Review of PTSD treatments

Many people, including significant proportions of active duty military personnel and veterans, suffer from post-traumatic stress disorder (PTSD), often in conjunction with other injuries or illnesses.

While several drugs and psychotherapies are used to treat PTSD, many of the studies concerning their effectiveness have problems; as a result, they do not provide a clear picture of what works and what doesn't, says a new report from the Institute of Medicine.

Given the growing number of veterans with PTSD, the U.S. Department of Veterans Affairs (VA), Congress, and the research community urgently need to take steps to overcome the problems that often plague studies of psychiatric therapies for PTSD, and to ensure the right studies are undertaken to yield data that would help clinicians treat PTSD sufferers, said the committee that wrote the report.

The committee reviewed 53 studies of pharmaceuticals and 37 studies of psychotherapies used in PTSD treatment and concluded that because of shortcomings in many of the studies, there is not enough reliable evidence to draw conclusions about the effectiveness of most treatments. There are sufficient data to conclude that exposure therapies -- such as exposing individuals to a real or surrogate threat in a safe environment to help them overcome their fears -- are effective in treating people with PTSD. But the committee emphasized that its findings should not be misread to suggest that any PTSD treatment ought to be discontinued or that only exposure therapies should be used to treat PTSD.

"At this time, we can make no judgment about the effectiveness of most psychotherapies or about any medications in helping patients with PTSD," said committee chair Alfred O. Berg, professor of family medicine, School of Medicine, University of Washington, Seattle. "These therapies may or may not be effective -- we just don't know in the absence of good data. Our findings underscore the urgent need for high-quality studies that can assist clinicians in providing the best possible care to veterans and others who suffer from this serious disorder."

PTSD is the most commonly diagnosed service-related mental disorder among military personnel returning from Iraq and Afghanistan. Surveys of these individuals indicate that around 12.6 percent of personnel who fought in Iraq and 6.2 percent who were in Afghanistan have experienced PTSD. Moreover, significant proportions of Vietnam veterans and veterans of earlier conflicts also report suffering from PTSD. The vast majority of people who experience the disorder also have other concurrent conditions, such as alcoholism, depression, drug use, or anxiety disorders. Sexual assault during military service is another factor that can lead to PTSD among service members.

Clinicians turn to both drugs and psychotherapeutic interventions to treat PTSD. Anticonvulsants, antidepressants -- including selective serotonin reuptake inhibitors (SSRIs) -- monoamine oxidase inhibitors (MAOIs), and novel antipsychotics such as olanzapine and risperidone are among the drugs used to treat these patients. Psychotherapies used in PTSD treatment include exposure to trauma-related memories or stimuli, cognitive therapy, coping skills training, and hypnosis.

The committee identified 90 studies that met its criteria for trials from which it could anticipate reliable and informative data on of PTSD therapies. However, several problems and limitations characterize much of the research on PTSD treatments, making the data less informative than expected. Many of the studies have problems in their design or how they were conducted, and high dropout rates -- ranging from 20 percent to 50 percent of participants -- reduced the certainty of several studies' results. Moreover, the majority of drug studies were funded by pharmaceutical firms and many of the psychotherapy studies were conducted by individuals who developed the techniques or their close collaborators. Further investigation is needed to know whether these treatments would produce the same results if tested by other researchers and in other settings.

In addition, the research has not taken into account potential differences in the effectiveness of treatments for subgroups such as those with traumatic brain injury, depression, or substance abuse; nor have studies examined the effects in ethnic minorities, women, and older individuals. Many studies excluded individuals with concurrent health problems such as depression and substance abuse, raising questions about whether the results apply to the many PTSD sufferers who have multiple conditions.

VA and other government agencies that fund clinical research should make sure that studies of PTSD therapies take necessary steps and employ methods that would handle effectively problems that affect the quality of the results. Although the nature of PTSD presents special challenges to researchers, the committee did find some high-quality studies that show it is possible to overcome the problems.

Congress should ensure that resources are available for VA and other federal agencies to fund quality research on treatment of PTSD and that all stakeholders -- including veterans -- are represented in the research planning, the report said.

The committee emphasized that its role was solely to review what is known about the effectiveness of various PTSD treatments, and not to offer or suggest guidelines on what health care professionals or patients should do. Efficacy is one of many factors that contribute to making decisions about treatment. Other factors include safety, clinician and patient preferences, access and availability of different treatment options, and ethical issues.

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