Value of Most Post-Traumatic Stress Treatments 'Uncertain'

THURSDAY Oct. 18, 2007 -- Doctors have little quality evidence to rely on when deciding how best to treat post-traumatic stress disorder (PTSD) in returning U.S. veterans, a new government-sponsored review of the data concludes.

The Institute of Medicine study was requested by the U.S. Department of Veterans Affairs, which noted that about 12.6 percent of personnel fighting in Iraq, and 6.2 percent of those returning from Afghanistan, have experienced symptoms of PTSD.

Unfortunately, an overabundance of studies with inadequate or flawed designs make it impossible to say whether drug treatments or most psychotherapies can help fight PTSD, the authors of the report told reporters at a press conference Thursday.

Only exposure therapy -- where the patient is re-exposed to the original stressor in a safe, controlled environment -- shows some solid data bolstering its claim to effectiveness, the researchers said.

As for other therapies, "I think it is important to point out that our assessment of inadequate evidence does not mean that the treatments are ineffective," said Dr. Alfred Berg, chairman of the committee that wrote the report and professor of family medicine at the University of Washington School of Medicine. "In most cases, we just don't know because of the absence of good data," he said.

The report is not meant as a guide for patients and their physicians as they work to fight PTSD, which can involve chronic and frightening nightmares, flashbacks, as well as avoidance behaviors that all diminish quality of life.

Instead, the report is meant to assess the current state of the science when it comes to PTSD research, said Dr. David Matchar, director of the Center for Clinical Health Policy Research at Duke University Medical Center.

"We don't want to see people getting a message that they should avoid seeking care because care doesn't work -- that's not at all the message of this report," said report co-author Matchar, who is also a professor of medicine at Duke. "It would be a mistake to receive this as a guideline -- it is not a guideline."

The Veterans Administration does have PTSD clinical practice guidelines in place, and they were last revised in 2004, Berg said. Any changes in those guidelines would not only affect veterans suffering from the condition, but a much wider population of patients. According to the experts, seven percent of Americans -- about 20 million people -- can expect to experience some form of PTSD during their lifetime.

In their review of the data, the IOM researchers pored through 53 trials investigating the effectiveness of medications against PTSD, including anticonvulsants, selective serotonin reuptake inhibitors (SSRIs) antidepressants (which include drugs such as Celexa, Paxil, Prozac and Zoloft), monoamine oxidase inhibitors, and certain antipsychotics.

They also looked at 37 studies that focused on the use of psychotherapies against PTSD. Those approaches included exposure therapy, cognitive therapy, coping skills training, and hypnosis.

Only studies involving exposure psychotherapy provided enough quality evidence to support the claim that it can ease PTSD, the researchers said.

All of the other pharmaceutical or behavioral treatments failed to reach that threshold, leaving the IOM team uncertain as to whether or not the therapies might be effective.

Much of that uncertainty was due to a preponderance of poorly conducted or incomplete trials, the experts said.

For example, many studies had participant dropout rates between 20 percent and 50 percent, making it nearly impossible for researchers to draw reliable conclusions.

In other cases, investigators weren't "blinded" as to which patients were getting a particular treatment or not, allowing bias to potentially creep into the results.

Furthermore, "the majority of the drug studies have been funded by the pharmaceutical manufacturers, and the majority of the psychotherapy studies have been conducted by the individuals who developed the techniques, or by their close collaborators," Berg noted. To help avoid bias, "We recommend that a broader range of investigators be supported to conduct studies that will replicate and confirm earlier studies," he said.

One expert wasn't surprised by the lack of consistent, quality data on PTSD treatments.

"PTSD does not take the same form in every person, and it doesn't have the same severity in every person," said Dr. Charles Goodstein, a clinical professor of psychiatry at New York University School of Medicine. "So, you're dealing with a very heterogeneous population and, moreover, the treatments for this population probably have to be tailor-made."

That assessment dovetails with the IOM report, which stressed the need for high-quality research on the effectiveness of treatments for particular types of patients. "These subpopulations include people with concurrent disorders such as substance abuse, depression, ethnic minorities and veterans with traumatic brain injuries," Berg said.

Conducting large, rigorous trials will cost money, but it could save the government many more dollars in the end, not to mention easing the burden on patients, Goodstein added.

"Why should people be subjected to forms of treatment that may not work?" he said. "Why should the government be paying money for treatments that don't work? Why should people be suffering with symptoms longer than they have to? These are all important questions, and that's really the bottom line of this report."

More information

Find out more about PTSD at the U.S. Department of Veterans Affairs.

Posted: October 2007


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