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Therapy Options for Post-traumatic Stress Disorder



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Am Fam Physician. 2004 May 1;69(9):2239-2240.

The type of psychologic help that should be provided after a major traumatic event (e.g., physical assault, severe accident, natural disaster) remains a matter of uncertainty. Debriefing after the event is advocated, but randomized controlled trials have shown that single-session individualized debriefing after the event does not reduce the incidence of chronic post-traumatic stress disorder (PTSD). Debriefing has been shown to provide some benefit over time, but these patients tend to improve to a lesser extent than those who do not receive debriefing. Group debriefing also has been suggested as an intervention in traumatized patients, but no randomized controlled trials have determined if this method actually is beneficial. Another obstacle to determining the appropriate intervention is that no methods have been established to identify patients who are unlikely to recover from a stressful event without early intervention. The objective of a study by Ehlers and colleagues was to determine if cognitive therapy or a self-help booklet provided in the initial months after a traumatic event would be more effective in preventing chronic PTSD than repeated assessment.

The participants in the study had been involved in a motor vehicle wreck and developed PTSD in the first three months after the crash. These persons had to meet the criteria for PTSD published in the Structured Clinical Interview in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition. In addition, they had to have moderate to severe symptoms as established by a validated scale.

Participants completed a three-week self-monitoring phase before randomization. If they were considered at risk for chronic PTSD at the end of these three weeks, they were randomly assigned to receive cognitive therapy, a self-help booklet on principles of cognitive-behavior therapy, or repeated assessments with no other interventions. The patients were reassessed at three and nine months. The main outcome measures were changes in the severity of PTSD symptoms, disability caused by the symptoms, and changes in associated symptoms.

There were 85 persons who met the inclusion criteria for the study. Those who participated in cognitive therapy had fewer symptoms of PTSD, depression, anxiety, and disability than those who received the self-help booklet or repeated assessments. In addition, fewer patients who had cognitive therapy met the criteria for PTSD at follow-up than those who received the other interventions. The patients who received the self-help booklet had no better outcomes than those who received repeated assessment. With regard to two measurements—high end-state functioning at follow-up and request for treatment—the self-help group had worse outcomes than the repeated assessment group.

The authors conclude that cognitive therapy is an effective intervention in patients with recent-onset PTSD. They note that the combination of an elevated initial symptom score and failure to improve with self-monitoring was useful in identifying patients with early PTSD symptoms who were not likely to improve without intervention.

Ehlers A, et al. A randomized controlled trial of cognitive therapy, a self-help booklet, and repeated assessments as early interventions for posttraumatic stress disorder. Arch Gen Psychiatry. October 2003;60:1024–32.



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