Evidence Based Practice For Ptsd

Predictors Of Ebp Use

A multivariate logistic regression model predicting receipt of any EBP had acceptable discrimination, with a concordance statistic of 0.77. Before controlling for site, almost all patient-level variables predicted EBP receipt. Far fewer patient factors predicted EBP receipt after controlling for site. These included female gender, alcohol use disorder, history of traumatic brain injury , admission later in FY15, length of stay greater than 6 weeks, and seeing more than 10 therapists during that stay. The sole patient factor that continued to predict not receiving an EBP after controlling for site was having a depressive disorder. Before controlling for site, the largest therapist predictor of EBP receipt was being an EBP consultant or trainer, followed by EBP certification, high self-rated skill level, and having 20 yr or more of clinical practice experience. Therapist factors that predicted not receiving EBP treatment included not having any EBP training, minority race, having worked in a VA residential PTSD program for 20 yr or more, and seeing 20 or more VA residential PTSD program patients per week. After controlling for site, only EBP consultant or trainer status remained as a positive therapist predictor of EBP receipt, whereas only minority race remained as a negative therapist predictor or EBP receipt. These results indicate a strong site effect on EBP receipt .

Grading The Soe For Major Comparisons And Outcomes

We will grade the SOE based on the guidance established for the Evidence-based Practice Center Program.33 Developed to grade the overall strength of a body of evidence, this approach incorporates five key domains: risk of bias , consistency, directness, precision of the evidence, and reporting bias. It also considers other optional domains that may be relevant for some scenarios, such as a dose-response association, plausible confounding that would decrease the observed effect, and strength of association .

Table 4 describes the grades of evidence that can be assigned. Grades reflect the strength of the body of evidence to answer KQs on the comparative effectiveness, efficacy, and harms of the interventions included in this review. Two reviewers will assess each domain for each key outcome, and differences will be resolved by consensus. We will grade the SOE for the outcomes deemed to be of greatest importance to decisionmakers and those most commonly reported in the literature. We expect these to include PTSD symptom reduction, quality of life, disability/functional impairment, and AEs.

Ptsd: Its Not What It Used To Be

When different interventions achieve very similar results like this, it is natural to consider possible commonalities across treatments that may be responsible for similar outcomes. Indeed, researchers have uncovered mechanisms that appear common across these psychotherapeutic techniques, including psychoeducation, imaginal exposure, cognitive processing, cognitive restructuring, and meaning-making . Additionally, it appears that all of these effective, evidence-based PTSD treatments comprise structured therapies delivered by certified healthcare professionals .

Lastly, research points to the interpersonal relationship between patient and therapist, known as a therapeutic alliance, as a powerful predictor of reduction in PTSD symptoms across treatments . The apparent benefits of current evidence-based treatments for PTSD over non-trauma-focused treatment approaches are marginal if any, likely due at least in part to these commonalities across treatment techniques.

2. High rates of patient nonresponse and dropout from treatment.

In addition to leading treatments having marginal benefits over other treatments, treatment nonresponse and treatment dropout are major hurdles for current evidence-based treatments . It is not uncommon for treatment nonresponse rates to be as high as 50 percent on some measures of expected outcome responses to treatment . This represents an extremely high percentage of individuals not responding to or reporting zero benefit from treatment.

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Viii Key Informants/technical Experts And Review Of Key Questions

Key Informants are the end users of research, including patients and caregivers, practicing clinicians, relevant professional and consumer organizations, purchasers of health care, and others with experience in making health care decisions.

Technical Experts constitute a multidisciplinary group of clinical, content, and methodological experts who provide input in defining populations, interventions, comparisons, and outcomes and identify particular studies or databases to search. They are selected to provide broad expertise and perspectives specific to the topic under development.

Key Informants and Technical Experts were included in a multi-stakeholder virtual workshop by PCORI in December 2016. The workshop reviewed scoping for the updated review, prioritization of key questions, a discussion of where the evidence based has accumulated since the prior review and emerging issues in PTSD. This PTSD protocol was developed based upon findings from the multi-stakeholder virtual workshop. Key Informants and Technical Experts do not do analysis of any kind nor do they contribute to the writing of the report. They have not reviewed the report, except as given the opportunity to do so through the peer or public review mechanism.

Characteristics Of Patients Who Saw Therapistrespondents

Patients who saw therapistrespondents were most commonly White men under the age of 35 yr . Their most common mental health comorbidities were depressive disorders, alcohol use disorders, and anxiety disorders. Patients were admitted evenly over the four quarters of the 2015 fiscal year, with a mean length of stay of over 50 d. During that time, they saw a mean of 6.4 clinicians who coded at least one encounter as psychotherapy, of whom approximately 2.8 were therapist survey respondents. Less than 20% of patients received an individual EBP, but the percentage of patients receiving any EBP was raised to just over 35% when accounting for group therapy.

Characteristics of Patients Treated Whose PTSD Residential Program Therapists Participated in Fiscal Year 2015 Survey

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High Dropout Rates Low Patient Satisfaction And Questionable Results

• Current treatments for PTSD have significant limitations.
• Dropout rates for traditional PTSD treatments can be high.
• Response rates for traditional PTSD treatments are less than stellar.

There is general agreement on six psychotherapy-based treatment techniques for posttraumatic stress disorder as the most effective, evidence-based approaches available. These treatment techniques are trauma-focused cognitive behavioral therapy interventions that include:

Medications, primarily selective serotonin reuptake inhibitors , are also evidence-based treatment approaches, though the literature demonstrates clear benefits of psychotherapeutic techniques over the use of medications in treating PTSD . Notably, the U.S. Department of Defense and U.S. Department of Veterans Affairs guidelines no longer endorse these types of medications as first-line treatments for PTSD instead, they recommend the manualized psychotherapies listed above as primary treatments for PTSD .

Other Medications For Ptsd

Topiramate is in the anti-epileptic category of medications and is thought to modulate glutamate neurotransmission. There has been recent interest in its use for PTSD. The systematic review that served as the evidence base for the guideline development panel reported moderate strength of evidence for a medium to large magnitude effect for PTSD symptom reduction.

However, the panel concluded that there was insufficient evidence to make a recommendation because the potential side effects/harms for topiramate are greater than they are for SSRI antidepressants. It is not uncommon for patients taking topiramate to note side effects of cognitive dulling. Topiramate has also been found helpful in reducing alcohol consumption in those with an alcohol use disorder, which frequently accompanies PTSD.

Adapted from with original content written by Matt Jeffreys, MD. Matthew J. Friedman, MD, PhD, Thomas Mellman, MD and Jeffrey Sonis, MD, MPH also contributed.

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Placing Clinical Practice Guidelines In Context

Provision of high quality, effective care that reduces symptoms and helps the patient return to higher levels of functioning is a shared goal for patients and their families, practitioners, policy makers, and administrators. But knowing which information to trust and prioritize is not easy, and synthesizing available research and determining preferable care options can be daunting. Clinical practice guidelines are an essential tool to guide clinical decision-making and make it easier for patients to get the care they need. Clinical practice guidelines are intended to be a centralbut clearly not the onlydeterminant of treatment choice. Other factors include patients preferences and histories, providers expertise and judgment, nonspecific factors in psychotherapy, and patients individual differences.

Ptsd In The Us Population Today

The National Center for PTSD made public estimates that whereas the lifetime prevalence of PTSD in the US population was 5% in men and 10% in women in the mid-to-late 1990s, the prevalence of PTSD among Vietnam veterans at this same time was at 15.2%. About 30% of the men and women who have spent time in more recent war zones experience PTSD.

Whereas the onset and progression of PTSD is characteristic for every individual subject, data suggest that most people who are exposed to a traumatic, stressful event will exhibit early symptoms of PTSD in the days and weeks following exposure. Available data from the National Center for PTSD suggest that 8% of men and 20% of women go on to develop PTSD and 30% of these individuals develop a chronic form that persists throughout their lifetimes. Complex PTSD, which is also referred to as disorder of extreme stress, results from exposure to prolonged traumatic circumstances, such as the year-on end threat of insurgent attacks among our military personnel currently in active deployment.

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Data Abstraction And Data Management

Two trained research team members will independently review all titles and abstracts identified through searches for eligibility against our inclusion/exclusion criteria using Abstrackr.28 Studies marked for possible inclusion by either reviewer will undergo a full-text review. For studies without adequate information to determine inclusion or exclusion, we will retrieve the full text and then make the determination. All results will be tracked in an EndNote® bibliographic database .

We will retrieve and review the full text of all titles included during the title/abstract review phase. Two trained team members will independently review each full-text article for inclusion or exclusion based on the eligibility criteria described above. All articles included in the prior PTSD systematic review also will be reevaluated for inclusion based on the inclusion and exclusion criteria of this updated review. If both reviewers agree that a study does not meet the eligibility criteria, the study will be excluded. If the reviewers disagree, conflicts will be resolved by discussion and consensus or by consulting a third member of the review team. As described above, all results will be tracked in an EndNote database. We will record the reason why each excluded full-text publication or publication included in the prior PTSD review did not satisfy the eligibility criteria so that we can later compile a comprehensive list of such studies.

Emr Template Documentation Of Ebp Receipt

We identified psychotherapy encounters using current procedural technology codes for individual and group psychotherapy. For each encounter, we determined whether therapists completed EMR templates indicating EBP delivery. When therapists check boxes on the EMR templates, they create string variables called health factors that are linked to the encounter. Using health factor data, we divided EBP encounters into PE-I, CPT-I, and CPT-G.

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Assessment Of Methodological Risk Of Bias Of Individual Studies

To assess the risk of bias of RCTs, we will use the same criteria used in the 2013 AHRQ review by Jonas and colleagues,26 which were based on the Agency for Healthcare Quality and Research Methods Guide for Comparative Effectiveness Reviews. These criteria are similar to the ROBINS-129 tool and the Cochrane RCT tool30 . For both RCTs and observational studies, ROB assessment will include questions to assess selection bias, confounding, performance bias, detection bias, and attrition bias concepts covered include those about adequacy of randomization , similarity of groups at baseline, masking, attrition, whether intention-to-treat analysis was used, method of handling dropouts and missing data, validity and reliability of outcome measures, and treatment fidelity.31

In general terms, a “good” study has the least bias, and its results are considered to be valid. A “fair” study is susceptible to some bias but probably not sufficient enough to invalidate its results. A “poor” study has significant bias that may invalidate its results.

What Do Ptsd Treatment Guidelines Recommend

The current NICE guidelines2 recommend selective serotonin reuptake inhibitors as a group and venlafaxine as the first-line pharmacological treatments for PTSD. The ISTSS guidelines,Reference Bisson, Berliner, Cloitre, Forbes, Jensen and Lewis3 like the original NICE guidelines, considered individual drugs separately and found fluoxetine, paroxetine and sertraline to be the only SSRIs with definite efficacy and therefore recommend these three by name, alongside the serotoninnoradrenaline reuptake inhibitor venlafaxine, as the pharmacological treatments of choice for PTSD.

Both the NICE and ISTSS guidelines recommend antipsychotic medications as second-line pharmacological approaches. NICE does not differentiate between antipsychotics ISTSS recommends quetiapine alone, as it was the only antipsychotic found to have any evidence of efficacy as a monotherapy and this was limited to one RCT with a total of 80 participants.

Ultimately, the differences in recommendations between these and the other major PTSD treatment guidelines are minor and they provide a clear and relatively consistent prescribing message.Reference Hamblen, Norman, Sonis, Phelps, Bisson and Nunes1

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Summary And Future Directions

In summary, PTSD is a relatively common and highly debilitating psychiatric disorder affecting approximately 8% of the U.S. population . Potent evidence-based psychosocial interventions are available, and several medications have FDA approval for the treatment of PTSD. While pharmacological treatments have shown some promise, more investigation and advancement in this area is needed. One of the most important concerns with the sole use of pharmacotherapy for PTSD treatment is the evidence that discontinuing treatment can be associated with relapse . Although relapse is relatively infrequent after one responds to an evidence-based psychotherapy for PTSD , a proportion of patients either drop out of therapy prematurely or do not respond to therapy . It is therefore critical to continue to investigate new strategies to improve upon the available treatments for PTSD.

Using Cbt To Treat Ptsd

Therapists use a variety of techniques to aid patients in reducing symptoms and improving functioning. Therapists employing CBT may encourage patients to re-evaluate their thinking patterns and assumptions in order to identify unhelpful patterns in thoughts, such as overgeneralizing bad outcomes, negative thinking that diminishes positive thinking, and always expecting catastrophic outcomes, to more balanced and effective thinking patterns. These are intended to help the person reconceptualize their understanding of traumatic experiences, as well as their understanding of themselves and their ability to cope.

Exposure to the trauma narrative, as well as reminders of the trauma or emotions associated with the trauma, are often used to help the patient reduce avoidance and maladaptive associations with the trauma. Note, this exposure is done in a controlled way, and planned collaboratively by the provider and patient so the patient chooses what they do. The goal is to return a sense of control, self-confidence, and predictability to the patient, and reduce escape and avoidance behaviors.

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Eye Movement Desensitization And Reprocessing

Eye movement desensitization and reprocessing therapy had also received empirical support for the treatment of PTSD . The model used to explain PTSD in EMDR is similar to cognitive-behavioral therapies in that PTSD is viewed as a result of insufficient processing of the traumatic memory. EMDR hypothesizes that the trauma memory, if not fully processed, is stored in its initial state, preserving any misperceptions or distorted thinking patterns that occurred at the time of the trauma.

Ptsd Assessment In The Military

Certain scales have been developed that specifically target military personnel.

Such differences in rates, depending on the assessment instrument may hold significance. According to the study there may be different explanations self-report instruments like the M-PTSD do not reflect DSM criteria as comprehensibly as the SCID. Symptoms may differ in both intensity and kind among older and younger prisoners of war. In the paradoxical side, it is possible for an individual to be diagnosed with PTSD while reporting minimal stress levels in fact, subjective stress can be seen as a confounding factor that can have an influence on diagnosis .

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How Cbt Can Help With Ptsd

Several theories specific to trauma explain how CBT can be helpful in reducing the symptoms of PTSD.

For example, emotional processing theory suggests that those who have experienced a traumatic event can develop associations among objectively safe reminders of the event , meaning and responses . Changing these associations that lead to unhealthy functioning is the core of emotional processing.

Social cognitive theory suggests that those who try to incorporate the experience of trauma into existing beliefs about oneself, others, and the world often wind up with unhelpful understandings of their experience and perceptions of control of self or the environment . For instance, if someone believes that bad things happen to bad people, being raped confirms that one is bad, not that one was unjustly violated.

Understanding these theories helps the therapist more effectively use cognitive behavioral treatment strategies.