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Mental Health Matters Journal for Psychiatrists & GP's

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Kate Johnson

April 29, 2012 (Arlington, Virginia) — Patients with posttraumatic stress disorder (PTSD) and comorbidities of major depressive disorder (MDD) or childhood sexual abuse (CSA) are particularly sensitive to not getting their treatment of choice, new research shows.

"What seems to be driving impaired recovery is not getting the treatment you want, and in certain subgroups — those with MDD and CSA — you see a particularly robust impact of this discrepancy," principal investigator Norah Feeny, PhD, director of the PTSD Treatment and Research Program, Case Western Reserve University, in Cleveland, Ohio, told delegates attending the Anxiety Disorders Association of America (ADAA) 32nd Annual Conference.

The findings underscore the importance of individualizing PTSD treatment, particularly because MDD and CSA are very common comorbidities in PTSD, with up to one half of PTSD patients meeting criteria for a current MDD, she said.

"A one-size-fits-all approach is not going to continue to work for the treatment of PTSD."

Diminished Response Rate

In the study, 200 PTSD patients were randomly assigned to having their choice (n = 97) of either prolonged exposure therapy (PE) or sertraline (SER) or to receiving either treatment regardless of their preference (n = 103).

In the choice group, 61 patients chose PE and 36 chose SER; in the random-treatment group, 55 received PE and 48 received SER.

PE consisted of 10 weekly sessions, each of which running 90 to 120 minutes; SER was given on a flexible dosing schedule (between 25 and 200 mg/day).

The mean age of the patients was 37 years; 75% were female, 65% were white, and 70% did not have a college education.

The median time since trauma exposure was almost 12 years. Childhood sexual abuse was reported by 24%, adult sexual abuse by 31%, nonsexual abuse by 22.5%, and motor vehicle accidents by 13.5%.

At the end of the treatment period, response, measured with the Posttraumatic Symptom Scale Interview (PSS-I), was robust for both treatments.

"Most people in both groups got better and lost their diagnoses by posttreatment," Dr. Feeny said.

However, compared with the group that got their preferred treatment, the response rate in the no-choice group was "a little bit diminished," she said.

Specifically, whereas the pre-to-posttreatment effect sizes in the choice group were 1.42 (SER) and 1.95 (PE), they were 0.95 and 1.35, respectively, in the no-choice group.

"Overall, in the whole sample, discrepancy matters. Those who get what is discrepant with what they want do more poorly — they drop out more, and they adhere less," said Dr. Feeny.

But a subgroup analysis picked out those with MDD and CSA as being particularly sensitive to this mismatch with treatment preference.

In these subgroups, the number needed to treat (NNT) is low, "meaning you need very few patients to see the impact," she said.

"This doubly randomized preference trial allows us to look at the impact of preference in ways that we can't in a standardized, randomized controlled trial, and the preference impacts in this trial are larger than the treatment modality impacts," she said. Additionally, "preference impacts are larger still among these subgroups."

Choice Often a Luxury

In an interview with Medscape Medical News, independent commentator Terence Keane, PhD, professor and vice-chair of the Department of Psychiatry at Boston University School of Medicine, in Massachusetts, and director of Behavioral Science at National Center for PTSD, said that treatment choice is often a luxury that is unavailable to many patients and clinicians.

"In so many ways, the kind of healthcare you get depends on which door you walk into, and if you walk into somebody's office who is very skilled at exposure therapy, you are way more likely to get exposure therapy, and if all they do is prescribe, you're way more likely to get a prescription. In this particular study, they were offered choices, but there aren't a lot of places that offer choices."

He said he hopes to see PTSD treatment move toward triaging patients "not only based on their problems, which is what happens now, but also on what's needed to treat them effectively."

"Most primary care physicians who have patients with mental health problems really don't want to touch the problems," he added. "They don't want to open the door because they're not trained, and if they open the door, the patient may actually disclose and take an hour or 2 hours of time, and their schedules are not equipped to handle that."

Dr. Feeny and Dr. Keane have disclosed no relevant financial relationships.

Anxiety Disorders Association of America (ADAA) 32nd Annual Conference. Session 318R, presented April 13, 2012.


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