E VIDENCE -B ASED T REATMENTS (EBT) IN THE C LINICAL P RACTICE OF PTSD T REATMENT

Spinazzola and colleagues (2005) reviewed the 34 adult treatment outcome trials that form the basis of the ISTSS Practice Guidelines for the Effective Treatment of PTSD (Foa et al., 2000). The authors point out that once an intervention has been found to demonstrate efficacy, the next question concerns its effectiveness, i.e. the ability of this intervention to transport well to clinical practice and achieve comparable post-intervention outcomes once experimental con-trols on setting, subject, and clinician characteristics are removed. The guidelines as a conse-quence of several empirically supported, symptom-based, manualized interventions represent, which treatments “work” for PTSD. Yet, Spinazzola and others (2005) argue that the samples might not be representative because of the restrictions. They reviewed these 34 studies con-cerning pretreatment attrition, exclusion criteria and sample characteristics. Concon-cerning pre-treatment attrition and exclusion the numbers range from 63% to 41% of all potential partici-pants, that have ultimately been randomized into treatment and 53% to 39% of the full set of screened individuals complete treatment. About 21% dropped out prior to starting treatment, 35% to 16% were screened out due to the presence of exclusionary criteria. The most common criteria excluding potential participants were related to the presence of co-morbid or severe pathology, which has been described above to co-occur with high regularity in individuals with PTSD (see 5.3). The authors conclude, that even though PTSD shows rapid response to brief, manual-driven and symptom-based protocols, many trauma victims also exhibit co-morbid dis-orders, many of which are highly treatment resistant. Accordingly, questions remain about the applicability of these treatments in clinical practice with PTSD in addition to severe co-morbid disorders or manifestations of acute behavioral disturbance (i.e., suicidal ideation). However, a survey concerning the later issue found that the vast majority of patients in RCTs presented with co-morbid disorders and conclude that findings of RCT studies may generalize more to clinical practice than previously thought; of patients not eligible, most have less, not more, se-vere forms of the disorders studied (Stirman, DeRubeis, Crits-Christoph, & Rothman, 2005).

Also Bradley and colleagues (2005) point out, that future research, which is intended to generalize to patients in practice, should avoid exclusion criteria other than those a clinician would impose in practice (e.g., schizophrenia), should avoid wait-list and other relatively inert control conditions, and should follow patients through at least 2 years.

Despite research findings and the guidelines by NICE and ISTSS pointing out exposure therapy as the treatment of choice, several authors emphasize the initial and essential goal of establishing safety for survivors of trauma (Waugaman & Waugaman, 2005; J. P. Wilson &

Drozdek, 2004), e.g. through patient education, social support, and anxiety management (Grinage, 2003). Summerfield (2005), for example, comments on the NICE guidelines that re-exposure to the details of the traumatic event, and the emotions evoked by it, would be highly problematic. Moreover, the professionally directed attention to the past, and to “emotion”, would have become fundamentally antitherapeutic and might lead rather to a chronic course than recovery. He suggests a pro-rehabilitation approach, tackling the future, aiming through graded normalization to enable the resumption of roles and activities that formerly had signi-fied health and competence. Already a decade ago van der Kolk (1996) points out that despite the fact that most studies with positive results for ameliorating PTSD have used a CBT frame-work, most clinicians treating traumatized patients continue to practice psychodynamic ther-apy. He emphasizes that there can be significant gaps between clinical impressions and scien-tific data and that until more comprehensive treatment outcome studies are available, therapists would be dependent on clinical wisdom. Despite discussions based on theoretical orientations of therapists, a controlled study on general practitioners in Scottland found, that only 28.9% of GPs had the knowledge to recognize PTSD and only 10.2% prescribed best practice for PTSD (Munro, Freeman, & Law, 2004).

In their work with refugees, Hopkins and colleagues (2005) criticize the recommended approach according to the NICE guidelines, stating that it ‘indeed does belittle their suffering to construe it in pure psychopathological terms’. Both comments warn against seeing a patient merely as a ‘disease’. There would only be a limited place for orthodox CBT of the type rec-ommended in the guidelines in the work with refugees. In addition, psychotherapeutic ap-proaches that address context and meaning as well as trauma-focused work are more likely to be effective. Regarding PTSD the ‘denial’ of the disorder is seen as morally necessary to ‘re-spect’ the ‘survivor’ of a trauma.

In addition to this critique, Grinage (2003) points out that 14% of patients with PTSD dis-continue psychotherapy, but the highest dropout rates of up to 50% would occur with exposure therapy, concluding that many patients have difficulty with re-experiencing the trauma. In con-trast to this, results of a review on dropout rates in exposure therapies in comparison to other active treatments indicated no difference in dropout rates between ET, CT, SIT, and EMDR (Hembree, Foa, Dorfan, Street, Kowalski, & Tu, 2003). Premature termination of treatment was instead associated with increased complexity and structure of treatment in the RCTs, such

as in combined treatments. Zayfert and colleagues (2005) state that the dropout rate from CBT for PTSD in clinical practice remains unknown, though they assume rates approximately twice those of RCTs due to treatment dropout and completer definitions, respectively, as well as co-morbid disorders and treatment ambivalence. In their survey on rates of imaginal exposure therapy utilization and completion of CBT for PTSD in a medical center they furthermore found, that only avoidance and depression were unique predictors of CBT dropout. This result is consistent with reported dropout predictors from RCTs of CBT for PTSD (Bryant et al., 2003), which is why the authors conclude that a treatment approach that directly addresses avoidance, social isolation, and depression, may be associated with greater rates of treatment completion. Zayfert et al. (2005) also report that most dropouts occurred before starting imagi-nal exposure therapy, although initiating exposure therapy was associated with greater likeli-hood of completion. However, even among patients who started exposure 40% did not com-plete treatment. The authors state that both failure to start exposure treatment and therapists who refrain from implementing exposure therapy with patients who appear at risk for dropout, may lead to drop out.

Rosen and others (2004) conducted a survey on prevailing PTSD treatment practices for veterans. They found that treatment providers, who were not specialized for PTSD, only rarely used validated assessment measures, and less consistently screened for PTSD than for depres-sion or substance use. These therapists would also rather provide present-focused psychother-apy practices and were significantly less likely to provide psychotherpsychother-apy directly addressing traumatic events as compared to therapists with particular expertise in PTSD. Overall, exposure therapy was rarely used. In this context Becker et al. (2004) found that most community thera-pists do not use imaginal exposure with PTSD sufferers primarily because they lack training or do not completely accept it. A survey of about 100 therapists working with torture survivors found that a negative attitude as well as unsuccessful treatments led to the fact that one third suffers from compassion fatigue and 15% from secondary traumatization (Gurris, 2005).

Concerning the patients’ acceptance of exposure, Zoellner and colleagues (2003) asked 273 women with varying degrees of trauma history and subsequent PTSD symptoms to choose between PE, the SSRI sertaline (SER) or no treatment. The women were more likely to choose PE (87.4%) than SER (6.9%) for the treatment of chronic PTSD. The perceived credibility of the treatment and personal reactions coincided with women’s choices. In addition, the

recog-nized mechanism of the treatment and its side effects also influenced the choice. The authors conclude that the women seemed to have a model for the development of PTSD and of thera-peutic change, which would be more consistent with psychotherapy than medication. However, if women in an outpatient treatment program were offered both PE and CT, only 18% elected to receive exposure therapy (Castillo, 2004; Castillo, Sandeen, Fallon, & Nye, 2001). Both treatments were introduced as equally effective. Yet, both treatments were offered as group treatments (at least 3 persons per group). Exposure treatment involves high levels of emotional intensity and the presence of others might enhance avoidance and thereby prevent women from choosing this approach. These results show that the patients’ treatment preference does not only rely on a treatment’s credibility but also on the alternatives offered as well as the setting.

Yet, both studies were conducted with women in the USA, the former, recruited participants via undergraduate psychology subject pools at universities, which limits the validity of the re-sults for other groups of patients suffering from PTSD.

Robertson and others (2004) recommend in his literature review for clinicians that al-though there is little data demonstrating the combined effects of medication and various psy-chotherapies, there is some evidence that medication may enhance the efficacy of psychother-apy. Rosen and colleagues (2004) report about the clinical practice with veterans that nearly all psychiatrists in general mental health or substance abuse programs personally prescribed medications for their PTSD patients. Generalist psychiatrists’ primary choices of medications, SSRIs and anticonvulsants, were similar to those of PTSD specialists, yet, the former were somewhat more likely to prescribe these medications for re-experiencing or withdrawal / avoidance symptoms. Generalists were also less likely than PTSD specialists to use beta-blockers to treat hyperarousal. Overall, SSRIs were the medications most commonly prescribed for re-experiencing (cluster B) and for avoidance / withdrawal (cluster C) symptoms of PTSD.

SSRIs and anticonvulsants were the medications most commonly prescribed for hyperarousal, irritability, or paranoia (cluster D symptoms). Most commonly trazodone (TCA) was pre-scribed for disturbed sleep. Benzodiazepines and beta-blockers were not widely prepre-scribed for veterans with PTSD: only one quarter of psychiatrists prescribed these drugs occasionally.

A review concerning clinical practice patterns of psychiatrists at the Intercultural Psychiat-ric Program in Oregon found that of 240 refugee patients 41% received tPsychiat-ricyclic antidepres-sants; 42% received an SSRI, and 17% received trazodone (Kinzie & Friedmann, 2004). The authors point out that these data represent the personal preference of the physicians rather than

any special clinical considerations. Accordingly, the use of SSRIs varied from 17% to 79% by specific physicians. Most of the patients taking SSRIs were taking another medicine, e.g., for insomnia. Almost no patients taking TCAs were on a secondary medicine.

In conclusion, clinical practice differs to some extent from the guidelines, which are based on research / treatment outcome studies. Therapists and researchers disagree with regard to treatment standards based on clinical wisdom as opposed to research outcome, even more when it comes to the psychotherapeutical and medical support of refugees and asylum seekers.