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When Treatment Doesn't Work: What Is Treatment-Resistant PTSD and Why Is It a Systemic Problem?

  • 03 August 2026
    Переглянуто: 146
  • Author:
    Kateryna Piskunova

Introduction

Post-Traumatic Stress Disorder (PTSD) is a mental health condition that can develop after experiencing or witnessing traumatic events. In the context of Russia’s full-scale war against Ukraine, it affects a significant number of people, including veterans, civilians, and the families of military personnel. At the same time, one of the most critical yet least discussed challenges in PTSD treatment is that standard therapeutic approaches fail to provide effective results for a substantial proportion of patients.
This article explores the phenomenon of treatment-resistant PTSD: what it is, how common it is, the mechanisms behind it, and why it poses a challenge not only for individual patients but for the entire mental health care system.

What Is PTSD and How Prevalent Is It?

PTSD develops following exposure to a traumatic event—such as combat, sexual violence, natural disasters, severe accidents, or other life-threatening situations. Symptoms include intrusive memories and flashbacks, avoidance of anything that reminds the person of the trauma, negative changes in thinking and mood, and a state of constant hypervigilance.
According to the World Health Organization, 3.9% of the global population will experience PTSD at some point during their lifetime. However, a 2024 meta-analysis covering 59 systematic reviews and a wide range of clinical and post-conflict populations reported a substantially higher overall prevalence of 23.95% (95% CI: 20.74–27.15) (Schincariol et al., 2024). This discrepancy is explained by differences in the populations being studied: the prevalence of PTSD in the general population differs significantly from its prevalence among high-risk groups.
The figures are considerably higher among veterans. According to the U.S. National Center for PTSD, of the 5.8 million veterans who received healthcare services in 2024, PTSD was diagnosed in 14% of men and 24% of women (VA, 2024). Among veterans who served in Operation Enduring Freedom and Operation Iraqi Freedom, the prevalence of PTSD ranged from 11% to 17% (Hoge et al., 2004).

Standard Treatments for PTSD

Current clinical guidelines recommend two main approaches to treating PTSD.

Psychotherapy

First-line treatments for PTSD include trauma-focused cognitive behavioral therapy (CBT), Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), and Eye Movement Desensitization and Reprocessing (EMDR). These interventions are supported by a strong body of scientific evidence and are widely used by the U.S. Department of Veterans Affairs (VA) as well as in mental health systems across many other countries.

Pharmacotherapy

The first-line pharmacological treatments are selective serotonin reuptake inhibitors (SSRIs), particularly sertraline and paroxetine. When these medications are ineffective or poorly tolerated, second-line options such as venlafaxine and mirtazapine may be considered (Alderman, 2003). Prazosin is also used to treat PTSD-related sleep disturbances.
Попри те, що ці методи підтримуються клінічними настановами і мають достатню доказову базу, вони залишаються неефективними для значної частки людей із ПТСР.

Treatment-Resistant PTSD: When Treatment Doesn't Work

Treatment-resistant PTSD is generally defined as PTSD in which a patient fails to achieve a clinically meaningful reduction in symptoms after completing one or more courses of first-line treatment. Although the exact definition varies across studies, the common criterion is an inadequate therapeutic response despite appropriate adherence to an evidence-based treatment protocol.
It is estimated that approximately 33% of people with PTSD have treatment-resistant PTSD (National Academies of Sciences, 2014). The non-response rates for individual treatment modalities are even higher: for cognitive behavioral therapy (CBT), they may reach 50%, while for selective serotonin reuptake inhibitors (SSRIs), they range from 20% to 40%.
A 2024 meta-analysis by Semmlinger et al., which included 86 studies involving 7,894 participants, confirmed that a substantial proportion of individuals with PTSD do not achieve clinically meaningful improvement after receiving first-line psychological treatment. The researchers also identified several predictors of poor treatment response, including greater symptom severity at baseline, the presence of comorbid mental health conditions, and the nature of the traumatic experience.

Veterans: A High-Risk Group

For veterans, treatment resistance presents an especially significant challenge. First, combat-related trauma is often cumulative and prolonged, rather than the result of a single traumatic event, making treatment substantially more complex. Second, PTSD in veterans is frequently accompanied by a high burden of comorbid conditions.
A 2024 study found that among 850,191 veterans with PTSD, more than 53% also experienced chronic pain (Moore et al., 2024). The coexistence of PTSD and chronic pain significantly complicates the treatment of both conditions. In addition, PTSD is associated with an increased risk of substance use disorders, depression, and anxiety disorders.
A study by Levi et al. (2022) analyzed treatment outcomes for 709 Israeli veterans with PTSD in real-world clinical settings. Full remission was achieved in only 39.4% of participants. Treatment proved to be least effective in addressing intrusive symptoms, flashbacks, and memory impairments, which showed little to no meaningful improvement. Treatment of comorbid depression yielded even poorer outcomes, with remission observed in just 4.1% of cases. The authors concluded that approximately two-thirds of veterans continued to meet the diagnostic criteria for PTSD even after completing treatment.

The Problem of Premature Discontinuation of Therapy

A separate and critically important challenge is the high rate of treatment dropout before therapy is completed. Individuals who begin treatment but do not complete it are unlikely to receive its full therapeutic benefit. At the same time, they are typically not counted among those classified as having failed to respond to treatment, meaning this issue is often underrepresented in treatment outcome statistics.
A large-scale 2025 meta-analysis examined 181 studies, 232 treatment protocols, and more than 124,000 active-duty service members and veterans. The findings were concerning: an average of 25.6% of participants discontinued therapy before completing the prescribed course of treatment (Penix-Smith & Swift, 2025).
At the same time, the dropout rates vary significantly depending on the treatment method:
  • — Cognitive-Process Therapy (CPT) in a weekly format — 40.1%
  • — Prolonged exposure (PE) therapy on a weekly basis — 34.7%
  • — Therapy using virtual reality technology — 37.2%
Intensive outpatient programs (IOPs) show lower dropout rates: when these programs are used, the dropout rate for CPT is 8.5%, and for PE, it is 5.5%.
A separate study of an outpatient VA clinic showed that of the veterans who began therapy (PE or CPT), 38.5% did not complete the course (Kehle-Forbes et al., 2016). A randomized clinical trial by Schnurr et al. (2022) reported even higher dropout rates: 56% in the prolonged exposure group and 47% in the cognitive-processing therapy group.
There are various reasons for premature termination of therapy: the intensity of the process of working through traumatic material, a lack of support between sessions, the stigma associated with seeking psychological help, logistical barriers, and insufficient motivation due to a lack of visible progress in the early stages.

Why First-Line Therapy Has Limited Effectiveness in Veterans

The paradox is that the methods with the strongest evidence base—prolonged exposure therapy and cognitive-process therapy—also have the highest dropout rates among veterans. This does not mean they are ineffective: for those who complete the course, they lead to significant improvement. However, the actual clinical effectiveness in the veteran population is significantly lower than the results seen in controlled trials.
Researchers attribute these outcomes to several factors. First, combat-related trauma is often cumulative and chronic, rather than a single traumatic event—the type of trauma for which these treatment approaches were originally developed. Second, veterans are far more likely to experience comorbid conditions, including chronic pain, substance use disorders (SUDs), and traumatic brain injuries (TBIs), all of which complicate the course of PTSD and reduce the effectiveness of standard therapies. Third, moral injury—characterized by feelings of guilt, shame, or betrayal associated with combat experiences—is often poorly addressed by traditional trauma-focused treatment protocols (Levi et al., 2022).
Stigma also plays a significant role. Within military culture, seeking psychological support is often perceived as a sign of weakness, discouraging both the initial decision to seek help and the continuation of treatment.

Suicidal tendencies as a consequence of untreated PTSD

Untreated or treatment-resistant PTSD is directly associated with an increased risk of suicide. According to the National Veteran Suicide Prevention Annual Report (VA, 2025), 6,398 veteran suicides were recorded in 2023—an average of 17.5 deaths per day. Among veterans who died by suicide in 2023, 26.6% had been diagnosed with PTSD during the previous calendar year (VA National Center for PTSD, 2024).
Overall, veterans have an approximately 1.5 times higher risk of suicide than their civilian peers, even after adjusting for differences in age and sex. Women veterans face an even greater disparity, with suicide rates approximately 2.5 times higher than those of civilian women (VA, 2025).
These figures underscore that the limited effectiveness of current PTSD treatments is not merely an abstract academic concern.

Conclusion

Treatment-resistant PTSD is a systemic challenge affecting at least one-third of all people diagnosed with the disorder. Among veterans, the situation is even more severe: a substantial proportion fail to achieve remission despite receiving first-line treatment, while nearly one in four discontinue therapy before completing the prescribed course.
This means that, in addition to improving access to existing treatments, it is critically important to develop new therapeutic approaches — especially for those for whom standard treatments are ineffective.
UPRA continues to monitor developments in the evidence base for PTSD treatment and to publish articles on new areas of research. The next article in this series will focus on the current state of scientific research in the field of psychedelic-assisted therapy as a potential approach for treating treatment-resistant PTSD.

References