Our nation's veterans continue to suffer emotional and psychological effects of war--some for decades. And while there has been greater attention directed recently toward post-traumatic stress disorder (PTSD), and more veterans are seeking help, current psychotherapy treatments are less than optimal, according to a new narrative review published in the August 4, 2015 issue of JAMA.
In a review of medical literature over a 35-year period, researchers from the Steven and Alexandra Cohen Center for Post-Traumatic Stress and Traumatic Brain Injury -- a program in the Department of Psychiatry at NYU Langone Medical Center -- and other institutions found that non-medical approaches to treat PTSD were effective in some patients but not in others, suggesting a need for broader, more personalized approaches to care.
The researchers looked at randomized clinical trials of psychotherapy for military-related PTSD to examine which psychotherapies improve symptoms. This included, in particular, a review of trials of two commonly-used, evidence-based treatment models: cognitive processing therapy (CPT) and prolonged exposure (PE) therapy.
Searches were conducted via PubMED, PsycINFO, and PILOTS for randomized clinical trials of individual and group psychotherapies for PTSD in military personnel and veterans published from January 1980 to March 2015. Of 891 publications initially identified, 36 were included in the JAMA Narrative review, representing 2,083 participants.
"Our findings showed that PE and CPT are not as broadly effective as we might have once thought or hoped," says Maria M. Steenkamp, PhD, assistant professor of psychiatry at NYU Langone and lead author of the study. "As many as two-thirds of veterans receiving CPT or PE keep their PTSD diagnosis after treatment, even if their symptoms improve. So there is room for improvement."
"The emotional effects of war are gaining attention," says Charles R. Marmar, MD, the Lucius Littauer Professor and chair of psychiatry at NYU Langone, director of its Cohen Veterans Center, and the senior author of the JAMA study. "And there are veterans from all wars who are struggling, not just those who most recently served in the wars in Iraq and Afghanistan."
In fact, recently released findings from another study led by Dr. Marmar and published July 22, 2015 in JAMA Psychiatry --the National Vietnam Veterans Longitudinal Study--found that over 270,000 Vietnam veterans -- 40 years since the end of that war -- are still suffering from clinically important levels of PTSD symptoms, and one-third of those have a current, major depressive disorder.
"There is a pressing need for innovation in treatments for PTSD and TBI to protect a new generation of veterans," adds Dr. Marmar.
Dr. Steenkamp suggests that the JAMA study indicates there is still much to learn about how to optimize PTSD treatments of veterans. "It is clear that there is no one-size-fits-all approach," she says. "Ideally, we have to move toward clinical options that match patients to treatments, based on their preferences and their comfort with talking about their trauma. One thing we do know is that veterans are unlikely to benefit unless they complete a full course of treatment. Finding ways to develop treatments that align with patient needs and preferences is important."
The U.S. Veterans Administration and the U.S. Department of Defense have been funding such approaches to treatment, Dr. Marmar says. "There are encouraging findings that while therapies that focus on processing trauma are generally effective for veterans who complete that course of treatment, there are alternatives for veterans who are emotionally unprepared to confront their war-zone experiences," he adds.
Understanding the underlying mechanisms that occur in specific patients is key. A novel five-year multicenter study led by NYU Langone's Cohen Veterans Center is looking into objective biological markers of PTSD and TBI in returning soldiers of the wars in Iraq and Afghanistan. The goal is to transform the way mental health disorders are diagnosed by identifying specific brain imaging and blood and other biological markers that can tell clinicians definitively that a person is suffering from PTSD or TBI or a combination. Presently, there is no single valid diagnostic test that can independently confirm either diagnosis. Stanford University, Emory University and the U.S. Department of Defense Systems Biology Program at Fort Detrick, Maryland are partners in this research.
"Collectively, these studies may bring us one-step further in tailoring treatment to the individual, monitoring progress, and measuring long-term effectiveness," Dr. Marmar says.
In addition to Drs. Steenkamp and Marmar, co-authors of this study include: Brett T. Litz, PhD, VA Boston Healthcare System, and Charles W. Hoge, MD, Walter Reed Army Institute of Research.