The recently-issued policy on screening and treating PTSD from the Army’s Office of the Surgeon General (OTSG) is dense, specific and should be helpful in advancing the field of post-traumatic stress disorder diagnosis and treatment.
Last week, I posted on the change in the criteria for diagnosing PTSD. Now we’ll examine a central focus of the policy: evidence-based treatment, including cognitive behavioral treatment (CBT), exposure-based treatment, and medication.
Evidence-based treatments are ones that are proven, in scientific trials, to be effective. The American Psychiatric Association and DoD-VA have published treatment guidelines.
There are other treatments that have not been proven, but show promise. They may be called evidence-informed treatments, or promising new treatments.
A brief description of these treatments follows. More information can be found in a number of forums, including at the National Center for Post-Traumatic Stress Disorder.
— Cognitive-behavioral treatment is a well-accepted method of treatment, where one tried to identify irrational thought and emotions, and correct them. For example, if one is depressed, one may think that the stranger on the street who does not say hello does not like you. But that is an irrational thought. It could be that he does not see you, or is too wrapped up in their own thoughts to notice you. So the therapist teaches the patient to recognize irrational negative thoughts and to replace them with positive ones.
— Exposure-based treatment requires gradual increasing exposures to what bothers you, until it no longer does. For people who are afraid of being in crowds, or driving across bridges, you ask them to imagine being in a crowded place or driving across the Bay Bridge, and then work up to when they can actually do it.
A promising form of exposure therapy is “Virtual Reality,” — a computer-based simulation of war zones. The Soldier or Marine puts on headphones and watches computer-based images of tanks driving down streets in Iraq or Afghanistan. There may be smells of dung or explosives added. The service member can crank the exposure up or down.
Unfortunately, both types of treatment usually involve 12 to 20 sessions. The typical length of therapy for Soldiers is three treatments, and that included Soldiers in the lengthy medical board process. Soldiers generally appear for only one, either because of their work schedule, or because they do not want to participate. Veterans, no longer on active duty, are more likely to complete the course of therapy.
Medication works more quickly, in most cases. However, there can be side effects. With the mild anti-depressants, used for both depression and PTSD, the side-effects are usually also mild. These medications include Prozac (fluoxetine), Zoloft (sertraline), Paxil (paroxetine), and other medications in the class of serotonin specific reuptake inhibitors (SSRIs).
There are many other therapies. EMDR (eye movement desensitization reprocessing) is also now evidence based. Complementary and alternative therapies, such as acupuncture and yoga, also are showing a lot of promise. My pet therapy is the use of therapy animals, but the research there is just beginning.
The good news is that the treatments for PTSD are effective. The bad news is that service members are still reluctant to seek treatment, because they are concerned about their careers. But the best news is that the field is advancing quickly. The new OTSG policy reflects the new knowledge.
The other point I would like to make (again), that taking care of service members and veterans is not just a military issue or a Department of Veterans Affairs problem. It should be a national priority, embraced by both sides of the aisle.