PTSD Treatment: The State of the Evidence

Paula P. Schnurr, Ph.DPaula P. Schnurr, Ph.DVA National Center for PTSD, Executive DivisionVA National Center for PTSD, Executive Division

Dartmouth Medical SchoolDartmouth Medical School

Overview

• Review evidence on the treatment of PTSD

• Describe the new VA/DoD Practice Guideline for PTSD

• Discuss implications for treating women veterans

Effectiveness of Treatments for PTSD

Only significant 1st and 2nd level categories are shown.

– Watts, Schnurr et al., under review. Effect sizes are represented as a modified Hedges g, indicating benefit relative to a control group. N = number of comparisons.

Meta-Regression of Psychotherapy and Medication Effects

Psychotherapy Medication

Effect size 1.13 .36**

Adjusted effect sizea .91 .41*

aAdjusted for type of comparison group, missing data procedure, blinding, % of veteran subjects, and % of women. *p<.05, **p<.001

– Watts, Schnurr et al., under review. Effect sizes are represented as a modified Hedges g, indicating benefit relative to a control group.

Effect Sizes for Types of Medication

NAnti-

depressantsEffect size(95% CI)

NAtypical Anti-

psychoticsEffect size(95% CI)

18 SSRIs .42 (.26-.58) 6 Risperidone .50 (.12-.87)

2 Venlafaxine .48 (.33-.63) 2 Olanzapine-.10 (-1.52-

1.31)

3 Tricyclics .36 (-.01-.73)

4 MAOIs .28 (-.10-.65)

3 Other ADs .14 (-.28-.55)

– Watts, Schnurr et al., under review. Effect sizes are represented as a modified Hedges g, indicating benefit relative to a control group.

Effect Sizes for Eye Movement Desensitization & Reprocessing for PTSD

–Chemtob et al., 2000, from ISTSS Practice Guideline

Effect Sizes for Types of Cognitive-Behavioral Therapy

Primarily Cognitive

Primarily Exposur

e

Cognitive &

Exposure

Stress Inoculation

Effect size

1.71 1.09 1.31 1.37

95% CI 1.21.2.12 .86-1.33 .93-1.69 .80-1.94

% waitlist control

71% 48% 72% 100%

All comparisons between treatments are not statistically significant

– Watts, Schnurr et al., under review. Effect sizes are represented as a modified Hedges g, indicating benefit relative to a control group.

Effect Sizes for Psychotherapy & Medication by Percentage of Veteran Subjects

N Psychotherapy N Medication

0% 53 1.26 (1.09-1.43) 10 .43 (.19-.69)**

1-20% 3 1.09 (.70-1.50) 17 .49 (.42-.56)*

21-99% 0 — 5 .19 (.00-.45)

100% 12 .46 (.11-.81) 19 .30 (.09-.52)

Psychotherapy > medication: *p<.05, **p<.001

– Watts, Schnurr et al., under review. Effect sizes are represented as a modified Hedges g, indicating benefit relative to a control group.

VA/DoD Clinical Practice Guideline for Management of Post-Traumatic Stress Update–2010

www.healthquality.va.gov www.qmo.amedd.army.mil

Why Have Clinical Practice Guidelines?

• To inform practice• To enhance patient

outcomes• To reduce unnecessary

variation• To promote efficient and

effective use of resources

Methods of Guideline Development

• Based on systematic reviews and meta-analyses of evidence

• Guidelines vary in what is considered and how evidence is weighted

- Well-done randomized controlled trials carry the highest weight

- Other studies may be considered- Quality and amount of evidence is considered

VA/DoD Guideline Content

• Module A: Acute stress reaction, early interventions, preventing PTSD

• Module B: Treatment of PTSD, management of specific symptoms

Event 4 days 1 month 3 months

ASR ASD | Acute PTSD Chronic PTSD

Module A | Module B

– Adapted from M.J. Friedman

Differences From the 2004 VA/DoD Guideline

• Original 5 modules have been consolidated into 2 modules:1. Acute Stress Response and early prevention of

PTSD

2. Treatment of PTSD

• Guideline recommendations are patient-centered, regardless of setting of care

• Psychological First Aid – Key concept as initial response

– Adapted from M.J. Friedman

More Differences From the 2004 VA/DoD Guideline

• Pharmacotherapy for prevention is now not recommended- Brief psychotherapy for symptomatic (> 2 weeks)

trauma survivors is recommended

• Stronger evidence for 1st line treatments:- Psychotherapy CBT (ET, CT, --SIT,

EMDR)- Pharmacotherapy (SSRI/SNRI)

• Inclusion of CAM: acupuncture• Recommendations to address specific symptoms

of insomnia, pain and anger– Adapted from M.J. Friedman

Strength of Recommendations

VA/DoD Practice Guideline: Psychotherapy Recommendations

Balance = Benefit - HarmSR SUBSTANTIAL SOMEWHAT UNKNOWN

A • Trauma-focused psychotherapy that includes components of exposure and/or cognitive restructuring; OR

• Stress inoculation training

C Patient Education, Imagery Rehearsal Therapy, Psychodynamic Therapy, Hypnosis, Relaxation Techniques, Group Therapy

I Family therapy Web-Based CBT,Dialectical Behavior Therapy, Acceptance & Commitment Therapy

SR = Strength of recommendation(Full Guideline, p. 115).

Level A Psychotherapy Choices

• Patients should be offered one of the evidence-based trauma-focused psychotherapeutic interventions that include components of exposure and/or cognitive restructuring; OR stress inoculation training. [A]

• Choice should be based on symptom severity, clinician expertise, and patient preference, and may include:

- Exposure therapy (e.g., Prolonged Exposure)

- Cognitive therapy (e.g., Cognitive Processing Therapy)

- Stress management therapy (e.g., SIT) or

- Eye Movement Desensitization & Reprocessing (EMDR)

Understanding the Evidence on Group-Based Treatment

• Recommendation for group: “Consider offering or providing” [Strength of recommendation: C]

• Findings do not favor trauma-focused vs. present-focused [Strength of recommendation: I]

• Analytic problems with current evidence- Influence of group members on each other can cause

observations to be statistically nonindependent

- Failing to address group clustering causes treatment effects to be overestimated

Effects of Corrected Analysis on Results of Group Treatment

Baldwin et al. (2006) reanalysis of significant tests for evidence-based group treatments-Corrected dfs-Varied ICC assumptions

Implications: evidence is optimistically biased

VA/DoD Practice Guideline: Pharmcotherapy Recommendations

Balance = Benefit - Harm

SR SUBSTANTIAL SOMEWHAT UNKNOWN NONE or HARM

A SSRIs, SNRIs

B Mirtazapine, Atypical AP (adjunct), TCAs, MAOIs (phenelzine), Prazosin (sleep), Nefazodone (caution)

C Prazosin (PTSD)

D Guanfacine, Topiramate, Valproate, TiagabineBenzodiazepines (harm)

I Buspirone, Bupropion, Non-benzo hypnotics, Lamotrigine, Clonidine, Gabapentin, Trazodone (adjunct), Atypical anti-psychotics (mono), Conventional anti-psychotics, Propranolol

SR = Strength of recommendation(Full Guideline, p. 149).

Pharmacotherapy Choices

• As monotherapy, strongly recommend [A]:

- SSRIs (fluoxetine, paroxetine, and sertraline have strongest support)

- SNRIs (venlafaxine has the strongest support for treatment of PTSD)

• As adjunctive therapy, recommend [B]:

- Atypical antipsychotics (risperidone and olanzapine)

– Adapted from M.J. Friedman

VA/DoD Guideline: Therapy Selection

• Explain the range of available and effective therapeutic options for PTSD to all patients with PTSD

• Patient education is recommended as an element of treatment of PTSD for all patients and family members [C]

• Patient and provider preferences should drive the selection of evidence-based psychotherapy and/or evidence-based pharmacotherapy as 1st line treatment

• Psychotherapies should be provided by practitioners who have been trained in that particular method

• A collaborative care approach to therapy administration, with care management, may be considered

In FY 2010, 5.9% of VA users were women

•Overall, 10.9% of women had PTSD vs. 8.2% of men

•Among OEF/OIF Veterans, 17.3% of women had PTSD vs. 23.6% of men

The Percentage of Veterans Who are Women is Growing

– National Center for Veterans Analysis and Statistics, 2010

Women Who Use VA have Poorer Health Relative to Women in the General Population

0

20

40

60

80

100

PF RP BP GH RE MH VT SF

SF-36 Subscales

Me

an

Sc

ore

– Frayne et al., J Gen Intern Med 21:S40 (2006)

Veterans

General population

Mental Health Subscales

Among VA Users, Women are More Likely Than Men to have Mental Health Problems

0

5

10

15

20

25

Women Men

From Frayne, VA Women’s Health Evaluation Initiative. Percents are based on presence of at least 2 instances of mental health condition ICD-9 codes in VA outpatient administrative data in FY08; includes veteran patients only. 26

31% of women vs. 20% of men have a diagnosed mental health condition

Among VA Users, Women are More Likely Than Men to have Military Sexual Trauma

VA Users Screened for MST

Men Women

Veterans Screened FY 2005 (N = 3,045,000)

1.1% 21.8%

OEF/OIF Veterans Screened FY 2001-2007 (N = 126,729)

0.7% 15.1%

– Kimerling et al., 2007 & in press

Implications of Findings for Treating PTSD in Women Veterans

• Sexual trauma is likely to be a focus

- e.g., in CSP #494 (Prolonged Exposure), 70% identified it as their index trauma

- Warzone trauma more common in OEF/OIF

• Little investigation of whether gender affects treatment response

- No conclusive evidence to date

• Some women prefer gender-specific treatment in women’s clinics & groups

Future Directions

• How do we maximize efficiency?- e.g., using D-cycloserine to boost the

effectiveness of exposure therapy

• How do we enhance access?- e.g., using telehealth

• What works for whom?- e.g., using comparative effectiveness

research to identify optimal strategies for individual patients