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Inserting a cautionary note in the enthusiasm about effective treatments for post-traumatic stress disorders (PTSD), an Institute of Medicine (IoM) panel concluded in October that only exposure therapies such as prolonged exposure and cognitive-processing therapy have enough evidence to recommend them for treatment. The independent review was requested by the Department of Veterans Affairs (VA).

"At this time, we can make no judgment about the effectiveness of most psychotherapies or about any medications in helping patients with PTSD," states Alfred O. Berg, MD, the University of Washington professor of family medicine who chaired the IoM committee. "These therapies may or may not be effective-we just don't know in the absence of good data."

In a review of 53 drug studies and 37 psychotherapy studies, the seven-member panel concluded that many PTSD studies are flawed in terms of design and high dropout rates, which limit their generalizablity. Moreover, most drug studies were funded by pharmaceutical companies, and many psychotherapy studies were conducted by people who developed the techniques or by their close collaborators, the report finds.

Besides listing a number of drugs that need more independent investigation, the panel asserted that the following psychotherapies need better evaluation:

  • Eye-movement desensitization and reprocessing.

  • Cognitive restructuring.

  • Coping-skills training.

  • Group psychotherapy.

This said, the findings shouldn't be interpreted to mean that exposure therapies are the only treatments that should be used to treat the condition, the report adds. The reports' authors do suggest, however, that Congress should provide resources to the VA and other federal agencies to fund high-quality PTSD research that includes veterans and other affected groups in research planning, it states.

Psychologists expert in PTSD commended the committee for its critical review and the VA for commissioning the independent study. However, many believe the report is flawed in several ways, including that it fails to address the difficulties in conducting PTSD research and to take into account existing reviews and guidelines conducted by other independent bodies.

"I think [the IoM panel] raised the bar too high and they're not realistic about what PTSD is and how hard it is to study and to keep people in treatment," says PTSD expert Barbara O. Rothbaum, PhD, director of the Trauma and Anxiety Recovery Program at Emory University. "High dropout is endemic in PTSD."

Dartmouth Medical School psychologist Paula P. Schnurr, PhD, well-known for her rigorous, large-scale studies of PTSD populations, says that in her view, the literature "differs from the conclusions of the report, in that there's good evidence that a wider range of cognitive behavioral therapies are effective."

In addition, the panel's findings are at odds with many reviews already done in the field, Rothbaum says. As one example, the committee did not support the evidence base on any drug at all, even though the Food and Drug Administration has approved the selective serotonin reuptake inhibitors paroxetine (Paxil) and sertaline (Zoloft) to treat PTSD. "There have been a number of reviews out there, and none has concluded that only one intervention works," she says.

-T. DeAngelis