Opinion
VIEWPOINT
Maria M. Steenkamp, PhD Steven and Alexandra Cohen Veterans Center for Posttraumatic Stress and Brain Injury, New York University Langone School of Medicine, New York; and Department of Psychiatry, New York University, New York.
Viewpoint
Corresponding Author: Maria M. Steenkamp, PhD, Department of Psychiatry, New York University, 1 Park Ave, Room 8-107, New York, NY 10016 (maria.steenkamp @nyumc.org). jamapsychiatry.com
True Evidence-Based Care for Posttraumatic Stress Disorder in Military Personnel and Veterans As the longest wars in US history draw to a close, treating the psychosocial sequelae of military trauma has become an important public health challenge. In contrast to previous wars, mental health care is for the first time leveraging science to treat deployment-related conditions such as posttraumatic stress disorder (PTSD). Evidence-based practice has become a driving principle behind the treatment of military-related PTSD and is considered a necessary safeguard against the use of unproven and ineffective interventions. However, a truly evidence-based approach to treating military-related PTSD differs from what it has come to mean in the recent clinical and research literature. Over the past 10 years, evidence-based practice for military-related PTSD in the United States has often become equated with the use of 2 empirically supported treatments, namely cognitive processing therapy (CPT) and prolonged exposure (PE) therapy. Cognitive processing therapy and PE are recommended as treatments of choice by the Department of Defense (DoD) and Department of Veterans Affairs (VA) treatment guidelines. Both are short-term trauma-focused interventions (ie, comprise approximately 12 sessions and target traumarelated memories and beliefs). They are the most studied psychotherapies for military-related PTSD and have been formally disseminated across the DoD and VA, with the goal that every VA patient have access to either CPT or PE. They are considered broadly effective, except for patients with blatant contraindications such as psychosis, active suicidality/homicidality, and severe substance misuse. Best practice for PTSD is typically described as consisting of one of these treatments (although in reality, a wide range of psychotherapies are used in these settings), with the assumption that patients receiving CPT or PE will demonstrate clinically meaningful symptom improvement. However, evidence-based practice as originally conceptualized entails a different vision. True evidencebased practice involves integrating 3 sets of information to inform care: the best-available research evidence, clinical judgment, and patient preference.1,2 In true evidence-based practice, evidence is individualized to each patient in a personalized evidence approach. This entails using clinical expertise to determine the degree of fit between the available evidence and the specific patient, as well as including patients in a shared decision-making process to ensure that their preferences and values are respected. What would such a true evidence-based treatment approach look like in the case of military-related PTSD? In a true evidence-based approach, the clinician first critically examines the strength, usability, and applicability of the available treatment outcome evidence. Few
randomized clinical trials of military-related PTSD have been conducted.3 The DoD/VA PTSD treatment guidelines are based primarily on studies with civilians, whose traumas (such as car crashes and assaults) typically differ from those experienced during deployment (such as killing and experiencing prolonged conditions of life threat); the extent to which findings from civilian treatment trials are easily translatable to veterans and servicemembers is debated. Even fewer trials have been published on US servicemembers and veterans with combat trauma, the modal population treated by the DoD and VA (in total, 2 PE trials and 3 CPT trials; 2 international studies have been conducted on Israeli and Australian veterans3). The 2 PE trials were small and both aimed primarily at studying biomarkers associated with PTSD symptom change. Of the 3 CPT trials, 2 examined group CPT; only 1 trial of individually administered CPT for combat-related PTSD has been conducted in US veterans.3 Similarly, few rigorous effectiveness data are available testing real-world outcomes, and the available studies are often published by clinics with allegiance to either CPT or PE and/or are selective in their study sample.4,5 Data from randomized clinical trials of militaryrelated PTSD also clearly show that CPT and PE are effective for some patients and not others. While beneficial to many patients, between one-third and half of veterans receiving CPT or PE do not demonstrate clinically meaningful symptom improvement.3 Even when patients do improve, symptoms often remain high: mean PTSD scores in trials of military-related PTSD have tended to remain at or above diagnostic thresholds following CPT or PE and approximately two-thirds of patients retain their PTSD diagnosis.3 Because extant studies tend to emphasize metrics of mean change (eg, effect sizes), this notable and important heterogeneity in patient outcomes is often obscured. Mean scores collapse patients who get better, worsen, or remain unchanged into a single metric. Also, a practical disadvantage of studies reporting average effects is that mean outcome data are less usable in practice: how will clinicians know whether their patients will be among those who respond to CPT and PE or not? Predictors of effectiveness remain understudied and poorly understood, and trials have typically not examined potential subgroups of participants. Adding further complexity to these mixed outcomes, the evidence shows that there are multiple roads to symptom improvement, of which trauma processing is just one. Randomized clinical trials using active comparison groups (rather than less rigorous waitlist or treatment-as-usual comparisons) have tended to support equivalence between disparate PTSD treatments.6 For example, CPT and PE are only marginally superior com(Reprinted) JAMA Psychiatry Published online February 17, 2016
Copyright 2016 American Medical Association. All rights reserved.
Downloaded From: http://archpsyc.jamanetwork.com/ by a New York University User on 02/20/2016
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Opinion Viewpoint
pared with structured nontrauma-focused psychotherapies that do not discuss the trauma, such as present-centered therapy, suggesting that trauma processing is not essential for improvement.3 Such findings are not easily reconciled theoretically and underscore the need for more research on the efficacy of both nontrauma-focused and trauma-focused interventions in troops and veterans, as well as research on moderators and predictors of outcomes. Such studies may elucidate how to optimally match patients to treatments and how to sequence different types of interventions in cases of nonresponse. Circumstances in which the scientific evidence is conflicting, incomplete, or of unclear relevance have been called “grey zones of clinical practice.”7 Grey zones represent situations in which the available evidence alone cannot guide clinical decision making and the clinician operates under some degree of uncertainty. This is currently the case with military-related PTSD, as the available evidence demonstrates heterogenous treatment outcomes that remain difficult to predict and that have uncertain relevance to the modal patient. When operating in a clinical grey zone, clinical judgment becomes essential to translate research findings on average effects to individual patients. The clinician must merge nomothetic research data with ideographic data specific to their patient (eg, treatment history, symptom presentation, and current psychosocial ARTICLE INFORMATION Published Online: February 17, 2016. doi:10.1001/jamapsychiatry.2015.2879. Conflict of Interest Disclosures: None reported. REFERENCES 1. Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ. 1996;312(7023):71-72. 2. Greenhalgh T, Howick J, Maskrey N; Evidence Based Medicine Renaissance Group. Evidence based medicine: a movement in crisis? BMJ. 2014; 348:g3725.
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stressors) to determine the clinical actions most likely to be of benefit. Patients should be included in this process through shared decision making that involves presenting them with the full spectrum of treatment choices.2 Thus, true evidence-based practice for military-related PTSD differs notably from preferentially applying PE or CPT without personalizing the evidence. Adopting a true evidence-based approach, with its equal emphasis on research evidence, clinical judgment, and patient preference, may help redress the large dropout rates currently plaguing military-related PTSD care3 and may result in better treatment outcomes than extant one-size-fits-all approaches, although this clearly remains an empirical question. Research studying all 3 aspects of this approach integratively is needed to move the field beyond a narrow and siloed focus on outcome data and to more accurately reflect real-world practice in which all 3 elements shape care. Research on clinical decision making and clinicians’ use of outcome data are particularly needed. True evidence-based practice encapsulates a philosophy that acknowledges the inherent complexity of treating a chronic psychiatric disorder, such as militaryrelated PTSD, and recognizes that applying empirically supported treatments does not, in and of itself, necessarily equate to best practice.2
3. Steenkamp MM, Litz BT, Hoge CW, Marmar CR. Psychotherapy for military-related PTSD: a review of randomized clinical trials. JAMA. 2015;314(5): 489-500. 4. Steenkamp MM, Litz BT. Prolonged exposure therapy in veterans affairs: the full picture. JAMA Psychiatry. 2014;71(2):211.
post-traumatic stress disorder: a meta-analysis of direct comparisons. Clin Psychol Rev. 2008;28(5): 746-758. 7. Naylor CD. Grey zones of clinical practice: some limits to evidence-based medicine. Lancet. 1995; 345(8953):840-842.
5. Steenkamp MM, Litz BT. Psychotherapy for military-related posttraumatic stress disorder: review of the evidence. Clin Psychol Rev. 2013;33(1): 45-53. 6. Benish SG, Imel ZE, Wampold BE. The relative efficacy of bona fide psychotherapies for treating
JAMA Psychiatry Published online February 17, 2016 (Reprinted)
Copyright 2016 American Medical Association. All rights reserved.
Downloaded From: http://archpsyc.jamanetwork.com/ by a New York University User on 02/20/2016
jamapsychiatry.com
VIEWPOINT
Maria M. Steenkamp, PhD Steven and Alexandra Cohen Veterans Center for Posttraumatic Stress and Brain Injury, New York University Langone School of Medicine, New York; and Department of Psychiatry, New York University, New York.
Viewpoint
Corresponding Author: Maria M. Steenkamp, PhD, Department of Psychiatry, New York University, 1 Park Ave, Room 8-107, New York, NY 10016 (maria.steenkamp @nyumc.org). jamapsychiatry.com
True Evidence-Based Care for Posttraumatic Stress Disorder in Military Personnel and Veterans As the longest wars in US history draw to a close, treating the psychosocial sequelae of military trauma has become an important public health challenge. In contrast to previous wars, mental health care is for the first time leveraging science to treat deployment-related conditions such as posttraumatic stress disorder (PTSD). Evidence-based practice has become a driving principle behind the treatment of military-related PTSD and is considered a necessary safeguard against the use of unproven and ineffective interventions. However, a truly evidence-based approach to treating military-related PTSD differs from what it has come to mean in the recent clinical and research literature. Over the past 10 years, evidence-based practice for military-related PTSD in the United States has often become equated with the use of 2 empirically supported treatments, namely cognitive processing therapy (CPT) and prolonged exposure (PE) therapy. Cognitive processing therapy and PE are recommended as treatments of choice by the Department of Defense (DoD) and Department of Veterans Affairs (VA) treatment guidelines. Both are short-term trauma-focused interventions (ie, comprise approximately 12 sessions and target traumarelated memories and beliefs). They are the most studied psychotherapies for military-related PTSD and have been formally disseminated across the DoD and VA, with the goal that every VA patient have access to either CPT or PE. They are considered broadly effective, except for patients with blatant contraindications such as psychosis, active suicidality/homicidality, and severe substance misuse. Best practice for PTSD is typically described as consisting of one of these treatments (although in reality, a wide range of psychotherapies are used in these settings), with the assumption that patients receiving CPT or PE will demonstrate clinically meaningful symptom improvement. However, evidence-based practice as originally conceptualized entails a different vision. True evidencebased practice involves integrating 3 sets of information to inform care: the best-available research evidence, clinical judgment, and patient preference.1,2 In true evidence-based practice, evidence is individualized to each patient in a personalized evidence approach. This entails using clinical expertise to determine the degree of fit between the available evidence and the specific patient, as well as including patients in a shared decision-making process to ensure that their preferences and values are respected. What would such a true evidence-based treatment approach look like in the case of military-related PTSD? In a true evidence-based approach, the clinician first critically examines the strength, usability, and applicability of the available treatment outcome evidence. Few
randomized clinical trials of military-related PTSD have been conducted.3 The DoD/VA PTSD treatment guidelines are based primarily on studies with civilians, whose traumas (such as car crashes and assaults) typically differ from those experienced during deployment (such as killing and experiencing prolonged conditions of life threat); the extent to which findings from civilian treatment trials are easily translatable to veterans and servicemembers is debated. Even fewer trials have been published on US servicemembers and veterans with combat trauma, the modal population treated by the DoD and VA (in total, 2 PE trials and 3 CPT trials; 2 international studies have been conducted on Israeli and Australian veterans3). The 2 PE trials were small and both aimed primarily at studying biomarkers associated with PTSD symptom change. Of the 3 CPT trials, 2 examined group CPT; only 1 trial of individually administered CPT for combat-related PTSD has been conducted in US veterans.3 Similarly, few rigorous effectiveness data are available testing real-world outcomes, and the available studies are often published by clinics with allegiance to either CPT or PE and/or are selective in their study sample.4,5 Data from randomized clinical trials of militaryrelated PTSD also clearly show that CPT and PE are effective for some patients and not others. While beneficial to many patients, between one-third and half of veterans receiving CPT or PE do not demonstrate clinically meaningful symptom improvement.3 Even when patients do improve, symptoms often remain high: mean PTSD scores in trials of military-related PTSD have tended to remain at or above diagnostic thresholds following CPT or PE and approximately two-thirds of patients retain their PTSD diagnosis.3 Because extant studies tend to emphasize metrics of mean change (eg, effect sizes), this notable and important heterogeneity in patient outcomes is often obscured. Mean scores collapse patients who get better, worsen, or remain unchanged into a single metric. Also, a practical disadvantage of studies reporting average effects is that mean outcome data are less usable in practice: how will clinicians know whether their patients will be among those who respond to CPT and PE or not? Predictors of effectiveness remain understudied and poorly understood, and trials have typically not examined potential subgroups of participants. Adding further complexity to these mixed outcomes, the evidence shows that there are multiple roads to symptom improvement, of which trauma processing is just one. Randomized clinical trials using active comparison groups (rather than less rigorous waitlist or treatment-as-usual comparisons) have tended to support equivalence between disparate PTSD treatments.6 For example, CPT and PE are only marginally superior com(Reprinted) JAMA Psychiatry Published online February 17, 2016
Copyright 2016 American Medical Association. All rights reserved.
Downloaded From: http://archpsyc.jamanetwork.com/ by a New York University User on 02/20/2016
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Opinion Viewpoint
pared with structured nontrauma-focused psychotherapies that do not discuss the trauma, such as present-centered therapy, suggesting that trauma processing is not essential for improvement.3 Such findings are not easily reconciled theoretically and underscore the need for more research on the efficacy of both nontrauma-focused and trauma-focused interventions in troops and veterans, as well as research on moderators and predictors of outcomes. Such studies may elucidate how to optimally match patients to treatments and how to sequence different types of interventions in cases of nonresponse. Circumstances in which the scientific evidence is conflicting, incomplete, or of unclear relevance have been called “grey zones of clinical practice.”7 Grey zones represent situations in which the available evidence alone cannot guide clinical decision making and the clinician operates under some degree of uncertainty. This is currently the case with military-related PTSD, as the available evidence demonstrates heterogenous treatment outcomes that remain difficult to predict and that have uncertain relevance to the modal patient. When operating in a clinical grey zone, clinical judgment becomes essential to translate research findings on average effects to individual patients. The clinician must merge nomothetic research data with ideographic data specific to their patient (eg, treatment history, symptom presentation, and current psychosocial ARTICLE INFORMATION Published Online: February 17, 2016. doi:10.1001/jamapsychiatry.2015.2879. Conflict of Interest Disclosures: None reported. REFERENCES 1. Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ. 1996;312(7023):71-72. 2. Greenhalgh T, Howick J, Maskrey N; Evidence Based Medicine Renaissance Group. Evidence based medicine: a movement in crisis? BMJ. 2014; 348:g3725.
E2
stressors) to determine the clinical actions most likely to be of benefit. Patients should be included in this process through shared decision making that involves presenting them with the full spectrum of treatment choices.2 Thus, true evidence-based practice for military-related PTSD differs notably from preferentially applying PE or CPT without personalizing the evidence. Adopting a true evidence-based approach, with its equal emphasis on research evidence, clinical judgment, and patient preference, may help redress the large dropout rates currently plaguing military-related PTSD care3 and may result in better treatment outcomes than extant one-size-fits-all approaches, although this clearly remains an empirical question. Research studying all 3 aspects of this approach integratively is needed to move the field beyond a narrow and siloed focus on outcome data and to more accurately reflect real-world practice in which all 3 elements shape care. Research on clinical decision making and clinicians’ use of outcome data are particularly needed. True evidence-based practice encapsulates a philosophy that acknowledges the inherent complexity of treating a chronic psychiatric disorder, such as militaryrelated PTSD, and recognizes that applying empirically supported treatments does not, in and of itself, necessarily equate to best practice.2
3. Steenkamp MM, Litz BT, Hoge CW, Marmar CR. Psychotherapy for military-related PTSD: a review of randomized clinical trials. JAMA. 2015;314(5): 489-500. 4. Steenkamp MM, Litz BT. Prolonged exposure therapy in veterans affairs: the full picture. JAMA Psychiatry. 2014;71(2):211.
post-traumatic stress disorder: a meta-analysis of direct comparisons. Clin Psychol Rev. 2008;28(5): 746-758. 7. Naylor CD. Grey zones of clinical practice: some limits to evidence-based medicine. Lancet. 1995; 345(8953):840-842.
5. Steenkamp MM, Litz BT. Psychotherapy for military-related posttraumatic stress disorder: review of the evidence. Clin Psychol Rev. 2013;33(1): 45-53. 6. Benish SG, Imel ZE, Wampold BE. The relative efficacy of bona fide psychotherapies for treating
JAMA Psychiatry Published online February 17, 2016 (Reprinted)
Copyright 2016 American Medical Association. All rights reserved.
Downloaded From: http://archpsyc.jamanetwork.com/ by a New York University User on 02/20/2016
jamapsychiatry.com
