At least in Britain, it’s official: psychotherapy works better than medication for PTSD. You shouldn’t be too surprised. The last time we covered PTSD (TCPR April 2004) we reviewed the SSRIs and found them to have evidence of only modest efficacy.
Now, according to the latest treatment guidelines from Britain's National Institute for Clinical Excellence (NICE), antidepressants are no longer recommended as a first-line treatment, but cognitive therapy is. You can check out these guidelines for free at http://guidance.nice.org.uk/CG26/guidance/pdf/English.
You might wonder why we are not patriotically focusing on our own APA guidelines (http://www.psych.org/psych_pract/treatg/pg/PTSD-PG-PartsA-B-C-New.pdf). Because the NICE guidelines are more current and, frankly, they’re better. Whereas the APA guidelines are conventional literature reviews, the NICE reviewers dig deeply into the data, often performing their own meta-analyses and including unpublished data where available. The two guidelines differ in terms of industry influence as well, with the APA practice guidelines committee composed primarily of academics with financial ties, vs. the NICE guidelines, which are funded exclusively by government sources.
At any rate, here are some treatment recommendations culled from the British guidelines and various other sources.
First-line treatment, according to NICE, should be psychotherapy, because controlled studies have yielded larger effect sizes for therapy than any type of medication. The most effective forms of PTSD therapy are cognitive behavioral therapy (CBT) and eye movement desensitization and reprocessing (EMDR). One particularly valuable aspect of these guidelines is a series of explanations of these therapeutic techniques in clear, nonacademic language, allowing the reader to move beyond the confusing labels and get to what you can do in the office with patients now.
Cognitive behavioral therapy (CBT). Sixteen randomized controlled trials evaluating CBT were reviewed and overall the treatment was quite effective for a wide range of trauma, including domestic violence, military combat, and accidents. CBT typically includes the following components:
1. Some form of “cognitive restructuring,” including reassurance that the person's reactions to the trauma are normal and will gradually get better.
2. Exposure. This can take several forms, but the key ingredient is that you help your patient revisit the traumatic event in a safe context, thereby diminishing the terror associated with it. Simply having your patient describe the event to you, more than once, is one technique. A related technique, advocated by Dr. Edna Foa (see TCPR April 2004 for our interview with her), is “prolonged exposure (PE)” in which patients recount the trauma, tape the narrative, and listen to the tape at home. PE also includes in vivo exposure in which the patient spends enough time in the avoided setting for the anxiety to diminish.
EMDR. EMDR appeared to be effective for PTSD, although the effect sizes were less impressive overall than CBT effect sizes.
In EMDR, patients are instructed to focus on the traumatic memory while they visually track something that is moving from side to side (such as the therapist’s finger). The therapist supplies positive emotional associations and beliefs to replace the negative ones. Some authorities have suggested that EMDR works because of the exposure-like components, and that the eye movement feature is superfluous and gimmicky.
Debriefing. Also called "critical incident stress debriefing" (CISD), debriefing is an attempt to prevent the later development of PTSD by providing immediate single session support and therapy. The NICE review found that CISD was not significantly better than control in any trial, and one trial actually showed that it may worsen symptoms at 13 month follow up.
Most studies of antidepressants for PTSD use as the outcome measure a popular scale of symptoms called the CAPS (Clinician Administered PTSD Scale). Most placebo-controlled studies of SSRIs show an advantage of active medication, but not a very large one. This, in turn, leads to only modest effect sizes. Most researchers regard effect sizes from 0.6 to 0.8 "moderate." Anything below 0.6 is considered to represent a small effect.
The NICE researchers chose an effect size of 0.5 as an a priori threshold for deciding whether a medication could be considered effective for PTSD. Using this criterion, neither of the two FDA-approved medications (Paxil or Zoloft) were deemed effective. Nonetheless, of the two, Paxil had the most consistent evidence of efficacy, and for this reason NICE ended up recommending Paxil for PTSD.
Three antidepressants surpassed the 0.5 effect size threshold: Remeron (mirtazapine), amitriptyline, and Nardil (phenelzine). However, this positive data was based on only one controlled study for each medication -- far less data than examined for the SSRIs.
Interestingly, NICE put in a special plug for Zyprexa, based on a single positive study showing that it was a helpful adjunct to SSRIs – something to consider, especially for symptoms of insomnia and hyperarousal.
Of course, these massive meta-analyses don’t generally comment on agents that are commonly in use but have not yet been tested in controlled trials. Here’s a brief run-down of medications commonly used off-label for PTSD:
Clonidine (Catapres). A favorite of child psychiatrists for insomnia in children, it has been helpful in PTSD hyperarousal. In adults, try 0.1 mg BID-TID for hyperarousal symptoms, or 0.1-0.3 mg QHS for nightmares.
Guanfacine. Long a favorite anti-arousal drug used by traumatologists, guanfacine received a blow recently when the first placebo controlled study of its use in PTSD found an effect size of 0 (Neylan TC et al., Am J Psychiatry 2006;163:2186-2188). As an aside, Shire has patented an extended release version of guanfacine which will probably soon receive FDA approval for ADHD (http://www.medicalnewstoday.com/medicalnews.php?newsid=57007).
Prazosin. See this month's interview with David Osser for more info – he has found it quite helpful for PTSD-related insomnia.
Propranolol. This beta blocker is often used in situational social phobia (e.g., stage fright), but an intriguing study showed some benefit when given to trauma survivors in the ER immediately after the trauma. The dose used was high – 40 mg QID (Pitman RK, et al., Biol Psychiatry 2002;51:189-192).
Topiramate (Topamax). A fair number of case series have endorsed Topamax for PTSD symptoms, especially for flashbacks and nightmares. The first placebo-controlled trial was recently published, showing statistically significant efficacy for flashbacks but not for PTSD symptoms as a whole (Tucker P, et al., J Clin Psych 2007 Feb;68(2):201-206). The median dose used was 150 mg QD.
Finally, what about the class of medication that is (anecdotally) most commonly prescribed in PTSD – benzodiazepines? Well, NICE barely even mentions them, so scant is the evidence for their use. Dr. Osser, in this month’s interview, does a good job reviewing the one or two studies that have been published. We recommend that you reserve them for patients who have no substance abuse history (or who have long-term sobriety), and that you keep the meds focused on treating specific anxiety symptoms that frequently occur in PTSD.