In late 2017, the Department of Veterans Affairs in conjunction with the Department of Defense published an update to their practice guidelines for the management of Posttraumatic Stress Disorder (PTSD). This two-part blog will highlight the major recommendations of the new practice guideline: part 1 will focus on recommendations for screening and assessment and part 2 will focus on treatment considerations. Although we hope that these blogs help to clarify the major elements of the new guideline, we strongly suggest that all clinicians review the guideline for themselves. The full guideline as well as the Clinician Summary and Pocket Guide can all be viewed and downloaded in PDF format here.
Part 2: Management of PTSD Symptoms: New Recommendations from the Department of Veterans Affairs and Department of Defense
Welcome back for part two of our series on the updated VA/DoD Guideline for the Management of PTSD. In part one, I reviewed the major recommendations regarding screening and assessment of PTSD. In this entry, I will discuss the recommendations about psychosocial and pharmacological treatments for PTSD.
Before we jump into our review of recommendations and suggestions, it’s important to take a quick look at the “qualifying statements” made at the beginning of the guideline. The guideline is based on the best available empirical data as of 2016 and is intended to “inform and assist decision making” (Department of Veterans Affairs, 2017, p.1). The authors go on to say that the specific recommendations and suggestions are not intended as a substitute for clinical decision making, nor are they intended to be a statement of clinical standards and practices in VA and DoD. Information on the process of drafting the guideline is presented which included a systematic review of the available literature by PTSD experts from various mental health disciplines.
Individual, manualized, trauma-focused psychotherapy received the highest recommendation. These therapies, which incorporate cognitive, exposure, or a combination of cognitive and exposure-based interventions, had the strongest empirical support when it comes to reducing PTSD symptoms. Specific examples of trauma-focused psychotherapy in the recommendation include Cognitive Processing Therapy (CPT), Prolonged Exposure Therapy (PE), and Eye Movement Desensitization and Reprocessing (EMDR). Trauma-focused therapy is recommended as a first-line treatment over pharmacotherapy on the basis of its efficacy, lower risk of side effects, better long-term effectiveness, and research suggesting that clients generally express a preference for psychotherapy over medication. Interestingly, the guideline advises against modifying the protocols of trauma-focused therapies unless they are “clinically necessary” and are “empirically and theoretically guided” (Department of Veterans Affairs, 2017, p. 21). Also, the provision of trauma-focused therapy via video teleconferencing is strongly recommended when in-person therapy is not possible.
When trauma-focused therapy is not available or not preferred by the client, pharmacotherapy (sertraline, paroxetine, fluoxetine, or venlafaxine) or manualized, non-trauma focused therapies (Present Centered Therapy, Stress Inoculation Therapy, Interpersonal Therapy) are recommended. The guideline states that empirical data regarding the relative efficacy of both these approaches is insufficient to determine which is more likely to be effective when compared to each other. Clinicians are encouraged to engage in shared decision making with their clients to determine the best approach. If you’re interested in learning more about shared decision making or SDM, check out Dr. Sharon Birman’s recent blog post, “Who makes the decisions around here?”
If the recommended treatments described above aren’t available or acceptable to the client, it is suggested that other types of manualized psychotherapy (e.g., Dialectical Behavior Therapy, Acceptance and Commitment Therapy, Seeking Safety) or group therapy be considered. However, the guideline notes that these forms of treatment do not have sufficient, available research to judge their overall efficacy. In other words, they don’t seem to be harmful, but it’s not clear if they are helpful, either. Other treatment approaches such as mind/body treatments (e.g., yoga) and certain medications (e.g., Prazosin) don’t have enough research to support their effectiveness for PTSD just yet and are therefore not recommended as stand-alone treatments. That said, these treatments may have value as adjunctive therapies that are provided together with one of the recommended treatments. Lastly, certain medications such as benzodiazepines and atypical antipsychotic medications are not recommended due to their apparent lack of efficacy and high risk of harmful side-effects.
As you can see, individual, trauma-focused psychotherapy is recommended as the most efficacious type of treatment available for PTSD. If you haven’t had the opportunity to learn one of these therapy protocols, you are in luck! CDP routinely offers training and consultation in CPT and PE. In fact, we have a CPT workshop scheduled for 18 June 2018 and a PE workshop scheduled for 2 August 2018. Both of these workshops are open to the general public and will be hosted in Second Life. If you have already attended a PE or CPT workshop and would like some assistance in implementing these protocols, check out our consultation landing page.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Andrew Santanello, Psy.D., is a licensed, clinical psychologist and Cognitive Behavioral Therapy trainer at the Center for Deployment Psychology.
U.S. Department of Veterans Affairs, & U.S. Department of Defense. (2017). VA/DoD clinical
practice guideline for management of post-traumatic stress. Washington, DC: Authors. Retrieved from: https://www.healthquality.va.gov/guidelines/MH/ptsd/VADoDPTSDCPGFinal.pdf