Little evidence to support therapies for post-traumatic stress disorder

Oct 22 2007

Post-traumatic stress disorder (PTSD) is a severe and ongoing emotional reaction to an extreme psychological trauma; it affects significant numbers of people, in particular military personnel and veterans, who have seen active duty in war zones.

It also affects people who have suffered major injuries or illnesses.

As many as 25% or more of patients that suffer from PTSD will have attempted suicide.

It is thought to be basically an anxiety disorder and is different from normal grief and adjustment after traumatic events; symptoms which appear within the first month of the trauma are called acute stress disorder but if no improvement of symptoms are seen after a month, PTSD is diagnosed.

PTSD is divided into three categories: Acute PTSD which subsides within three months; if symptoms persist, the diagnosis is changed to chronic PTSD.

The third category, delayed-onset PTSD, may occur months, years or even decades after the traumatic event.

PTSD symptoms include nightmares, flashbacks, emotional detachment or numbing of feelings, insomnia, avoidance of reminders and extreme distress when exposed to the reminders ("triggers"), loss of appetite, irritability, hypervigilance, memory loss (may appear as difficulty paying attention), excessive startle response, clinical depression, and anxiety.

A person suffering from PTSD may also be suffering from clinical depression (or bipolar disorder), general anxiety disorder, and a variety of addictions.

Treatment commonly involves psychotherapy and the use of drugs to alleviate the symptoms but there has long been concern as to the effectiveness of current therapies and despite numerous studies on the condition, the effectiveness of most treatments remains unclear.

Anticonvulsants, antidepressants which include selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), and the new antipsychotics such as olanzapine and risperidone are among the drugs used to treat PTSD patients.

Psychotherapies used in PTSD treatment include exposure to trauma-related memories or stimuli, cognitive therapy, coping skills training, and hypnosis.

According to a new report from the Institute of Medicine, a review of 53 studies of pharmaceuticals and 37 studies of psychotherapies used in PTSD treatment, the shortcomings of many of the studies means there is little reliable evidence about the effectiveness of most treatments.

The growing number of veterans with PTSD has prompted demands from the U.S. Department of Veterans Affairs (VA), Congress and the research community for the right studies to be undertaken which will offer credible information for those treating PTSD sufferers.

The committee responsible for the report were led by Alfred O. Berg, professor of family medicine at the University of Washington, and he says at present no judgment can be offered about the effectiveness of most psychotherapies or about any medications in helping patients with PTSD.

Berg says their findings underscore the urgent need for high-quality studies that can assist doctors in providing the best possible care to veterans and others who suffer from the serious disorder.

The committee however also say 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.

The committee identified 90 studies worthy of review but many suffered from problems in their design, how they were conducted, and high dropout rates ranging from 20 percent to 50 percent of participants.

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.

The committee says further investigation is needed to find out whether these treatments would produce the same results if tested by other researchers, in other settings.

Potential differences in the effectiveness of treatments for subgroups such as those with traumatic brain injury, depression, or substance abuse were not accounted for nor were the effects in ethnic minorities, women, and older individuals.

Many studies also excluded individuals with other health problems such as depression and substance abuse.

The committee acknowledges the special challenges PTSD does present to researchers, and did discover some high-quality studies that show it is possible to overcome the problems.

According to the report, the only proven treatment for PTSD is exposure therapy, during which patients are exposed to sights and sounds that simulate their traumatic experiences to help them learn to cope.

Apparently psychological treatments for PTSD such cognitive restructuring, coping skills training, eye-movement desensitization and reprocessing therapy, and group therapy, are not supported by scientific evidence.

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

The committee emphasises 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.

The study was sponsored by the U.S. Department of Veterans Affairs.

The Institute of Medicine provides independent, objective, evidence-based advice to policymakers, health professionals, the private sector, and the public.