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BY TOM BERGER, CHAIR
By now most of you have seen the news, as reported in The
Washington Post on October 19, that “most PTSD treatments
[have] not proven effective.” With one exception
for “exposure therapy,” this was the consensus
reached by the National Academy’s Institute of Medicine’s
Committee on Post-traumatic Stress Disorder in its long-awaited
report, “Treatment of Post-traumatic Stress Disorder:
An Assessment of the Evidence.”
The 250-page report
reviewed 2,771 published studies conducted since 1980 when
PTSD was added to the DSM III. It determined that only
53 psychotherapy studies and 37 pharmacological studies
included the scientific methodological criteria of randomized
control trials, placebo-controlled pharmacological trials,
and wait list or similar controls.
In other words, the group
found that 2,681 studies did not control or account for all
the variables encountered in either a study’s design,
implementation, or data analyses. For example, there were
problems with small sample sizes, high dropout rates, missing
data, and the lack of follow-up. This led to the committee’s
conclusion of “scientific
inadequacy” for all these studies. Additionally and
significantly, not all of the 90 reviewed studies included
a veteran cohort.
The IOM report does note, however, that
OEF and OIF veterans suffering from PTSD “might be
different” from
veterans of previous wars, and that studies of those veterans
(read: Vietnam veterans) “may be minimally informative” about
PTSD treatment effectiveness for our newest veterans. The
committee also stated that the evidence for treatment effectiveness “fails
to address the effects of high rates of co-morbidity” among
veterans suffering from PTSD with major depression, TBI,
or substance abuse, and that the evidence is “silent” on
the impact and usefulness of such treatments for ethnic and
cultural minorities. The report also briefly mentions military
sexual trauma.
Pharmacological treatment: 37 studies were
reviewed, of which 13 included a predominantly male veteran
(both American and international) cohort whose primary trauma
was combat. The other 24 studies included victims of sexual
abuse, physical assault, accidental injury, witnessing trauma
(acts of genocide, for example), and motor vehicle accidents.
The IOM Committee identified 22 drugs that it organized into
seven “classes,” plus
a miscellaneous “other” drug category. In each
class-category the evidence was judged to be inadequate to
determine effectiveness in the treatment of PTSD.
The classes-categories
included: (1) Alpha adrenergic blockers (such as Prazosin);
(2) Anticonvulsants (Topiramate, Tiagabine, and Lamotrigine);
(3) “Novel” antipsychotic medications
(Olanzapine or Risperidone); (4) Benzodiazepines (including
Alprozolam) (It’s worth noting that many clinical guidelines
recommend that benzodiazepines not be used in the treatment
of PTSD); (5) Monoamine oxidase inhibitors (MAOIs such as
Phenelzine); (6) Selective serotonin reuptake inhibitors
(SSRIs such as Sertraline, Fluoxetine, Paroxetine, and Citalopram—all
of the research trials with SSRIs were sponsored by the pharmacy
industry); (7) Other anti-depressants (tricyclic anti- depressants
such as Imipramine, Desipramine, and Amitriptyline); and
(8) “Other drugs” such as Naltrexone (used for
clients with alcohol dependence), Cycloserine, and Inositol.
Psychotherapy
treatment: 53 studies were reviewed, of which ten included
a predominantly male veteran cohort. An additional 17 studies
included victims of sexual or physical abuse. The remainder
included victims of other types of trauma or mixed traumas.
The IOM Committee grouped the psychotherapy treatment studies
into the following categories: exposure therapy, cognitive
restructuring therapy, exposure plus cognitive restructuring,
exposure plus coping skills training, eye-movement desensitization
and reprocessing (EMDR), coping skills training, other psychotherapies,
and group format psychotherapy. The committee also noted “that
virtually all of the recent literature on psychotherapies
for PTSD examines interventions that some experts consider
components of cognitive behavioral therapy (CBT).”
Exposure
therapy: According to the committee, exposure therapy refers
to several closely related techniques such as prolonged exposure
therapy, direct exposure therapy, and multiple-channel exposure
therapy. They were evaluated by the IOM group as one category,
both alone and in combination with other treatments. So the
exposure therapy studies may have included psychoeducation,
breathing retraining, and relaxation, in addition to the
exposure therapy (specifically imaginal and in vivo exposure,
flooding, and directed therapeutic exposure).
Some exposure
therapy programs also require completing homework, generally
repeated exposure to a trauma tape or some other record of
the trauma narrative. Exposure studies are lengthy and require
a considerable investment of time, emotion, and effort by
clinician and client. According to the report, “the
committee judged that the quality of the overall body of
evidence supporting exposure therapies is moderate to high,
with the best studies all pointing in the same direction
with an important clinical benefit. The committee is confident
in both the presence of a positive effect and in its clinical
significance.” Therefore, the committee noted, the
evidence is sufficient to conclude that exposure therapy
is effective in the treatment of PTSD.
However, the committee
specifically noted that the evidence for the effectiveness “of
exposure therapy in veterans, especially in males with chronic
PTSD, is less consistent than the general body of evidence.” In
addition, the committee noted that “exposure therapies
(e.g., prolonged exposure), as delivered, often contain components
of other CBT approaches, such as cognitive restructuring
and coping skills training. Thus, the conclusion that the
evidence supports the efficacy of exposure therapy should
not be interpreted too narrowly.”
Cognitive restructuring: The committee found the cognitive restructuring studies to
be of “moderate” quality,
but with “important limitations,” and concluded
that the evidence is inadequate to determine its effectiveness.
EMDR
(eye movement desensitization and reprocessing): The committee
found many of the EMDR studies to be flawed or of such low
quality that no conclusion could be made with regard to its
effectiveness.
Coping skills: The committee
determined that the overall body of evidence for coping skills
training was of such low quality that no conclusion could
be made with regard to its effectiveness.
Other psychotherapies, including eclectic psychotherapy,
hypnotherapy, psychodynamic therapy, and brainwave neurofeedback:
Because of the limited evidence, the committee “believes
it would be inappropriate to reach a conclusion” about
the effectiveness of these treatments.
Group therapy: The
committee noted that group therapy is commonly used in veterans’ groups
but also noted that “because
of the lack of well-designed studies comparing group and
individual formats and lack of controls,” no conclusion
about the effectiveness of group therapy could be made.
Despite
noting the shortcomings among research studies of PTSD, one
of the most important committee findings is that current
PTSD treatment research on veterans is “inadequate
to answer questions about interventions, settings, and length
of treatment that are applicable in this particular population.” In
addition, the report unequivocally stated that “the
committee reached a strong consensus that additional high-quality
research is essential for every treatment modality. This
extends equally to the one treatment modality exposure therapies
for which the committee found the evidence to be the strongest.” And
the committee’s report also included a series of eight
detailed recommendations by which the VA can address this
inadequacy.
As you might expect, the VA issued a press release
only 27 minutes after the IOM report became available to
the public. In the press release, the VA’s Deputy Chief
of Mental Health Services, Dr. Antonette Zeiss, stated: “VA
is pleased to see that IOM agrees with us that exposure-based
therapies are effective treatments for PTSD.”
The VVA
PTSD/SA Committee will be monitoring the VA closely to see
if and how it responds to the IOM Committee’s
recommendations. This VVA committee chair is from Missouri:
Show me.
Committee Notes: the PTSD/SA Committee is proud to
announce its 2007-09 membership: Tom Berger (Chair), Randy
Bane, Pat Bessigano, Liz Cannon, Tony Catapano, Bob Corsa,
Marsha Four, Sandy Miller, Wayne Reynolds, Ed Ryan, Fr. Phil
Salois (Vice Chair), Jim Shott, and Dan Stenvold; AVVA members
and Special Advisers Kathy Andras, Kathleen Aylward-Barnes,
Frances Cartier, Felicea Catapano, Donna Cowell, Dee Hagge,
Paul Harrigan, Mary Miller, Diane Nicholson, Nancy Switzer,
and Mary Yeomans; In Memoriam Members Randy “Doc” Barnes,
Steve Mason, and Linda Van Devanter; and VVA Staff Liaison
Mokie Pratt Porter.
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©2006-
2008, Vietnam Veterans of America. All Rights Reserved. 8605 Cameron
Street, Silver Spring, MD 20910