Integrating Evidence-Based Treatments for PTSD with CAM Practices

Abstract

PSYCHIATRIC ANNALS 43:7 | JULY 2013 With the following article on mindfulness, Psychiatric Annals completes a series, guest edited by COL (retired) Elspeth Cameron Ritchie, MD, MPH, on the use of complementary/and alternative medicine (CAM), or integrative modalities for the treatment of posttraumatic stress disorder (PTSD) in service members and veterans. This month, Marina Khusid, MD, ND, MSA, explores a variety of mindfulness techniques that support first-line treatments for PTSD, for example by facilitating the patient’s engagement in care and addressing hyperarousal symptoms and comorbid conditions. In addition to mindfulness, this series, has provided relevant information on acupuncture, virtual reality (VR) exposure therapy, stellate ganglion block, and animal-assisted therapies, just a few of a much longer list of CAM practices that include natural dietary supplements, homeopathy, meditation, yoga, tai chi, biofeedback, massage, chiropractic manipulation, traditional medical systems (eg, Ayurvedic, Chinese), energy medicine, and others. The series has also discussed the complexity of research methodology and described two intensive outpatient programs heavily invested in CAM treatments: Overcoming Adversity and Stress Injury Support (OASIS) in San Diego, and the National Intrepid Center of Excellence (NICoE) in Bethesda, MD. It has been estimated that 41% of service members and veterans rely on one or more CAM treatments,1 a rate very similar to estimates in civilian populations. Furthermore, CAM is more often used by those who have a greater number of health symptoms. In one study, more than two-thirds of service members and veterans with a history of PTSD reported using one or more CAM treatments.1 Given the wide array of CAM practices and belief in their effectiveness, how should clinicians treating PTSD approach the topic of CAM treatments? First is to use this as an opportunity to better understand patients’ health expectations and beliefs to help guide treatment planning, and address any concerns about evidence-based psychotherapies or pharmacotherapies. Second is to understand the low level of evidence for CAM modalities, and formulate an approach that is consistent with the current Veterans Administration (VA)/Department of Defense (DoD) Posttraumatic Stress Clinical Practice Guideline (CPG), which provides a solid conceptual outline for clinical practice.2 Although there is insufficient evidence to recommend any particular CAM modality as a firstline treatment for PTSD, the CPG indicates that CAM may be used adjunctively along with evidencebased treatments. It is helpful to think of how these modalities may be used to target specific symptoms. A recent US Army Medical Command policy on the evaluation and treatment of PTSD recommended that the goals of CAM services “should be aligned as much as possible with traumafocused treatment goals, for example, in improving sleep, reducing point of view