By Shankar Vedantam
Washington Post Staff Writer
Friday, October 19, 2007; A03
The majority of treatments for post-traumatic stress disorder that are used to treat hundreds of thousands of veterans lack rigorous scientific evidence that they are effective, according to a report issued yesterday by a panel of the federal government's top scientists.
The report by the National Academies emphasized that the therapies might not be useless. Rather, it said, the evidence is weak when it comes to drawing any kind of conclusion about most of them. The findings of the panel, widely considered the nation's most influential scientific arbiter, will have far-reaching consequences. The report comes when awareness of PTSD has risen as a result of its incidence among veterans returning from the wars in Iraq and Afghanistan.
"If a treatment that is not shown to be efficacious is nevertheless delivered to veterans, and if the treatment is relatively inert, even if it does not harm the veterans, it may demoralize the veteran," said Richard McNally, a Harvard University psychologist and PTSD expert. "Providing treatments that do not have a good basis in evidence can result in people not improving, therefore getting demoralized and therefore not seeking treatment that can actually help them."
The report did find strong evidence that one particular treatment known as exposure therapy was effective; the technique asks patients to repeatedly reimagine traumatic events as a way to make the events lose their potency. In a statement, the Department of Veterans Affairs said it was ramping up its ability to provide this therapy to patients.
But the panel failed to find evidence that any medication was effective in treating PTSD -- this included the drugs Paxil and Zoloft, which have been approved by the Food and Drug Administration to treat the disorder.
"A very high percentage of people who have been diagnosed with PTSD are on medications," said Larry Scott, the founder of the advocacy group VA Watchdog dot Org, which serves as an information clearinghouse for veterans.
Most of the evidence supporting the use of medications and psychological therapies for PTSD has been assembled by pharmaceutical companies that make the drugs or by researchers with conflicts of interest in the outcome of the studies, and lack independent and rigorous proof, the report said.
The researchers also found there was insufficient evidence to support the use of a range of psychotherapies known as cognitive restructuring, coping skills training, eye-movement desensitization and reprocessing therapy, and group therapy. Cognitive restructuring is a technique that trains patients to reinterpret a traumatic event from a different perspective. In the eye-movement therapy, patients are asked to think about traumatic memories while tracking quick movements of a therapist's finger.
A host of complicated political, economic and medical issues swirl around the issue of PTSD in a time of war. Many veterans advocacy groups are convinced that the government is trying to limit the spiraling costs of treating the flashbacks, anxieties and co-occurring psychiatric disorders that mark PTSD.
"I see the IOM report and the VA's acceptance as an indication that the agency will continue to move away from pharmaceutical-based therapies and group therapy for veterans with PTSD and continue to push their agenda of cognitive processing therapy as a 'cure,' as stated by former VA Secretary Jim Nicholson," Scott added. "If VA declares a veteran 'cured' of PTSD, this will mean the reduction or loss of disability compensation."
In the new report, scientists said evidence for many issues besides treatment efficacy was also limited. It is not clear, for example, how early treatment for PTSD should be started or how long such therapy should be offered.
"We found much of the research on PTSD to have major limitations when judged against contemporary standards for conducting trials," said Alfred O. Berg, professor of family medicine at the University of Washington, who chaired the panel that conducted a comprehensive review of the evidence for PTSD treatments.
Part of the problem, Berg said, is that studies for PTSD have been conducted over a long period of time. The modern standards the panel sought to apply simply happened to be much higher.
"Our report certainly must raise questions about treatments and whether they are effective or not, but our assessment of inadequate evidence does not mean the treatments are ineffective," Berg said. "It could mean some of the therapies are more effective than the exposure therapy, where we did find proof of effectiveness" but only that the other therapies lack evidence to show that this is the case.
Berg and another author, David Matchar, a professor of medicine at Duke University Medical Center, said a sustained national effort for high-quality research on PTSD, with a special focus on veterans and minority groups, was needed.
Edna B. Foa, a professor of clinical psychology in the department of psychiatry at the University of Pennsylvania, and one of the pioneers in developing exposure therapy as a PTSD treatment said the technique was based on the insight that many victims of trauma do all they can to avoid being reminded of traumatic events.
A rape victim might avoid going out in the evenings, while someone injured in an auto accident might avoid getting into any kind of vehicle. Soldiers might avoid movies or TV shows about war.
Two things happen in this process, Foa said. Patients come to replace actual recollections of trauma with other perceptions -- taking on blame and guilt, for example, for being afraid. Second, by avoiding situations, patients can fail to see that much of life is not dangerous -- the movie is only fiction.
Foa said she has patients recount traumatic events aloud with their eyes closed. She records the patient, and then has the patient listen to the tape repeatedly.
"People don't recover because they avoid thinking about the trauma," Foa said. "Every time the trauma comes to the mind, they push it away. They don't allow themselves to process and digest the memory, so it keeps on haunting them with nightmares, flashbacks."
Foa also has patients make lists of situations that trigger anxiety and encourages them to deliberately expose themselves to the least-frightening situation. As people realize that many situations are harmless, Foa said they replace images of self-doubt and helplessness with a more healthy outlook.