Cognitive Therapy Benefits Only Some Patients with PTSD

When people have expressed PTSD symptoms for about 6 months to a year and a half, the disorder becomes entrenched.
When people have expressed PTSD symptoms for about 6 months to a year and a half, the disorder becomes entrenched.

Early cognitive and prolonged exposure therapy are associated with accelerated recovery from post-traumatic stress disorder (PTSD), however the long-term effects of therapy are unclear.

“PTSD is very often a disorder that starts by trauma survivors expressing symptoms shortly or immediately after trauma. The majority of those [patients] express symptoms, which I think, are basically normal reactions of being shocked,” Arieh Shalev, MD of NYU Langone Medical Center in New York, said in an interview. “There is a minority, depending on the severity of the traumatic event, that remains with symptoms for a very long period of time.”

"When people have expressed those symptoms for about 6 months to a year and a half, they are there to stay. The disorder becomes entrenched or gets into a prolonged, basically unremitting phase. The importance of intervening early is actually to try and prevent people from getting to this stable pathological equilibrium,” he said.

Dr Shalev and colleagues sought to investigate the long-term effects of cognitive behavioral therapy (CBT) on PTSD outcomes. Their findings were published in the Journal of Clinical Psychiatry. For the study, patients admitted with acute PTSD based on DSM-IV criteria were randomized to 12 weeks of cognitive therapy (n=40), prolonged exposure (n=63), placebo (n=23), or concealed escitalopram (n=23). Participants, including those who declined treatment (n=82), were followed and assessed at 5 months and 36 months.

At 5-month follow-up, patients in the cognitive therapy and prolonged exposure groups demonstrated a lower prevalence of PTSD (18.2% and 21.4%, respectively) than the placebo, escitalopram, and no-intervention groups (P=.001). The authors also noted reduced Clinician-administered PTSD Scale (CAPS) scores in the cognitive therapy and prolonged exposure groups from baseline to 5 months that remained stable.

At the 3-year assessment, researchers found a similar prevalence of PTSD in the groups (P=.74) and similar levels of PTSD symptoms based on CAPS scores (P=.99).

The results suggest that “providing CBT effectively reduces the duration of suffering and dysfunctioning.” The authors explained that the prevalence of PTSD at 3 years was in line with previous findings that indicate nearly one-third of patients with PTSD do not recover.

“Once you've recovered with therapy, then [PTSD] is stable. You don't relapse,” Dr Shalev said. “There are people who do not respond [to therapy] and they deserve a second-line treatment that we should now be much more active in researching.”

The study was funded by the US Public Health Services. Dr Shalev reported a grant from Lundbeck Pharmaceuticals Ltd.

Reference

Shalev AY, Ankri Y, Gilad M, et al. Long-Term Outcome of Early Interventions to Prevent Posttraumatic Stress Disorder. J Clin Psychiatry. 2016; doi:10.4088/JCP.15m09932.

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