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NOVEMBER/DECEMBER 2007

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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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