Clinical Pearls: PTSD and trauma-informed care 

April 11, 2023
By CSHP Pharmacy Student

This article is part of a series appearing in Interactions, our biweekly newsletter, written and researched by CSHP's students. We've created this series as a valuable learning activity for pharmacy students undertaking rotations at CSHP. Crafting these pieces not only helps students gain in-depth knowledge of specific conditions, treatments, and resources, it also helps them hone their skills in research, critical appraisal, evaluation, synthesis, and writing – all of which will serve them well in clinical practice. The Professional Practice Team works with the students to select hot topics that are of interest and utility to both the students and to you, the reader. We hope you enjoy this piece by one of our future colleagues! Let us know what you think: If you would like to provide any comments or constructive feedback for our students, please email us at


Trauma is widespread globally and in Canada.1,2 Results from the World Mental Health Consortium revealed that around 70% of respondents reported having experienced a traumatic event at least once in their lifetime, while recent findings from the national Survey on Mental Health and Stressful Events found this to be true for 64% of Canadians.1,2 Although there is growing awareness of a broader definition of trauma (e.g., intergenerational, historical, interpersonal),3 the term most found in literature is one that describes the psychological response that manifests after experiencing or witnessing a distressing event.4 When this response persists, a person can develop post-traumatic stress disorder (PTSD), which is a potentially debilitating mental condition characterized by the following possible symptoms:  
  • Recurrent distressing memories, nightmares, and flashbacks related to the traumatic event(s).5
  • Intense feelings of distress and/or physiological reactions to internal or external reminders of the traumatic event(s).5
  • Avoidance of distressing thoughts or the avoidance of external reminders of the traumatic event(s) (e.g., people, locations, objects, situations) that arouse distressing memories, thoughts, and feelings.5
  • Negative changes to cognition and mood (e.g., persistent negative beliefs of oneself, others, or the world, feelings of detachment, or inability to experience positive emotions).5
  • Changes in arousal and reactivity (e.g., hypervigilance, exaggerated startle response, and insomnia).5

PTSD symptoms may vary in frequency and severity between individuals; however, prior to obtaining a formal diagnosis of PTSD, all individuals must have experienced their symptoms for at least one month, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).5

Canada has one of the highest rates of PTSD in the world, with 8% of Canadian adults meeting the criteria for probable PTSD.2,6 Worldwide, the prevalence of PTSD differs among certain populations. Some populations that may be at higher risk of PTSD include survivors of sexual violence, women, younger adults, military veterans, and racially and culturally marginalized individuals.2,3,7-10 Furthermore, PTSD has been associated with an increased risk of substance use disorders, chronic diseases, co-morbid mental health conditions, accelerated aging, hospitalization, and suicide.1,11,12 Despite this, a cross-national survey found that only half of respondents reported seeking any kind of treatment.1 


Currently, there is no specific treatment, psychological or pharmacological, that promises a cure for PTSD. However, there are several different treatments available that can help alleviate symptoms and make PTSD more manageable for affected individuals. Initial treatment of PTSD usually involves the use of trauma-focused psychotherapy, as recommended by national guidelines.11,13 Meta-analyses of over 30 randomized controlled trials (RCTs) of psychotherapies have found trauma-focused cognitive-behavioural therapy (TFCBT), eye movement desensitisation and reprocessing (EMDR) therapy, stress management, and group TFCBT to be effective for managing PTSD compared to control.11,14,15 Other approaches include prolonged exposure (PE) therapy and cognitive processing therapy (CPT).11 Efficacy between psychotherapies are comparable; thus, the choice of psychotherapy should be a shared decision between the patient and the healthcare provider.11,16

Although psychotherapy is the recommended first-line treatment for PTSD, depending on availability, patient preference and circumstances, pharmacotherapy may also be considered as first-line treatment.13,17 For example, patients with comorbid conditions such as depression may start with pharmacological treatment until their symptoms are stable.13,16 Following improvement of symptoms, psychotherapy may be introduced; however, the benefit of combining the use of psychotherapies and pharmacotherapies requires further research.11, 13,16 One RCT found there to be no difference in efficacy between combination therapy of sertraline plus PE therapy and PE therapy plus placebo.18

The mechanism by which PTSD manifests itself physiologically is not entirely clear; however, studies have linked the dysregulation of neurotransmitters, reduced hippocampal volume, and genetic differences, to its pathophysiology and susceptibility in individuals.19, 20 First-line pharmacologic treatments for PTSD attempt to reduce the total severity of core symptoms (e.g., intrusive memories, avoidance, and hyperarousal) by targeting neurotransmitter imbalances.13 Currently, there is evidence from RCTs and meta-analyses to support the use of the selective serotonin reuptake inhibitors (SSRIs) fluoxetine, paroxetine, and sertraline and the serotonin-norepinephrine reuptake inhibitor (SNRI) venlafaxine as first-line agents.11 See the table below for an overview of the current pharmacologic recommendations. 

Table 1. Examples of recommended pharmacologic therapies for PTSD 11

Antidepressants such as mirtazapine, fluvoxamine, and phenelzine have shown evidence of efficacy in reducing the total severity of the core intrusion, avoidance, and hyperarousal symptoms of PTSD in smaller RCTs and are considered second-line agents accordingly.11 For patients with suboptimal responses to first-line options, providers can consider the addition of second-generation antipsychotics such as aripiprazole, olanzapine, and quetiapine to treatment plans.13Furthermore, providers can consider augmenting first-line agents with medications such as prazosin and trazadone: Several studies have shown evidence for the use of the alpha1-adrenergic antagonist prazosin in reducing traumatic nightmares, and the antidepressant trazadone is recommended in a number of PTSD clinical guidelines to treat insomnia.11,13  

Despite evidence to support the use of these therapies for PTSD, many patients do not find success in available treatments.30 In one meta-analysis comparing psychotherapies and pharmacotherapies for PTSD, researchers found that the average drop-out rate across all 55 studies included in their search was 29%.30 Reasons for treatment discontinuation vary greatly, ranging from difficulties to tolerating the use of traumatic images in trauma-focused psychotherapy31, to adverse events in SSRIs.17,32 Because of these potential challenges to current treatments, there has been a push in recent years to explore different agents as possible alternatives.13,33,34 Cannabis has been proposed as an alternative treatment for PTSD for its ability to increase serotonin and dopamine levels in the brain.13,35 Similarly, MDMA, which is the active ingredient in the illicit drug Ecstasy/Molly, has been proposed for its ability to reduce activity in the amygdala, the structure in the brain that processes fearful memories and emotions, and increase serotonin release.33,34 However, due to the limited evidence to support these two agents, they currently cannot be recommended to treat PTSD.13,33 Benzodiazepines (BZDs), while not a newly explored agent in PTSD research, has historically been widely prescribed to treat anxiety and insomnia.36 However, like cannabis and MDMA, BZDs are not recommended; this is due to their lack of efficacy in improving core PTSD symptoms37, sleep disturbances38, and their addictive properties.13

What is trauma-informed care?

Trauma-informed care (TIC) is a term that has recently risen in popularity in various mental health and addiction, medical, educational, and correctional settings.3,39 TIC relies on the concept that integrating the knowledge of the impact of trauma into all levels of care and services leads to improved support and outcomes for people living with trauma.3,39 Essentially, TIC provides a way for understanding how trauma affects people which can then be used to create policies and programs that promote a culture of safety and empowerment for those affected by trauma.12 The four key elements of TIC, as outlined in a 2014 initiative by the Substance Abuse and Mental Health Services Administration, include: realizing the widespread impact of trauma, recognizing the common reactions to trauma in both patients and staff, and responding by integrating knowledge about trauma into all levels of organizational structure to resist re-traumatization.40

In the hospital pharmacy setting, one example of TIC could include recognizing how trauma can affect medication adherence.41 A recent meta-analysis found that PTSD is associated with increased non-adherence, especially within the context of medical-event induced traumas such as those stemming from stroke or cancer diagnoses.42 A TIC framework can aid pharmacists in realizing when trauma may be affecting treatment outcomes and help them work with patients to adjust their treatment plans and goals accordingly.39,43 In a real-world example outlined in the American Journal of Health-System Pharmacy, clinical pharmacist Jennifer Cocohoba at the University of California, Women’s HIV Program, shared how she approached developing a treatment plan for a patient whose husband had died from an adverse drug reaction.44 Because of the patient’s trauma regarding taking medication, instead of starting them on an optimal medication regimen, Cocohoba had them start with small doses until they were be comfortable with introducing the optimal antiretroviral therapy at a later date.44 Other examples of TIC that are non-exclusive to hospital pharmacy could include having a list of referral sources to trauma services readily available to all patients, using welcoming and inclusive language on all signage, and encouraging self-care practices among staff.39,45

Despite the rise in popularity of TIC3,12, evidence to support its role in improving patient outcomes to date has been limited.39,46 Nonetheless, it is well known that trauma and PTSD can have significant consequences on patients’ mental health, quality of life, and mortality.11 It is important that policymakers and pharmacists alike are aware of emerging trauma frameworks like TIC so that evidence-based best practices can be developed that will achieve positive patient outcomes.   


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