Is it better to treat post-traumatic stress by consciously processing traumatic events or by prolonged exposure to memory of the trauma? Both methods have proven effective over time; but now the Department of Veterans Affairs is studying how they compare to each other in hopes of fine-tuning the therapy delivery system.
"Treatment for PTSD works. PTSD does not have to be a chronic disorder," said Dr. Paula Schnur, executive director of the VA's National Center for Posttraumatic Stress Disorder in White River Junction, Vermont and a professor of psychiatry at the Geisel School of Medicine at Dartmouth. "We're at a state right now where we have a number of treatments that are effective, but what we don't know very much about is how the treatments compare with each other."
According to the National Institutes of Health, PTSD affects a total of about 7.7 million American adult -- civilians, active-duty military and veterans -- who have experienced or witnessed traumatic events.
The Department of Veterans Affairs estimates that PTSD afflicts about 31 percent of Vietnam veterans, 10 percent of Gulf War (Desert Storm) veterans, 11 percent of veterans of the war in Afghanistan, and 20 percent of Iraqi war veterans.
Schnur, who will mark her 29th year at the VA this month, said it was a privilege to be at the forefront of VA research on improving treatments.
"Being in the VA has been an incredible opportunity as a scientist to be doing the kind of research that can make a difference," she said.
Her research has focused on the long-term physical and mental health outcomes of exposure to traumatic events, and she is currently overseeing a comparative study of two of the main regimens offered by the VA -- prolonged exposure therapy (PE) and cognitive processing therapy (CPT).
In PE, the therapist will work with the veteran "to gradually approach trauma-related memories, feelings and situations," according to the American Psychological Association’s description of the treatment. "Most people want to avoid anything that reminds them of the trauma they experienced, but doing so reinforces their fear. By facing what has been avoided, a person can decrease symptoms of PTSD by actively learning that the trauma-related memories and cues are not dangerous and do not need to be avoided."
In CPT, the therapist works with the patient to evaluate and change the upsetting thoughts brought on by the traumatic event or events, according to the VA's National Center for PTSD.
The treatment can involve writing about the event to help the patient decide whether there are more helpful ways to think about the trauma, the center said.
In its outline for CPT posted on the VA's website, the center said that "towards the end of therapy, you and your provider will focus on some specific areas of your life that may have been affected by the trauma, including your sense of safety, trust, control, self-esteem and intimacy."
Schnur said she was currently overseeing "comparative effectiveness research" on PE and CPT to consider if “one a bit better than another, does one have more side effects?"
The goal was to help the veteran decide what was best for him or her, personally.
"Which works best for each patient? We really do have to do this kind of comparison to move to answering these questions for veterans and their clinicians," she said.
Currently, "we really don't know whether one might have an edge over the other," Schnur said.
The comparison study on PE and CPT has thus far enrolled more than 900 veterans, male and female from all eras, at 17 VA sites nationwide, she said.
The plan is to finish collecting data by next spring in hopes of arriving at answers by mid-2019.
In its budget request for Fiscal Year 2019, the VA called for an expansion of mental health services that would provide "more than 15.2 million outpatient visits, an increase of nearly 162,000 visits above 2018."
The request was for $8.6 billion for veterans' mental health services, which would be an increase of 5.8 percent above the 2018 current estimate, and would also include $190 million for suicide prevention outreach, the VA said.
Much of the mental health funding will be directed at what is now called PTSD but has been known by other names for as long as there have been wars. Treatises have been written on how Achilles probably suffered from PTSD.
It was called "soldier's heart" in the Civil War; in World War I, it was "shell shock;" and in World War II, "battle fatigue" or "combat fatigue."
Much has been written about the use of yoga, tai chi, acupuncture, the involvement of veterans with dogs or horses, and other alternatives as treatment for PTSD, but Schnur said they all should be considered as secondary or complimentary to PE and CPT.
"Our view of the evidence is that we don't recommend them as primary treatment," Schnur said.
However, the VA in July also set up the Creating Options for Veterans Expedited Recovery Commission (COVER) to explore alternative PTSD treatments developed in the private sector.
"The COVER Commission will examine the evidence-based therapy treatment model used by the Secretary of Veterans Affairs for treating mental health conditions of veterans and the potential benefits of incorporating complementary and integrative health treatments available in non-Department facilities," VA officials said when announcing the commission's creation.
-- Richard Sisk can be reached at Richard.Sisk@Military.com.