WASHINGTON - There isn't enough evidence to tell if most treatments for post-traumatic stress disorder work, says a scientific review that highlights the urgency of finding answers as thousands of suffering veterans return from Iraq.
The one proven treatment is exposure therapy in which PTSD patients are gradually exposed to sights and sounds that essentially simulate their trauma, to help them learn to cope, advisers to the government reported Thursday.
The lack of evidence for other therapies doesn't mean patients should give them up -- they still should get whatever care their personal doctors deem most promising, stressed Thursday's report from the Institute of Medicine.
"The take-home message for patients should be that they seek care," said Dr. David Matchar of Duke University, who co-authored the report, which was requested by the Department of Veterans Affairs as it struggles with an influx of patients.
"That is the way medicine is practiced -- we do the best we can with what we've got," Matchar added. But, "we need better."
While PTSD was first recognized in Vietnam veterans, war is far from its only trigger. Crime, accidents and other trauma can cause it in civilians, too. Sufferers experience nightmares, flashbacks and physical symptoms that make them feel as if they are reliving the trauma, even many years later.
"Not only veterans, but millions who have been exposed to trauma suffer from PTSD," noted Dr. Alfred Berg of the University of Washington, who chaired the Institute of Medicine panel. "Research on this disorder should be a high priority, and VA should take the lead to ensure that the specific needs of veterans are addressed adequately."
Today, PTSD is the most commonly diagnosed mental disorder among veterans returning from Iraq and Afghanistan, affecting an estimated 13 percent and 6 percent of them, respectively, the report found.
Delays in care for both mental and physical health problems plague many injured veterans, as the Pentagon and VA struggle with backlogs in processing disability benefits and in coordinating services. Ensuring prompt PTSD care was a key recommendation of a presidential panel appointed last summer to investigate those problems.
Thursday's report addresses a somewhat different issue: Once a patient arrives for treatment, what to offer? The VA asked the prestigious Institute of Medicine to review the scientific evidence for medications and psychological treatments -- before the department updates its own treatment guidelines.
Exposure therapies already are offered in the VA system, and "we will redouble our efforts to ensure our mental health staff are trained to provide these effective psychotherapies," said Antonette Zeiss, a clinical psychologist who is deputy chief of VA's mental health services.
Other existing treatments will remain, too, she said, but VA officials planned to meet Thursday to begin planning new research to better prove their value.
"The other treatments have not definitely been shown to be effective. That's different from being shown to be ineffective," Zeiss cautioned. "They are some of the best clinical tools we have. But we should continue to try to understand them better, understand for whom they work."
Aside from exposure therapies, most of the research so far done on other treatments has been of poor quality, Berg said. Some studies had huge numbers of participants drop out, for example, meaning there's no way to know if they left in frustration or because they felt better. Many lumped together patients with varying degrees of PTSD, spurred by very different traumas, making it hard to tease out effects.
Few studies even have tracked patients for longer than six or 12 months to see if any treatment effects last, even though PTSD in many people lasts far longer.
"It's the poster child for difficult research," Matchar said.
Aside from which treatments truly work, the report raised a list of additional concerns:
- It's not clear if veterans and civilians need different types of therapy.
- Depression and other co-existing problems may complicate treatment.
- It's not clear if treatment works best soon after symptoms begin, or is equally effective later.
