Psychotherapy for Military-Related PTSD Does Not Have to Be Trauma-Focused

Peter Roy-Byrne, MD reviewing Steenkamp MM et al. JAMA 2015 Aug 4. Polusny MA et al. JAMA 2015 Aug 4. Kearney DJ and Simpson TL. JAMA 2015 Aug 4.

In a research review and a treatment study, improvement was seen with non–trauma-focused psychotherapy, but only a minority of patients achieved remission with any psychotherapy type.

Many returning military veterans suffer from post-traumatic stress disorder (PTSD). Although antidepressant medications are effective, evidence of effectiveness is more extensive for trauma-focused psychotherapies for PTSD, leading to their recommendation as first-line treatments. Two reports now provide more data.

Steenkamp and colleagues reviewed 36 randomized, controlled studies of psychotherapy for military PTSD. Fifteen studies were of trauma-focused psychotherapy. Cognitive processing therapy (CPT) and prolonged exposure (PE), the gold-standard therapies used in Veterans Affairs settings, showed large effect sizes (with better evidence for CPT than for PE), but 35% to 50% of veterans showed no appreciable effect and two thirds continued to have PTSD. Moreover, in comparisons with non–trauma-focused therapies, trauma-focused approaches showed only marginal differences that were unlikely to be clinically important. In the 21 studies of non–trauma-focused therapies, several were effective, including present-centered therapy, attention-bias modification, mindfulness, and other complementary therapies.

In a randomized study, Polusny and colleagues compared the effectiveness of two non–trauma-focused treatments, mindfulness-based stress reduction (MBSR; NEJM JW Psychiatry Jul 2015 and Lancet 2015; 386:63) and present-centered therapy, in 116 veterans. Each therapy involved nine group sessions. More MBSR recipients than present-centered therapy recipients experienced symptom reduction (48% vs. 28%), but overall more than half showed no appreciable effects. At 2-month follow-up, the groups had similar proportions of participants with continued PTSD diagnoses.

Citation(s):

Steenkamp MM et al. Psychotherapy for military-related PTSD: A review of randomized clinical trials. JAMA 2015 Aug 4; 314:489.

Polusny MA et al. Mindfulness-based stress reduction for posttraumatic stress disorder among veterans: A randomized clinical trial. JAMA 2015 Aug 4; 314:456. 

Kearney DJ and Simpson TL.Broadening the approach to posttraumatic stress disorder and the consequences of trauma. JAMA 2015 Aug 4; 314:453.