PTSD: what the 2023 VA/DoD guideline recommends and how Ukrainian readers should read it

This is a review of a document, not the editors’ own assessment: we retell the provisions of the guideline and clearly name the author of each conclusion. “Management of Posttraumatic Stress Disorder and Acute Stress Disorder” (2023) is a clinical guideline of the US Department of Veterans Affairs and Department of Defense (VA/DoD). It contains 34 evidence-based recommendations in three modules: acute stress reaction or disorder (A), assessment and diagnosis of PTSD (B), and management of PTSD (C). The document is intended for clinicians and does not replace their judgement.

Psychotherapy as the first choice

The guideline recommends three trauma-focused psychotherapies:

• Cognitive Processing Therapy (CPT);
• Prolonged Exposure (PE);
• eye movement desensitisation and reprocessing (EMDR).

Psychotherapy is favoured over medication because of “larger and more persistent improvement” (the wording of the ISTSS summary). Less strongly supported, but “suggested”, are Ehlers’ cognitive therapy, Present-Centered Therapy, Written Exposure Therapy and mindfulness-based stress reduction (MBSR).

Medication

• Recommended: paroxetine, sertraline and venlafaxine.
• Prazosin is not suggested for PTSD overall, but is suggested for consideration for nightmares.

What the guideline does not recommend

• Benzodiazepines, cannabis and its derivatives — the guideline recommends against using them.
• Electroconvulsive therapy and vagus nerve stimulation — it suggests not using them, either as monotherapy or as an add-on to medication.
• For many other methods there is not enough evidence to advise either for or against.

How the decision is made

The algorithm starts with one of the three recommended trauma-focused psychotherapies and then moves to medication or “suggested” methods depending on the patient’s preference or availability. The guideline stresses shared decision-making: collaboration between patient and professional that takes the person’s values and preferences into account. It also recommends measurement-based care — following the person’s condition with validated scales to see when the goal has been reached and when progress has stalled and the method should be changed.

How to read this in Ukraine

• This is a document for American service members and veterans. It is not a Ukrainian protocol, and the availability of the methods in Ukraine varies.
• The general idea — trauma-focused psychotherapy as the first line, not a “pill for everything” — matches the approach the WHO calls evidence-based psychological interventions for prolonged distress.
• Look for a professional who works specifically with trauma-focused methods, and ask which ones. Do not start or stop medication on your own.

Where to get help in Ukraine

• 7333 — “Lifeline Ukraine”, 24 hours a day, free and anonymous: suicide prevention and mental health support;
• 0 800 100 102 — the line of the National Psychological Association, daily from 10:00 to 20:00;
• 0 800 33 20 29 — the crisis line of the Ukrainian Veterans Fund, 24 hours a day.

The numbers are taken from the Cabinet of Ministers’ page about the “Ty yak?” (“Are you okay?”) programme (June 2023); please check that they are still valid before calling. If you have thoughts of suicide or are in immediate danger, call 103 or 112.

Sources

• VA/DoD: Management of PTSD and Acute Stress Disorder (2023)
• ISTSS: Using the 2023 VA/DoD Clinical Practice Guideline for Management of PTSD and ASD
• WHO: Mental health in emergencies

This material is for information only and does not replace consultation with a doctor or psychologist. Self-medication can be harmful to your health.