Medication versus trauma-focused psychotherapy for adults with posttraumatic stress disorder: A systematic review and meta-analysis

Acupuncture Therapy for Military Veterans Suffering from Posttraumatic Stress Disorder and Related Symptoms: A Scoping Review of Clinical Studies

Military personnel in combat face a high risk of developing posttraumatic stress disorder (PTSD). In this study, a protocol-based scoping review was conducted to identify the current status of research on the efficacy of acupuncture for treating combat-related PTSD in military personnel. A literature search was conducted across 14 databases in November 2022, and data from the included studies were collected and descriptively analyzed. A total of eight studies were included. Participants were assessed for core PTSD symptoms using the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-5 and the Clinician-Administered PTSD Scale, as well as related symptoms, such as sleep issues. Although the efficacy of acupuncture has been substantiated in numerous studies, certain metrics did not exhibit improvement. Auricular acupuncture was the most commonly used treatment (50%) followed by manual acupuncture (25%) and a combination of both (25%). Shenmen and Kidney points were frequently targeted at auricular acupoints. The treatment period varied between 5 days and 2 months. While adverse events were reported in two of the fifty-five patients in the intervention group and in four of the sixty-four patients in the control group in the randomized controlled trial studies, no fatal adverse events were reported.

Do treatments for mental disorders affect relationship satisfaction? A systematic review and meta-analysis

Objective: Psychiatric disorders have been linked to poor social functioning, including deficits in relationship satisfaction. Treatments have shown strong effectiveness in reducing clinical symptoms for a range of disorders, though less is known of the effects disorder-focused treatments have on relationship satisfaction.

Methods: The present study describes a systematic review that was conducted to determine the efficacy of treatments for specific psychiatric disorders in improving relationship satisfaction. Surprisingly, only seventeen studies were identified and included in the review.

Results: We found that a majority of these studies reported modest improvement in relationship satisfaction among people who completed treatment. However, studies were severely hampered by methodological limitations, and all therapy-related improvements could be attributable to placebo effects or the passage of time.

Conclusion: Important gaps in the literature were found that future research should seek to address to maximize treatment outcomes and psychosocial functioning.

A Rapid Review of "Low-Threshold" Psychiatric Medication Prescribing: Considerations for Street Medicine and Beyond

OBJECTIVE

No widely accepted clinical guidelines, and scant directly applicable pragmatic research, are available to guide the prescription of psychiatric medications in "low-threshold" outpatient settings, such as street outreach, urgent care, and crisis care, as well as walk-in, shelter, and bridge and transition clinics. Providers frequently prescribe medications in these settings without patients' having firm psychiatric diagnoses and without medical records to guide clinical decision making. Persons who receive medications in these settings often seek help voluntarily and intermittently for mental illness symptoms. However, because of structural and individual factors, such patients may not engage in longitudinal outpatient psychiatric care. The authors reviewed the literature on psychiatric medication prescribing in low-threshold settings and offer clinical considerations for such prescribing.

METHODS

The authors conducted a rapid literature review (N=2,215 abstracts), which was augmented with up-to-date clinical prescribing literature, the authors' collective clinical experience, and DSM-5 section II diagnostic criteria to provide considerations for prescribing medications in low-threshold settings.

RESULTS

For individuals for whom diagnostic uncertainty is prominent, a symptom-based diagnostic and treatment approach may be best suited to weigh the risks and benefits of medication use in low-threshold settings. Practical considerations for treating patients with clinical presentations of psychosis and trauma, as well as mood, anxiety, and substance use disorders, in low-threshold settings are discussed.

CONCLUSIONS

An urgent need exists to invest in pragmatic research and guideline development to delineate best-practice prescribing in low-threshold settings.

A comparison of prolonged exposure therapy, pharmacotherapy, and their combination for PTSD: What works best and for whom; study protocol for a randomized trial

BACKGROUND

Several efficacious psychological and pharmacological treatments for posttraumatic stress disorder (PTSD) are available; however, the comparative effectiveness of these treatments represents a major gap in the literature. The proposed study will compare the effectiveness of two leading PTSD treatments - Prolonged Exposure (PE) therapy and pharmacotherapy with paroxetine or venlafaxine extended release - as well as the combination of PE and medication.

METHODS

In a randomized clinical trial, veterans with PTSD (N = 450) recruited across six Veterans Affairs Medical Centers will complete assessments at baseline, mid-treatment (Week 7), post-treatment (Week 14), and follow-up (Weeks 27 and 40). The primary outcome will be change in (both clinician-rated and self-reported) PTSD severity. Depression symptoms, quality of life, and functioning will also be measured and examined as secondary outcomes. Baseline demographic and clinical data will be used to develop "personalized advantage indices" (PAIs), with the goal of identifying who is most likely to benefit from which treatment.

CONCLUSIONS

This planned trial will yield findings to directly inform clinical practice guidelines for PTSD, by providing comparative effectiveness data to support recommendations about what can be considered the "first-line" treatment option(s) for PTSD. Further, findings from this trial have the potential to guide treatment planning for individual patients, through implementation of PAIs developed from study data, in service of "personalized medicine."

TRIAL REGISTRATION

https://clinicaltrials.gov/ct2/show/NCT04961190.

To BDZ or not to BDZ? That is the question! Is there reliable scientific evidence for or against using benzodiazepines in the aftermath of potentially traumatic events for the prevention of PTSD? A systematic review and meta-analysis

BACKGROUND

Most international guidelines suggest that benzodiazepines (BDZs) may be inefficient or iatrogenic in the aftermath of a potentially traumatic event (PTE). The goal of this study was to assess the strength of the evidence on whether the use of BDZs in the aftermath of a PTE negatively affects the incidence and severity of post-traumatic stress disorder (PTSD).

METHODS

We systematically scrutinized the ISI Web of Knowledge, MEDLINE, SCOPUS, and PTSDpubs electronic databases in addition to citation searching. We included original studies providing data about the development of PTSD in adults after BDZ administration in the aftermath of a PTE. We screened 387 abstracts and selected eight studies for the qualitative synthesis and seven for the meta-analysis. We performed two separate meta-analyses, one for randomized clinical trials (RCTs) and the other for cohort studies. Heterogeneity between studies was evaluated with Higgins I² statistic and tested using the χ². This study was registered at PROSPERO (number 127170).

RESULTS

The meta-analysis of the cohort studies showed an increased risk of PTSD in patients who received BDZs compared to those who did not (risk ratio (RR) = 1.53; 95% confidence interval (CI): 1.05-2.23) with a modest heterogeneity among studies (I² = 41.8, p = 0.143). Regarding the RCTs, the combined measure revealed a tendency toward an increased severity of the PTSD symptoms (standardized mean difference (SMD): 0.24; 95% CI: 0.32-0.79).

CONCLUSION

The studies reviewed showed a possible harmful effect of BDZs when used immediately after a PTE. However, these conclusions were based on a small number of studies of poor to moderate methodological quality.

The efficacy of psychotherapies and pharmacotherapies for mental disorders in adults: an umbrella review and meta-analytic evaluation of recent meta-analyses

Mental disorders represent a worldwide public health concern. Psychotherapies and pharmacotherapies are recommended as first line treatments. However, evidence has emerged that their efficacy may be overestimated, due to a variety of shortcomings in clinical trials (e.g., publication bias, weak control conditions such as waiting list). We performed an umbrella review of recent meta-analyses of randomized controlled trials (RCTs) of psychotherapies and pharmacotherapies for the main mental disorders in adults. We selected meta-analyses that formally assessed risk of bias or quality of studies, excluded weak comparators, and used effect sizes for target symptoms as primary outcome. We searched PubMed and PsycINFO and individual records of the Cochrane Library for meta-analyses published between January 2014 and March 2021 comparing psychotherapies or pharmacotherapies with placebo or treatment-as-usual (TAU), or psychotherapies vs. pharmacotherapies head-to-head, or the combination of psychotherapy with pharmacotherapy to either monotherapy. One hundred and two meta-analyses, encompassing 3,782 RCTs and 650,514 patients, were included, covering depressive disorders, anxiety disorders, post-traumatic stress disorder, obsessive-compulsive disorder, somatoform disorders, eating disorders, attention-deficit/hyperactivity disorder, substance use disorders, insomnia, schizophrenia spectrum disorders, and bipolar disorder. Across disorders and treatments, the majority of effect sizes for target symptoms were small. A random effect meta-analytic evaluation of the effect sizes reported by the largest meta-analyses per disorder yielded a standardized mean difference (SMD) of 0.34 (95% CI: 0.26-0.42) for psychotherapies and 0.36 (95% CI: 0.32-0.41) for pharmacotherapies compared with placebo or TAU. The SMD for head-to-head comparisons of psychotherapies vs. pharmacotherapies was 0.11 (95% CI: -0.05 to 0.26). The SMD for the combined treatment compared with either monotherapy was 0.31 (95% CI: 0.19-0.44). Risk of bias was often high. After more than half a century of research, thousands of RCTs and millions of invested funds, the effect sizes of psychotherapies and pharmacotherapies for mental disorders are limited, suggesting a ceiling effect for treatment research as presently conducted. A paradigm shift in research seems to be required to achieve further progress.

Posttraumatic Stress Disorder and Anxiety-Related Conditions

PURPOSE OF REVIEW

This article provides a synopsis of current assessment and treatment considerations for posttraumatic stress disorder (PTSD) and related anxiety disorder characteristics. Epidemiologic and neurobiological data are reviewed as well as common associated symptoms, including sleep disruption, and treatment approaches to these conditions.

RECENT FINDINGS

PTSD is no longer considered an anxiety-related disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition classification and instead is associated with trauma/stressor-related disorders. PTSD symptoms are clustered into four domains including intrusive experiences, avoidance, mood, and arousal symptoms. Despite this reclassification, similarities exist in consideration of diagnosis, treatment, and comorbidities with anxiety disorders. PTSD and anxiety-related disorders are heterogeneous, which is reflected by the neural circuits involved in the genesis of symptoms that may vary across symptom domains. Treatment is likely to benefit from consideration of this heterogeneity.Research in animal models of fear and anxiety, as well as in humans, suggests that patients with PTSD and generalized anxiety disorder have difficulty accurately determining safety from danger and struggle to suppress fear in the presence of safety cues.Empirically supported psychotherapies commonly involved exposure (fear extinction learning) and are recommended for PTSD. Cognitive-behavioral therapy has been shown to be effective in other anxiety-related disorders. Selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) are commonly used in the treatment of PTSD and anxiety disorders in which pharmacologic intervention is supported. Treating sleep disruption including sleep apnea (continuous positive airway pressure [CPAP]), nightmares, and insomnia (preferably via psychotherapy) may improve symptoms of PTSD, as well as improve mood in anxiety disorders.

SUMMARY

PTSD has a lifetime prevalence that is close to 10% and shares neurobiological features with anxiety disorders. Anxiety disorders are the most common class of mental conditions and are highly comorbid with other disorders; treatment considerations typically include cognitive-behavioral therapy and pharmacologic intervention. Developing technologies show some promise as treatment alternatives in the future.

Management of Post-traumatic Stress Disorder in Veterans and Military Service Members: A Review of Pharmacologic and Psychotherapeutic Interventions Since 2016

PURPOSE OF REVIEW

It is vitally important that providers treating post-traumatic stress disorder continue to stay abreast of research advances in the treatment of this disorder. This article updates the reader about advances in research in PTSD treatment in the past four years as well as the evolving recommendations of clinical practice guidelines.

RECENT FINDINGS

One of the most important developments is that trauma-focused therapy (TFT) has emerged as the first-line treatment for PTSD with pharmacologic options often being noted as second-line or adjunctive. The quality and quantity of research into the treatment of PTSD continue to grow; however, the pace of research into treatment options lags behind our understanding of the development, course, and prognosis of the disorder. The development of new research-based evidence in the treatment of PTSD, both pharmacologic and psychotherapeutic, is needed and likely to necessitate frequent updates and re-evaluations of clinical practice guidelines.