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 Evidence-Based Treatment of PTSD

BRIEFING OUTLINE
PURPOSE: To provide information on current evidence-based treatments of
PTSD and their use in Army MTFs.

1. Overview of treatments and current

literature supporting them
.~ , 2. ' Currerit practices across the AMEDE>
,. 3~ Findings of the Rand Study "Invisible
•
Wounds of War"
4. The Way Ahead towards quality and
standardization

l<b)(6) Slide 2 of 10 7 Aug 08

 Evidence-Based Treatment of PTSD

TYPES OF TREATMENT
• Cognitive-behavioral treatments (CST)
- Exposure therapy, Systematic desensitization, Stress
inoculation training, Cognitive therapy, Cognitive processing
therapy (CPT)
• Pharmacotherapy
- Antidepressants (SSRI/SNRls, MAOls, TCAs)
- Anti-adrenergics (Prazosin, Propranolol)
- Anticonvulsants (Carbamazepine)
- Antipsychotics (Quetiapine, Risperidone)
- Benzodiazepines (BZDs)
• Psychological debriefing
• Adjunctive treatments
- EMDR, Psychodynamic therapy, Hypnosis

l(b)(6) Slide 3 of 10 7 Aug 08

 Evidence-Based Treatment of PTSD

EVIDENCE-BASED EFFECTIVENESS
• Good evidence, effective
CBT, Exposure therapy, CPT, EMOR (eye movements probably add
nothing)
SSRls
• Limited evidence, maybe effective
Prazosin (specific symptoms)
Psychodynamic therapy
Acupuncture
Hypnosis
• Ineffective or no benefit
- Biofeedback, CISO (maybe even harmful), BZOs
• Insufficient evidence to evaluate
Marital and family therapy, Combination therapy, Length of therapy,
other CAM

l(b)(6 ) Slide 4 of 10 7 Aug 08

 Evidence-Based Treatment of PTSD

TREATMENTS AT AMEDD MTFs

• Data call in progress of the RMCs to see which therapies
enumerated in the Rand Study and which outcome measures
are being used to evaluate effectiveness
• All respondents to date indicate they use CST, Group therapy,
marital and family therapy, and at least one other evidence-
based therapy
• Almost all also use pharmacotherapy, CPT, Psychosocial
rehab, and various exposure therapies; 2/3 use EMDR
• Only those specifically trained use CST, CPT, and EMDR
• Of the ineffective therapies, 2/3 use CISD
• Most use clinical assessment of improvement as outcome,
some use standardized scales or surveys
l(b)(6) I Slide 5 of 10 7 Aug 08
 Evidence-Based Treatment of PTSD

PTSD TRAINING BY AMEDDC&S

• Basic, Intermediate, and Advanced Courses

• Basic and Intermediate are web-based courses on recognition
and treatment of PTSD
• Advanced Courses are week-long practical courses in CPT,
PET, EMDR
• EMDR includes supervised clinical practice via tele-
consultation and certification by the EMDR Institute
• 311 BH providers have been trained to date, next FY plan is
for four iterations each of these three evidence-based
treatments.

l(b)(6) Slide 6 of 10 7 Aug 08

 ~ Evidence-Based Treatment of PTSD
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FINDINGS FROM THE RAND STUDY

• Lack of infrastructure to routinely measure processes or

outcomes
• Routine performance measurement of psychotherapy is
notably lacking (common in the civilian sector as well)
• Limited efforts to train providers in evidence-based
practices
• The new Center of Excellence can be an excellent
vehicle to provide leadership and institutionalize
excellence of care, training, and quality improvement

l(b)(6) Slide 7 of 10 7 Aug 08

 Evidence-Based Treatment of PTSD

RECOMMENDATIONS

• Training
- Expand current efforts to train providers in evidence-based
therapies (AMEDDC&S, Center for Deployment Psychology)
- Should include didactic and practical instruction, supervised
clinical practice (e.g., tele-supervision)
- Leverage DCoE and VA talent and collaboration to
institutionalize training and promulgation of supported
therapies

l(b)(6) Slide 8 of 10 7 Aug 08

 Evidence-Based Treatment of PTSD

RECOMMENDATIONS

• Process Measures
- Rates of evidence-based services
• VA uses audits
• Special CPT codes for type of psychotherapy
- Documentation of individual patient improvement
• Clinical assessment vs. standardized scales
• Capture in AHLTA to evaluate both process and aggregate for
program effectiveness

l(b)(6) Slide 9 of 10 7 Aug 08

 Evidence-Based Treatment of PTSD

RECOMMENDATIONS

• Outcome Measures
- Functional outcomes relevant to the military
• RTD rates
• MEB ratings
- Satisfaction - patient perception of quality care (VA)
• Research (DCoE, Consortium)
- Adjunctive therapies (cf. more easily studied manualized
therapies)
- Optimum length of therapies

11b)(6) Slide 10 of 10 7 Aug DB