Combination treatment with both a selective serotonin reuptake inhibitor and a form of cognitive-behavioral therapy may be more effective than either treatment alone for this debilitating and often chronic disorder.
Posttraumatic stress disorder (PTSD) is easy to miss and difficult to live with. Despite being the fifth most common psychiatric disorder, it is correctly diagnosed less than 20% of the time. And, left untreated, its symptoms can last a lifetime. The good news is that effective treatments for PTSD do exist. Both selective serotonin reuptake inhibitors and cognitive-behavioral therapy (CBT) are effective, and therapy that combines the two shows particular promise.
Researchers delivered that message to participating psychiatrists and medical directors at the Behavioral Healthcare and Informatics Tomorrow conference, held Sept. 22-25, 2002, in Washington, D.C. The two speakers, Duke University psychiatrist Jonathan Davidson, M.D., and University of Pennsylvania psychologist Edna Foa, Ph.D., are working together on a study that compares medication-only and combined treatment for patients with PTSD.
Recent studies, according to Davidson, have found that as few as 4% of PTSD cases are picked up in either academic or community health centers (Davidson, 2001).
But psychiatrists do have some room for error. Pharmacotherapy with an SSRI is widely accepted as first-line treatment for PTSD. So if a psychiatrist misdiagnoses the disorder as depression or anxiety and chooses to treat it with an SSRI, the patient's symptoms will likely improve. According to Davidson, however, PTSD requires longer-term treatment at lower dosage levels than is often the case with other disorders.
Numerous studies have found that SSRIs can quickly reduce the intensity of affective symptoms, memories and impulsive behavior while also reducing excessive inhibitions. The U.S. Food and Drug Administration approved sertraline (Zoloft) for treatment of PTSD in 1999 and paroxetine (Paxil) in 2001.
Drugs alone can be effective, but they may work even better when combined with CBT, Davidson said. Either way, treatment must be individualized and long-term.
For psychosocial treatment, correctly diagnosing PTSD is a more critical issue, Foa said. Patients with PTSD who receive psychotherapy tailored to treat the wrong disorder are not likely to get the most benefit.
Cognitive-behavioral therapy for PTSD can be divided into two approaches: prolonged-exposure therapy (PET) and anxiety management. Foa has found PET to be the more effective of the two. It involves a set of techniques designed to help patients confront situations they fear in a safe and systematic way in order to change cognition about the traumatic event. The therapy is usually completed in 10 sessions, which can take place in as few as five weeks.
Among 96 female patients in a randomized trial, PET resulted in a 65% mean reduction in PTSD symptoms, compared to no reduction in symptoms among wait-listed controls (Foa et al., 1999). Between 90% and 95% of patients who receive the therapy improve by at least 30%. Only 10% of patients recieving PET do not respond to it, and many patients remit completely, Foa said.
Data from the National Comorbidity Survey show that between 50% and 70% of people are exposed to trauma in their lifetime, but only 8% to 12% of the population will go on to develop PTSD (Kessler, 2000).
Despite its prevalence, PTSD largely goes undetected, and patients often will not volunteer information about their exposure to trauma. People usually do not complain about PTSD per se, Davidson said. Instead they have somatic complaints, depression or sleep problems. They may abuse alcohol and drugs or attempt suicide. They tend to present in emergency departments.
It is the doctor's task, Davidson said, to get behind these problems and find out whether PTSD is the cause.
Time is a critical factor in identifying and treating PTSD. Most recovery occurs in the first three months following a traumatic event and can continue through the first year, Foa said. Beyond that time, symptoms tend to persist, and PTSD becomes a chronic condition.
People who do not share their experiences and tend to push away thoughts of the trauma are more at risk for developing PTSD, Foa has found. Worse, they tend to interpret symptoms of PTSD as dangerous, so they try not to think about the event, afraid that thinking about it will cause more symptoms.
Not everyone exposed to trauma develops PTSD, a fact that can be forgotten in the moments following an event, when being traumatized can be equated with the need for therapy. "It's important to remember that most people are resilient," Foa said.
Over the years, she has advanced the theory that people who are most at risk for developing PTSD have exaggerated negative thoughts about themselves and about the world, which they tend to view as an extremely dangerous place. They also tend to engage in self-blame.
Left untreated, a person with PTSD can experience symptoms for 20 years or more. Rates of attempted suicide for PTSD sufferers are as high as 19% (Davidson et al., 1991). Comorbidity is also a problem. In addition to depression, anxiety and substance abuse, PTSD is associated with hypertension, bronchial asthma, peptic ulcers and other diseases (Davidson et al., 1991). Previous research has estimated the average work loss for people with PTSD to be 3.6 days a month, resulting in an annual loss in productivity of $3 billion in the United States (Kessler, 2000).
The disorder requires long-term treatment with medication, Davidson said. "We have to--in our own minds--have that expectation and communicate that to patients so they don't get discouraged that it's been 12 weeks and they're only 30% better."
A study led by Davidson that appeared in the December 2001 issue of the American Journal of Psychiatry was the first to examine the long-term effects of sertraline for PTSD in a double-blind, placebo-controlled trial. The study found that the largest proportion of worsening symptoms occurred during the first two months after the patient stopped taking the drug.
Prolonged-exposure therapy may mitigate the relapse that occurs after drug discontinuation, Foa reported. The therapy works to change a person's concept about what happened during a traumatic event, even decades later. For example, one woman treated by Foa had been gang-raped by four men at the age of 16. Twenty years later, she still blamed herself for what happened. It was only through the process of PET that she grew to realize that she could not have done anything to prevent what had happened to her.
It has been Foa's experience that people with PTSD who receive five weeks of such therapy, even after 20 years with the disorder, usually do not relapse. Instead, the person may experience a temporary increase in symptoms around the event's anniversary.
Prolonged-exposure therapy involves four elements: education about common reactions to trauma, breathing retraining, prolonged repeated exposure to the trauma memory, and repeated in vivo exposure to situations that the client is avoiding because of assault-related fear.
The two main procedures involved in PET are the patient's recounting of traumatic memories and in vivo confrontation with situations that remind the patient of the trauma. Recounting the memory allows the patient to reorganize it as an episodic memory, one that occurred at a specific point in time and space and is separate from other memories of similar events, Foa said.
Real-life exposure to settings that remind the patient of the trauma occurs on a sliding scale of subjective discomfort. The situation has to be safe, Foa said, and the goal is to gradually expose the patient to settings that provoke more anxiety for them. For example, a rape victim may avoid crowds or wearing dresses. On a scale of 0 to 100, going to the mall might rank a 50. Wearing a dress could be a 60 and going to a party where men are present could be a 70.
The goal for patients is to reclaim their lives, Foa said. As they gradually recover, their views about themselves and the world become more positive.
"The problem with prolonged exposure is dissemination," Foa said. But that is not for a lack of cooperation among psychologists and psychiatrists, and the therapy is now beginning to gain widespread recognition for its effectiveness.
In June, Foa's treatment program in Philadelphia received an exemplary substance abuse prevention award from the Substance Abuse and Mental Health Services Administration, and it is one of 25 model programs listed this year in its National Registry of Effective Prevention Programs.
She is also working on disseminating the treatment to rape crisis centers. Counselors trained in PET in the Philadelphia area are seeing the same results as are clinicians in her program, in terms of a drop in symptom severity. The U.S. Department of Veterans Affairs also is looking into the treatment strategy, comparing PET with present-centered therapy services at 12 sites.
Some studies have looked at improving on PET, Foa said, but have found that adding procedures such as cognitive and family therapy have not achieved better results than has PET alone (Foa and Street, 2001).
Combined Treatment Study
Preliminary findings from the first study adding PET to medication treatment suggest the strategy is highly effective in reducing symptoms and preventing relapse in patients with PTSD. Foa, Davidson and Barbara Rothbaum, Ph.D., of Emory University conducted the three-center study.
Subjects began the study with 10 weeks of sertraline treatment. They were then randomized into two groups for an additional five weeks of treatment: one that continued receiving only sertraline and one that received a combination of sertraline and twice-weekly PET.
Combined therapy made little to no difference for patients who had an excellent response to drug therapy during the first 10 weeks. But for subjects who responded only partially to the initial treatment, combined therapy was found to be about three times more effective than continuing treatment with only the SSRI. Overall, the effect size for people who received combined therapy was nearly twice that of those who continued to receive medication only.
This form of cognitive-behavioral therapy also may play a role in preventing relapse after treatment is discontinued, Foa said, but data will not be available until later this year. Foa and colleagues are now completing a six-month follow-up of research subjects.
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