Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.

For persons with PTSD (and those exposed to traumatic event/s as defined by DSM-IV-TR or ICD-10), what is the comparative effectiveness of different psychotherapy modalities/psychological treatments?

• Is EMDR an effective treatment for PTSD? Is the evidence sufficient to recommend EMDR as an evidence-based treatment for PTSD? (Note conflicting conclusions in 2007 IOM report vs. evidence-based guidelines by NICE and others)
• As a potentially important precursor to the above question: Is EMDR best classified as a type of trauma-focused psychological treatment (or psychotherapy), or is it a substantively different treatment? In systematic reviews and guidelines, EMDR has been classified variously as a type of trauma-focused therapy, CBT, and as its own treatment, which may explain some of the different conclusions regarding its efficacy/effectiveness.
• For persons with PTSD (and those exposed to traumatic event/s as defined by DSM-IV-TR or ICD-10), what is the comparative effectiveness of different psychotherapy modalities /psychological treatments vs. SSRIs and other pharmacotherapies?
• Considering variations in patient treatment preferences, values, and resources (e.g., Schottenbauer et al., 2008; Tarrier, 2010), what are the relative advantages of psychological vs. pharmacological treatments for PTSD? When there is equivalent efficacy/effectiveness, what are the potential advantages of one treatment over another?
• How do these differ among sub-groups of patients (with different demographic characteristics and resources) and across the primary treatment settings for PTSD?
• Do variations in patient preferences (and value judgments) for treatment options have a significant effect on treatment utilization, drop-out, adherence and/or therapeutic response (Feeny et al., 2009)? If so, what are the policy implications of this with respect to development of clinical practice guidelines (e.g., creation and dissemination of evidence-based recommendations f

Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)

yes

If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:

• Different psychotherapies/psychological treatments and pharmacological interventions for PTSD (and for persons exposed to traumatic events)

What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)

• Persons exposed to diverse sources/types of trauma
• Patients with PTSD
• Children, Adolescents & Adults (including older adults/veterans)
• Men & Women
• Psychological co-morbidities
• Traumatic Brain Injury (TBI) or other physical injuries
• Other medical co-morbidities)
• Major Depression/Anxiety Disorders and other mental health co-morbidities
• Substance Abuse Disorders

Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)

• Military personnel/Combat veterans
• Victims of assault/rape
• Victims and responders to natural disasters
• Victims and responders to terrorist attacks
• Racial & Ethnic Minorities
• Persons with history of prior exposure to trauma (especially military personnel)

Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)

• Amelioration of PTSD symptoms (number, frequency, & severity)
• Remission of PTSD (diagnosis)
• Improved patient functioning (return to premorbid levels of psychosocial functioning)
• Adjustment to home environment (military and disaster responders)
• Interpersonal/social functioning (e.g., reduced marital conflict)

Describe any health-related risks, side effects, or harms that you are concerned about.

• Short- and long-term adverse effects of pharmacological treatments
• Including adverse effects specific to various subgroups of the patients with PTSD (e.g., children, women, TBI patients, etc.)
• Harms associated with different psychotherapies or different methods of exposure therapy?
• Including adverse effects specific to various subgroups of patients with PTSD (e.g., victims of particular type of trauma, pts with psychological comorbidities)
• Exacerbation of PTSD (and associated) symptoms
• Suicide

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?

yes

Which priority area(s) and population(s) does this topic apply to? (check all that apply)

EHC Priority Conditions (updated in 2008)

• Depression and other mental health disorders
• Functional limitations and disability
• Substance abuse

AHRQ Priority Populations

• Low income groups
• Minority groups
• Women
• Children
• Elderly
• Individuals with special health care needs, including individuals with disabilities or who need chronic care or end-of-life health care

Federal Health Care Program

• Medicaid
• Medicare
• State Children's Health Insurance Program (SCHIP)
• Other

Importance

Describe why this topic is important.

• Most individuals with distress related to trauma exposure and/or PTSD, and in need of help, do not receive mental health treatment.
• Among those persons who do receive care for PTSD (or PTSD symptoms) there is wide variation in the treatment offered/provided. In fact, according to some surveys, the majority of traumatized persons do not receive evidence-based treatment as outlined in current guidelines by NICE (2005) and others. Furthermore, as many as 50% of patients who receive evidence-based treatment, drop-out prematurely or do not respond to treatment and are classified as “treatment resistant.”
• High economic and social costs of PTSD, especially among military personnel/veterans and other public servants and disaster responders (e.g., police, fire fighters, etc.).
• Need to promote the development of new evidence-based treatments for PTSD, as well as to better match patient populations to best available treatments.

What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)

• There continues to be controversy regarding the effectiveness of available psychotherapies and pharmacotherapies for PTSD. Systematic reviews and evidence-based guidelines report conflicting recommendations, and clinicians (and patients) may be uncertain as to what treatment to select (or recommend) among the reportedly “evidence-based” approaches.
• According to recent surveys, the majority of persons presenting with PTSD receive psychotropic medication, yet evidence-based guidelines emphasize cognitive-behavioral therapy (or “trauma-focused” psychotherapy) as the preferred first line treatment for PTSD.
• The Institute of Medicine and other Federal agencies (e.g., VA Health Care System) have identified PTSD as a priority area for quality improvement and comparative effectiveness research, due in part, to evidence of higher rates of PTSD among soldiers returning from Persian Gulf than previously reported, as well as increased need for mental health services.

Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)

yes

If yes, please explain:

• Uncertainty regarding the effectiveness of different psychotherapy modalities (psychological treatments).
• Uncertainty regarding the role of “exposure therapy” in the treatment of PTSD.
• For instance, in their 2007 report on PTSD, the IOM determined that the “the evidence is sufficient to conclude the efficacy of exposure therapies in the treatment of PTSD” (p. 1). Furthermore, the IOM reported insufficient evidence in support of EMDR, coping skills training, and cognitive restructuring, in spite of the fact that these approaches are generally considered variations of CBT that typically entail some form of systematic exposure.
• Uncertainty regarding the effectiveness and potential harms of medications for PTSD.
• IOM (2007) reported inadequate evidence to determine the efficacy of pharmacotherapies in the treatment of PTSD, and NICE reported that “drug treatments should not be a routine first-line treatment for adults in preference to trauma-focused psychological therapies.” However, in contrast, guidelines by the International Society for Traumatic Stress Studies (ISTSS; 2009) state “although some medications qualify as Level A treatments, their overall efficacy is not as great as that achieved with some cognitive-behavioral treatments” (p. 567).
• Uncertainty regarding the best point (or points) of intervention following exposure to trauma/s and the trajectory of PTSD from onset to development of chronic symptomatology.
• Confusion regarding the harms/effectiveness of “early” intervention following exposure to trauma/disaster.
• Not clear about the effectiveness of SAHMSA’s various “evidence-based” treatments/guides for trauma and PTSD - How should these be reconciled with recommendations in evidence-based guidelines? (http://www.ptsd.va.gov/professional/pages/treatment.asp)

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?

• For psychologists and other stakeholders, this will provided a current synthesis of data on the effectiveness and potential harms of psychotherapeutic/psychological pharmacological for PTSD, as well as the potential advantages of various treatments for sub-groups of patients with various demographic characteristics and preferences. This information will help guide psychologists in discussing using evidence-based treatments (or referring to another provider as needed), as well as inform consumers.
• In addition, it will identify gaps in data and areas for improvement in treatment implementation and dissemination, which will guide future research by psychologists and other researchers (and may result in greater funding for such research).

Describe the timeframe in which an answer to your question is needed.

• Urgent need for comparative effectiveness data to improve patient care for large number of military personal who served in the Persian Gulf, as well as those affected by natural and man-made disasters.

Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.

• Populations exposed to repeated traumas, including military and those in high crime areas, etc.
• Disparities in quality of care for PTSD among military personnel/veterans
• Children & Adolescents

Nominator Information

Other Information About You: (optional)

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

• For psychologists and other stakeholders, this will provided a current synthesis of data on the effectiveness and potential harms of psychotherapeutic/psychological pharmacological for PTSD, as well as the potential advantages of various treatments for sub-groups of patients with various demographic characteristics and preferences. This information will help guide psychologists in discussing using evidence-based treatments (or referring to another provider as needed), as well as inform consumers.
• In addition, it will identify gaps in data and areas for improvement in treatment implementation and dissemination, which will guide future research by psychologists and other researchers (and may result in greater funding for such research).

Are you making a suggestion as an individual or on behalf of an organization?

Organization

Please tell us how you heard about the Effective Health Care Program

Through my work