Post-traumatic stress disorder is arguably the most challenging problem combat veterans face. Estimates vary, but experts believe that between 10 and 20 percent of Iraq and Afghanistan veterans suffer from the disorder. Considering that more than two million service members have deployed over the past 15 years, the actual number of men and women affected is in the hundreds of thousands.
And this data is just those who actually meet criteria for the disorder. Countless others suffer from significant post-traumatic stress symptoms and fall short of the full-blown disorder.
Considering that PTSD wreaks havoc on the veteran and their loved ones and costs billions of dollars each year, finding and using the most effective treatments are critical.
A variety of civilian and military organizations and universities have accepted this task. To date, the results have been mixed. Arguably, the greatest strides have been made in non-pharmacological treatment options. Indeed, advances in medication have been slow and unimpressive.
Historically, medications and talk therapy have been considered “first-line treatments.” This term basically means they should be used firs, and if they fail, then you try something else. In fact, the joint treatment guidelines published by the Department of Defense and Veterans Administration puts medications and psychotherapy on equaling footing. The same is true for the American Psychiatric Association. Not all agree. The debate about whether medications or talk therapies should be first-line has been ongoing since the start of the Iraq and Afghanistan wars. More accurately, the debate has been happening much longer than that; the wars have reinvigorated the topic.
The Veterans Administration and Department of Defense guidelines and the PTSD guide book for the American Psychiatric Association have staunch opposition. Organizations from the United Kingdom and Australia and the World Health Organization take the position that trauma-focused psychotherapies such as Prolonged Exposure, Cognitive Processing Therapy and Eye Movement Desensitization and Reprocessing are most effective when it comes to treating PTSD.
Basically, their stance is that the evidence for meds is just not as strong. A recent study carried out by military and VA researchers and published in the journal Depression and Anxiety, supports this position.
After sifting through more than 60,000 possibilities, the researchers identified 55 psychotherapy and medication studies for PTSD–adding up to around 6,300 total study participants. This sample is a sizeable one from which to draw conclusions.
What did they find? Trauma-focused psychotherapies outperformed psychotherapies that do not specifically discuss the trauma. They also beat out medications.
Stress Inoculation Training
These results do not mean other psychotherapies are useless. For example, the researchers noted that Stress Inoculation Training is effective for PTSD. Stress Inoculation Training, developed by notable psychologist Donald Meichenbaum, is a credible talk therapy that has been around for decades. It just may not be as effective as the trauma-focused therapies.
The same is true for medications. A variety of medications are used for PTSD even though only two are approved by the Food and Drug Administration (sertraline [Zoloft] and paroxetine [Paxil]).
These drugs, as well as fluoxetine [Prozac], citalopram [Celexa], and escitalopram [Lexapro] are commonly used for PTSD and they do work for some people. But again, they may not be as useful as certain psychotherapies, particularly those that focus specifically on the trauma.
Moreover, these medications also cause intolerable side effects for some. The most common include stomach upset, sexual dysfunction and insomnia.
But, in all fairness, a valid criticism of trauma-focused therapies is that they also cause side effects that lead to early dropout and termination. Specifically, the emotional intensity of reliving the trauma through talking and thinking about it is too much for some to handle.
The bottom line is that the current United States based treatment guidelines for PTSD may need to join the ranks of their European and Australian counterparts. Specifically, medications may need to be identified as “second-line” treatments. In other words, they should only be used if an effective talk therapy is not available.
The results of this study challenge the current status quo with regard to treating our combat veterans. It is time to take a close look at how we prioritize PTSD treatments and make adjustments to our national treatment guidelines as necessary. At a minimum, we owe this to the men and women who have sacrificed so much for our country.
*This article is adapted from Dr. Moore’s column “Kevlar for the Mind” published in Military Times.