GuidelinesOther guideline
Summary points
These are the approved guidelines published by the South African Society of Psychiatrists to provide an overview on treatment and management of commonly diagnosed psychiatric illnesses. The guidelines include consensus recommendations, based on peer contribution and using the international evidence based guidelines that are suitable for the local South African health service.
Please note that parts of this guideline may be out of date, an update will be published as soon as it is available.
- PTSD is a challenging disorder to treat.
- It should be recognised that the majority of individuals with PTSD in South Africa may not have guaranteed access to diagnostic, pharmacotherapeutic and evidence-based psychotherapeutic services as suggested in this guideline.
- Antidepressants (in particular SSRIs) and CBT (exposure-based, trauma-focused CBT) remain the mainstay of treatment for the disorder.
- Use an SSRI or SNRI as first-line therapy and treat the patient at the maximum tolerated dose for at least 4 - 6 weeks before assessing responsiveness.
- Once a patient has responded to drug treatment, it should be continued for at least 12 - 24 months before considering gradual withdrawal.
- Cost should be factored into the choice of medication; the most affordable medication should preferably be selected to allow for funding of the minimum of 1 year of suggested pharmacotherapy.
- The minimum course of exposure-based, trauma-focused CBT is 8 - 12 weekly or biweekly sessions for exposure to a single-incident trauma.
- In deciding on a treatment plan for the patient, it is important to consider the following at baseline and follow-up assessments: the presence of ongoing trauma, comorbid diagnoses (both psychiatric and medical), suicidality, substance abuse, psychosis, pregnancy, treatment compliance, pharmacokinetic (drug-drug interaction) issues, and legal or compensation issues.
- There is no evidence for the efficacy of systematic, brief, single-session interventions (i.e. debriefing) focusing on the traumatic incident. However, providing general practical and social support and guidance to anyone following a traumatic incident is recommended.
- The quest to investigate novel pharmacological agents (e.g. D-cycloserine, a partial agonist of N-methyl-D-aspartate (NMDA) receptor through its mechanism on fear extinction) and therapeutic strategies (e.g. virtual reality exposure therapy), for the management of PTSD remains an ongoing pursuit.
- Several other novel agents (e.g. propranolol, hydrocortisone) have been investigated in the prevention of PTSD (i.e. as prophylaxis) with mixed results. Currently SSRIs are being investigated in placebo-controlled trials as an early intervention in ASD to prevent the later development of PTSD. However, there is insufficient evidence to recommend the use of any of these agents.