New PTSD Guidelines Favor Psychotherapy Over Medication, but Miss Brain Stimulation
The American Psychological Association (APA) has updated its PTSD treatment guidelines for the first time since 2017. The document prioritizes non-drug therapies over medication. However, doctors say it still misses the evaluation of brain stimulation techniques.
After seven years, the American Psychiatric Association (APA) updated its guidelines for the treatment of post-traumatic stress disorder (PTSD). It now suggests psychotherapy as the primary line of treatment rather than medicine. The new guidelines were based on 15 systematic reviews, up from just one review used in the document’s previous 2017 edition, and offer an expanded clinical picture of trauma behind PTSD.
Despite that, clinicians from Flow Neuroscience, a healthcare company that developed a clinically proven, non-invasive depression treatment, say that new guidelines lack a broader view on alternative techniques for PTSD treatment.
The APA suggests three psychotherapies as initial treatments: trauma-focused cognitive behavioral therapy, extended exposure therapy, and cognitive processing therapy.
Regarding pharmacological treatment, the majority of the 31 drugs examined in the revised guidelines were classified as having insufficient evidence. APA only puts SSRIs and SNRIs as potential second-line treatments with small to moderate effectiveness.
“Psychotherapy works so well with PTSD patients because it addresses the root cause of the condition – psychological trauma. It doesn’t just mask symptoms, as can be the case with drug treatments,” explains Dr. Nearney.
Dr. Nearney also notes that, to achieve better results, psychotherapy can be combined with supporting brain stimulation interventions like transcranial direct-current stimulation (tDCS), clinically proven to treat PTSD. Studies highlight that tDCS improves clinical symptoms immediately, with efficacy lasting for at least 1 month.
“What I’ve seen in my practice is that tDCS can really help people with PTSD. It tends to give timely results with almost no side effects, whilst also improving low mood symptoms that commonly co-exist with PTSD” says Dr. Nearney. “Leaving out tDCS and other promising neuromodulation methods keeps these guidelines stuck in the past, and patients deserve better than that.”
In general, tDCS clinical trials have shown this technique to be effective both as stand-alone and in combination with other alternative techniques, such as virtual reality experiences.
“tDCS can be used to specifically regulate excitation in the dorsolateral prefrontal cortex. This brain region is less active in people with PTSD, and is involved in anxiety and stress processing,” explains Dr. Nearney. “Such precision makes tDCS more suitable for PTSD patients than many other brain stimulation methods.”
In comparison, neuromodulation techniques like vagus nerve stimulation (VNS) and electroconvulsive therapy (ECT), also used for PTSD, are much less targeted. VNS activates the entire vagus nerve, which stimulates multiple body organs. And ECT stimulates the whole brain rather than focusing on its specific regions.
Despite not reviewing neuromodulation techniques, APA did look into several emerging treatments. Some of those are recently becoming even more popular: MDMA-assisted therapy and ketamine. The APA named these treatments “simply insufficient to recommend for or against” at the moment.
Given the severe side effects that many patients experience, Dr. Nearney added it has taken a long time to make psychotherapy the first-line option and to move medication treatments like SSRIs to secondary recommendations. Alternatives must be thoroughly investigated in order to ensure that patients have access to a greater variety of tried-and-true, non-pharmacological remedies and to properly update the guidelines.
