonat*[ti] OR newborn*[ti] OR 

paediatric*[ti] OR pediatric*[ti] OR perinatal[ti] OR prenatal[ti] OR teen*[ti] OR 

toddler*[ti] OR young*[ti] OR youth*[ti])
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 177 of 200

Set 

Number Concept Search statement

14 Limits Filters activated: Publication date from 2009/01/01 to 2016/12/31, English

Set 

Number Concept Search statement

1 PTSD “acute stress disorder”[tiab] OR “acute stress disorders”[tiab] OR “acute stress 

reaction”[tiab] OR “acute stress reactions”[tiab] OR “combat and operational stress 

reaction”[tiab] OR “combat disorder”[tiab] OR “combat disorders”[tiab] OR “combat 

fatigue”[tiab] OR “combat stress”[tiab] OR “post-traumatic neurosis”[tiab] OR “posttraumatic neuroses”[tiab] OR “post-traumatic psychoses”[tiab] OR “post-traumatic 

psychosis”[tiab] OR “post-traumatic stress”[tiab] OR “post-traumatic syndrome”[tiab] OR 

“post-traumatic syndromes”[tiab] OR “posttraumatic neurosis”[tiab] OR “posttraumatic 

neuroses”[tiab] OR “posttraumatic psychoses”[tiab] OR “posttraumatic psychosis”[tiab]

OR “posttraumatic stress”[tiab] OR “posttraumatic syndrome”[tiab] OR “posttraumatic 

syndromes”[tiab] OR ptsd OR “stress disorder”[tiab] OR “stress disorders”[tiab] OR 

“trauma syndrome”[tiab] OR “trauma syndromes”[tiab] OR “traumatic stress”[tiab] OR 

“war neuroses”[tiab] OR “war neurosis”[tiab] 

2 Trauma-focused 

Psychotherapy

Accelerated Resolution Therapy[tiab] OR ART[tiab] OR (Behavior*[tiab] AND 

therap*[tiab]) OR (behaviour*[tiab] AND therap*[tiab]) OR “BEP-TG”[tiab] OR “Brief 

eclectic psychotherapy”[tiab] OR CBCT[tiab] OR CBT[tiab] OR “cognitive behavioral 

conjoint therapy”[tiab] OR “cognitive behavioral therapy”[tiab] OR “Cognitive Processing 

Therapy”[tiab] OR (cognitive[tiab] AND therap*[tiab]) OR Ehlers[tiab] OR EMDR[tiab] OR 

“emotional freedom”[tiab] OR (exposure[tiab] AND therap*[tiab]) OR “Eye Movement 

Desensitization”[tiab] OR “imagery rehearsal”[tiab] OR Mindfulness[tiab] OR “Narrative 

Therapy”[tiab] OR “Prolonged Exposure Therapy”[tiab] OR “thought field therapy”[tiab]

OR “trauma focused”[tiab] OR “virtual reality”[tiab] OR “Written Exposure Therapy”[tiab]

3 Non-trauma-focused 

Psychotherapy

“acceptance and commitment therapy”[tiab] OR “behavioral activation”[tiab] OR 

((couples[tiab] OR family[tiab] OR marriage[tiab] OR marital[tiab]) AND (therap*[tiab] OR 

counsel*[tiab])) OR “emotion focused”[tiab] OR “interpersonal therapy”[tiab] OR IPT[tiab] 

OR meditation OR mindfulness OR “Neurolinguistic programming”[tiab] OR PCT[tiab] OR 

“Present Centered Therapy”[tiab] OR “Problem Solving Therapy”[tiab] OR 

Psychoanalysis[tiab] OR psychodynamic*[tiab] OR psychotherap*[tiab] OR relaxation[tiab] 

OR “Seeking Safety”[tiab] OR SIT[tiab] OR “Socioenvironmental Therapy”[tiab] OR “Stress 

Inoculation Therapy”[tiab] OR “supportive counseling”[tiab]

4 Combine 

Psychotherapies

#2 OR #3

5 PTSD & 

Psychotherapies

#1 AND #4

6 Systematic Reviews & 

Meta Analyses

#5 AND (Cochrane[tiab] OR (systematic*[tiab] AND review*[tiab]) OR metaanaly*[tiab] OR 

“meta analysis”[tiab] OR “meta analyses”[tiab] OR search*[ab])

7 RCTs #5 AND (random*[tiab] OR nct*[tiab])

8 Combine SRs & RCTs #6 OR #7

9 In-Process Subsets #8 AND (inprocess[sb] OR publisher[sb] OR pubmednotmedline[sb])

10 Limits Filters activated: Publication date from 2009/01/01 to 2016/12/31, English

11 Remove Age #10 NOT (adolescen*[ti] OR antenatal[ti] OR babies[ti] OR baby[ti] OR birth[ti] OR 

child*[ti] OR infan*[ti] OR kid[ti] OR kids[ti] OR neonat*[ti] OR newborn*[ti] OR 

paediatric*[ti] OR pediatric*[ti] OR perinatal[ti] OR prenatal[ti] OR teen*[ti] OR 

toddler*[ti] OR young*[ti] OR youth*[ti])
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 178 of 200

Set 

Number Concept Search statement

1 PTSD “acute stress disorder”[tiab] OR “acute stress disorders”[tiab] OR “acute stress 

reaction”[tiab] OR “acute stress reactions”[tiab] OR “combat and operational stress 

reaction”[tiab] OR “combat disorder”[tiab] OR “combat disorders”[tiab] OR “combat 

fatigue”[tiab] OR “combat stress”[tiab] OR “post-traumatic neurosis”[tiab] OR “posttraumatic neuroses”[tiab] OR “post-traumatic psychoses”[tiab] OR “post-traumatic 

psychosis”[tiab] OR “post-traumatic stress”[tiab] OR “post-traumatic syndrome”[tiab]

OR “post-traumatic syndromes”[tiab] OR “posttraumatic neurosis”[tiab] OR 

“posttraumatic neuroses”[tiab] OR “posttraumatic psychoses”[tiab] OR “posttraumatic 

psychosis”[tiab] OR “posttraumatic stress”[tiab] OR “posttraumatic syndrome”[tiab] OR 

“posttraumatic syndromes”[tiab] OR ptsd OR “stress disorder”[tiab] OR “stress 

disorders”[tiab] OR “trauma syndrome”[tiab] OR “trauma syndromes”[tiab] OR 

“traumatic stress”[tiab] OR “war neuroses”[tiab] OR “war neurosis”[tiab] 

2 Brief Interventions ((Brief[tiab[ OR “short term”[tiab] OR “time limited”[tiab]) AND (CBT[tiab] OR 

counsel*[tiab] OR intervention*[tiab] OR therap*[tiab] OR treatment*[tiab])

3 Combine PTSD & 

Brief Interventions

#1 AND #2

4 Systematic Reviews & 

Meta Analyses

#3 AND (Cochrane[tiab] OR (systematic*[tiab] AND review*[tiab]) OR metaanaly*[tiab] 

OR “meta analysis”[tiab] OR “meta analyses”[tiab] OR search*[ab])

5 RCTs #3 AND (random*[tiab] OR nct*[tiab])

6 Combine SRs & RCTs #4 OR #5

7 In-Process Subsets #6 AND (inprocess[sb] OR publisher[sb] OR pubmednotmedline[sb])

8 Remove Age #7 NOT (adolescen*[ti] OR antenatal[ti] OR babies[ti] OR baby[ti] OR birth[ti] OR 

child*[ti] OR infan*[ti] OR kid[ti] OR kids[ti] OR neonat*[ti] OR newborn*[ti] OR 

paediatric*[ti] OR pediatric*[ti] OR perinatal[ti] OR prenatal[ti] OR teen*[ti] OR 

toddler*[ti] OR young*[ti] OR youth*[ti])

9 Filters Filters activated: Publication date from 2009/01/01 to 2016/12/31, English
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 179 of 200

Set 

Number Concept Search statement

1 PTSD “acute stress disorder”[tiab] OR “acute stress disorders”[tiab] OR “acute stress 

reaction”[tiab] OR “acute stress reactions”[tiab] OR “combat and operational stress 

reaction”[tiab] OR “combat disorder”[tiab] OR “combat disorders”[tiab] OR “combat 

fatigue”[tiab] OR “combat stress”[tiab] OR “post-traumatic neurosis”[tiab] OR “posttraumatic neuroses”[tiab] OR “post-traumatic psychoses”[tiab] OR “post-traumatic 

psychosis”[tiab] OR “post-traumatic stress”[tiab] OR “post-traumatic syndrome”[tiab] OR 

“post-traumatic syndromes”[tiab] OR “posttraumatic neurosis”[tiab] OR “posttraumatic 

neuroses”[tiab] OR “posttraumatic psychoses”[tiab] OR “posttraumatic psychosis”[tiab] OR 

“posttraumatic stress”[tiab] OR “posttraumatic syndrome”[tiab] OR “posttraumatic 

syndromes”[tiab] OR ptsd OR “stress disorder”[tiab] OR “stress disorders”[tiab] OR 

“trauma syndrome”[tiab] OR “trauma syndromes”[tiab] OR “traumatic stress”[tiab] OR 

“war neuroses”[tiab] OR “war neurosis”[tiab] 

2 Interventions (((convulsive[tiab] or "electric shock"[tiab] or electroconvuls*[tiab] or electroshock[tiab] or 

shock[tiab]) AND (therap*[tiab] or treatment*[tiab])) or (ECS[tiab] or ECT[tiab] or 

rTMS[tiab] or TMS[tiab] or "transcranial magnetic stimulation"[tiab]) or (("high 

pressure"[tiab] or hyperbaric[tiab]) AND (oxygen[tiab] or oxygenation[tiab])) or ("stellate 

ganglion"[tiab] AND block*[tiab]))

3 Combine #1 AND #2

4 Systematic Reviews & 

Meta Analyses

#3 AND (Cochrane[tiab] OR (systematic*[tiab] AND review*[tiab]) OR metaanaly*[tiab] OR 

“meta analysis”[tiab] OR “meta analyses”[tiab] OR search*[ab])

5 RCTs #3 AND (random*[tiab] OR nct*[tiab])

6 Combine SRs & RCTs #4 OR #5

7 In-Process Subsets #6 AND (inprocess[sb] OR publisher[sb] OR pubmednotmedline[sb])

8 Limits Filters activated: Publication date from 2009/01/01 to 2016/12/31, English

Set 

Number Concept Search statement

1 PTSD “acute stress disorder”[tiab] OR “acute stress disorders”[tiab] OR “acute stress 

reaction”[tiab] OR “acute stress reactions”[tiab] OR “combat and operational stress 

reaction”[tiab] OR “combat disorder”[tiab] OR “combat disorders”[tiab] OR “combat 

fatigue”[tiab] OR “combat stress”[tiab] OR “post-traumatic neurosis”[tiab] OR “posttraumatic neuroses”[tiab] OR “post-traumatic psychoses”[tiab] OR “post-traumatic 

psychosis”[tiab] OR “post-traumatic stress”[tiab] OR “post-traumatic syndrome”[tiab] OR 

“post-traumatic syndromes”[tiab] OR “posttraumatic neurosis”[tiab] OR “posttraumatic 

neuroses”[tiab] OR “posttraumatic psychoses”[tiab] OR “posttraumatic psychosis”[tiab] OR 

“posttraumatic stress”[tiab] OR “posttraumatic syndrome”[tiab] OR “posttraumatic 

syndromes”[tiab] OR ptsd OR “stress disorder”[tiab] OR “stress disorders”[tiab] OR 

“trauma syndrome”[tiab] OR “trauma syndromes”[tiab] OR “traumatic stress”[tiab] OR 

“war neuroses”[tiab] OR “war neurosis”[tiab] 

2 CAM Interventions Acupuncture[tiab] OR ((“animal assisted”[tiab] OR art[tiab] OR “creative art”[tiab] OR 

“creative arts”[tiab] OR dance[tiab] OR drama[tiab] OR movement[tiab] OR music[tiab] OR 

recreational[tiab]) AND therap*[tiab]) OR ((alternative[tiab] OR complementary[tiab] OR 

integrative[tiab]) AND medicine[tiab]) OR (dietary[tiab] AND supplement*[tiab]) OR 

exercise[tiab] OR fishing[tiab] OR herbs[tiab] OR herbal[tiab] OR Homeopath*[tiab] OR 

mantram[tiab] OR meditation[tiab] OR meditate*[tiab] OR mindbody[tiab] OR “mind 

body”[tiab] OR mindfulness[tiab] OR phytotherapy[tiab] OR “progressive muscle 

relaxation”[tiab] OR Psychodrama[tiab] OR relaxation[tiab] OR “Tai Chi”[tiab] OR “Tai 

Ji”[tiab] OR Yoga[tiab]

3 Combine PTSD & CAM 

Interventions

#1 AND #2

4 Systematic Reviews & 

Meta Analyses

#3 AND (Cochrane[tiab] OR (systematic*[tiab] AND review*[tiab]) OR metaanaly*[tiab] OR 

“meta analysis”[tiab] OR “meta analyses”[tiab] OR search*[ab])

5 RCTs #3 AND (random*[tiab] OR nct*[tiab])
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 180 of 200

Set 

Number Concept Search statement

6 Combine SRs & RCTs #4 OR #5

7 In-Process Subsets #6 AND (inprocess[sb] OR publisher[sb] OR pubmednotmedline[sb])

8 Remove Out of Scope 

Ages

#7 NOT (adolescen*[ti] OR antenatal[ti] OR babies[ti] OR baby[ti] OR birth[ti] OR child*[ti]

OR infan*[ti] OR kid[ti] OR kids[ti] OR neonat*[ti] OR newborn*[ti] OR paediatric*[ti] OR 

pediatric*[ti] OR perinatal[ti] OR prenatal[ti] OR teen*[ti] OR toddler*[ti] OR young*[ti] OR 

youth*[ti])

9 Limits Filters activated: Publication date from 2009/01/01 to 2016/12/31, English

Set 

Number Concept Search statement

1 PTSD “acute stress disorder”[tiab] OR “acute stress disorders”[tiab] OR “acute stress 

reaction”[tiab] OR “acute stress reactions”[tiab] OR “combat and operational stress 

reaction”[tiab] OR “combat disorder”[tiab] OR “combat disorders”[tiab] OR “combat 

fatigue”[tiab] OR “combat stress”[tiab] OR “post-traumatic neurosis”[tiab] OR “posttraumatic neuroses”[tiab] OR “post-traumatic psychoses”[tiab] OR “post-traumatic 

psychosis”[tiab] OR “post-traumatic stress”[tiab] OR “post-traumatic syndrome”[tiab] OR 

“post-traumatic syndromes”[tiab] OR “posttraumatic neurosis”[tiab] OR “posttraumatic 

neuroses”[tiab] OR “posttraumatic psychoses”[tiab] OR “posttraumatic psychosis”[tiab] OR 

“posttraumatic stress”[tiab] OR “posttraumatic syndrome”[tiab] OR “posttraumatic 

syndromes”[tiab] OR ptsd OR “stress disorder”[tiab] OR “stress disorders”[tiab] OR 

“trauma syndrome”[tiab] OR “trauma syndromes”[tiab] OR “traumatic stress”[tiab] OR 

“war neuroses”[tiab] OR “war neurosis”[tiab] 

2 Group/Peer 

Interventions

“community therapy”[tiab] OR “community treatment”[tiab] OR “encounter group”[tiab] 

OR “group counseling”[tiab] OR “group intervention”[tiab] OR “group psychotherapy”[tiab] 

OR “Group setting”[tiab] OR “Group therapy”[tiab] OR “group treatment”[tiab] OR “peer 

counseling”[tiab] OR “peer group”[tiab] OR “peer groups”[tiab] OR “Peer support”[tiab] OR 

“Self-help”[tiab] OR “social group”[tiab] OR “social support”[tiab] OR “Support group”[tiab] 

OR “Support groups”[tiab] OR “Supportive Psychotherapy”[tiab] OR “supportive 

psychotherapies”[tiab] OR “Supportive therapy”[tiab] OR “supportive therapies”[tiab]

3 Combine PTSD & 

Interventions

#1 AND #2

4 Systematic Reviews & 

Meta Analyses

#3 AND (Cochrane[tiab] OR (systematic*[tiab] AND review*[tiab]) OR metaanaly*[tiab] OR 

“meta analysis”[tiab] OR “meta analyses”[tiab] OR search*[ab])

5 RCTs #3 AND (random*[tiab] OR nct*[tiab])

6 Combine SRs & RCTs #4 OR #5

7 Remove Non-Adult 

Abstracts

#6 NOT (adolescen*[ti] OR antenatal[ti] OR babies[ti] OR baby[ti] OR birth[ti] OR child*[ti]

OR infan*[ti] OR kid[ti] OR kids[ti] OR neonat*[ti] OR newborn*[ti] OR paediatric*[ti] OR 

pediatric*[ti] OR perinatal[ti] OR prenatal[ti] OR teen*[ti] OR toddler*[ti] OR young*[ti] OR 

youth*[ti])

8 In-Process Subsets #7 AND (inprocess[sb] OR publisher[sb] OR pubmednotmedline[sb])

9 Limits Filters activated: Publication date from 2009/01/01 to 2016/12/31, English
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 181 of 200

Set 

Number Concept Search statement

1 PTSD “acute stress disorder”[tiab] OR “acute stress disorders”[tiab] OR “acute stress 

reaction”[tiab] OR “acute stress reactions”[tiab] OR “combat and operational stress 

reaction”[tiab] OR “combat disorder”[tiab] OR “combat disorders”[tiab] OR “combat 

fatigue”[tiab] OR “combat stress”[tiab] OR “post-traumatic neurosis”[tiab] OR “posttraumatic neuroses”[tiab] OR “post-traumatic psychoses”[tiab] OR “post-traumatic 

psychosis”[tiab] OR “post-traumatic stress”[tiab] OR “post-traumatic syndrome”[tiab] OR 

“post-traumatic syndromes”[tiab] OR “posttraumatic neurosis”[tiab] OR “posttraumatic 

neuroses”[tiab] OR “posttraumatic psychoses”[tiab] OR “posttraumatic psychosis”[tiab] OR 

“posttraumatic stress”[tiab] OR “posttraumatic syndrome”[tiab] OR “posttraumatic 

syndromes”[tiab] OR ptsd OR “stress disorder”[tiab] OR “stress disorders”[tiab] OR 

“trauma syndrome”[tiab] OR “trauma syndromes”[tiab] OR “traumatic stress”[tiab] OR 

“war neuroses”[tiab] OR “war neurosis”[tiab] 

2 Collaborative Care “Care management”[tiab] OR “Collaborative care”[tiab] OR “Coordinated Anxiety Learning 

and Management”[tiab] OR “Coordinated care”[tiab] OR “Embedded behavioral 

health”[tiab] OR “Mental health integration”[tiab] OR PCMHI[tiab] OR “Primary Care 

Mental Health Integration”[tiab] OR “Re-Engineering Systems of Primary Care Treatment in 

the Military”[tiab] OR “re-engineering systems for the primary care treatment of 

PTSD”[tiab] OR “RESPECT MIL”[tiab] OR “RESPECT PTSD”[tiab] OR “Stepped care”[tiab] OR 

“STepped Enhancement of PTSD Services Using Primary Care”[tiab] OR “STEPS UP”[tiab] 

OR TIDES[tiab] OR “Translating Initiatives for Depression into Effective Solutions”[tiab]

3 Combine PTSD & 

Collaborative Care

#1 AND #2

4 Systematic Reviews & 

Meta Analyses

#3 AND (Cochrane[tiab] OR (systematic*[tiab] AND review*[tiab]) OR metaanaly*[tiab] OR 

“meta analysis”[tiab] OR “meta analyses”[tiab] OR search*[ab])

5 RCTs #3 AND (random*[tiab] OR nct*[tiab])

6 Combine SRs & RCTs #4 OR #5

7 Remove Non-Adult 

Abstracts

#6 NOT (adolescen*[ti] OR antenatal[ti] OR babies[ti] OR baby[ti] OR birth[ti] OR child*[ti]

OR infan*[ti] OR kid[ti] OR kids[ti] OR neonat*[ti] OR newborn*[ti] OR paediatric*[ti] OR 

pediatric*[ti] OR perinatal[ti] OR prenatal[ti] OR teen*[ti] OR toddler*[ti] OR young*[ti] OR 

youth*[ti])

8 In-Process Subsets #7 AND (inprocess[sb] OR publisher[sb] OR pubmednotmedline[sb])

9 Limits Filters activated: Publication date from 2009/01/01 to 2016/12/31, English

Set 

Number Concept Search statement

1 PTSD “acute stress disorder”[tiab] OR “acute stress disorders”[tiab] OR “acute stress 

reaction”[tiab] OR “acute stress reactions”[tiab] OR “combat and operational stress 

reaction”[tiab] OR “combat disorder”[tiab] OR “combat disorders”[tiab] OR “combat 

fatigue”[tiab] OR “combat stress”[tiab] OR “post-traumatic neurosis”[tiab] OR “posttraumatic neuroses”[tiab] OR “post-traumatic psychoses”[tiab] OR “post-traumatic 

psychosis”[tiab] OR “post-traumatic stress”[tiab] OR “post-traumatic syndrome”[tiab] OR 

“post-traumatic syndromes”[tiab] OR “posttraumatic neurosis”[tiab] OR “posttraumatic 

neuroses”[tiab] OR “posttraumatic psychoses”[tiab] OR “posttraumatic psychosis”[tiab] OR 

“posttraumatic stress”[tiab] OR “posttraumatic syndrome”[tiab] OR “posttraumatic 

syndromes”[tiab] OR ptsd OR “stress disorder”[tiab] OR “stress disorders”[tiab] OR “trauma 

syndrome”[tiab] OR “trauma syndromes”[tiab] OR “traumatic stress”[tiab] OR “war 

neuroses”[tiab] OR “war neurosis”[tiab] 
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 182 of 200

Set 

Number Concept Search statement

2 Technologies “clinical video teleconferencing”[tiab] OR CVT[tiab] OR Ehealth[tiab] OR “e-health”[tiab] OR 

Smartphone*[tiab] OR Tele-communication*[tiab] OR Tele-conferenc*[tiab] OR Telehealth*[tiab] OR Tele-medicine[tiab] OR Tele-monitor*[tiab] OR Tele-psych*[tiab] OR 

Telecommunication*[tiab] OR Teleconferenc*[tiab] OR Teleconsultation*[tiab] OR 

Telehealth*[tiab] OR Telemedicine[tiab] OR Telemonitor*[tiab] OR Telephone[tiab] OR 

Telepsych*[tiab] OR “telephone care management”[tiab] OR “virtual reality”[tiab] OR 

(video[tiab] AND (conferenc*[tiab] OR tele-conferenc*[tiab] OR teleconference*[tiab])) OR 

(Mobile[tiab] AND (application*[tiab] OR app[tiab] OR apps[tiab] OR device*[tiab] OR 

phone*[tiab]))

3 Combine PTSD & 

Technologies

#1 AND #2

4 Systematic Reviews & 

Meta Analyses

#3 AND (Cochrane[tiab] OR (systematic*[tiab] AND review*[tiab]) OR metaanaly*[tiab] OR 

“meta analysis”[tiab] OR “meta analyses”[tiab] OR search*[ab])

5 RCTs #3 AND (random*[tiab] OR nct*[tiab])

6 Combine SRs & RCTs #4 OR #5

7 Remove Non-Adult 

Citations

#6 NOT (adolescen*[ti] OR antenatal[ti] OR babies[ti] OR baby[ti] OR birth[ti] OR child*[ti]

OR infan*[ti] OR kid[ti] OR kids[ti] OR neonat*[ti] OR newborn*[ti] OR paediatric*[ti] OR 

pediatric*[ti] OR perinatal[ti] OR prenatal[ti] OR teen*[ti] OR toddler*[ti] OR young*[ti] OR 

youth*[ti])

8 In-Process Subsets #7 AND (inprocess[sb] OR publisher[sb] OR pubmednotmedline[sb])

9 Limits Filters activated: Publication date from 2009/01/01 to 2016/12/31, English

PubMed syntax:

[Mesh] = search as a subject heading

[majr] = search as a major subject heading

* = truncation character (wildcard)

[ti] = limit to title field

[tiab] = limit to title and abstract fields

[tw] = text word
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Appendix H: Abbreviation List

Abbreviation Definition

ACT Acceptance and Commitment Therapy

AHRQ Agency for Healthcare Research and Quality

Army STARRS Army Study to Assess Risk and Resilience in Service Members

ASD Acute stress disorder

ASR Acute stress reaction

AUD Alcohol use disorder

AUDIT-C Alcohol Use Disorders Identification Test—Consumption

BEP Brief Eclectic Psychotherapy

CAPS Clinician-Administered PTSD Scale

CAPS-5 Clinician Administered PTSD Scale for DSM-5

CBCT Cognitive Behavioral Conjoint Therapy

CBT Cognitive behavioral therapy

CBT-I Cognitive Behavioral Therapy for Insomnia

CGIC Clinical Global Impression of Change Scale

CIH Complementary and integrative health

CISD Critical Incident Stress Debriefing

COI Conflict of interest

COPD Chronic obstructive pulmonary disorder

COR Contracting officer’s representative

COSR Combat and Operational Stress Reaction

CPG Clinical practice guideline

CPT Cognitive Processing Therapy

CS Comparative study

DLPFC Dorsolateral prefrontal cortex

DoD Department of Defense

DSM-5 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

EBPWG Evidence-Based Practice Work Group

ECT Electroconvulsive therapy

EMDR Eye Movement Desensitization and Reprocessing

ERRT Exposure, Relaxation, and Rescripting Therapy

ES Effect size

FDA Food and Drug Administration

GRADE Grading of Recommendations Assessment, Development and Evaluation

HBOT Hyperbaric oxygen therapy

HealthVIEWS Health of Vietnam-Era Women’s Study

Hz Hertz

HIV Human immunodeficiency virus

iCBT Internet-based cognitive behavioral therapy

IPT Interpersonal Psychotherapy
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Abbreviation Definition

IR Immediate release

IRT Imagery Rehearsal Therapy

IV Intravenous

KQ Key question

LFT Liver function test

MAOIs Monoamine oxidase inhibitors

MBSR Mindfulness-based stress reduction

MDD Major depressive disorder

mg Milligram

MI Myocardial infarction

mTBI Concussion/mild traumatic brain injury

NCS-R National Comorbidity Survey-Replication

NESARC National Epidemiologic Survey on Alcohol and Related Conditions

NET Narrative Exposure Therapy

NICE National Institute for Health and Care Excellence

NLP Neurolinguistic programming

NVVLS National Vietnam Veterans Longitudinal Study

NVVRS National Vietnam Veterans Readjustment Study

OEF Operation Enduring Freedom

OIF Operation Iraqi Freedom

OND Operation New Dawn

OUC Optimized usual care

PC-PTSD Primary Care PTSD Screen

PCL PTSD Checklist

PCL-5 DSM-5 PTSD Checklist

PCL-C PTSD Checklist – Civilian Version

PCT Present-centered therapy

PDS Posttraumatic Diagnostic Scale

PE Prolonged exposure

PHQ-9 Patient Health Questionnaire-9

PICOTS Population, intervention, comparison, outcome, timing and setting framework

PSSI-I Posttraumatic Stress Disorder Symptom Scale Interview for DSM-5

PTSD Posttraumatic stress disorder

QoL Quality of life

RCT Randomized controlled trial

rTMS Repetitive transcranial magnetic stimulation

SCID-5 Structured Clinical Interview for DSM-5

SDM Shared decision making

SGA Second generation antipsychotic

SGB Stellate ganglion block
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Abbreviation Definition

SIADH Syndrome of inappropriate anti-diuretic hormone

SIT Stress Inoculation Training

SNRI Serotonin norepinephrine reuptake inhibitor

SR Systematic review

SSRI Selective serotonin reuptake inhibitor

SUD Substance use disorder

TBI Traumatic brain injury

TCA Tricyclic antidepressant

USPSTF U.S. Preventive Services Task Force

VA Department of Veterans Affairs

VNS Vagal nerve stimulation

VTC Video-teleconferencing

WTU Warrior Transition Unit

XR Extended release
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References 

1. U.S. Department of Veteran Affairs, Department of Defense. Guideline for guidelines. Veterans

Health Administration, Office of Quality & Performance, Evidence Review Subgroup; Revised April

10, 2013.

2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5®).

Fifth ed. Arlington, VA: American Psychiatric Association; 2013.

3. Herman JL. Complex PTSD: A syndrome in survivors of prolonged and repeated trauma. Journal of

traumatic stress. 1992;5(3):377-391.

4. Hoge CW, Yehuda R, Castro CA, et al. Unintended consequences of changing the definition of

posttraumatic stress disorder in DSM-5: Critique and call for action. JAMA Psychiatry. Jul 1

2016;73(7):750-752.

5. Friedman MJ, Kilpatrick DG, Schnurr PP, Weathers FW. Correcting misconceptions about the

diagnostic criteria for posttraumatic stress disorder in DSM-5. JAMA Psychiatry. Jul 1

2016;73(7):753-754.

6. Pietrzak RH, Goldstein RB, Southwick SM, Grant BF. Prevalence and Axis I comorbidity of full and

partial posttraumatic stress disorder in the United States: Results from wave 2 of the National

Epidemiologic Survey on Alcohol and Related Conditions. J Anxiety Disord. Apr 2011;25(3):456-465.

7. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-ofonset distributions of DSM-IV disorders in the national comorbidity survey replication. Arch Gen

Psychiatry. Jun 2005;62(6):593-602.

8. Goldstein RB, Smith SM, Chou SP, et al. The epidemiology of DSM-5 posttraumatic stress disorder in

the United States: Results from the National Epidemiologic Survey on Alcohol and Related

Conditions-III. Soc Psychiatry Psychiatr Epidemiol. Aug 2016;51(8):1137-1148.

9. Gates MA, Holowka DW, Vasterling JJ, Keane TM, Marx BP, Rosen RC. Posttraumatic stress disorder

in Veterans and military personnel: Epidemiology, screening, and case recognition. Psychol Serv. Nov

2012;9(4):361-382.

10. Kok BC, Herrell RK, Thomas JL, Hoge CW. Posttraumatic stress disorder associated with combat

service in Iraq or Afghanistan: Reconciling prevalence differences between studies. J Nerv Ment Dis.

May 2012;200(5):444-450.

11. Ramchand R, Schell TL, Karney BR, Osilla KC, Burns RM, Caldarone LB. Disparate prevalence

estimates of PTSD among service members who served in Iraq and Afghanistan: Possible

explanations. J Trauma Stress. Feb 2010;23(1):59-68.

12. Richardson LK, Frueh BC, Acierno R. Prevalence estimates of combat-related post-traumatic stress

disorder: Critical review. Aust N Z J Psychiatry. Jan 2010;44(1):4-19.

13. Schell TL, Marshall GN. Survey of individuals previously deployed for OEF/OIF. Invisible wounds of

war: Psychological and cognitive injuries, their consequences, and services to assist recovery.

2008:87-115.

14. Ramchand R, Rudavsky R, Grant S, Tanielian T, Jaycox L. Prevalence of, risk factors for, and

consequences of posttraumatic stress disorder and other mental health problems in military

populations deployed to Iraq and Afghanistan. Curr Psychiatry Rep. May 2015;17(5):37.

15. Thomas JL, Wilk JE, Riviere LA, McGurk D, Castro CA, Hoge CW. Prevalence of mental health

problems and functional impairment among active component and National Guard soldiers 3 and 12

months following combat in Iraq. Arch Gen Psychiatry. Jun 2010;67(6):614-623.

16. LeardMann CA, Smith TC, Smith B, Wells TS, Ryan MA. Baseline self reported functional health and

vulnerability to post-traumatic stress disorder after combat deployment: Prospective US military

cohort study. BMJ. Apr 16 2009;338:b1273.
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 187 of 200

17. Smith TC, Ryan MA, Wingard DL, Slymen DJ, Sallis JF, Kritz-Silverstein D. New onset and persistent

symptoms of post-traumatic stress disorder self reported after deployment and combat exposures:

Prospective population based US military cohort study. BMJ. Feb 16 2008;336(7640):366-371.

18. Kessler RC, Heeringa SG, Stein MB, et al. Thirty-day prevalence of DSM-IV mental disorders among

nondeployed soldiers in the US Army: Results from the Army study to assess risk and resilience in

Service Members (Army STARRS). JAMA Psychiatry. May 2014;71(5):504-513.

19. Armed Forces Health Surveillance Branch. Mental health conditions among active component U.S.

Armed Forces. Defense Medical Surveillance System (DMSS). Public Health Division, Defense Health

Agency. (2017).

20. Wisco BE, Marx BP, Wolf EJ, Miller MW, Southwick SM, Pietrzak RH. Posttraumatic stress disorder in

the US Veteran population: Results from the national health and resilience in Veterans study. J Clin

Psychiatry. Dec 2014;75(12):1338-1346.

21. Magruder KM, Yeager DE. The prevalence of PTSD across war eras and the effect of deployment on

PTSD: A systematic review and meta-analysis. Psychiatric Annals. 2009;39(8).

22. Kulka R, Schlenger WE, Fairbank JA, et al. National Vietnam Veterans readjustment study (NVVRS):

Description, current status, and initial PTSD prevalence estimates. Washington, DC: Veterans

Administration. 1988.

23. Marmar CR, Schlenger W, Henn-Haase C, et al. Course of posttraumatic stress disorder 40 years

after the Vietnam war: Findings from the national Vietnam Veterans longitudinal study. JAMA

Psychiatry. Sep 2015;72(9):875-881.

24. Magruder K, Serpi T, Kimerling R, et al. Prevalence of posttraumatic stress disorder in Vietnam-era

women Veterans: The health of Vietnam-era women's study (HealthVIEWS). JAMA Psychiatry. Nov

2015;72(11):1127-1134.

25. Magruder KM, Goldberg J, Forsberg CW, et al. Long-term trajectories of PTSD in Vietnam-era

Veterans: The course and consequences of PTSD in twins. J Trauma Stress. Feb 2016;29(1):5-16.

26. Greenberg G, Hoff R. 2016 Veterans with PTSD data sheet: National, VISN, and VAMC tables.

Northeast Program Evaluation Center. West Haven, CT: Northeast Program Evaluation Center.

(2016).

27. Harpaz-Rotem I, Hoff R. FY2015 overview of PTSD patient population data sheet. VA Office of

Mental Health Operations. West Haven, CT: Northeast Program Evaluation Center. (2015).

28. Olatunji BO, Cisler JM, Tolin DF. Quality of life in the anxiety disorders: A meta-analytic review. Clin

Psychol Rev. Jun 2007;27(5):572-581.

29. Schnurr PP, Lunney CA, Bovin MJ, Marx BP. Posttraumatic stress disorder and quality of life:

Extension of findings to Veterans of the wars in Iraq and Afghanistan. Clin Psychol Rev. Dec

2009;29(8):727-735.

30. Levine AB, Levine LM, Levine TB. Posttraumatic stress disorder and cardiometabolic disease.

Cardiology. 2014;127(1):1-19.

31. Andrews J, Guyatt G, Oxman AD, et al. GRADE guidelines: 14. Going from evidence to

recommendations: The significance and presentation of recommendations. J Clin Epidemiol. Jul

2013;66(7):719-725.

32. Newberry SJ, Ahmadzai N, Motala A, et al. AHRQ methods for effective health care. Surveillance and

identification of signals for updating systematic reviews: Implementation and early experience.

Rockville (MD): Agency for Healthcare Research and Quality (US); 2013.

33. Guirguis-Blake J, Calonge N, Miller T, Siu A, Teutsch S, Whitlock E. Current processes of the U.S.

Preventive Services Task Force: Refining evidence-based recommendation development. Ann Intern

Med. Jul 17 2007;147(2):117-122.

34. The guidelines manual. London: National Institute for Health and Care Excellence;2012.

https://www.nice.org.uk/process/pmg6/chapter/introduction.
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 188 of 200

35. Martinez Garcia L, McFarlane E, Barnes S, Sanabria AJ, Alonso-Coello P, Alderson P. Updated

recommendations: An assessment of NICE clinical guidelines. Implement Sci. 2014;9:72.

36. White CM, Ip S, McPheeters M, et al. AHRQ methods for effective health care using existing

systematic reviews to replace de novo processes in conducting comparative effectiveness reviews.

Methods guide for effectiveness and comparative effectiveness reviews. Rockville (MD): Agency for

Healthcare Research and Quality (US); 2008.

37. Institute of Medicine (US) Committe on Standards for Developing Trustworthy Clinical Practice

Guidelines, R Graham, M Mancher, D Miller Wolman, et al., editors. Clinical practice guidelines we

can trust. Washington, DC: National Academies Press;2011.

38. Schunemann HJ, Fretheim A, Oxman AD. Improving the use of research evidence in guideline

development: 10. Integrating values and consumer involvement. Health Res Policy Syst. 2006;4:22.

39. Bertakis KD, Azari R. Patient-centered care is associated with decreased health care utilization. J Am

Board Fam Med. May-Jun 2011;24(3):229-239.

40. Robinson JH, Callister LC, Berry JA, Dearing KA. Patient-centered care and adherence: Definitions

and applications to improve outcomes. J Am Acad Nurse Pract. Dec 2008;20(12):600-607.

41. Institute of Medicine. Crossing the quality chasm: A new health system for the 21st century.

Washington DC: National Academies Press;2001.

42. Society for Medical Decision Making Committee on Standardization of Clinical Algorithms. Proposal

for clinical algorithm standards. Med Decis Making. Apr-Jun 1992;12(2):149-154.

43. Marshall SS, Haywood KL, Fitzpatrick R. Patient involvement and collaboration in shared decisionmaking: A structured review to inform chronic disease management. Report from the patientreported health instruments group to the Department of Health. 2005.

44. Mott JM, Stanley MA, Street RL, Jr., Grady RH, Teng EJ. Increasing engagement in evidence-based

PTSD treatment through shared decision-making: A pilot study. Mil Med. Feb 2014;179(2):143-149.

45. Stacey D, Legare F, Col NF, et al. Decision aids for people facing health treatment or screening

decisions. Cochrane Database Syst Rev. 2014(1):CD001431.

46. Watts BV, Schnurr PP, Zayed M, Young-Xu Y, Stender P, Llewellyn-Thomas H. A randomized

controlled clinical trial of a patient decision aid for posttraumatic stress disorder. Psychiatr Serv. Feb

1 2015;66(2):149-154.

47. Unützer J, Harbin H, Schoenbaum M, Druss B. The collaborative care model: An approach for

integrating physical and mental health care in medicaid health homes (pp. 1–13). Health Home,

Information Resource Center. Retreived from https://www.medicaid.gov/state-resource-center/

medicaid-state-technical-assistance/health-homes-technical-assistance/health-homeinformation-resource-center.html. 2013.

48. Zatzick D, Jurkovich G, Rivara FP, et al. A randomized stepped care intervention trial targeting

posttraumatic stress disorder for surgically hospitalized injury survivors. Ann Surg. Mar

2013;257(3):390-399.

49. Zatzick D, O'Connor SS, Russo J, et al. Technology-enhanced stepped collaborative care targeting

posttraumatic stress disorder and comorbidity after injury: A randomized controlled trial. J Trauma

Stress. Oct 2015;28(5):391-400.

50. Fortney JC, Pyne JM, Kimbrell TA, et al. Telemedicine-based collaborative care for posttraumatic

stress disorder: A randomized clinical trial. JAMA Psychiatry. Jan 2015;72(1):58-67.

51. Schnurr PP, Friedman MJ, Oxman TE, et al. RESPECT-PTSD: Re-engineering systems for the primary

care treatment of PTSD, a randomized controlled trial. J Gen Intern Med. Jan 2013;28(1):32-40.

52. Meredith LS, Eisenman DP, Han B, et al. Impact of collaborative care for underserved patients with

PTSD in primary care: A randomized controlled trial. J Gen Intern Med. May 2016;31(5):509-517.
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 189 of 200

53. Craske MG, Stein MB, Sullivan G, et al. Disorder-specific impact of coordinated anxiety learning and

management treatment for anxiety disorders in primary care. Arch Gen Psychiatry. Apr

2011;68(4):378-388.

54. Peek C. Lexicon for behavioral health and primary care integration: Concepts and definitions

developed by expert concensus. Rockville, MD: Agency for Healthcare Research and Quality

Retrieved from http://integrationacademy.ahrq.gov/sites/default/files/Lexicon.pdf. 2013.

55. Engel CC, Jaycox LH, Freed MC, et al. Centrally assisted collaborative telecare for posttraumatic

stress disorder and depression among military personnel attending primary care: A randomized

clinical trial. JAMA internal medicine. 2016;176(7):948-956.

56. Spoont MR, Williams JW, Jr., Kehle-Forbes S, Nieuwsma JA, Mann-Wrobel MC, Gross R. Does this

patient have posttraumatic stress disorder?: Rational clinical examination systematic review. JAMA.

Aug 04 2015;314(5):501-510.

57. Siu AL, Bibbins-Domingo K, Grossman DC, et al. Screening for depression in adults: US Preventive

Services Task Force recommendation statement. JAMA. Jan 26 2016;315(4):380-387.

58. Bovin MJ, Marx BP, Weathers FW, et al. Psychometric properties of the PTSD checklist for diagnostic

and statistical manual of mental disorders-fifth edition (PCL-5) in veterans. Psychol Assess. Nov

2016;28(11):1379-1391.

59. Prins A, Bovin MJ, Smolenski DJ, et al. The primary care PTSD screen for DSM-5 (PC-PTSD-5):

Development and evaluation within a Veteran primary care sample. J Gen Intern Med. Oct

2016;31(10):1206-1211.

60. Terhakopian A, Sinaii N, Engel CC, Schnurr PP, Hoge CW. Estimating population prevalence of

posttraumatic stress disorder: An example using the PTSD checklist. J Trauma Stress. Jun

2008;21(3):290-300.

61. Hoge CW, Riviere LA, Wilk JE, Herrell RK, Weathers FW. The prevalence of post-traumatic stress

disorder (PTSD) in US combat soldiers: A head-to-head comparison of DSM-5 versus DSM-IV-TR

symptom criteria with the PTSD checklist. Lancet Psychiatry. Sep 2014;1(4):269-277.

62. Ursano RJ, Kessler RC, Stein MB, et al. Risk factors, methods, and timing of suicide attempts among

US Army soldiers. JAMA Psychiatry. Jul 01 2016;73(7):741-749.

63. Smith SM, Goldstein RB, Grant BF. The association between post-traumatic stress disorder and

lifetime DSM-5 psychiatric disorders among Veterans: Data from the National Epidemiologic Survey

on Alcohol and Related Conditions-III (NESARC-III). J Psychiatr Res. Nov 2016;82:16-22.

64. Reardon A, Brief D, Miller M, Keane T. Assessment of PTSD and its comorbidities in adults. Handbook

of PTSD: science and practice. 2nd ed. New York: Guilford. 2014:369-390.

65. Weathers FW, Marx BP, Friedman MJ, Schnurr PP. Posttraumatic stress disorder in DSM-5: New

criteria, new measures, and implications for assessment. Psychological Injury and Law. 2014;7(2):93-

107.

66. U.S. Department of Veteran Affairs. PTSD and DSM-5. Washington D.C.: 2017.

http://www.ptsd.va.gov/professional/PTSD-overview/dsm5_criteria_ptsd.asp. Updated February

21, 2017. Accessed February 23, 2017.

67. Weathers F, Blake D, Schnurr P, Kaloupek D, Marx B, Keane T. The clinician-administered PTSD scale

for DSM-5 (CAPS-5). Interview available from the National Center for PTSD at www.ptsd.va.gov.

2013.

68. Foa EB, McLean CP, Zang Y, et al. Psychometric properties of the posttraumatic stress disorder

symptom scale interview for DSM-5 (PSSI-5). Psychol Assess. Oct 2016;28(10):1159-1165.

69. First M, Williams J, Karg R, Spitzer R. Structured clinical interview for DSM-5 disorders, clinician

version (SCID-5-CV). Arlington, VA: American Psychiatric Association. 2015.

70. Kroenke K, Spitzer RL, Williams JB. The patient health questionnaire-2: Validity of a two-item

depression screener. Med Care. Nov 2003;41(11):1284-1292.
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 190 of 200

71. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: Validity of a brief depression severity measure. J Gen

Intern Med. Sep 2001;16(9):606-613.

72. Bradley KA, Kivlahan DR, Zhou XH, et al. Using alcohol screening results and treatment history to

assess the severity of at-risk drinking in Veterans Affairs primary care patients. Alcohol Clin Exp Res.

Mar 2004;28(3):448-455.

73. Interagency Task Force on Military and Veterans Mental Health. Common Mental Health Metrics

Work Group. 2015 draft plan and recommendations (ITF recommendation #3). June 15, 2015.

74. Fortney JC, Unützer J, Wrenn G, et al. A tipping point for measurement-based care. Psychiatric

Services. 2017;68(2):179-188.

75. The IOM model: A tool for prevention planning and implementation. 2006. http://www.carsrp.org/publications/Prevention%20Tactics/PT8.13.06.pdf. Accessed March 29, 2017.

76. Rothbaum BO, Kearns MC, Price M, et al. Early intervention may prevent the development of

posttraumatic stress disorder: A randomized pilot civilian study with modified prolonged exposure.

Biol Psychiatry. Dec 01 2012;72(11):957-963.

77. Forneris CA, Gartlehner G, Brownley KA, et al. Interventions to prevent post-traumatic stress

disorder: A systematic review. Am J Prev Med. Jun 2013;44(6):635-650.

78. Mulligan K, Fear NT, Jones N, et al. Postdeployment battlemind training for the U.K. Armed forces: A

cluster randomized controlled trial. J Consult Clin Psychol. Jun 2012;80(3):331-341.

79. Hruska B, Cullen PK, Delahanty DL. Pharmacological modulation of acute trauma memories to

prevent PTSD: Considerations from a developmental perspective. Neurobiol Learn Mem. Jul

2014;112:122-129.

80. Pitman RK, Sanders KM, Zusman RM, et al. Pilot study of secondary prevention of posttraumatic

stress disorder with propranolol. Biol Psychiatry. Jan 15 2002;51(2):189-192.

81. Hoge EA, Worthington JJ, Nagurney JT, et al. Effect of acute posttrauma propranolol on PTSD

outcome and physiological responses during script-driven imagery. CNS Neurosci Ther. Jan

2012;18(1):21-27.

82. Stein MB, Kerridge C, Dimsdale JE, Hoyt DB. Pharmacotherapy to prevent PTSD: Results from a

randomized controlled proof-of-concept trial in physically injured patients. J Trauma Stress. Dec

2007;20(6):923-932.

83. Amos T, Stein DJ, Ipser JC. Pharmacological interventions for preventing post-traumatic stress

disorder (PTSD). Cochrane Database Syst Rev. 2014(7):CD006239.

84. Mellman TA, Bustamante V, David D, Fins AI. Hypnotic medication in the aftermath of trauma. J Clin

Psychiatry. Dec 2002;63(12):1183-1184.

85. Schelling G, Briegel J, Roozendaal B, Stoll C, Rothenhausler HB, Kapfhammer HP. The effect of stress

doses of hydrocortisone during septic shock on posttraumatic stress disorder in survivors. Biol

Psychiatry. Dec 15 2001;50(12):978-985.

86. Delahanty DL, Gabert-Quillen C, Ostrowski SA, et al. The efficacy of initial hydrocortisone

administration at preventing posttraumatic distress in adult trauma patients: A randomized trial.

CNS Spectr. Apr 2013;18(2):103-111.

87. Zohar J, Yahalom H, Kozlovsky N, et al. High dose hydrocortisone immediately after trauma may

alter the trajectory of PTSD: Interplay between clinical and animal studies. Eur

Neuropsychopharmacol. Nov 2011;21(11):796-809.

88. Weis F, Kilger E, Roozendaal B, et al. Stress doses of hydrocortisone reduce chronic stress symptoms

and improve health-related quality of life in high-risk patients after cardiac surgery: A randomized

study. J Thorac Cardiovasc Surg. Feb 2006;131(2):277-282.

89. Kliem S, Kroger C. Prevention of chronic PTSD with early cognitive behavioral therapy. A metaanalysis using mixed-effects modeling. Behav Res Ther. Nov 2013;51(11):753-761.
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 191 of 200

90. Shalev AY, Ankri Y, Israeli-Shalev Y, Peleg T, Adessky R, Freedman S. Prevention of posttraumatic

stress disorder by early treatment: Results from the Jerusalem trauma outreach and prevention

study. Arch Gen Psychiatry. Feb 2012;69(2):166-176.

91. Suliman S, Seedat S, Pingo J, Sutherland T, Zohar J, Stein DJ. Escitalopram in the prevention of

posttraumatic stress disorder: A pilot randomized controlled trial. BMC Psychiatry. 2015;15:24.

92. Lee DJ, Schnitzlein CW, Wolf JP, Vythilingam M, Rasmusson AM, Hoge CW. Psychotherapy versus

pharmacotherapy for posttraumatic stress disorder: Systemic review and meta-analyses to

determine first-line treatments. Depress Anxiety. Sep 2016;33(9):792-806.

93. Watts BV, Schnurr PP, Mayo L, Young-Xu Y, Weeks WB, Friedman MJ. Meta-analysis of the efficacy

of treatments for posttraumatic stress disorder. J Clin Psychiatry. Jun 2013;74(6):e541-550.

94. Simiola V, Neilson EC, Thompson R, Cook JM. Preferences for trauma treatment: A systematic

review of the empirical literature. Psychol Trauma. Nov 2015;7(6):516-524.

95. Swift JK, Greenberg RP, Tompkins KA, Parkin SR. Treatment refusal and premature termination in

psychotherapy, pharmacotherapy, and their combination: A meta-analysis of head-to-head

comparisons. Psychotherapy. 2017;54(1):47-57.

96. Schnurr PP. Focusing on trauma-focused psychotherapy for posttraumatic stress disorder. Current

Opinion in Psychology. 2017;14:56-60.

97. Foa EB, Hembree EA, Cahill SP, et al. Randomized trial of prolonged exposure for posttraumatic

stress disorder with and without cognitive restructuring: Outcome at academic and community

clinics. J Consult Clin Psychol. Oct 2005;73(5):953-964.

98. Resick PA, Nishith P, Weaver TL, Astin MC, Feuer CA. A comparison of cognitive-processing therapy

with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress

disorder in female rape victims. J Consult Clin Psychol. Aug 2002;70(4):867-879.

99. Shapiro F. Eye movement desensitization: A new treatment for post-traumatic stress disorder. J

Behav Ther Exp Psychiatry. Sep 1989;20(3):211-217.

100. Rothbaum BO, Astin MC, Marsteller F. Prolonged exposure versus eye movement desensitization 

and reprocessing (EMDR) for PTSD rape victims. J Trauma Stress. Dec 2005;18(6):607-616.

101. Ehlers A, Clark DM, Hackmann A, et al. A randomized controlled trial of cognitive therapy, a self-help 

booklet, and repeated assessments as early interventions for posttraumatic stress disorder. Arch 

Gen Psychiatry. Oct 2003;60(10):1024-1032.

102. Ehlers A, Grey N, Wild J, et al. Implementation of cognitive therapy for PTSD in routine clinical care: 

Effectiveness and moderators of outcome in a consecutive sample. Behav Res Ther. Nov 

2013;51(11):742-752.

103. Ehlers A, Hackmann A, Grey N, et al. A randomized controlled trial of 7-day intensive and standard 

weekly cognitive therapy for PTSD and emotion-focused supportive therapy. Am J Psychiatry. Mar 

2014;171(3):294-304.

104. Blanchard EB, Hickling EJ, Devineni T, et al. A controlled evaluation of cognitive behavioural therapy 

for posttraumatic stress in motor vehicle accident survivors. Behav Res Ther. Jan 2003;41(1):79-96.

105. Bryant RA, Mastrodomenico J, Felmingham KL, et al. Treatment of acute stress disorder: A 

randomized controlled trial. Arch Gen Psychiatry. Jun 2008;65(6):659-667.

106. Bryant RA, Moulds ML, Guthrie RM, et al. A randomized controlled trial of exposure therapy and 

cognitive restructuring for posttraumatic stress disorder. J Consult Clin Psychol. Aug 2008;76(4):695-

703.

107. Kubany ES, Hill EE, Owens JA, et al. Cognitive trauma therapy for battered women with PTSD (CTTBW). J Consult Clin Psychol. Feb 2004;72(1):3-18.

108. Marks I, Lovell K, Noshirvani H, Livanou M, Thrasher S. Treatment of posttraumatic stress disorder 

by exposure and/or cognitive restructuring: A controlled study. Arch Gen Psychiatry. Apr 

1998;55(4):317-325.
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 192 of 200

109. Power K, McGoldrick T, Brown K, et al. A controlled comparison of eye movement desensitization 

and reprocessing versus exposure plus cognitive restructuring versus waiting list in the treatment of 

post-traumatic stress disorder. Clinical Psychology & Psychotherapy. 2002;9(5):299-318.

110. Gersons BP, Carlier IV, Lamberts RD, van der Kolk BA. Randomized clinical trial of brief eclectic 

psychotherapy for police officers with posttraumatic stress disorder. J Trauma Stress. Apr 

2000;13(2):333-347.

111. Lindauer RJ, Gersons BP, van Meijel EP, et al. Effects of brief eclectic psychotherapy in patients with 

posttraumatic stress disorder: Randomized clinical trial. J Trauma Stress. Jun 2005;18(3):205-212.

112. Nijdam MJ, Gersons BP, Reitsma JB, de Jongh A, Olff M. Brief eclectic psychotherapy v. Eye 

movement desensitisation and reprocessing therapy for post-traumatic stress disorder: Randomised 

controlled trial. Br J Psychiatry. Mar 2012;200(3):224-231.

113. Ertl V, Pfeiffer A, Schauer E, Elbert T, Neuner F. Community-implemented trauma therapy for former 

child soldiers in northern Uganda: A randomized controlled trial. JAMA. Aug 3 2011;306(5):503-512. 

114. Stenmark H, Catani C, Neuner F, Elbert T, Holen A. Treating PTSD in refugees and asylum seekers 

within the general health care system. A randomized controlled multicenter study. Behav Res Ther. 

Oct 2013;51(10):641-647.

115. Sloan DM, Marx BP, Bovin MJ, Feinstein BA, Gallagher MW. Written exposure as an intervention for 

PTSD: A randomized clinical trial with motor vehicle accident survivors. Behav Res Ther. Oct 

2012;50(10):627-635.

116. Resick PA, Galovski TE, O'Brien Uhlmansiek M, Scher CD, Clum GA, Young-Xu Y. A randomized clinical 

trial to dismantle components of cognitive processing therapy for posttraumatic stress disorder in 

female victims of interpersonal violence. J Consult Clin Psychol. Apr 2008;76(2):243-258.

117. Bisson JI, Roberts NP, Andrew M, Cooper R, Lewis C. Psychological therapies for chronic posttraumatic stress disorder (PTSD) in adults. Cochrane Database Syst Rev. 2013(12):CD003388.

118. Cusack K, Jonas DE, Forneris CA, et al. Psychological treatments for adults with posttraumatic stress 

disorder: A systematic review and meta-analysis. Clin Psychol Rev. Feb 2016;43:128-141.

119. Foa EB, Dancu CV, Hembree EA, Jaycox LH, Meadows EA, Street GP. A comparison of exposure 

therapy, stress inoculation training, and their combination for reducing posttraumatic stress 

disorder in female assault victims. J Consult Clin Psychol. Apr 1999;67(2):194-200.

120. Meichenbaum DH, Deffenbacher JL. Stress inoculation training. The Counseling Psychologist. 

1988;16(1):69-90.

121. Suris A, Link-Malcolm J, Chard K, Ahn C, North C. A randomized clinical trial of cognitive processing 

therapy for Veterans with PTSD related to military sexual trauma. J Trauma Stress. Feb 

2013;26(1):28-37.

122. Markowitz JC, Petkova E, Biyanova T, Ding K, Suh EJ, Neria Y. Exploring personality diagnosis stability 

following acute psychotherapy for chronic posttraumatic stress disorder. Depress Anxiety. Dec 

2015;32(12):919-926.

123. Markowitz JC, Petkova E, Neria Y, et al. Is exposure necessary? A randomized clinical trial of 

interpersonal psychotherapy for PTSD. Am J Psychiatry. May 2015;172(5):430-440.

124. Linehan M. Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford 

Press; 1993.

125. Cloitre M, Stovall-McClough KC, Nooner K, et al. Treatment for PTSD related to childhood abuse: A 

randomized controlled trial. American Journal of Psychiatry. 2010;167(8):915-924.

126. Walser RD, Westrup D. Acceptance and commitment therapy for the treatment of post-traumatic 

stress disorder and trauma-related problems: A practitioner's guide to using mindfulness and 

acceptance strategies. New Harbinger Publications; 2007.
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 193 of 200

127. Roberts NP, Roberts PA, Jones N, Bisson JI. Psychological interventions for post-traumatic stress 

disorder and comorbid substance use disorder: A systematic review and meta-analysis. Clin Psychol 

Rev. Jun 2015;38:25-38.

128. Spiegel H, Spiegel D. Trance and treatment: Clinical uses of hypnosis. American Psychiatric Pub; 

2008.

129. Brom D, Kleber RJ, Defares PB. Brief psychotherapy for posttraumatic stress disorders. J Consult Clin 

Psychol. Oct 1989;57(5):607-612.

130. Bryant RA, Moulds ML, Guthrie RM, Dang ST, Nixon RD. Imaginal exposure alone and imaginal 

exposure with cognitive restructuring in treatment of posttraumatic stress disorder. J Consult Clin 

Psychol. Aug 2003;71(4):706-712.

131. Foa EB, Rothbaum BO, Riggs DS, Murdock TB. Treatment of posttraumatic stress disorder in rape 

victims: A comparison between cognitive-behavioral procedures and counseling. J Consult Clin 

Psychol. Oct 1991;59(5):715-723.

132. Lang AJ, Schnurr PP, Jain S, et al. Randomized controlled trial of acceptance and commitment 

therapy for distress and impairment in OEF/OIF/OND Veterans. Psychol Trauma. Jun 20 2016.

133. Resick PA, Monson CM, Chard KM. Cognitive processing therapy for PTSD: A comprehensive manual.

Guilford Publications; 2016.

134. Sloan DM, Feinstein BA, Gallagher MW, Beck JG, Keane TM. Efficacy of group treatment for 

posttraumatic stress disorder symptoms: A meta-analysis. Psychological Trauma: Theory, Research, 

Practice, and Policy. 2013;5(2):176.

135. Resick PA, Wachen JS, Dondanville KA, et al. Effect of group vs individual cognitive processing 

therapy in active-duty military seeking treatment for posttraumatic stress disorder: A randomized 

clinical trial. JAMA Psychiatry. 2017;74(1):28-36. 

136. Resick PA, Wachen JS, Mintz J, et al. A randomized clinical trial of group cognitive processing therapy 

compared with group present-centered therapy for PTSD among active duty military personnel. J 

Consult Clin Psychol. Dec 2015;83(6):1058-1068.

137. Castillo DT, Chee CL, Nason E, et al. Group-delivered cognitive/exposure therapy for PTSD in women 

veterans: A randomized controlled trial. Psychol Trauma. May 2016;8(3):404-412.

138. Monson CM, Fredman SJ, Macdonald A, Pukay-Martin ND, Resick PA, Schnurr PP. Effect of cognitivebehavioral couple therapy for PTSD: A randomized controlled trial. JAMA. Aug 15 2012;308(7):700-

709.

139. Sautter FJ, Glynn SM, Cretu JB, Senturk D, Vaught AS. Efficacy of structured approach therapy in 

reducing PTSD in returning veterans: A randomized clinical trial. Psychological services. 

2015;12(3):199.

140. Hoskins M, Pearce J, Bethell A, et al. Pharmacotherapy for post-traumatic stress disorder: Systematic 

review and meta-analysis. Br J Psychiatry. Feb 2015;206(2):93-100.

141. Davis LL, Jewell ME, Ambrose S, et al. A placebo-controlled study of nefazodone for the treatment of 

chronic posttraumatic stress disorder: A preliminary study. J Clin Psychopharmacol. Jun 

2004;24(3):291-297.

142. McRae AL, Brady KT, Mellman TA, et al. Comparison of nefazodone and sertraline for the treatment 

of posttraumatic stress disorder. Depress Anxiety. 2004;19(3):190-196.

143. Saygin MZ, Sungur MZ, Sabol EU, Çetinkaya P. Nefazodone versus sertraline in treatment of 

posttraumatic stress disorder. Bull Clin Psychopharmacol. 2002;12:1-5.

144. Kosten TR, Frank JB, Dan E, McDougle CJ, Giller EL, Jr. Pharmacotherapy for posttraumatic stress 

disorder using phenelzine or imipramine. J Nerv Ment Dis. Jun 1991;179(6):366-370.

145. Villarreal G, Hamner MB, Canive JM, et al. Efficacy of quetiapine monotherapy in posttraumatic 

stress disorder: A randomized, placebo-controlled trial. Am J Psychiatry. Dec 01 2016;173(12):1205-

1212.
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 194 of 200

146. Butterfield MI, Becker ME, Connor KM, Sutherland S, Churchill LE, Davidson JR. Olanzapine in the 

treatment of post-traumatic stress disorder: A pilot study. Int Clin Psychopharmacol. Jul 

2001;16(4):197-203.

147. Carey P, Suliman S, Ganesan K, Seedat S, Stein DJ. Olanzapine monotherapy in posttraumatic stress 

disorder: Efficacy in a randomized, double-blind, placebo-controlled study. Hum Psychopharmacol. 

Jul 2012;27(4):386-391.

148. Davidson J, Kudler H, Smith R, et al. Treatment of posttraumatic stress disorder with amitriptyline 

and placebo. Arch Gen Psychiatry. Mar 1990;47(3):259-266.

149. Jonas DE, Cusack K, Forneris CA, et al. Psychological and pharmacological treatments for adults with 

posttraumatic stress disorder (PTSD). Rockville, MD: 2013. 

150. Tucker P, Trautman RP, Wyatt DB, et al. Efficacy and safety of topiramate monotherapy in civilian

posttraumatic stress disorder: A randomized, double-blind, placebo-controlled study. J Clin 

Psychiatry. Feb 2007;68(2):201-206.

151. Yeh MS, Mari JJ, Costa MC, Andreoli SB, Bressan RA, Mello MF. A double-blind randomized 

controlled trial to study the efficacy of topiramate in a civilian sample of PTSD. CNS Neurosci Ther. 

Oct 2011;17(5):305-310.

152. Hertzberg MA, Butterfield MI, Feldman ME, et al. A preliminary study of lamotrigine for the 

treatment of posttraumatic stress disorder. Biol Psychiatry. May 01 1999;45(9):1226-1229.

153. Davis LL, Davidson JR, Ward LC, Bartolucci A, Bowden CL, Petty F. Divalproex in the treatment of 

posttraumatic stress disorder: A randomized, double-blind, placebo-controlled trial in a veteran 

population. J Clin Psychopharmacol. Feb 2008;28(1):84-88.

154. Davidson JR, Brady K, Mellman TA, Stein MB, Pollack MH. The efficacy and tolerability of tiagabine in 

adult patients with post-traumatic stress disorder. J Clin Psychopharmacol. Feb 2007;27(1):85-88.

155. Neylan TC, Lenoci M, Samuelson KW, et al. No improvement of posttraumatic stress disorder 

symptoms with guanfacine treatment. Am J Psychiatry. Dec 2006;163(12):2186-2188.

156. Davis LL, Ward C, Rasmusson A, Newell JM, Frazier E, Southwick SM. A placebo-controlled trial of 

guanfacine for the treatment of posttraumatic stress disorder in Veterans. Psychopharmacol Bull. 

2008;41(1):8-18.

157. Reich DB, Winternitz S, Hennen J, Watts T, Stanculescu C. A preliminary study of risperidone in the 

treatment of posttraumatic stress disorder related to childhood abuse in women. J Clin Psychiatry. 

Dec 2004;65(12):1601-1606.

158. Padala PR, Madison J, Monnahan M, et al. Risperidone monotherapy for post-traumatic stress 

disorder related to sexual assault and domestic abuse in women. Int Clin Psychopharmacol. Sep 

2006;21(5):275-280.

159. Braun P, Greenberg D, Dasberg H, Lerer B. Core symptoms of posttraumatic stress disorder 

unimproved by alprazolam treatment. J Clin Psychiatry. Jun 1990;51(6):236-238.

160. Cates ME, Bishop MH, Davis LL, Lowe JS, Woolley TW. Clonazepam for treatment of sleep 

disturbances associated with combat-related posttraumatic stress disorder. Ann Pharmacother. Sep 

2004;38(9):1395-1399. 

161. Rothbaum BO, Price M, Jovanovic T, et al. A randomized, double-blind evaluation of D-cycloserine or 

alprazolam combined with virtual reality exposure therapy for posttraumatic stress disorder in Iraq 

and Afghanistan war veterans. Am J Psychiatry. Jun 2014;171(6):640-648.

162. Guina J, Rossetter SR, De RB, Nahhas RW, Welton RS. Benzodiazepines for PTSD: A systematic review 

and meta-analysis. J Psychiatr Pract. Jul 2015;21(4):281-303.

163. Matar MA, Zohar J, Kaplan Z, Cohen H. Alprazolam treatment immediately after stress exposure 

interferes with the normal HPA-stress response and increases vulnerability to subsequent stress in 

an animal model of PTSD. Eur Neuropsychopharmacol. Apr 2009;19(4):283-295.
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 195 of 200

164. Hebert MA, Potegal M, Moore T, Evenson AR, Meyerhoff JL. Diazepam enhances conditioned defeat 

in hamsters (Mesocricetus auratus). Pharmacol Biochem Behav. Nov 1996;55(3):405-413.

165. Feder A, Parides MK, Murrough JW, et al. Efficacy of intravenous ketamine for treatment of chronic 

posttraumatic stress disorder: A randomized clinical trial. JAMA Psychiatry. Jun 2014;71(6):681-688.

166. Ludascher P, Schmahl C, Feldmann RE, Jr., Kleindienst N, Schneider M, Bohus M. No evidence for 

differential dose effects of hydrocortisone on intrusive memories in female patients with complex 

post-traumatic stress disorder--a randomized, double-blind, placebo-controlled, crossover study. J 

Psychopharmacol. Oct 2015;29(10):1077-1084.

167. Wilkinson ST, Radhakrishnan R, D'Souza DC. A systematic review of the evidence for medical 

marijuana in psychiatric indications. J Clin Psychiatry. Aug 2016;77(8):1050-1064.

168. Belendiuk KA, Baldini LL, Bonn-Miller MO. Narrative review of the safety and efficacy of marijuana 

for the treatment of commonly state-approved medical and psychiatric disorders. Addict Sci Clin 

Pract. Apr 21 2015;10:10.

169. Steenkamp MM, Blessing EM, Galatzer-Levy IR, Hollahan LC, Anderson WT. Marijuana and other

cannabinoids as a treatment for posttraumatic stress disorder: A literature review. Depress Anxiety. 

Mar 2017;34(3):207-216.

170. Kansagara D, O’Neil M, Nugent S, et al. Benefits and harms of cannabis in chronic pain or posttraumatic stress disorder: A systematic review. Department of Veterans Affairs Evidence-based 

Synthesis Program (ESP). Washington, DC: Quality Enhancement Research Initiative. (2016).

171. Becker ME, Hertzberg MA, Moore SD, Dennis MF, Bukenya DS, Beckham JC. A placebo-controlled 

trial of bupropion SR in the treatment of chronic posttraumatic stress disorder. J Clin 

Psychopharmacol. Apr 2007;27(2):193-197.

172. Davidson JR, Weisler RH, Butterfield MI, et al. Mirtazapine vs placebo in posttraumatic stress 

disorder: A pilot trial. Biol Psychiatry. Jan 15 2003;53(2):188-191.

173. Chung MY, Min KH, Jun YJ, Kim SS, Kim WC, Jun EM. Efficacy and tolerability of mirtazapine and 

sertraline in Korean Veterans with posttraumatic stress disorder: A randomized open label trial. 

Hum Psychopharmacol. Oct 2004;19(7):489-494.

174. Pollack MH, Hoge EA, Worthington JJ, et al. Eszopiclone for the treatment of posttraumatic stress 

disorder and associated insomnia: A randomized, double-blind, placebo-controlled trial. J Clin 

Psychiatry. Jul 2011;72(7):892-897.

175. Heresco-Levy U, Kremer I, Javitt DC, et al. Pilot-controlled trial of d-cycloserine for the treatment of 

post-traumatic stress disorder. Int J Neuropsychopharmacol. Dec 2002;5(4):301-307.

176. Akuchekian S, Amanat S. The comparison of topiramate and placebo in the treatment of 

posttraumatic stress disorder: A randomized, double-blind study. Journal of Research in Medical 

Sciences. 2004;9(5):240-244.

177. Manteghi AA, Hebrani P, Mortezania M, Haghighi MB, Javanbakht A. Baclofen add-on to citalopram 

in treatment of posttraumatic stress disorder. J Clin Psychopharmacol. Apr 2014;34(2):240-243.

178. Baniasadi M, Hosseini G, Fayyazi Bordbar MR, Rezaei Ardani A, Mostafavi Toroghi H. Effect of 

pregabalin augmentation in treatment of patients with combat-related chronic posttraumatic stress 

disorder: A randomized controlled trial. J Psychiatr Pract. Nov 2014;20(6):419-427.

179. Ori R, Amos T, Bergman H, Soares-Weiser K, Ipser JC, Stein DJ. Augmentation of cognitive and 

behavioural therapies (CBT) with d-cycloserine for anxiety and related disorders. Cochrane Database 

Syst Rev. 2015(5):CD007803.

180. Stein MB, Kline NA, Matloff JL. Adjunctive olanzapine for SSRI-resistant combat-related PTSD: A 

double-blind, placebo-controlled study. Am J Psychiatry. Oct 2002;159(10):1777-1779.

181. Krystal JH, Pietrzak RH, Rosenheck RA, et al. Sleep disturbance in chronic military-related PTSD: 

Clinical impact and response to adjunctive risperidone in the Veterans Affairs Cooperative Study# 

504. The Journal of clinical psychiatry. 2016;77(4):483-491.
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 196 of 200

182. Hamner MB, Faldowski RA, Robert S, Ulmer HG, Horner MD, Lorberbaum JP. A preliminary 

controlled trial of divalproex in posttraumatic stress disorder. Ann Clin Psychiatry. Apr-Jun 

2009;21(2):89-94.

183. Yehuda R, Bierer LM, Pratchett LC, et al. Cortisol augmentation of a psychological treatment for 

warfighters with posttraumatic stress disorder: Randomized trial showing improved treatment 

retention and outcome. Psychoneuroendocrinology. Jan 2015;51:589-597.

184. Schneier FR, Campeas R, Carcamo J, et al. Combined mirtazapine and SSRI treatment of PTSD: A 

placebo-controlled trial. Depress Anxiety. Aug 2015;32(8):570-579.

185. Raskind MA, Peskind ER, Kanter ED, et al. Reduction of nightmares and other PTSD symptoms in 

combat Veterans by prazosin: A placebo-controlled study. Am J Psychiatry. Feb 2003;160(2):371-

373.

186. Raskind MA, Peskind ER, Hoff DJ, et al. A parallel group placebo controlled study of prazosin for 

trauma nightmares and sleep disturbance in combat Veterans with post-traumatic stress disorder. 

Biol Psychiatry. Apr 15 2007;61(8):928-934.

187. Raskind MA, Peterson K, Williams T, et al. A trial of prazosin for combat trauma PTSD with 

nightmares in active-duty soldiers returned from Iraq and Afghanistan. Am J Psychiatry. Sep 

2013;170(9):1003-1010.

188. Germain A, Richardson R, Moul DE, et al. Placebo-controlled comparison of prazosin and cognitivebehavioral treatments for sleep disturbances in US military Veterans. J Psychosom Res. Feb 

2012;72(2):89-96.

189. VA Cooperative Study #563. Prazosin and combat trauma PTSD (PACT). ClinicalTrials.gov, 

NCT00532493. Accessed February 16, 2016.

190. Khachatryan D, Groll D, Booij L, Sepehry AA, Schutz CG. Prazosin for treating sleep disturbances in 

adults with posttraumatic stress disorder: A systematic review and meta-analysis of randomized 

controlled trials. Gen Hosp Psychiatry. Mar-Apr 2016;39:46-52.

191. Simon NM, Connor KM, Lang AJ, et al. Paroxetine CR augmentation for posttraumatic stress disorder 

refractory to prolonged exposure therapy. J Clin Psychiatry. Mar 2008;69(3):400-405.

192. Rothbaum BO, Cahill SP, Foa EB, et al. Augmentation of sertraline with prolonged exposure in the 

treatment of posttraumatic stress disorder. J Trauma Stress. Oct 2006;19(5):625-638.

193. Schneier FR, Neria Y, Pavlicova M, et al. Combined prolonged exposure therapy and paroxetine for 

PTSD related to the world trade center attack: A randomized controlled trial. Am J Psychiatry. Jan 

2012;169(1):80-88.

194. Popiel A, Zawadzki B, Praglowska E, Teichman Y. Prolonged exposure, paroxetine and the 

combination in the treatment of PTSD following a motor vehicle accident. A randomized clinical trial 

- the "TRAKT" study. J Behav Ther Exp Psychiatry. Sep 2015;48:17-26.

195. Berlim MT, Van Den Eynde F. Repetitive transcranial magnetic stimulation over the dorsolateral 

prefrontal cortex for treating posttraumatic stress disorder: An exploratory meta-analysis of 

randomized, double-blind and sham-controlled trials. Can J Psychiatry. Sep 2014;59(9):487-496.

196. Cohen H, Kaplan Z, Kotler M, Kouperman I, Moisa R, Grisaru N. Repetitive transcranial magnetic 

stimulation of the right dorsolateral prefrontal cortex in posttraumatic stress disorder: A doubleblind, placebo-controlled study. Am J Psychiatry. Mar 2004;161(3):515-524. 

197. Watts BV, Landon B, Groft A, Young-Xu Y. A sham controlled study of repetitive transcranial 

magnetic stimulation for posttraumatic stress disorder. Brain Stimul. Jan 2012;5(1):38-43.

198. Boggio PS, Rocha M, Oliveira MO, et al. Noninvasive brain stimulation with high-frequency and lowintensity repetitive transcranial magnetic stimulation treatment for posttraumatic stress disorder. J 

Clin Psychiatry. Aug 2010;71(8):992-999.

199. Helsley S, Sheikh T, Kim KY, Park SK. ECT therapy in PTSD. Am J Psychiatry. Mar 1999;156(3):494-495.
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 197 of 200

200. Langevin JP, Koek RJ, Schwartz HN, et al. Deep brain stimulation of the basolateral amygdala for 

treatment-refractory posttraumatic stress disorder. Biol Psychiatry. May 15 2016;79(10):e82-84.

201. Miller RS, Weaver LK, Bahraini N, et al. Effects of hyperbaric oxygen on symptoms and quality of life 

among service members with persistent postconcussion symptoms: A randomized clinical trial. 

JAMA Intern Med. Jan 2015;175(1):43-52.

202. Mulvaney SW, Lynch JH, Hickey MJ, et al. Stellate ganglion block used to treat symptoms associated 

with combat-related post-traumatic stress disorder: A case series of 166 patients. Mil Med. Oct 

2014;179(10):1133-1140.

203. Hanling SR, Hickey A, Lesnik I, et al. Stellate ganglion block for the treatment of posttraumatic stress 

disorder: A randomized, double-blind, controlled trial. Reg Anesth Pain Med. Jul-Aug 

2016;41(4):494-500.

204. Hollifield M, Sinclair-Lian N, Warner TD, Hammerschlag R. Acupuncture for posttraumatic stress 

disorder: A randomized controlled pilot trial. J Nerv Ment Dis. Jun 2007;195(6):504-513.

205. Engel CC, Cordova EH, Benedek DM, et al. Randomized effectiveness trial of a brief course of 

acupuncture for posttraumatic stress disorder. Med Care. Dec 2014;52(12 Suppl 5):S57-64. 

206. Zhang Y, Bin F, Xie J-p, Xu F-z, Jiong C. Clinical study on treatment of the earthquake-caused posttraumatic stress disorder by cognitive-behavior therapy and acupoint stimulation. Journal of 

Traditional Chinese Medicine. 2011;31(1):60-63.

207. Wahbeh H, Senders A, Neuendorf R, Cayton J. Complementary and alternative medicine for 

posttraumatic stress disorder symptoms: A systematic review. J Evid Based Complementary Altern 

Med. Mar 2014;19(3):161-175. 

208. Rosenbaum S, Vancampfort D, Steel Z, Newby J, Ward PB, Stubbs B. Physical activity in the 

treatment of post-traumatic stress disorder: A systematic review and meta-analysis. Psychiatry Res. 

Dec 2015;230(2):130-136. 

209. Polusny MA, Erbes CR, Thuras P, et al. Mindfulness-based stress reduction for posttraumatic stress

disorder among Veterans: A randomized clinical trial. JAMA. Aug 4 2015;314(5):456-465.

210. Kearney DJ, McDermott K, Malte C, Martinez M, Simpson TL. Effects of participation in a 

mindfulness program for Veterans with posttraumatic stress disorder: A randomized controlled pilot 

study. J Clin Psychol. Jan 2013;69(1):14-27.

211. Mitchell KS, Dick AM, DiMartino DM, et al. A pilot study of a randomized controlled trial of yoga as 

an intervention for PTSD symptoms in women. J Trauma Stress. Apr 2014;27(2):121-128.

212. Quinones N, Maquet YG, Velez DM, Lopez MA. Efficacy of a satyananda yoga intervention for 

reintegrating adults diagnosed with posttraumatic stress disorder. Int J Yoga Therap. 2015;25(1):89-

99.

213. van der Kolk BA, Stone L, West J, et al. Yoga as an adjunctive treatment for posttraumatic stress 

disorder: A randomized controlled trial. J Clin Psychiatry. Jun 2014;75(6):e559-565.

214. Bormann JE, Thorp SR, Wetherell JL, Golshan S, Lang AJ. Medication-based mantram intervention for 

Veterans with posttraumatic stress disorder: A randomized trial. Psychological Trauma: Theory, 

Research, Practice, and Policy. 2013;5(3):259-267.

215. Bormann JE, Thorp S, Wetherell JL, Golshan S. A spiritually based group intervention for combat 

veterans with posttraumatic stress disorder: Feasibility study. J Holist Nurs. Jun 2008;26(2):109-116.

216. Spence J, Titov N, Dear BF, et al. Randomized controlled trial of internet-delivered cognitive 

behavioral therapy for posttraumatic stress disorder. Depress Anxiety. Jul 2011;28(7):541-550.

217. Spence J, Titov N, Johnston L, Jones MP, Dear BF, Solley K. Internet-based trauma-focused cognitive 

behavioural therapy for PTSD with and without exposure components: A randomised controlled 

trial. J Affect Disord. Jun 2014;162:73-80.

218. Ivarsson D, Blom M, Hesser H, et al. Guided internet-delivered cognitive behavior therapy for posttraumatic stress disorder: A randomized controlled trial. Internet Interventions. 2014;1(1):33-40.
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 198 of 200

219. Hobfoll SE, Blais RK, Stevens NR, Walt L, Gengler R. Vets prevail online intervention reduces PTSD 

and depression in Veterans with mild-to-moderate symptoms. J Consult Clin Psychol. Jan 

2016;84(1):31-42.

220. Knaevelsrud C, Brand J, Lange A, Ruwaard J, Wagner B. Web-based psychotherapy for posttraumatic 

stress disorder in war-traumatized Arab patients: Randomized controlled trial. J Med Internet Res. 

2015;17(3):e71.

221. Possemato K, Kuhn E, Johnson E, et al. Using PTSD coach in primary care with and without clinician 

support: A pilot randomized controlled trial. Gen Hosp Psychiatry. Jan-Feb 2016;38:94-98.

222. Engel CC, Litz B, Magruder KM, et al. Delivery of self training and education for stressful situations 

(DESTRESS-PC): A randomized trial of nurse assisted online self-management for PTSD in primary 

care. Gen Hosp Psychiatry. Jul-Aug 2015;37(4):323-328.

223. Morland LA, Greene CJ, Rosen CS, et al. Telemedicine for anger management therapy in a rural 

population of combat Veterans with posttraumatic stress disorder: A randomized noninferiority 

trial. J Clin Psychiatry. Jul 2010;71(7):855-863.

224. Yuen EK, Gros DF, Price M, et al. Randomized controlled trial of home-based telehealth versus inperson prolonged exposure for combat-related PTSD in Veterans: Preliminary results. J Clin Psychol. 

Jun 2015;71(6):500-512.

225. Morland LA, Mackintosh MA, Rosen CS, et al. Telemedicine versus in-person delivery of cognitive 

processing therapy for women with posttraumatic stress disorder: A randomized noninferiority trial. 

Depress Anxiety. Nov 2015;32(11):811-820.

226. Morland LA, Hynes AK, Mackintosh MA, Resick PA, Chard KM. Group cognitive processing therapy 

delivered to Veterans via telehealth: A pilot cohort. J Trauma Stress. Aug 2011;24(4):465-469.

227. Maieritsch KP, Smith TL, Hessinger JD, Ahearn EP, Eickhoff JC, Zhao Q. Randomized controlled 

equivalence trial comparing videoconference and in person delivery of cognitive processing therapy 

for PTSD. J Telemed Telecare. Jun 2016;22(4):238-243.

228. van den Berg DP, de Bont PA, van der Vleugel BM, et al. Prolonged exposure vs eye movement 

desensitization and reprocessing vs waiting list for posttraumatic stress disorder in patients with a 

psychotic disorder: A randomized clinical trial. JAMA Psychiatry. Mar 2015;72(3):259-267.

229. Mueser KT, Gottlieb JD, Xie H, et al. Evaluation of cognitive restructuring for post-traumatic stress 

disorder in people with severe mental illness. The British Journal of Psychiatry. 2015;206(6):501-508.

230. Wolf EJ, Lunney CA, Schnurr PP. The influence of the dissociative subtype of posttraumatic stress 

disorder on treatment efficacy in female Veterans and active duty Service Members. J Consult Clin 

Psychol. Jan 2016;84(1):95-100.

231. Halvorsen JO, Stenmark H, Neuner F, Nordahl HM. Does dissociation moderate treatment outcomes 

of narrative exposure therapy for PTSD? A secondary analysis from a randomized controlled clinical 

trial. Behav Res Ther. Jun 2014;57:21-28.

232. Rizvi SL, Vogt DS, Resick PA. Cognitive and affective predictors of treatment outcome in cognitive 

processing therapy and prolonged exposure for posttraumatic stress disorder. Behav Res Ther. Sep 

2009;47(9):737-743.

233. Gallegos AM, Streltzov NA, Stecker T. Improving treatment engagement for returning Operation 

Enduring Freedom and Operation Iraqi Freedom Veterans with posttraumatic stress disorder, 

depression, and suicidal ideation. J Nerv Ment Dis. May 2016;204(5):339-343.

234. Shemesh E, Annunziato RA, Rubinstein D, et al. Screening for depression and suicidality in patients 

with cardiovascular illnesses. Am J Cardiol. Nov 01 2009;104(9):1194-1197.

235. Jacobson IG, Ryan MA, Hooper TI, et al. Alcohol use and alcohol-related problems before and after 

military combat deployment. JAMA. Aug 13 2008;300(6):663-675.
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 199 of 200

236. Seal KH, Cohen G, Waldrop A, Cohen BE, Maguen S, Ren L. Substance use disorders in Iraq and 

Afghanistan Veterans in VA healthcare, 2001-2010: Implications for screening, diagnosis and 

treatment. Drug Alcohol Depend. Jul 1 2011;116(1-3):93-101.

237. Zandberg LJ, Rosenfield D, McLean CP, Powers MB, Asnaani A, Foa EB. Concurrent treatment of 

posttraumatic stress disorder and alcohol dependence: Predictors and moderators of outcome. J 

Consult Clin Psychol. Jan 2016;84(1):43-56.

238. Haller M, Norman SB, Cummins K, et al. Integrated cognitive behavioral therapy versus cognitive 

processing therapy for adults with depression, substance use disorder, and trauma. J Subst Abuse 

Treat. Mar 2016;62:38-48.

239. McGovern MP, Lambert-Harris C, Xie H, Meier A, McLeman B, Saunders E. A randomized controlled 

trial of treatments for co-occurring substance use disorders and post-traumatic stress disorder. 

Addiction. Jul 2015;110(7):1194-1204.

240. Batki SL, Pennington DL, Lasher B, et al. Topiramate treatment of alcohol use disorder in Veterans 

with posttraumatic stress disorder: A randomized controlled pilot trial. Alcohol Clin Exp Res. Aug 

2014;38(8):2169-2177.

241. Simpson TL, Malte CA, Dietel B, et al. A pilot trial of prazosin, an alpha-1 adrenergic antagonist, for 

comorbid alcohol dependence and posttraumatic stress disorder. Alcohol Clin Exp Res. May 

2015;39(5):808-817.

242. Petrakis IL, Ralevski E, Desai N, et al. Noradrenergic vs serotonergic antidepressant with or without 

naltrexone for Veterans with PTSD and comorbid alcohol dependence. Neuropsychopharmacology. 

Mar 2012;37(4):996-1004.

243. Neylan TC, Marmar CR, Metzler TJ, et al. Sleep disturbances in the Vietnam generation: Findings 

from a nationally representative sample of male Vietnam veterans. Am J Psychiatry. Jul 

1998;155(7):929-933.

244. Lewis V, Creamer M, Failla S. Is poor sleep in Veterans a function of post-traumatic stress disorder? 

Mil Med. Sep 2009;174(9):948-951.

245. Belleville G, Guay S, Marchand A. Persistence of sleep disturbances following cognitive-behavior 

therapy for posttraumatic stress disorder. J Psychosom Res. Apr 2011;70(4):318-327.

246. Zayfert C, DeViva JC. Residual insomnia following cognitive behavioral therapy for PTSD. J Trauma 

Stress. Feb 2004;17(1):69-73.

247. Qaseem A, Kansagara D, Forciea MA, Cooke M, Denberg TD. Management of chronic insomnia 

disorder in adults: A clinical practice guideline from the American College of Physicians. Ann Intern 

Med. Jul 19 2016;165(2):125-133.

248. Ho FY, Chan CS, Tang KN. Cognitive-behavioral therapy for sleep disturbances in treating 

posttraumatic stress disorder symptoms: A meta-analysis of randomized controlled trials. Clin 

Psychol Rev. Feb 2016;43:90-102.

249. Talbot NL, Chaudron LH, Ward EA, et al. A randomized effectiveness trial of interpersonal 

psychotherapy for depressed women with sexual abuse histories. Psychiatr Serv. Apr 

2011;62(4):374-380.

250. Zachariae R, Lyby MS, Ritterband LM, O'Toole MS. Efficacy of internet-delivered cognitive-behavioral 

therapy for insomnia - a systematic review and meta-analysis of randomized controlled trials. Sleep 

Med Rev. Dec 2016;30:1-10.

251. Ritterband LM, Thorndike FP, Ingersoll KS, et al. Effect of a web-based cognitive behavior therapy for 

insomnia intervention with 1-year follow-up: A randomized clinical trial. JAMA Psychiatry. Jan 01 

2017;74(1):68-75.

252. Krakow B, Hollifield M, Johnston L, et al. Imagery rehearsal therapy for chronic nightmares in sexual 

assault survivors with posttraumatic stress disorder: A randomized controlled trial. JAMA. Aug 

2001;286(5):537-545. 
VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

June 2017 Page 200 of 200

253. Krakow B, Sandoval D, Schrader R, et al. Treatment of chronic nightmares in adjudicated adolescent 

girls in a residential facility. J Adolesc Health. Aug 2001;29(2):94-100.

254. Cook JM, Harb GC, Gehrman PR, et al. Imagery rehearsal for posttraumatic nightmares: A 

randomized controlled trial. J Trauma Stress. Oct 2010;23(5):553-563.

255. Margolies SO, Rybarczyk B, Vrana SR, Leszczyszyn DJ, Lynch J. Efficacy of a cognitive-behavioral 

treatment for insomnia and nightmares in Afghanistan and Iraq Veterans with PTSD. J Clin Psychol. 

Oct 2013;69(10):1026-1042.

256. Davis JL, Rhudy JL, Pruiksma KE, et al. Physiological predictors of response to exposure, relaxation, 

and rescripting therapy for chronic nightmares in a randomized clinical trial. J Clin Sleep Med. Dec 15 

2011;7(6):622-631.

257. Davis JL, Wright DC. Randomized clinical trial for treatment of chronic nightmares in traumaexposed adults. J Trauma Stress. Apr 2007;20(2):123-133.

258. Agency for Health Research and Quality. The Effective Health Care Program stakeholder guide 

Appendix D: Research questions & PICO(TS) 2011. 

http://www.ahrq.gov/clinic/epcpartner/stakeholderguide/. 

259. Andrews JC, Schunemann HJ, Oxman AD, et al. GRADE guidelines: 15. Going from evidence to 

recommendation-determinants of a recommendation's direction and strength. J Clin Epidemiol. Jul 

2013;66(7):726-735.