Treatment of Posttraumatic Stress Disorder An Assessment of the Evidence (2008) / Chapter Skim
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From page 1... ...
. The committee was given five major tasks: review the scientific evidence and make conclusions regarding efficacy; note restrictions of the conclusions to certain settings, populations, and so on; comment on gaps and future research; answer several questions related to the goals, timing, and length of treatment; and finally, note areas where the evidence base is limited by inadequate attention or poor quality.
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From page 2... ...
. The committee conducted a systematic and comprehensive search of the relevant published literature and identified a total of 2,771 studies, and from that list included only randomized controlled trials (RCTs; placebocontrolled pharmacotherapy trials and wait-list or similar controls in the psychotherapy trials)
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It is extremely difficult to answer questions of efficacy in an uncontrolled way because of the variability of treatments, outcome measures, disease course, and patient choice. RCTs are the most reliable form of evidence for efficacy, and the committee found that the characteristics of the disorder, its measurement, and its treatment are sufficiently heterogeneous that observational studies were unlikely to provide useful evidence beyond the data available from RCTs.
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From page 4... ...
Often studies reported data only on those completing therapy, a strategy biased in favor of showing a treatment effect. Those studies incorporating a strategy to deal statistically with the dropouts usually used "last observation carried forward," a method that may bias results in either direction depending on context.
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From page 5... ...
* -- If approximately equal loss to follow-up in each arm, study quality is af fected by the analytic methods used to handle missing data: o Up to 10% missing outcome data acceptable without formal missing data methods employed (i.e., may use completer analysis or last ob servation carried forward [LOCF]
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From page 6... ...
The studies that were excluded were open-label trials, a retrospec tive chart review, and a study that did not use an overall PTSD outcome measure. • The committee reviewed eight studies of anticonvulsants and ex cluded five (all open label, one a maintenance study)
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From page 7... ...
The committee also made note of one RCT of opioid antagonist naltrexone in patients with alcohol dependence, which did not meet inclusion criteria, that it suggested a benefit to using naltrexone in an important subpopulation. For the all drug classes and specific drugs reviewed in each of the following classes, the committee concludes that the evidence is inadequate to determine efficacy in the treatment of PTSD: • alpha-adrenergic blocker prazosin, • anticonvulsants, • novel antipsychotics olanzapine and risperidone, • benzodiazepines, • MAOIs phenelzine and brofaromine, • SSRIs, • other antidepressants, and • other drugs (naltrexone, cycloserine, or inositol)
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The largest proportion of CBT studies included an e xposure-based therapy. The committee recognized that exposure is frequently administered in combination with another CBT technique, and that led the committee to group together studies with exposure and exposure plus something else (such as cognitive restructuring or a coping skills training modality [e.g., relaxation]
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• The committee reviewed four RCTs of coping skills and excluded one study because it did not have a control or comparison group. The committee concludes that the evidence is inadequate to determine the efficacy of the following psychotherapy modalities in the treatment of PTSD: • EMDR • cognitive restructuring • coping skills training In the category of "other psychotherapies", the committee reviewed a total of four RCTs of eclectic psychotherapy (two studies)
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From page 10... ...
. Further, many studies lack basic characteristics of internal validity including high dropout rates handled with weak missing data analyses and high differential dropout among treatment arms.
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The committee recognizes that the successful conduct of research directly applicable to veterans will require close collaboration among funding agencies (Department of Defense, National Institute of Mental Health, National Institute of Alcohol Abuse and Alcohol ism, National Institute of Drug Abuse) , veterans' groups, and clinical service settings.
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study aimed to reproduce some real-life settings in allowing participants' choice and offering alternatives when a course of treatment did not work, and used an outcome measure of "remission" meaning becoming symptom free. Another study brought to the committee's attention is the CATIE (Clinical Antipsychotic Trials of Intervention Effectiveness)
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From page 13... ...
follow-up should be conducted on treatments of any length found to be efficacious. CONCLUDING OBSERVATIONS In this report the committee sought to describe the evidence regarding the efficacy of available treatment modalities for PTSD, identify some of the major issues in the field, and make recommendations to help guide further research in PTSD treatment.
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From page 14... ...
The principal finding of the committee is that the scientific evidence on treatment modalities for PTSD does not reach the level of certainty that would be desired for such a common and serious condition among veterans. For some modalities, for example novel antipsychotic drugs and SSRIs, the committee debated whether to characterize the body of evidence as "suggestive" or "inadequate." It is important to emphasize that in the larger picture of PTSD treatment, had the debate ended with "suggestive" conclusions (rather than the "inadequate" conclusions the committee finally reached)
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From page 15... ...
2002. A controlled comparison of eye movement desensitization and reprocessing versus exposure plus cognitive restructuring versus waiting list in the treatment of post-traumatic stress disorder.
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