Comparative Effectiveness Review Number 92 Effective Health Care Program Psychological and Pharmacological Treatments for Adults With Posttraumatic Stress Disorder (PTSD) Executive Summary Background Effective Health Care Program Posttraumatic stress disorder (PTSD) is a mental disorder that may develop The Effective Health Care Program following exposure to a traumatic was initiated in 2005 to provide event. According to the 4th edition of valid evidence about the comparative the “Diagnostic and Statistical Manual effectiveness of different medical of Mental Disorders: DSM-IV-TR,”1 interventions. The object is to help the essential feature of PTSD is the consumers, health care providers, development of characteristic and others in making informed symptoms following exposure to a choices among treatment alternatives. traumatic stressor. PTSD is characterized Through its Comparative Effectiveness by three core symptom clusters: Reviews, the program supports (1) reexperiencing, (2) avoidance or systematic appraisals of existing numbing (or both), and (3) hyperarousal. scientific evidence regarding The full DSM-IV-TR criteria are listed treatments for high-priority health in Table A. conditions. It also promotes and generates new scientific evidence by Examples of traumatic events include identifying gaps in existing scientific military combat, motor vehicle evidence and supporting new research. collisions, violent personal assault, The program puts special emphasis being taken hostage, a terrorist attack, on translating findings into a variety torture, natural or human-caused of useful formats for different disasters, and, in some cases, being stakeholders, including consumers. diagnosed with a life-threatening illness.1 PTSD develops in up to a third of The full report and this summary are individuals who are exposed to extreme available at www.effectivehealthcare. stressors, and symptoms almost always ahrq.gov/reports/final.cfm. emerge within days of the exposure.2 Shortly after exposure to trauma, many people experience some of the symptoms of those exposed to trauma, PTSD of PTSD; in most people, those symptoms symptoms persist and are associated with resolve spontaneously in the first several impairment in social or occupational weeks after the trauma. However, in functioning.3 Although approximately approximately 10 percent to 20 percent 50 percent of those diagnosed with PTSD Effective Health Care 1 Table A. Diagnostic criteria (DSM-IV-TR) for posttraumatic stress disorder Criterion Symptom or Description Criterion A: Trauma (both) • Traumatic event that involved actual or threatened death, serious injury, or threat to physical integrity • Intense response of fear, helplessness, or horror Criterion B: Reexperiencing symptoms • Intrusive recollections of events (1 or more) • Recurrent distressing dreams of the event • Acting or feeling as if the traumatic event were recurring • Distress at internal or external reminders of the trauma • Physiological reaction to internal or external reminders Criterion C: Persistent avoidance and • Avoidance of thoughts, feelings, or conversations associated with trauma numbing (3 or more) • Avoidance of activities, places, or people that arouse recollections of trauma • Failure to recall an important aspect of trauma • Loss of interest or participation in significant activities • Detachment from others • Restricted range of affect • Lost sense of the future Criterion D: Hyperarousal (2 or more) • Difficulty falling or staying asleep • Irritability or outburst of anger • Difficulty concentrating • Hypervigilance • Exaggerated startle response Criterion E: Duration of disturbance • Duration of disturbance symptoms is more than 1 month Criterion F: Clinically significant distress • Disturbance causes clinically significant distress or impairment in social, or impairment occupational, or other important areas of function DSM-IV-TR = Diagnostic and Statistical Manual of Mental Disorders improve without treatment in 1 year, 10 percent to family discord; and reduced educational attainment, work 20 percent develop a chronic unremitting course.4 earnings, marriage attainment, and child rearing.7 PTSD is associated with an increased risk of suicide,8 high medical The 2000 National Comorbidity Survey—Replication costs, and high social costs. Epidemiologic studies have (NCS-R) estimated lifetime prevalence of PTSD among also found that a high percentage of individuals with PTSD adults in the United States to be 6.8 percent and current have another psychiatric disorder, most notably substance (12-month) prevalence to be 3.6 percent.5 Estimates from use disorders or major depressive disorder.9 the National Vietnam Veterans Readjustment Survey (NVVRS) found a lifetime PTSD prevalence estimate of Treatment Strategies for PTSD 18.7 percent and a current PTSD prevalence estimate of Treatments available for PTSD span a variety of 9.1 percent among Vietnam veterans.5 More recent surveys psychological and pharmacological categories. Specific of military personnel have yielded estimates ranging psychological interventions that have been studied for the from 6.2 percent for U.S. service members who fought in treatment of patients with PTSD include the following: Afghanistan to 12.6 percent for those who fought in Iraq.6 brief eclectic psychotherapy; cognitive behavioral People with PTSD suffer decreased role functioning, therapy (CBT), such as cognitive processing therapy such as work impairment, and experience many other (CPT), cognitive therapy (CT), cognitive restructuring adverse life-course consequences, including job losses; (CR), coping skills therapy (including stress inoculation 2 therapy), and exposure-based therapies; eye movement guideline from the ISTSS acknowledges that practical desensitization and reprocessing (EMDR); hypnosis and considerations, such as unavailability of trauma-focused hypnotherapy; interpersonal therapy; and psychodynamic psychological treatment or patient preferences, may guide therapy. These therapies are designed to minimize the treatment decisions.15 intrusion, avoidance, and hyperarousal symptoms of PTSD by some combination of reexperiencing and Scope and Key Questions working through trauma-related memories and emotions The main objective of this report is to conduct a and teaching better methods of managing trauma-related systematic review and meta-analysis of the efficacy and 2 stressors. The therapies are delivered predominantly comparative effectiveness and harms of psychological to individuals; some can also be conducted in a group and pharmacological interventions for adults with PTSD. 10,11 setting. In this review, we address the following Key Questions Many pharmacological therapies have been studied for (KQs): treatment of patients with PTSD, including selective KQ 1: What is the comparative effectiveness of different serotonin reuptake inhibitors (SSRIs), serotonin and psychological treatments for adults diagnosed with PTSD? norepinephrine reuptake inhibitors (SNRIs), other second- KQ 2: What is the comparative effectiveness of different generation antidepressants, tricyclic antidepressants, pharmacological treatments for adults diagnosed with monoamine oxidase (MAO) inhibitors, alpha- PTSD? blockers, second-generation (atypical) antipsychotics, anticonvulsants (mood stabilizers), and benzodiazepines. KQ 3: What is the comparative effectiveness of different Currently, only paroxetine and sertraline are approved by psychological treatments versus pharmacological the U.S. Food and Drug Administration for treatment of treatments for adults diagnosed with PTSD? patients with PTSD. KQ 4: How do combinations of psychological treatments and pharmacological treatments (e.g., CBT plus Existing Guidance paroxetine) compare with either one alone (i.e., one Numerous organizations have produced guidelines for the psychological or one pharmacological treatment)? treatment of patients with PTSD, including the Department KQ 5: Are any of the treatment approaches for PTSD of Veterans Affairs and Department of Defense (VA, DoD), more effective than other approaches for victims of the American Psychiatric Association (APA), the United particular types of trauma? Kingdom’s National Institute for Health and Clinical Excellence (NICE), the International Society for Traumatic KQ 6: What adverse effects are associated with treatments Stress Studies (ISTSS), the Institute of Medicine (IOM), for adults diagnosed with PTSD? and the Australian National Health and Medical Research We developed an analytic framework to guide the Council.12-16 All of these guidelines agree that trauma- systematic review process. The population is limited to focused psychological interventions (i.e., those that adults with a diagnosis of PTSD. Because we wanted to treat PTSD by directly addressing thoughts, feelings, or assess whether the evidence suggested any differences in memories of the traumatic event) are empirically supported response to various treatments for trauma subgroups first-line treatments for adults with PTSD, and all, except (e.g., military personnel), we identified subgroups of the IOM report,2 recognize at least some benefit of interest as noted in Figure A. pharmacologic treatments for PTSD. Beyond that broad agreement, however, lies some Methods disagreement. Various guidelines and systematic reviews Literature Search Strategy have arrived at different conclusions and led to different recommendations about broad categories of treatments We searched MEDLINE®, the Cochrane Library,