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Three Buckets for Treatment of PTSD


June is PTSD Awareness Month, a time to increase awareness of posttraumatic stress disorder (PTSD) and effective treatments.

Learn more about PTSD.

I currently work for the Veterans Health Administration in Washington, D.C., where I treat a lot of patients for PTSD. Some have received treatment before. Others have hidden their symptoms while in the military, and are now presenting for the first time. Often they are coming to treatment because their partner or parents have insisted.

For my patients, I usually describe three buckets as a framework to understand different treatment strategies. The first bucket is medication. The second is psychotherapy. The third is everything else, including exercise, yoga, meditation and other strategies that reduce the adrenaline overload of PTSD.

The first two approaches have been shown to work in scientific clinical trials. The others are still in the anecdotal phases. In other words, they work for some, but we do not know who and how.

First bucket: Medications

Medications are very helpful for PTSD. Common medications include the antidepressant SSRIs (selective serotonin reuptake inhibitors), such as sertraline (Zoloft), paroxetine (Paxil) and others. They are effective for PTSD symptoms in most patients. They have side effects, which are usually mild, such as dizziness and nausea. These usually go away in a few days.

For a definition of PTSD and more information see APA’s Help with PTSD page or the National Center for PTSD.

Problematic side effects are sexual ones, which include delayed erections and decreased libido. If there are sexual side-effects, we can usually manage them by switching medications, drug holidays or with phosphodiesterase inhibitors, such as sildenafil (Viagra).

I try to always ask about sexual health and functioning. I find that if I do not, and a service member or veteran has problems with erections or libido, they will discontinue the medication and not come back. If we talk through the side-effects, we can usually make it work.

Second bucket: Psychotherapy

Psychotherapy is talking therapy, also called cognitive behavioral therapy or cognitive processing therapy. In general, this process includes talking about the trauma and reducing the anxiety associated with it.

The problem with this approach is that many service members and veterans do not like relieving the trauma, especially with someone who has not been there with them in combat.

Third bucket: Everything Else

There are lots of strategies that reduce the adrenaline rush of PTSD. Many are self-management: yoga, meditation, deep breathing. I am a fan of canine and equine therapy. Art and music therapy are often useful. They help bring down the adrenaline overload of PTSD. Regular exercise is also helpful for many people.

Other promising treatments are more technical, including transcranial magnetic stimulation (TMS), acupuncture and stellate ganglion block. None of the last buckets of treatment are yet evidence-based, that is, validated in scientific studies, but they are getting there. They work for some patients.


I encourage my patients to read everything they can, including online sources, and to pick a treatment regimen that works for them.

About the Author

By Col. (ret) Elspeth Cameron Ritchie, M.D., M.P.H.
Veterans Health Administration




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