How should I approach the management of a patient with PTSD who is also experiencing depression?

Approach to managing a patient with PTSD and comorbid depression:

• Assess severity: Evaluate the severity of both PTSD and depression, including risk of suicide or harm, and functional impairment.
• Treat PTSD first: Usually, treat the PTSD first because successful PTSD treatment often improves depression.
• Treat depression first if severe: If depression is severe enough to impair engagement with PTSD psychological treatments or if there is significant suicide risk, treat the depression first.
• Psychological therapies: Refer for trauma-focused psychological therapies as first-line treatment for PTSD, which may also benefit depression.
• Pharmacological treatment: Consider antidepressants (SSRIs or venlafaxine) if the patient prefers drug treatment, cannot engage in psychological therapies, has significant comorbid depression, or if referral/treatment is delayed.
• Monitor closely: Review drug effectiveness and adverse effects regularly, especially in younger adults due to increased suicide risk with SSRIs/SNRIs.
• Address additional needs: Manage any barriers to therapy such as substance misuse or emotional dysregulation, and consider extra support for complex PTSD.
• Coordinate care: Ensure clear communication and shared care arrangements between primary and specialist services, involving the patient and carers.

This approach balances treating PTSD and depression effectively, prioritizing patient safety and preferences.

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