Guideline Development Panel for the Treatment of Posttraumatic Stress Disorder in Adults Adopted as APA Policy
Guideline Development Panel for the Treatment of Posttraumatic Stress Disorder in Adults Adopted as APA Policy February 24, 2017
PTSD
CLINICAL PRACTICE
GUIDELINE for the Treatment of
Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD) in Adults
American Psychological Association
Guideline Development Panel for the Treatment of PTSD in Adults
Adopted as APA Policy February 24, 2017
GDP Members:
Christine A. Courtois, Chair
Jeffrey Sonis, Vice-Chair
Laura S. Brown
Joan Cook
John A. Fairbank
Matthew Friedman
Joseph P. Gone
Russell Jones
Annette La Greca
Thomas Mellman
John Roberts
Priscilla Schulz
APA Guidelines Staff:
Lynn F. Bufka
Raquel Halfond
Howard Kurtzman
i
Abstract
Description: The American Psychological Association (APA) developed this guideline to
provide recommendations on psychological and pharmacological treatments for posttraumatic
stress disorder (PTSD) in adults.
Methods: This guideline used methods recommended by the Institute of Medicine report,
Clinical Practice Guidelines We Can Trust (IOM, 2011). Those methods are designed to
produce guidelines that are based on evidence and patient preferences and are transparent,
free of conflict of interest, and worthy of public trust. The guideline used a comprehensive
systematic review (Psychological and Pharmacological Treatments for Adults With
Posttraumatic Stress Disorder (PTSD)) conducted by the Research Triangle Institute-University
of North Carolina Evidence-based Practice Center as its primary evidence base (Jonas,
Cusack, Forneris, Wilkins, Sonis, Middleton, et al., 2013). The systematic review was based on
English-language studies published between 1980 and 2012; complementary and alternative
treatments were not included in the systematic review. An updated search was conducted by
APA to identify studies published between 2012 and June 1, 2016, to determine if the
recommendations made by the panel based on the systematic review were likely to hold up
based on more recent evidence; risk of bias assessment, strength of evidence rating and meta-
analyses were not conducted on the studies identified through the updated search.
The guideline development panel (GDP) consisted of health professionals from the disciplines
of psychology, psychiatry, social work, and family medicine as well as community members,
who self-identified as having had PTSD. The GDP made recommendations based on 1)
strength of evidence; 2) treatment outcomes and the balance of benefits vs. harms and burdens
of interventions; 3) patient values and preferences; and 4) applicability of the evidence to
various treatment populations. PTSD symptom reduction and serious harms were selected by
the GDP as critical outcomes for making recommendations. Various other outcomes were
ii
selected as important, including those related to remission, quality of life, disability, comorbid
conditions and adverse events.
The target audience for this guideline includes all clinicians as well as researchers, patients and
policy makers.
Recommendations: The panel strongly recommends the use of the following
psychotherapies/interventions (all interventions that follow listed in alphabetical order) for adult
patients with PTSD: cognitive behavioral therapy (CBT), cognitive processing therapy (CPT),
cognitive therapy (CT), and prolonged exposure therapy (PE). The panel suggests the use of
brief eclectic psychotherapy (BEP), eye movement desensitization and reprocessing (EMDR),
and narrative exposure therapy (NET). There is insufficient evidence to recommend for or
against offering Seeking Safety (SS) or relaxation (RLX). For medications, the panel suggests
offering the following (in alphabetical order): fluoxetine, paroxetine, sertraline, and venlafaxine.
There is insufficient evidence to recommend for or against offering risperidone and topiramate.
Based on the updated search, the panel concluded that all of its treatment recommendations,
except those for EMDR and NET, were unlikely to change. The panel also concluded that,
based on studies published between 2012 and June 2016, the recommendations for EMDR and
NET may change from conditional (“the panel suggests”) to strong (“the panel recommends”).
(Note: This abstract was prepared following approval of the guideline document as APA policy
by the APA Council of Representatives at its February 2017 meeting.)
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Table of Contents
Abstract ………………………………………………………………………………………………………………….. i
Table of Contents ……………………………………………………………………………………………………. iii
Disclaimer …………………………………………………………………………………………………………….. vii
Executive Summary ……………………………………………………………………………………………… ES-1
Scope of the Document What the Guideline Addresses and What it Does Not …………………………………………………………….. 1
Table 1. Summary of Recommendations …………………………………………………………………….. 4
Introduction to the Topic …………………………………………………………………………………………. 6 Background and Justification: The Scope of the Problem ………………………………………………………… 6
Defining Trauma …………………………………………………………………………………………………………………. 6 Posttraumatic Reactions and Diagnoses …………………………………………………………………………………. 7 Available PTSD Treatment Guidelines …………………………………………………………………………………… 10
The APA Clinical Practice Guideline for the Treatment of PTSD ………………………………………………. 11 Institute of Medicine Standards as the Basis for this CPG ……………………………………………………….. 11 Treatment Outcomes Considered in the Guideline ………………………………………………………………… 15 The RTI-UNC Systematic Key Questions and Analytic Framework …………………………………………….. 17
Process and Methods of the CPG ………………………………………………………………………………. 17 Undertaking the Systematic Review ………………………………………………………………………………….. 17
Scoping …………………………………………………………………………………………………………………………….. 17 Vetting and Appointment of Members to the PTSD Treatment GDP ……………………………………….. 18 Conflicts of Interest ……………………………………………………………………………………………………………. 18 Comprehensive Search of the Professional Literature ……………………………………………………………. 20 Decisions Regarding Assessment and Inclusion/Exclusion of Studies ……………………………………….. 21
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Table of Contents
Assessing Strength of Evidence ……………………………………………………………………………………………. 21 Types of Comparison (control) Groups Used by Studies Included in the RTI-UNC Systematic Review …. 23 The Development and Use of Evidence Profiles …………………………………………………………………….. 24 The Development and Use of Decision Tables ……………………………………………………………………….. 25 Completion of Decision Tables ……………………………………………………………………………………………. 28 Rating of Aggregate/Global SOE ………………………………………………………………………………………….. 28 Assessing Magnitude of Benefits …………………………………………………………………………………………. 29 Assessing Magnitude of Harm/Burdens ……………………………………………………………………………….. 31 Assessing Patient Values and Preferences …………………………………………………………………………….. 34 Applicability of Evidence …………………………………………………………………………………………………….. 35
Decision-Making Regarding Treatment Recommendations …………………………………………………….. 37 External Review Process …………………………………………………………………………………………………….. 38 Detailed Recommendations ………………………………………………………………………………………………… 39 Impact of New Trials on Recommendations ………………………………………………………………………….. 50
Considerations for Treatment Implementation ……………………………………………………………. 61 Informed Consent ………………………………………………………………………………………………………….. 62 Role of Patient and Therapist Factors in Treatments for PTSD ……………………………………………….. 62 Professional Competence ………………………………………………………………………………………………… 64 Monitoring Treatment Response ………………………………………………………………………………………. 65 Culture and Diversity Competence ……………………………………………………………………………………. 66
Discussion …………………………………………………………………………………………………………….. 67 How the APA PTSD Guideline Recommendations Are Similar To or Different From Other PTSD Guidelines ……………………………………………………………………………………………………………………. 67 Strengths and Weaknesses of the RTI-UNC Systematic Review ………………………………………………. 72
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Table of Contents
Treatment Effect Heterogeneity: Subgroup Effects ……………………………………………………………… 75 Generalizability (Applicability) …………………………………………………………………………………………. 76 Community Member Input ………………………………………………………………………………………………. 80 Clinician Input Regarding Psychotherapy ……………………………………………………………………………. 82
Limitations of Existing Treatment Research Literature: Future Research Needs ………………… 83 Gaps in the Literature …………………………………………………………………………………………………….. 83 Methodological Improvements ………………………………………………………………………………………… 86
Guideline Summary and Future Directions ………………………………………………………………….. 90
Conflicts of Interest ………………………………………………………………………………………………… 93
Author Disclosure …………………………………………………………………………………………………… 95
Developer ……………………………………………………………………………………………………………… 99
Funding Source/Sponsor ………………………………………………………………………………………… 100
Acknowledgments ………………………………………………………………………………………………… 101
References ………………………………………………………………………………………………………….. 102
vi
Appendices (New Document)
A. Descriptions of Treatments and Strength of Recommendations
B. Treatment Dose, Timing, and Duration as Described in Reviewed Studies
C. Evidence Profiles Prepared for APA by RTI-UNC Scientists
D. Decision Tables
E. Definition of Key Terms
F. Additional Tables and Figure for Updated Evidence (2012-2016)
G. Trials Identified Through Search Update (published 2012-2016) Matching One or More Recommendations
H. Trials Identified Through Search Update (published 2012-2016) Matching One or More Evidence Profiles but Not Matching Any Recommendations
I. Trials Identified Through Search Update (published 2012-2016) That Would Not Have Met Criteria for Inclusion in Systematic Review
J. APA Declarations/COI Form
K. Voting Procedures Established by Advisory Steering Committee (ASC)
L. Strength of Evidence Ratings for Psychotherapies and Medications
vii
Disclaimer
This guideline is intended to be aspirational and is not intended to create a requirement
for practice. It is not intended to limit scope of practice in licensing laws for psychologists or for
other independently licensed professionals, nor limit coverage for reimbursement by third party
payers.
The term guideline refers to statements that suggest or recommend specific professional
behavior, endeavor, or conduct for psychologists or other independently licensed professionals.
Guidelines differ from standards in that standards are mandatory and may be accompanied by
an enforcement mechanism. In contrast, guidelines are aspirational in intent. They are intended
to facilitate the continued systematic development of the profession and to help assure a high
level of professional practice by psychologists and other professionals. Guidelines are not
intended to be mandatory or exhaustive and may not be applicable to every professional and
clinical situation. They are not definitive and they are not intended to take precedence over the
judgment of psychologists and other professionals. The different types of guidelines produced
by the APA were detailed in an association document published in the American Psychologist in
December, 2015 (American Psychological Association, 2015).
The recommendations made by the APA PTSD Guideline Development Panel (GDP)
were developed after careful review of the evidence. The GDP endorses the following statement
from the British National Institute for Health and Care Excellence (NICE, 2016) “When
exercising their judgement, professionals are expected to take this guideline fully into account,
alongside the individual needs, preferences and values of their patients or service users. The
application of the recommendations in this guideline is not mandatory and the guideline does
not override the responsibility of healthcare professionals to make decisions appropriate to the
circumstances of the individual patient, in consultation with the patient and/or their carer or
guardian,” (p.18).
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Executive Summary
Scope of the Guideline
This guideline is intended to provide treatment recommendations for Posttraumatic
Stress Disorder (PTSD) in adults, based on a systematic review of the evidence for treatment
Psychological and Pharmacological Treatments for Adults With Posttraumatic Stress Disorder
(PTSD) conducted by the Research Triangle Institute- University of North Carolina Evidence-
Based Practice Center (RTI-UNC EPC) (Jonas, Cusack, Forneris, Wilkins, Sonis, Middleton, et
al., 2013).The RTI-UNC Systematic Review addressed the following Key Questions:
1. What is the efficacy of psychological and medication treatments for adults with
PTSD, compared to no treatment or to inactive controls?
2. What is their comparative effectiveness (i.e., psychological treatments compared to
other psychological treatments, medication treatments compared to other medication
treatments, and psychological treatments compared to medication treatments)?
3. Which treatments work best for which patients1? In other words, do patient
characteristics or type of trauma modify treatment effects?
4. Do serious harms of treatments or patient preferences influence treatment
recommendations?
Although of considerable importance in the treatment of PTSD, this guideline does not address
complementary or alternative treatments, assessment and screening of PTSD, subthreshold
PTSD, PTSD prevention, PTSD treatment in children, dose/timing/duration of treatment, or cost.
It is the hope of panel members that future iterations of this guideline include these topics as
their evidence base develops.
1 To be consistent with evidence-based clinical practice guidelines in other areas of health care, we use the term patient to refer to the person receiving psychological services. However, we recognize that in many situations there are important and valid reasons for using such terms as client, consumer or person in place of patient to describe the recipients of services.
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Recommendations
Following its detailed review and independent analysis of the findings of the systematic
review, the APA Guideline Development Panel (GDP) strongly recommends the use of the
following psychotherapies/interventions (all interventions that follow listed in alphabetical order)
for adult patients with PTSD: cognitive behavioral therapy (CBT)2, cognitive processing therapy
(CPT), cognitive therapy (CT), and prolonged exposure therapy (PE). The panel suggests the
use of brief eclectic psychotherapy (BEP), eye movement desensitization and reprocessing
(EMDR), and narrative exposure therapy (NET). There is insufficient evidence to recommend for
or against offering Seeking Safety (SS) or relaxation (RLX). For medications, the panel
suggests offering the following (in alphabetical order): fluoxetine, paroxetine, sertraline, and
venlafaxine. There is insufficient evidence to recommend for or against offering risperidone and
topiramate.
Impact of New Trials on Recommendations
The systematic review that was used as the evidence base for this guideline included
trials that had been published prior to May 24, 2012. To determine whether the panel
recommendations based on that evidence would hold up in the face of new evidence published
since that time, the panel conducted a revised search, to identify trials published between May
25, 2012 and June 1, 2016. The panel concluded that, based on the new trials, its
recommendations for all of the interventions except two (EMDR and NET) were unlikely to
change; there was insufficient evidence to determine whether the conditional recommendations
for EMDR and NET3 would change to strong.
2 The systematic review did not evaluate trauma-focused CBT separately from CBT that was not trauma-focused. Accordingly, the panel’s recommendations are based on CBT as a category that encompasses all types of CBT and are not limited to trauma-focused CBT.
3 As we discuss later in this report, the panel acknowledges uncertainty in the stability of our conditional recommendations for EMDR and NET on the basis of more recent evidence that could result in an upgraded recommendation pending future meta-analyses.
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Introduction
Trauma involves events that pose significant threat (physical, emotional, or
psychological) to the safety of the victim or loved ones/friends and are overwhelming and
shocking. Many individuals exposed to traumatic events experience a range of posttraumatic
psychophysiological reactions though most of these reactions remit spontaneously within
approximately the first month of occurrence (Rothbaum, Foa, Riggs, Murdock, & Walsh, 1992;
Nugent, Saunders, Williams, Hanson, Smith, & Fitzgerald, 2009; Orcutt, Erickson, & Wolfe,
2004). A number of risk and resilience factors (such as age, severity, duration, and availability of
support) may affect whether the reactions remit. If they persist, they might meet criteria for one
or more posttraumatic diagnoses such as Acute Stress Disorder (ASD) or Posttraumatic Stress
Disorder (PTSD).The 5th edition of the Diagnostic and Statistical Manual of Mental Disorders,
DSM-5, (American Psychiatric Association, 2013), defines PTSD as comprised of four clusters
of symptoms including intrusive and recurrent memories of the trauma, avoidance of trauma-
related stimuli, numbing and/or negative changes in mood or cognitions pertaining to the
trauma, and changes in reactivity and arousal. The DSM-IV-TR (American Psychiatric
Association, 2000) previously defined PTSD as being comprised of three symptom clusters
including avoidance and numbing, re-experiencing, and hyperarousal. Of note, all of the studies
included in the RTI-UNC systematic review that served as the evidence base for that report
used DSM-IV-TR or earlier DSM criteria and are those discussed throughout this guideline.
Furthermore, PTSD can range from relatively mild to totally debilitating and has also
been found to create vulnerability for revictimization and retraumatization (see Duckworth and
Follette, 2012) for a comprehensive overview). Some individuals and populations are especially
at risk and co-morbidities such as substance use and abuse, depression, anxiety, dissociation
and dissociative disorders, personality disorders, psychosis, cognitive impairment, violence
towards self and others, increased risk of non-suicidal self-injury and of suicide, are common to
the diagnosis. Psychosocial impacts can include homelessness, poverty, and incarceration. All
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of these factors make PTSD a complicated and challenging psychophysiological and
psychosocial disorder to treat and suggest the need for further guidance to indicate which
treatments are effective and for whom.
Currently, numerous guidelines from various agencies and professional organizations
recommend several trauma-focused psychological interventions for treating PTSD and most
acknowledge some benefit of several medication treatments as well. The present guideline
differs from other guidelines in several ways. It fully follows and builds upon the standards set
forth by the Institute of Medicine (IOM) (now the National Academy of Medicine) of the National
Academies of Sciences, Engineering, and Medicine standards for developing high-quality,
independent, and reliable practice guidelines (IOM, 2011a & 2011b). Its recommendations and
suggestions for treatment are based on an analysis of a comprehensive independent systematic
review of the literature for treatment of PTSD in adults. Further, panel members who worked on
the present guideline document were an interdisciplinary group from professions including
psychology, social work, primary care, and psychiatry–and included consumer members as
well. Finally, the present guideline includes attention to potential and actual harms and burdens
of PTSD treatments and patient preferences as part of the process.
In addition to these strengths, the guideline also has some limitations. Gaps in the
current empirical literature regarding treatment comparisons, evaluation of moderators of
treatment effects, inclusion of participants with comorbidities, measurement of potential side
effects and harms, and assessment of important outcomes and the timing of their assessment
all need to be addressed to answer important clinical questions. Additionally, methodological
improvements that minimize attrition/dropout, decrease missing data and ensure sufficient
power will improve the quality of the findings and hence the possible conclusions that can be
drawn. Finally, the panel did not have data on which to make recommendations for some
treatments in use because they arise from traditions with non-RCT research practices or the
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quality of the research base has not been subjected to the level of critical appraisal of
systematic review.
It was the panel’s goal in the development of this guideline to render a collective
judgment and decision-making process that is transparent so that interested readers might
appropriately appreciate the rationale for the recommendations made in response to the
evidence in the systematic review. It is also recognized that this guideline may provide a
foundation for developing key questions for future systematic reviews leading to updated
recommendations regarding effective treatments for PTSD. Finally, it should be reiterated that a
clinical practice guideline is based on the best available evidence at the time and should not be
construed as a standard of care or prescribing a specific course of treatment.
Process and Method
At the outset, panel members discussed a range of relevant outcomes and determined
which were most critical for deciding whether to recommend or not recommend a treatment
through a modified Delphi survey. The panel decided that PTSD symptom reduction and serious
harms/adverse events were the most critical outcomes and that remission (no longer having
symptoms), loss of PTSD diagnosis, quality of life, disability or functional impairment, prevention
or reduction of comorbid medical or psychiatric conditions, adverse events leading to
withdrawals (treatment discontinuation), and other adverse events, and burdens were important
though not critical.
The primary evidence base for the present guideline was the systematic review,
Psychological and Pharmacological Treatments for Adults With Posttraumatic Stress Disorder
(PTSD) (Jonas et al., 2013) produced by the Research Triangle International- University of
North Carolina Evidence Based Practice Center (RTI-UNC EPC) which followed the protocol set
forth by the Institute of Medicine (2011b) for conducting systematic reviews. The comprehensive
and transparent systematic review addressed psychological and pharmacological treatments for
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PTSD. The trials included in the systematic review included samples that, as a whole, were
broadly diverse in terms of gender, race, ethnicity and type of trauma.
APA’s Advisory Steering Committee for Development of Clinical Practice Guidelines
(ASC) issued a call for panel member nominations (including self-nominations) for individuals
from a variety of backgrounds (consumer, psychology, social work, psychiatry, general
medicine) with content and treatment knowledge or methodological expertise. Conflicts of
interest (financial and non-financial) were considered and managed both during panel member
selection and throughout the guideline development process. Panel members were asked to
complete a COI form (see Appendix J) and that was reviewed by APA staff and ASC members
before members were appointed to the GDP. Additionally, they were asked to present the
details of their forms to other members in the first face to face meeting and to update their COI’s
yearly or on an as-needed basis and to submit it to staff for review.
The panel considered four factors as it drafted recommendations: 1) overall strength of
the evidence; 2) the balance of benefits vs. harms/burdens; 3) patient values and preferences;
and 4) applicability. Based on the combination of these factors, the panel made a strong or
conditional recommendation for or against each particular treatment or made a statement that
there was insufficient evidence to be able to make a recommendation for or against. The panel
used a tool called a decision table to document its decision-making process for each
recommendation. Copies of the decision tables are available in Appendix D.
Discussion
For treating PTSD in adults, the present guideline strongly recommends cognitive
behavioral therapy (CBT), cognitive processing therapy (CPT), cognitive therapy (CT), and
prolonged exposure therapy (PE) and suggests the use of brief eclectic psychotherapy (BEP),
eye movement desensitization and reprocessing (EMDR), and narrative exposure therapy
(NET). These recommendations are largely but not entirely consistent with those of various
other organizations. The present guideline also suggests the use of fluoxetine, paroxetine,
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sertraline, and venlafaxine. These recommendations add to the pharmacotherapy
recommendations of other organizations. Although some psychotherapies (CBT, CPT, CT, PE)
received strong recommendations but no medications did, the panel does not make
recommendations of psychotherapy before or instead of medications or use the term “first-line”
treatment because there was insufficient evidence from the systematic review on direct
comparisons between psychotherapy and medications for PTSD. The implications of this
distinction are that efficacy inferences for psychotherapies and those for pharmacotherapies
may not be truly comparable across these classes of treatment owing to the differential
stringency of these typical control conditions. The strength of the panel’s recommendations for
all interventions depended, to some extent, on the magnitude of the beneficial effect (i.e., the
effect size). But the effect size magnitude in a trial can be influenced by the type of the
comparator in the trial. Since all of the medication trials used placebo comparators while the
psychotherapy did not (and could not …) and there was insufficient evidence on direct
comparison of the two types of treatments, the panel did not make any recommendations about
psychotherapy versus medication treatment. Clinical judgment and patient preferences (as well
as patient response to psychotherapy or psychopharmacology) are all important factors in
deciding the course of treatment for PTSD.
Treatment effect heterogeneity (sub-group effects) was evaluated in the RTI-UNC
Systematic Review. Its authors concluded that the research evidence was insufficient to
determine treatment effect heterogeneity by many of the subgroups that were examined.
Members of the current guideline development panel agreed that the randomized trials included
in the review do not sufficiently address the important issue of which treatments are best for
which patients and constitutes an important future research need.
Generalizability (applicability) of systematic review findings to an external population
means that the magnitude and direction of an intervention effect, based on included trials, is
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similar to the magnitude and direction of intervention effect that would be expected in that
external population. Absence of generalizability occurs when there is heterogeneity of treatment
effects (e.g., by gender, ethnicity, trauma type or other significant factors) and when there are
differences between the distribution of those characteristics in the samples included in a
systematic review and the external population. The authors of the RTI-UNC Systematic Review
concluded that there was insufficient evidence “to determine whether the findings are applicable
to all those with PTSD or whether they are applicable only to certain groups” and insufficient
evidence about whether there were subgroup effects. Based in part on this conclusion,
members of the APA panel did not reach consensus about the generalizability of the systematic
review’s findings, reflecting differences of opinion found in the literature about conditions
required to demonstrate generalizability (Post, de Beer, & Guyatt, 2013; Rothwell, 2005). Some
panel members think that lack of generalizability to all subgroups should be assumed in the face
of insufficient evidence about generalizability. Others on the panel believe that, in the face of
insufficient evidence about generalizability or strong theoretical rationale to suggest treatment
effect heterogeneity, generalizability to most subgroups should be assumed. Panel members
agree however that examination of treatment effect heterogeneity with diverse samples should
be prioritized for future research.
Community members on the GDP shared what they considered to be important patient
values and preferences for PTSD treatment. These included such things as having a
psychotherapist who is aware of and knowledgeable about trauma, who offers information about
treatment, teaches coping skills, works from a personalized approach, and is sensitive to
cultural and socio-demographic differences. Likewise, clinicians on the panel shared their views
of general patient values and preferences gained from their experience providing treatment.
They found variation in patient preferences for trauma-focused therapies, preference for
psychotherapy over medication in many cases (though a minority prefers medication) and some
who prefer no treatment whatsoever. Many seek short-term treatment and want to experience
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significant symptom relief and alleviation of their suffering. Clinicians and community members
also reported that patients want information about treatment, value culturally sensitive
therapists, and have various preferences regarding intensity and pace of treatment. An open
question is whether patient preference for specific treatment varies by treating provider such
that patients choose professionals able to provide preferred treatment or identify a treatment as
preferred on the basis of what the provider is able to offer.
In order to implement interventions effectively a number of considerations are relevant,
including informed consent and the role of patient and relationship factors in treatment. Informed
consent includes providing patients with information about potential available treatments before
treatment commences and to aid in decision making. Informed consent includes discussion and
can include written material about the process and procedures involved, effectiveness and risks-
benefits, and associated emotional and practical demands. Second, there is a body of literature
that has shown an association between patient and patient-therapist factors (sometimes
referred to as “common factors”), relationship factors, and treatment outcomes. These factors
include such things as patient coping style, expectation for change, and therapist empathy and
collaboration. Clinicians are encouraged to bear these factors in mind when implementing
recommended treatments.
Other treatment considerations include the therapist working from a trauma-informed4
approach and attending to the role of socio-economic, cultural or other diversity or contextual
issues. These may facilitate whether patients find therapist actions and recommendations
intelligible, useful, and worthwhile. They may also have a direct impact on the treatment
application. Finally, while monitoring PTSD symptoms during treatment can provide insight into
progress and treatment targets and guidance when adjusting treatment seems necessary, it is
unclear as of yet whether this treatment monitoring improves patient outcomes. 4 Treatment approaches that directly focus on the details of trauma event(s)/experience(s) in order to assist the patient to process the cognitions, emotions, somatic reactions, and/or memories associated with the trauma. The theory is that once these are processed sufficiently to arrive at a point of resolution, completion, or a change of perspective, trauma symptoms should decline or remit.
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Although the research evidence is strong for the efficacy of particular psychotherapy and
pharmacological treatments for adults with PTSD, many other treatments are being used or are
under development and there are still significant gaps in the literature. These include the lack of
RCTs for newer treatments, the comparative effectiveness of psychological and
pharmacological treatments and combinations of treatments, subgroup effects, applicability of
findings to patients with comorbidities and PTSD, patient preferences for care, and impact of
treatments on important patient-oriented outcomes such as quality of life, long-term treatment
effects, adverse effects and harms, along with other outcomes that are not so easily quantifiable
such as moral injury, emotional regulation, identity and sense of self, and ability to form intimate
relationships.
In addition to the research gaps noted, there are other methodological concerns with
many of the current PTSD treatment trials that should be addressed in future trials. Specifically,
the panel recommends that investigators design trials to minimize attrition, identify reasons for
attrition/dropout, decrease missing data, and incorporate rigorous methods of handling missing
