Broadening the Approach to Posttraumatic Stress Disorder and the Consequences of Trauma

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JAMA

August 4, 2015

It is common for individuals to experience potentially life-threatening traumatic events over the course of their lives and subsequently to experience psychological distress associated with the traumatic events. Although most people recover from such distress without lasting consequences, some develop posttraumatic stress disorder (PTSD), which, left untreated, may result in symptoms, such as nightmares, intrusive memories, and emotional numbing, that can last for decades.¹

Military personnel are at particularly high risk of PTSD because deployments to combat zones increase the risk of exposure to trauma. The effects of PTSD on military and civilian patients, their families, and society in general can be profound. Posttraumatic stress disorder is associated with increased risks of suicide, depression, substance use disorders, intimate partner violence, unemployment, and persistently low quality of life.² In addition, trauma and PTSD are associated with a higher risk of other health problems, including coronary artery disease, arthritis, asthma, gastrointestinal symptoms, and all-cause mortality.^3,4 There are also spiritual and moral dimensions to experiencing or committing acts of trauma, which can endure across the life span.⁵

Given the marked influence of PTSD on multiple domains of health and well-being, reliable assessment tools and effective treatments for PTSD suitable for broad implementation are needed. To aid the field in identifying reliable assessment tools, Spoont et al⁶ reviewed the literature on brief screening instruments and report their findings in this issue of JAMA. Based on their evaluation of 23 studies involving 15 different screening instruments for PTSD, the authors determined that 2 screening instruments, the Primary Care PTSD screener (PC-PTSD) and the PTSD Checklist (PCL), performed best. The 4-item PC-PTSD had a positive likelihood ratio of 6.9 (95% CI, 5.5-8.8) and a negative likelihood ratio of 0.30 (95% CI, 0.21-0.44) using the same score indicating a positive screening result as used by the Department of Veterans Affairs in all of its primary care clinics. The 17-item PCL had a positive likelihood ratio of 5.2 (95% CI, 3.6-7.5) and a negative likelihood ratio of 0.33 (95% CI, 0.29-0.37) using scores of around 40 as indicating a positive screening result. The authors suggest that the performance characteristics of these 2 screening tools may make them reasonable for use in primary care clinics or in community settings with high-risk populations.

Also in this issue of JAMA, Steenkamp et al⁷ reviewed 36 clinical trials of individual and group psychotherapies for military-related PTSD involving 2521 patients and provide evidence that treatment outcomes are often suboptimal. The authors report that 2 trauma-focused therapies, cognitive processing therapy (CPT) and prolonged exposure, have been the most frequently studied psychotherapies for military-related PTSD. The review found that approximately half to two-thirds of participants receiving CPT and prolonged exposure attained clinically meaningful symptom improvement (defined as a 10- to 12-point decrease in interviewer-assessed or self-reported symptoms). However, two-thirds of treatment responders continued to have symptom scores that exceeded the threshold for a diagnosis of PTSD. New innovative and engaging approaches for the treatment of PTSD are needed.

Steenkamp et al⁷ also found that trauma-focused psychotherapies, which are considered first-line therapies in most treatment guidelines for military-related PTSD, yielded outcomes that were only marginally superior to non–trauma-focused approaches. Trauma-focused therapies are forms of cognitive behavioral therapy that assist patients to confront their memories, thoughts, emotions, and beliefs associated with the traumatic event(s). Trauma-focused therapies include CPT, prolonged exposure therapy, and eye movement desensitization and reprocessing therapy. In contrast to trauma-focused therapies, non–trauma-focused approaches do not directly address trauma-related beliefs, emotions, or memories but instead teach coping skills such as stress management, relaxation, and problem solving for situations when patients are faced with reminders of the trauma, relationship difficulties, and other daily stressors.

Present-centered therapy (PCT) is a non–trauma-focused therapy that emphasizes problem solving and can be delivered in a group format. Rather than teaching patients new coping skills, PCT emphasizes the individual’s existing skills and strengths to cope effectively with current stressors that may be exacerbated by PTSD symptoms.⁸ In their review, Steenkamp et al⁷ report that PCT is only marginally inferior to trauma-focused therapies for military-related PTSD. For example, a recent randomized trial by Suris and colleagues⁹ found that although CPT was associated with significantly greater reductions in PTSD at the immediate posttreatment assessment than was PCT, these between-group differences did not persist at the 2-, 4-, or 6-month follow-ups. Additionally, in a trial comparing prolonged exposure and PCT, Schnurr and colleagues¹⁰ found that although prolonged exposure was associated with a small statistically significant advantage over PCT, there were no clinically meaningful differences between the 2 therapies. An advantage of PCT is its acceptability to patients, as evidenced by a recent meta-analysis that found that PCT had superior treatment retention compared with trauma-focused therapies.⁸

Also in this issue of JAMA, Polusny et al¹¹ report the results of a clinical trial comparing 2 non–trauma-focused therapies, mindfulness-based stress reduction (MBSR) and PCT. The investigators randomly assigned 58 veterans with PTSD to receive MBSR and another 58 to receive group PCT, delivered in 9 weekly group sessions. The MBSR program teaches mindfulness meditation practices to enhance the ability of patients with PTSD to attend to their thoughts, emotions, and sensations with an attitude of nonjudgment, kindness, and curiosity. The investigators found that compared with PCT, MBSR (modified from its widely available form by the addition of educational materials about PTSD in the first session) resulted in greater reduction in self-reported PTSD symptoms at 2-month follow-up (change in mean PTSD Checklist scores with MBSR, from 63.6 to 54.4 vs with PCT, from 58.5 to 56.0; difference, 6.44; 95% CI, 3.34-9.53; P < .001) and improved quality of life (change in mean score on the World Health Organization Quality of Life–Brief with MBSR, from 75.6 to 80.2 vs with PCT, from 76.4 to 75.8; mean difference in improvement, 5.22; 95% CI, 1.73-8.71; t = 2.94; P=.004; d = 0.73). However, there was no significant between-group difference in the rate of remission of PTSD diagnosis.

The rate of clinically significant PTSD symptom reduction of 49% for those randomized to MBSR is similar to that reported for empirically supported treatment approaches to PTSD, as described above, and consistent with the rate of clinically significant improvement in PTSD symptoms of 48% found in a before-and-after study of MBSR among veterans.¹² Although the results reported by Polusny et al¹¹ are promising, the short duration of follow-up calls into question whether the effects of MBSR persist over time; thus, additional studies of MBSR and other mindfulness-based interventions for PTSD are warranted.

Group interventions such as PCT and MBSR could expand the availability of therapies for PTSD. Given the large number of individuals with PTSD, not all of whom will opt for or benefit sufficiently from existing approaches, additional treatments suitable for broad implementation are needed. If additional studies confirm that MBSR is efficacious for PTSD, it may represent a cost-effective approach to care. Mindfulness-based stress reduction can be led by facilitators who are not psychotherapists, which could expand the availability of PTSD practitioners and services. Other non–trauma-focused approaches to PTSD include forms of meditation for which there is initial support among military personnel.^13,14

The contrasting approaches of trauma-focused and non–trauma-focused therapies for PTSD and the generally suboptimal rates of symptom reduction among PTSD therapies in general raise the question of whether clinical strategies such as accounting for patient preference and patient-treatment matching should be used to improve response rates. Preferences for one mode of therapy or another may influence the willingness of a patient to initiate and remain in treatment, which in turn may affect therapeutic efficacy. In a randomized trial of patient preference for PTSD psychotherapy or the antidepressant sertraline, a previous report by Le and colleagues¹⁵ found that allowing patients to choose their treatment was cost-effective. Additional studies are needed to understand the effects of patient preference on PTSD treatment outcomes. In addition, this approach is consistent with an emerging approach in medicine that emphasizes patient-centered care.

With regard to patient-treatment matching, there is currently little available evidence regarding which patients are likely to benefit most from which particular treatments. Thus, there are limited meaningful data with which to educate patients about treatment approaches that may be especially helpful to them personally. However, a pilot study of a 30-minute shared decision-making intervention showed promise as a technique to increase engagement in evidence-based treatment for PTSD,¹⁶ but more definitive studies are needed. Patient-centered decision aids have the potential to increase overall treatment efficacy and decrease costs associated with serial unsuccessful treatment attempts.

Although there could be multiple reasons for the limited response rates observed in clinical trials, the review by Steenkamp et al⁷ also suggests that interventions of limited duration (typically 2-3 months) may not be a realistic model of care for patients with PTSD. Time-limited approaches work well for some patients.¹⁷ However, patients who have PTSD that has persisted for years may require long-term care, just as patients with other chronic medical or psychiatric disorders, such as diabetes, chronic pain, and substance use disorders, require ongoing clinical management. For veterans who have had PTSD for decades, a long-term approach that encourages them to continue to actively address symptoms could be helpful. Thus, the development and evaluation of long-term treatment models are needed.

Another potential approach for improving patient outcomes is to involve family members in treatment, as recommended in a recent report of PTSD therapy by the Institute of Medicine.¹⁸ For mindfulness-based and other skills-based approaches, inclusion of family members in groups or homework practices might help support the patients to consistently practice the new skills at home and in their everyday lives through encouragement and reminders that are available more frequently and organically than would be the case through weekly sessions with the instructor. Additionally, if family members are also learning more effective ways of coping with stress and the family is working together to support the patient, these efforts might lead to additional gains over time or shifts in family relational dynamics in support of a more robust recovery.

It has also been suggested that available PTSD therapies focus too narrowly on the remission of symptoms such as intrusion, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity. Posttraumatic stress disorder and its initiating traumatic events can affect multiple domains of health. Although many trials of PTSD treatments have included quality-of-life assessments, little attention has been paid to quality of life as a therapeutic goal for patients with PTSD.¹⁹ From a patient’s point of view, an improvement in quality of life is likely to be clinically meaningful, especially for those whose posttreatment symptom scores remain at or above the threshold criteria for PTSD. A potentially advantageous aspect of mindfulness-based interventions is that they may provide benefit for domains of health beyond PTSD symptomatology. A recent VA Evidence-based Synthesis Program report²⁰ indicated a benefit of MBSR for overall health status, depression, chronic illness, and possibly pain—conditions that commonly accompany PTSD.

Substantial progress is being made in the recognition and treatment of PTSD, but additional work is needed to identify treatments that improve long-term outcomes in patients with PTSD. Taken together, the articles by Spoont et al,⁶ Steenkamp et al,⁷ and Polusny et al¹¹ offer important insights into the assessment of PTSD as well as psychotherapy approaches for treating it. Given that PTSD is a disabling and often persistent illness that can affect individuals exposed to different types of trauma, it is essential to develop therapeutic alternatives for patients to achieve their personal therapeutic goals.

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