PTSD Treatment: The State of the Evidence

1. PTSD Treatment: The State of the Evidence Paula P. Schnurr, Ph.D VA National Center for PTSD, Executive Division Dartmouth Medical School

2. Overview • Review evidence on the treatment of PTSD • Describe the new VA/DoD Practice Guideline for PTSD • Discuss implications for treating women veterans

3. 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.

4. Meta-Regression of Psychotherapy and Medication Effects – Watts, Schnurr et al., under review. Effect sizes are represented as a modified Hedges g, indicating benefit relative to a control group.

5. Effect Sizes for Types of Medication

6. Effect Sizes for Eye Movement Desensitization & Reprocessing for PTSD –Chemtob et al., 2000, from ISTSS Practice Guideline

7. Effect Sizes for Types of Cognitive-Behavioral Therapy – Watts, Schnurr et al., under review. Effect sizes are represented as a modified Hedges g, indicating benefit relative to a control group.

8. Effect Sizes for Psychotherapy & Medication by Percentage of Veteran Subjects – Watts, Schnurr et al., under review. Effect sizes are represented as a modified Hedges g, indicating benefit relative to a control group.

9. VA/DoD Clinical Practice Guideline for Management of Post-Traumatic Stress Update–2010 www.healthquality.va.gov www.qmo.amedd.army.mil

10. Why Have Clinical Practice Guidelines? • To inform practice • To enhance patient outcomes • To reduce unnecessary variation • To promote efficient and effective use of resources

11. 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

12. VA/DoD Guideline Content • Module A: Acute stress reaction, early interventions, preventing PTSD • Module B: Treatment of PTSD, management of specific symptoms Module A | Module B Event ASR ASD | Acute PTSD Chronic PTSD 4 days 1 month 3 months – Adapted from M.J. Friedman

13. Differences From the 2004 VA/DoD Guideline • Original 5 modules have been consolidated into 2 modules: • Acute Stress Response and early prevention of PTSD • 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

14. More Differences From the 2004 VA/DoD Guideline • Pharmacotherapy for prevention is now notrecommended • Brief psychotherapy for symptomatic (> 2 weeks) trauma survivors is recommended • Stronger evidence for 1st line treatments: • PsychotherapyCBT (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

15. Strength of Recommendations

16. VA/DoD Practice Guideline: Psychotherapy Recommendations SR = Strength of recommendation (Full Guideline, p. 115) .

17. 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; ORstress 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)

18. 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

19. 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

20. VA/DoD Practice Guideline: Pharmcotherapy Recommendations SR = Strength of recommendation (Full Guideline, p. 149) .

21. 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

22. 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

23. 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

24. The Percentage of Veterans Who are Women is Growing – National Center for Veterans Analysis and Statistics, 2010

25. Women Who Use VA have Poorer Health Relative to Women in the General Population Mental Health Subscales • Veterans • General population – Frayne et al., J Gen Intern Med 21:S40 (2006)

26. Among VA Users, Women are More Likely Than Men to have Mental Health Problems 31% of women vs. 20% of men have a diagnosed mental health condition 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

27. Among VA Users, Women are More Likely Than Men to have Military Sexual Trauma – Kimerling et al., 2007 & in press

28. 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

29. 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