EMDR for PTSD treatment in military context: a case study of Cyprus

Back to table of contents Previous article Next article Professional NewsFull AccessMajor Study Will Assess 'What Works' in PTSD CareAaron LevinAaron LevinPublished Online:1 Apr 2011https://doi.org/10.1176/pn.46.7.psychnews_46_7_4_1AbstractThe Department of Defense and the Department of Veterans Affairs have received enormous funding from Congress for treating PTSD, but we can't view that as a bottomless pit," Navy Capt. Paul Hammer, M.C., said at the first meeting of an Institute of Medicine (IOM) panel that will study the current status of research and treatment of posttraumatic stress disorder (PTSD). "We have to learn to treat PTSD at a reasonable cost," said Hammer, an APA member and the new director of the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury. Doing that requires knowing more about the disorder, its causes, diagnosis, and treatment, so the Department of Defense (DoD) requested the IOM study. The panel is chaired by Sandro Galea, M.D., Dr.P.H., a professor and chair of the Department of Epidemiology in the Mailman School of Public Health at Columbia University. The request came three years after another report from the IOM noting that "significant gaps" existed in the evidence underlying nearly all treatments for PTSD (Psychiatric News, December 7, 2007). The earlier report said that only therapies that included some element of exposure to reminders of trauma—like prolonged exposure therapy, cognitive-behavioral therapy, or cognitive-processing therapy—were backed by sufficient evidence from clinical trials. "The 2007 PTSD report was simply an evaluation of the evidence on best practices for PTSD," said Galea. "Our mandate with this study is to understand what the best approach to screening, prevention, treatment, and rehabilitation for PTSD is and what DoD and the Department of Veterans Affairs [VA] should be doing about it." The panel will spend two years gathering information from the two federal departments "on programs and methods available for the prevention, screening, diagnosis, treatment, and rehabilitation of posttraumatic stress disorder," as well as study clinical trials of innovative treatments and services. The panel will then take another two years to evaluate the rates of success of each modality. The study could clarify how well current PTSD programs are working and identify gaps in assessment and treatment, said Hammer during the panel's initial meeting in late February. About 2.4 percent of the 2.2 million deployed service members have been diagnosed with PTSD, but depending on survey methodology, 10 percent to 17 percent of service members report some symptoms of PTSD, he noted. Several areas require special attention in any study of PTSD in military populations, Hammer pointed out.For example, "patterns of comorbidities are different in military populations, compared to the civilian sector," he said. Mild traumatic brain injury, pain, and substance abuse are common. In addition, combat troops less often report Category A ("horror") PTSD symptoms, because their military training and experience prepares them for battle. But they also have less access to protective factors due to their frequent re-exposure and the "tough-it-out" military culture, he said. National Guard and Reserve personnel are at even greater risk of PTSD and have less access to therapists skilled in PTSD care for military populations because they are dispersed geographically after they return from war zones. The armed forces have used several strategies to protect troops. Education and training begin at the start of military service. Increased screening and surveillance, interventions to manage combat stress in the field, and a full spectrum of available treatments in war zones and at home also serve as factors that may mitigate the likelihood or severity of PTSD. The Military Health System has increased behavioral health staffing from about 4,000 in 2007 to about 6,500 now, so fewer referrals for care go unfulfilled. Spending on PTSD care for the current cohort of veterans is likely to be high, and the true costs of treating them needed to be made clear, said Hammer. But more work needs to be done first. "Data are problematic on the effectiveness of current therapies," said Hammer. "We don't know what type of therapy is used or whether the therapist has made individual modifications. We don't have the ability to track measures over time." The executive director of the VA's National Center for PTSD (NCPTSD), Matthew Friedman, M.D., Ph.D., stressed that more should be done to monitor outcomes in clinical practice, expand the use of evidence-based therapies and clinical practice guidelines, and increase quality improvement and program evaluation efforts. The National Center for PTSD is a hub for research into the neuroscience of PTSD and its treatment, along with ways to move that research into the clinic. Basic research there now addresses mechanisms underlying the development of PTSD, as well as resilience, treatment effectiveness, and treatment resistance, Friedman told the IOM panel. The NCPTSD also provides PTSD-related assessment tools, training, treatment guides, and consultation services within the VA, he said. In addition, it provides information on PTSD and its treatment for outside clinicians and for the public via its Web site. The IOM study, when completed, will help guide future DoD and VA policies for screening, diagnosing, and treating service members and veterans. That can't come too soon, said Hammer. "We need to get it right and target well for what works," said Hammer.Information on the Institute of Medicine's "Assessment of Ongoing Efforts in the Treatment of PTSD" is posted at <www.iom.edu/Activities/Veterans/PTSDTreatment.aspx>. The Web site for the National Center for PTSD is <www.ptsd.va.gov>. ISSUES New Archived

Predictors of Likelihood and Intensity of Past-Year Mental Health Service Use in an Active Canadian Military Sample

Intensive prolonged exposure therapy for combat-related posttraumatic stress disorder: Design and methodology of a randomized clinical trial

The Psychiatric Ramifications of Moral Injury Among Veterans

Clinical Characteristics and Health Service Use of Veterans With Comorbid Bipolar Disorder and PTSD

The integrative management of PTSD: A review of conventional and CAM approaches used to prevent and treat PTSD with emphasis on military personnel

There are multiple well-established evidence-based treatments for posttraumatic stress disorder (PTSD). However, recent clinical trials have shown that combat-related PTSD in military populations is less responsive to evidence-based treatments than PTSD in most civilian populations. Traumatic death of a close friend or colleague is a common deployment-related experience for active duty military personnel. When compared with research on trauma and PTSD in general, research on traumatic loss suggests that it is related to higher prevalence and severity of PTSD symptoms. Experiencing a traumatic loss is also related to the development of prolonged grief disorder, which is highly comorbid with depression. This study examined the association between having traumatic loss-related PTSD and treatment response to cognitive processing therapy in active duty military personnel. Participants included 213 active duty service members recruited across two randomized clinical trials. Results showed that service members with primary traumatic loss-related PTSD (n = 44) recovered less from depressive symptoms than those who reported different primary traumatic events (n = 169), B = -4.40. Tests of mediation found that less depression recovery suppressed recovery from PTSD symptoms in individuals with traumatic loss-related PTSD, B = 3.75. These findings suggest that evidence-based treatments for PTSD should better accommodate loss and grief in military populations.

Posttraumatic Stress Disorder Among Military Returnees From Afghanistan and Iraq

Over the past 2 decades, there has been significant research on the diagnosis and treatment of posttraumatic stress disorder (PTSD) in U.S. service members and veterans. Despite considerable progress, a number of challenges have limited these advancements. In contrast, over the past 7 decades, the field of cancer has been a model of significant advancements and overcoming clinical and research barriers. This article reviews the similarities and differences between clinical and research approaches to cancer and PTSD and how the field of cancer might serve as be a roadmap for advancing PTSD research. Related to diagnosis, there are now more than 200 types of cancer that are classified according to where they start in the body and the type of cells that are involved. In contrast, although PTSD can result from exposure to many different types of trauma, there is currently only one type of PTSD according to published diagnostic guidelines. More research funding has been dedicated to cancer than probably any other medical condition. As a result, more advancements have been made in the diagnosis and treatment of cancer than perhaps any other condition. Clinical trials for PTSD have been ongoing for about half as long as cancer. The findings from initial PTSD clinical trials in military populations were criticized because of poorer treatment outcomes compared to civilians. Although recent trials have achieved better outcomes, the successful approach to cancer treatment may help guide future clinical and research approaches to the treatment of PTSD. Patients in cancer clinical trials are provided with informed consent outlining the potential risks and benefits of treatment. Despite the significant side effects of cancer treatments, most patients pursue one or more rounds of treatment. Participants in PTSD trials also complete informed consent. However, the lack of systematic adverse event monitoring has resulted in limited data on side effects. This may contribute to high drop-out rates with PTSD treatments even though the risk of side effects is minor compared to cancer. For many decades, there was significant stigma associated with the diagnosis of cancer. Much of this stigma has now been reduced with improved cancer treatments and public health campaigns. In contrast, significant stigma continues to exist with PTSD, especially among military service members. Considerable clinical, research, and public advocacy activities have focused on cancer survivorship. In contrast, few former PTSD patients refer to themselves as PTSD survivors. The PTSD community would benefit greatly from PTSD survivorship advocates. Most cancer patients, researchers, and clinicians have a shared goal of hoping for a cure for cancer. In contrast, there has been little emphasis on curing PTSD or treating it into remission. This is despite the fact that the potential for PTSD to be treated into remission or cured is better than many types of cancer. In summary, the similarities and differences between cancer and PTSD may help guide future clinical and research approaches to PTSD in service members and veterans.

Back to table of contents Previous article Next article Professional NewsFull AccessExperts on PTSD in Military Searching for What WorksAaron LevinAaron LevinSearch for more papers by this authorPublished Online:21 Sep 2012https://doi.org/10.1176/pn.47.18.psychnews_47_18_6-aAbstractAn Institute of Medicine committee released an initial assessment of treatments for posttraumatic stress disorder (PTSD) July 13 and wasted no time beginning work on the study’s second phase at a meeting in Washington, D.C., August 27.The new round of information gathering, again chaired by Sandro Galea, M.D., Dr.P.H., a professor and chair of epidemiology at Columbia University, will look at practices and studies under way by the Department of Defense and Department of Veterans Affairs (VA) (Psychiatric News, August 17).The VA has been conducting a range of research studies on PTSD, as well as other mental illnesses, and coordinating with the Department of Defense to avoid research duplication, Antonette Zeiss, Ph.D., the VA’s chief consultant for mental health services, told the panel.Working with its National Center for PTSD, the VA has set up mentoring and consultation programs to advise VA clinicians on both clinical and administrative aspects of PTSD care.An update on PTSD-related neurobiological and epidemiological research conducted by the VA will be presented to the committee later in the year, said Zeiss.The push to “do something” about mental health problems among military personnel half a decade ago resulted in Congress’s funding many programs of varying substance and quality.Now it is necessary to sort out which ones are actually effective in helping troops with PTSD symptoms.However, even defining a “program” isn’t easy, said RAND Corporation health policy researcher Carrie Farmer, Ph.D. There is no master list of such programs within the Department of Defense, for example.Farmer and her colleagues initially identified 650 entities, which they finally whittled down to 211 programs that fit a working definition of providing “services, interventions, or other interactive efforts to address [the] psychological health” of service members or their families.These programs were targeted at preventing mental health problems, identifying individuals in need of help and connecting them to care, and providing clinical services.The present nonsystem has many drawbacks, said Farmer. Programs often began based on someone’s clever idea, rather than on evidence that the approach can be effective.“Most programs are not collecting data that could be used for outcome evaluation, so it is hard to compare them,” Farmer pointed out. “And it is difficult without needs assessment to see if needs are being met.”Psychotherapy for PTSD in military populations is a complex, difficult process, Navy Capt. Paul Hammer, MC, director of the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, told panelists at the Institute of Medicine. “It’s more like chemotherapy than giving a pill for pneumonia.”DCoEThe Department of Defense is also trying to evaluate its own programs, said Navy Capt. Paul Hammer, MC, director of the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury.Hammer reiterated the need to measure the outcomes of care for service members and veterans.“The difficulty is getting everyone on board with agreed measures that are integrated into electronic health records,” he said. He noted that the long-promised interconnection of Department of Defense and VA electronic records was still not a reality.Also, medical practices in the Army, Navy, and Air Force are governed by the decisions of each service’s surgeon general. Getting the surgeons general to agree on any clinical matter has been a matter of persuasion within working groups at the Pentagon, Hammer said.Efforts to reduce stigma are bearing fruit after many years, but more progress needs to be shown, he said. He expects that as many senior noncommissioned officers retire, they will seek treatment once they are no longer worried about how entry into mental health care would affect their careers.At the same time, Hammer also cautioned against overidealizing to troops or the public the capabilities of psychotherapy to treat PTSD.“We have to come to terms with the fact that exposure-based therapy is really difficult stuff for both the patient and the therapist, too,” he said. “It’s more like chemotherapy than just giving someone a pill for pneumonia.”Nor are military veterans in the same category as people with serious mental illness, he said. “We have numerous effective treatments, but too many clinicians are working on a chronic mental illness paradigm rather than getting aggressive with treatment.”Hammer, who served two tours of duty in Iraq, imagined the day when a couple of battle-hardened veterans would be walking across the base, and one would say to the other: “I’m going to see my therapist now.”“And it wouldn’t matter if it was a psychotherapist or a physical therapist,” he said. “Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial Assessment” is posted at www.iom.edu/Reports/2012/Treatment-for-Posttraumatic-Stress-Disorder-in-Military-and-Veteran-Populations-Initial-Assessment.aspx. ISSUES NewArchived

The role of cortisol in development and treatment of PTSD among service members: A narrative review

Background: Currently, there is a paucity of pharmacological treatment options for posttraumatic stress disorder (PTSD), and the development of a novel pharmacotherapeutic approach has become a matter of great interest. Objective: We conducted a 12-week open-label clinical trial to examine the efficacy and safety of memantine, an N-methyl-D-aspartate receptor antagonist, in the treatment of civilian PTSD. Method: Thirteen adult patients with DSM-IV PTSD, all civilian women, were enrolled. They were monitored at an ambulatory care facility every week until 4 weeks and then every 4 weeks until 12 weeks. Memantine was added to each patient’s current medication, with the initial dosage of 5 mg/day and then titrated. Concomitant medications were essentially kept unchanged during the trial. The primary outcome was PTSD diagnosis and severity assessed with the Posttraumatic Diagnostic Scale (PDS). Results: Of the 13 cases, one dropped out and two were discarded due to the protocol deviation, and the analysis was done for the remaining 10. Mean PDS total scores decreased from 32.3 ± 9.7 at baseline to 12.2 ± 7.9 at endpoint, which was statistically significant with a large effect (paired t-test: p = .002, d = 1.35); intrusion, avoidance, hyperarousal symptoms were all significantly improved from baseline to endpoint. Six patients no longer fulfilled the diagnostic criteria of PTSD at endpoint. Some adverse, but not serious, effects possibly related to memantine were observed, including sleep problems, sleepiness, sedation, weight change and hypotension. Conclusions: Memantine significantly reduced PTSD symptoms in civilian female PTSD patients and the drug was well tolerated. Future randomized controlled trials are necessary to verify the efficacy and safety of memantine in the treatment of PTSD.

Veterans and military service members have increased risk for post-traumatic stress disorder (PTSD) and consequent problems with health, psychosocial functioning, and quality of life. In this population and others, shame and guilt have emerged as contributors to PTSD, but there is a considerable need for research that precisely demonstrates how shame and guilt are associated with PTSD.This study examined whether a) trauma-related shame predicts PTSD severity beyond the effects of trauma-related guilt and b) shame accounts for a greater proportion of variance in PTSD symptoms than guilt. We collected cross-sectional self-report data on measures of PTSD symptom severity based on Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria, trauma-related shame, and trauma-related guilt via online survey. Participants included 61 US veterans and active duty service members. Hierarchical multiple regression and relative weights analysis were used to test hypotheses. In step 1 of regression analysis, guilt was significantly associated with PTSD.However, when shame was added to the model, the effect of guilt became non-significant, and only shame significant predicted PTSD.Results from relative weights analysis indicated that both shame and guilt predicted PTSD, jointly accounting for 46% of the variance in PTSD. Compared to guilt, trauma-related shame accounted for significantly more explained variance in PTSD. This study provided evidence that among US veterans and service members, trauma-related shame and guilt differ in their association with PTSD and that trauma-related shame, in particular, is associated with the severity of PTSD. Trauma-related shame and guilt explained almost half of the observed variance in PTSD symptom severity among this sample of US military veterans and service members. Trauma-related shame and guilt each made a unique contribution to PTSD severity after accounting for the similarity between these two emotions; however, shame was particularly associated with increased PTSD severity. These results highlight the importance of assessing and addressing trauma-related shame and guilt in PTSD treatment among military populations. We suggest that emotion- and compassion-focused techniques may be particularly relevant for addressing trauma-related shame and guilt. Limitations of the study Cross-sectional data does not allow for determination of causal relationships. Although sufficiently powered, the sample size is small. The present sample self-selected to participate in a study about stress and emotions.

Even after the most effective posttraumatic stress disorder (PTSD) treatments, symptoms often persist. Understanding residual symptoms is particularly relevant in military populations, who may be less responsive to PTSD interventions. The sample consisted of 282 male service members who engaged in a residential PTSD treatment program at a military treatment facility that provided evidence-based PTSD psychotherapies and adjunctive interventions. PTSD and depression symptoms were assessed before and after treatment and weekly during treatment via the PTSD Checklist-Military Version and Patient Health Questionnaire-8. Logistic regression with Hochberg's step-up procedure compared the likelihood of individual residual symptoms between service members who did (n = 92, 32.6%) and did not (n = 190, 67.4%) experience clinically significant PTSD change (≥ 10-point PTSD Checklist-Military Version reduction). Not achieving clinically significant PTSD change was associated with greater odds of nearly all residual symptoms (OR = 2.03-6.18), excluding two Patient Health Questionnaire-8 items (appetite and psychomotor changes). Among service members experiencing clinically significant PTSD change, concentration difficulties (73.3%), physical reactions to reminders (71.1%), and intrusions (70.8%) were PTSD symptoms most likely to persist. Poor sleep (56.2%), low energy (50.0%), and concentration difficulties (48.3%) were the most common for depression. To our knowledge, this study is the first to examine residual PTSD and depression symptoms following residential PTSD treatment for active duty service members. Given the low rates of clinically significant PTSD change and the high frequency of residual symptoms, strategies may be needed to improve residential PTSD treatment outcomes in the military. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Government Programs Helping to Identify More PTSD Sufferers