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Viewpoint |

True Evidence-Based Care for Posttraumatic Stress Disorder in Military Personnel and Veterans

Maria M. Steenkamp, PhD1,2
[+] Author Affiliations
1Steven and Alexandra Cohen Veterans Center for Posttraumatic Stress and Brain Injury, New York University Langone School of Medicine, New York
2Department of Psychiatry, New York University, New York
JAMA Psychiatry. 2016;73(5):431-432. doi:10.1001/jamapsychiatry.2015.2879.
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This Viewpoint discusses true evidence-based practice and using it to personalize treatment for military veterans and servicemembers with posttraumatic stress disorder.

As the longest wars in US history draw to a close, treating the psychosocial sequelae of military trauma has become an important public health challenge. In contrast to previous wars, mental health care is for the first time leveraging science to treat deployment-related conditions such as posttraumatic stress disorder (PTSD). Evidence-based practice has become a driving principle behind the treatment of military-related PTSD and is considered a necessary safeguard against the use of unproven and ineffective interventions. However, a truly evidence-based approach to treating military-related PTSD differs from what it has come to mean in the recent clinical and research literature.

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True Evidence-Based Care for Posttraumatic Stress Disorder in Military Personnel and Veterans - A Reply
Posted on March 10, 2016
Sonya B. Norman (1), Kathleen M. Chard (2), Sheila A. M. Rauch (3), Edna B. Foa (4), Candice M. Monson (5), Patricia A. Resick (6)
(1) National Center for PTSD, (2) Cincinnati VA Medical Center, (3) Atlanta VA Medical Center, (4) University of Pennsylvania, (5) Ryerson University, (6) Duke University
Conflict of Interest: None Declared
In her opinion piece, Steenkamp (1) asserts that true evidence-based practice includes individualized integration of the specific relevant evidence base, clinical judgement, and patient preference. She notes that a large body of evidence supports the efficacy of cognitive processing therapy (CPT) and prolonged exposure therapy (PE) for the treatment of posttraumatic stress disorder (PTSD) but expresses concern that there is not yet adequate data with veterans. Specifically, she writes that only 5 RCTs have been conducted with PE or CPT with veterans and that more effectiveness research is needed.

In fact, Steenkamp omitted several studies that have shown effectiveness in U.S. and international veteran and service member groups. (See 2,3,4) She unfairly disregarded significant available data, asserting that some studies were conducted by clinics with “allegiance” to either CPT or PE.

It is also worth noting that the argument that 2 to 3 efficacy studies with a given population are not adequate to establish efficacy with that population is inconsistent with standards of psychotherapy treatment research. (5) Two or more well-done RCTs with a specific population are adequate to establish efficacy. Continuing to conduct basic efficacy trials is redundant, a poor use of resources, and it is questionable whether this would be ethical. Instead, the field must move forward to new questions, including how to make these treatments work better, faster, and with more patients.

Steenkamp notes that the VA/DoD Clinical Practice Guideline for PTSD (6) recommends PE and CPT as first-line treatments for PTSD. There are additional compelling reasons to offer these treatments to veterans. Several other guidelines and reviews of PTSD treatment (2,4,5,6,7,8) also give CPT and PE first tier ratings. In addition, both treatments call for clinician judgement and a strong working alliance in implementing the interventions with a given client. In this vein, PE and CPT are effective not only for treating PTSD but also for treating associated problems, including depression, general anxiety, guilt, suicidal ideation, anger and quality of life.

Given extensive research establishing the efficacy of CPT and PE, the more than adequate research specifically with veterans and service members, and the consistency with which these treatments are recommended as first line treatments, makes ignoring available evidence in treatment planning a disservice and irresponsible care. Further, implementing PE and CPT in their various approved formats, with always-paid attention to the therapeutic relationship and patient preference, shows good clinical judgement.

References

1. Steenkamp MM. (2016). True evidence-based care for posttraumatic stress disorder in military personnel and veterans. JAMA Psychiatry, 2016;published on line ahead of print. Published on-line on 02/17/2016. doi:10.1001/jamapsychiatry.2015.2879.

2. Foa EB, Keane TM, Friedman MJ, & Cohen J. (Eds.). Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies (2nd ed.). New York: Guilford Press; 2008.

3. Karlin BE, Ruzek JI, Chard KM, Eftekhari A, Monson CM, Hembree EA, Foa EA. Dissemination of evidence-based psychological treatments for posttraumatic stress disorder in the Veterans Health Administration. Journal of Traumatic Stress, 23, pp 663-673; 2010.

4. Jonas DE, Cusack K, Forneris CA, et al. Psychological and Pharmacological Treatments for Adults With Posttraumatic Stress Disorder (PTSD) [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2013 Apr. (Comparative Effectiveness Reviews, No. 92.) Available from: http://www.ncbi.nlm.nih.gov/books/NBK137702/

5. Institute of Medicine (IOM). Treatment of PTSD: Assessment of the evidence. Washington, DC: National Academies Press; 2007.

6. Management of Post-Traumatic Stress Working Group. VA/DOD clinical practice guideline for management of post-traumatic stress. Washington (DC): Department of Veterans Affairs, Department of Defense; 2010. Available from:http://www.healthquality.va.gov/ptsd/ptsd_full.pdf

7. Institute of Medicine (IOM). Treatment of Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Washington, DC: National Academies Press; 2014.

8. Institute of Medicine (IOM). Treatment of Posttraumatic Stress Disorder in Military and Veteran Populations: Initial Assessment. Washington, DC: National Academies Press; 2012.

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