How should I approach the management of a patient with PTSD who is als

Guideline-aligned answer with reasoning, red flags and references. Clinically reviewed by Dr Kola Tytler MBBS CertHE MBA MRCGP.

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.

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