The wars in Iraq and Afghanistan have given rise to significant rates of posttraumatic stress disorder in service members and veterans.
Although estimates vary, most experts agree that rates of PTSD may be as high as 15 percent. Veterans of the Vietnam War share a similar prevalence rate.
Often referred to as the “signature injury” of our country’s most recent military conflicts, PTSD is indeed a complex and troubling psychiatric issue faced by hundreds of thousands of current and former military personnel.
Millions of dollars are spent each year funding federal, academic, and non-profit agencies focused on developing and refining treatments, exploring means for prevention, and improving quality of life.
In spite of the efforts over the past decade, few advances in treatment of combat PTSD have occurred. Currently, preferred trauma-focused psychotherapies include cognitive processing therapy (CPT) and prolonged exposure (PE).
Although other treatments are available and used such as Eye Movement Desensitization and Reprocessing, Stress Inoculation, and Accelerated Resolution Therapy, CPT and PE receive the most research attention and receive greater support with the Departments of Veterans Affairs and Defense.
But, a recent study published in the Journal of the American Medical Association reveals that these trauma-focused therapies may not be as effective as once thought.
Researchers reviewed close to 900 publications for possible inclusion in the study; three dozen made the cut.
The studies included in the analyses were PTSD focused randomized clinical trials of individual and group psychotherapies with veterans and active duty troops.
Impressively, the publication dates of the included studies ranged from 1980 to 2015. After analyzing data from nearly 900 individuals diagnosed with PTSD who received CPT or PE, the study revealed two important results: approximately two-thirds of troops continued to meet criteria for a PTSD diagnosis after “successful” treatment and one-quarter dropped out.
The results do not mean that CPT and PE are ineffective. There are numerous studies with civilian trauma survivors highlighting high tolerability and efficacy rates.
And in the present review, results were meaningful when CPT and PE were compared to no treatment at all.
In fact, a sizable proportion of service members and veterans showed clinically meaningful drops in measures designed to assess the presence of trauma symptoms.
Unfortunately, reductions in scores on these clinical measures were not significant enough in two-thirds of patients to be classified as remitted or “cured.”
And, of even greater significance is that when compared to non-trauma focused treatments like interpersonal psychotherapy and present-centered therapy, PE and CPT were only marginally better.
The results from the review support a longstanding and seemingly valid criticism that trauma-focused therapies are too distressing for a subset of patients, which leads to dropout or premature termination.
Approximately one in four patients terminated treatment prematurely for both treatments. And in one study of PE, nearly 40 percent quit therapy.
Reliving the most emotionally charged aspects of a trauma memory is difficult. And if the patient is not able to stay with the intervention long enough in order for habituation to the memory to occur then it’s unlikely improvement in symptomatology will follow.
The Bottom Line
The bottom line is that service members and veterans who receive a trauma-focused therapy for their PTSD do improve.
Unfortunately, it’s not enough.
In order to get better control of this condition that impacts a sizable portion of our military, we need to explore other treatment options.
I believe it will require us to reduce our focus on narrowly defined and proprietary interventions and refocus our efforts on individualizing an array of traditional and non-traditional services for our wounded warriors.
One option is to explore alternative and complementary treatments like equine, recreation, art, and music therapy as well as meditation and mindfulness.
These approaches to wellness and healing are gaining popularity, particularly within non-profit, non-governmental organizations.
For example, Boulder Crest Retreat, a grassroots, privately funded center in Bluemont, Virginia, provides free therapeutic retreats to combat veterans and their families utilizing these non-traditional approaches.
In order to effectively address the complex issues of combat PTSD, I believe we need to foster innovation, research, and application of those methods often overlooked by the mainstream behavioral healthcare system.
* This article was adapted from a previous article written by Dr. Moore for his column “Kevlar for the Mind.”
PTSD treatment photo available from Shutterstock