APA's Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Posttraumatic Stress Disorder was published in October 2004. Since that time, a number of well-designed randomized controlled trials of pharmacological and psychotherapeutic interventions for posttraumatic stress disorder (PTSD) have been conducted in various populations exposed to trauma. Numerous case reports, small case series, and open trials have also been reported, but they will not be the focus of this guideline watch. While early intervention studies for acute stress disorder (ASD) are currently in progress, no major research on the treatment of ASD has been completed since publication of the 2004 guideline.

Factors predicting development of ASD or PTSD have still not been established. A 2008 study by Bryant et al. (1) found that ASD was a poorer predictor of getting PTSD than just having PTSD criteria alone in the acute stage.

In response to increased attention on U.S. military veterans returning from combat in Iraq and Afghanistan, the Institute of Medicine has also reviewed and summarized the evidence supporting treatment for PTSD (2). The 2007 report recognizes that there is evidence for the pharmacological treatment of combat-related PTSD but states that this evidence is not as strong as the evidence for treatment of other trauma-related PTSD. In particular, the report states that large randomized controlled trials, considered a standard of evidence in other areas of medicine, are lacking from the evidence base. The report concludes that existing evidence is sufficient only to establish the efficacy of exposure-based psychotherapies in the treatment of PTSD. However, there was disagreement among the report authors about this conclusion, and the report includes a dissenting opinion by one author about the strength of the evidence for pharmacotherapy.

Our review concludes that the best evidence from recent studies bolsters support for exposure-based psychotherapies as well as for pharmacological intervention in many circumstances. Emerging evidence suggests the potential for psychotherapy to be facilitated by at least one recently identified pharmacological agent (d-cycloserine). Recently published studies also suggest that in certain patient populations new pharmacotherapeutic options, such as prazosin, may be more effective than other widely prescribed medications (e.g., selective serotonin reuptake inhibitors [SSRIs]) indicated for PTSD.

As described in the 2004 guideline, the generalizability of findings from available studies on treatments for PTSD is limited by small numbers of subjects, variable inclusion criteria (e.g., patients with treatment-resistant illness, patients receiving multiple treatments), nonstandardized outcome measures, inadequate controls, and lack of replication. These issues also limit meaningful comparison of data for psychopharmacological versus psychotherapeutic approaches. Specific recommendations to improve psychotherapy research for PTSD have been put forward by Schottenbauer et al. (3).

For the period from October 2007 to October 2008, Dr. Benedek reports no competing interests, Dr. Friedman reports receiving an honorarium from AstraZeneca for participating in a symposium, Dr. Zatzick reports no competing interests, and Dr. Ursano reports no competing interests. The Executive Committee on Practice Guidelines has reviewed this watch and found no evidence of influence from these relationships.

The American Psychiatric Association's (APA's) practice guidelines are developed by expert work groups using an explicit methodology that includes rigorous review of available evidence, broad peer review of iterative drafts, and formal approval by the APA Assembly and Board of Trustees. APA practice guidelines are intended to assist psychiatrists in clinical decision making. They are not intended to be a standard of care.

The ultimate judgment regarding a particular clinical procedure or treatment plan must be made by the psychiatrist in light of the clinical data presented by the patient and the diagnostic and treatment options available. Guideline watches summarize significant developments in practice since publication of an APA practice guideline. Watches may be authored and reviewed by experts associated with the original guideline development effort and are approved for publication by APA's Executive Committee on Practice Guidelines. Thus, watches represent opinion of the authors and approval of the Executive Committee but not policy of the APA. This guideline watch was published in March 2009. Copyright © 2009. American Psychiatric Association. All rights reserved.