Clinicians Digest Mar/Apr 2008 - Page 5


A Single Treatment for PTSD?

When the Department of Defense asked the prestigious Institute of Medicine (IOM), an arm of the National Academy of Sciences, to determine the most effective treatments for post-traumatic stress disorder, the hope was that this would put treatment decisions for thousands of veterans suffering from PTSD on a solid empirical foundation. But after reviewing 90 clinical trials of different medications and therapies, the IOM report concluded that only exposure therapy was effective, a finding which has created more controversy than consensus.

According to the report, studies on every other medication and therapy frequently used to treat PTSD—including EMDR, cognitive restructuring, coping skills training, and psychodynamic and group therapy—were too compromised by methodological limitations or didn't have enough positive results to demonstrate their efficacy.

Proponents of treatments that didn't make the grade have strongly challenged IOM's conclusions. Some researchers, including John Carlson, former editor of the International Journal of Stress Management and author of an EMDR study which the IOM report found lacking, wrote the IOM committee that they'd ignored or misstated information in several studies. Critics also complained that a number of treatments IOM failed to find effective are recommended by prestigious mental health and governmental organizations around the world. For example, Britain's Cochrane Report of April 20, 2005, prepared by a group of international health care reviewers, endorses stress management and EMDR as PTSD treatments, with EMDR's efficacy matching that of exposure therapy.

Even supporters of the IOM report, like PTSD expert Richard McNally, director of clinical training at Harvard University, agree that the IOM used unusually rigorous standards, raising methodological issues often overlooked by reviewers. For example, the IOM was dissatisfied with the way many studies handled treatment dropouts. It criticized studies run by people with a "financial or intellectual interest" in the outcome, although other organizations believe that the risk of researcher bias is outweighed by the fact that familiarity with a treatment helps ensure it's conducted correctly. Some approaches that have proven to be effective with PTSD were discounted because of the restricted populations they examined. The IOM felt, for example, that what works for a rape victim with PTSD may not work for a soldier. While McNally sees in this a move by the IOM to improve research guidelines, critics like Carlson accuse the report of selectively moving the goalposts to favor exposure therapy.

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