Many Therapy Recommendations Downgraded
SILVER SPRING, MD — The new VA/DoD posttraumatic stress disorder (PTSD) clinical practice guideline, published late last year, has drawn strong criticism from some experts in the field.
The disagreement with the new guideline is so strong, in fact, that authors of a recent Viewpoint article in JAMA Psychiatry urged that federal clinicians continue to follow the 2017 clinical practice guideline (CPG) and not adopt the recommendations of the new one.1
“Compared with the 2017 version, however, what is immediately apparent is the considerable reduction in recommended treatments and absence of new recommended strategies for clinicians caring for servicemembers and veterans,” according to the article. “This is particularly concerning given the high dropout rates and moderate efficacy of most PTSD treatments in these populations. It is important to understand the reasons and implications of these changes and determine how this will improve clinical outcomes—the stated purpose of the CPG.”
The authors of the commentary are Charles W. Hoge, MD, of the Walter Reed Army Institute of Research in Silver Spring, MD; Kathleen M. Chard, PhD, of the Cincinnati VAMC; and Rachel Yehuda, PhD, of the James J. Peters Veterans Affairs Medical Center, and Icahn School of Medicine at Mount Sinai in New York.
The commentators pointed out that, of seven trauma-focused therapies strongly recommended in 2017, only three retained that status: cognitive processing therapy (CPT), prolonged exposure (PE) and eye-movement desensitization and reprocessing (EMDR), adding, “All European versions of exposure or cognitive trauma-focused therapies (Ehlers’ cognitive therapy [CT], brief eclectic psychotherapy [BEP], narrative exposure therapy [NET]) and written exposure therapy (WET) were downgraded to the following: suggest/weak for (CT, WET) or insufficient evidence/neither for not against (BEP, NET).”
The guideline authors explained that their review, passed on a “more rigorous application of GRADE and accumulated new evidence,” led to the downgrading of some specific treatments.
Significant changes to the strength of the recommendations include the following:
- Some trauma-focused psychotherapies that previously received a Strong for recommendation (Brief Eclectic Psychotherapy and Narrative Exposure Therapy [NET] were downgraded to Neither for nor against [Recommendation 10], and Ehlers’ Cognitive Therapy [CT] for PTSD and written narrative exposure, now called Written Exposure Therapy [WET], was downgraded to Weak for [Recommendation].
- Some nontrauma-focused psychotherapies that previously received a Weak for recommendation (Stress Inoculation Training [SIT] and Interpersonal Psychotherapy [IPT] were downgraded to Neither for nor against [Recommendation 10]).
- One medication that previously received a Strong for recommendation (Fluoxetine was downgraded to Neither for nor against [Recommendation 16]).
- Some medications that previously received a Weak for recommendation (Nefazodone, phenelzine and imipramine were downgraded to Neither for nor against [Recommendation 16]).
- A Weak designation was included in recommendations for prazosin for nightmares (Recommendation 32) and Mindfulness-Based Stress Reduction® (MBSR) for overall PTSD symptoms (Recommendation 26).
The JAMA Psychiatry Viewpoint responded strongly, stating, “CPGs ideally refresh our understanding of the evidence, shape clinical practice, and guide innovation. Although disproportionate research investment in recent years has gone into PE and CPT studies, no new evidence calls into question the utility of the downgraded therapies. The downgrading occurred, not because the evidence changed, but because the workgroup decided to evaluate therapies in a new way, inconsistent with previous reviews.”
In essence, the critics noted, each therapy was evaluated separately, which they said was inappropriate for trauma-focused psychotherapies, which “largely show equivalence in head-to-head trials, consistent with similar theoretical mechanisms. The workgroup’s restrictive strategy set the evidence bar too high for all but the most heavily researched therapies, and resulted in downgrading the strength of cumulative evidence across numerous comparable treatments.”
The Viewpoint authors also decried “the loss of the foundational distinction between trauma- and nontrauma-focused therapies,” explaining, “The supportive psychotherapy, present-centered therapy (PCT), is now listed alongside 2 trauma-focused therapies, WET and CT, as preferred second-line treatments. PCT was developed as the comparison condition to control for nonspecific effects of therapy but fared unexpectedly well in trials compared with PE and CPT. However, this does not make PCT a bona fide therapy; large effects are often observed in placebo arms of psychiatric trials, and adopting PCT as a therapeutic option is akin to recommending a placebo medication found comparable with an active medication.”
They pointed out that more than 20 other trauma and nontrauma psychotherapies were listed as having “insufficient evidence” bin, although several are well established and/or have been shown effective in head-to-head random clinical trials, such as BEP, NET, cognitive behavioral conjoint therapy, dialectical behavioral therapy, stress inoculation training, interpersonal therapy and adaptive disclosure.
Fewer Medications
The critique also noted that fewer medications are recommended than before, including three antidepressants vs. four. It argues that research doesn’t support the “primacy of the recommended therapies, particularly the most recent study in veterans that found comparable outcomes between sertraline vs. PE vs. combination.”3
Another key problem with the new CPG is that it advises using National Center for PTSD screening tools, though other well-validated instruments are available, according to the commentary. The authors wrote that the Clinician Administered PTSD Scale [CAPS]) “may be suitable for PTSD specialty clinics, but it is unfeasible in routine VA/DoD mental health and primary care clinics due to extensive training and administration time.”
“We cannot risk setting progress back by narrowing evidence-based options and potentially constraining practice through health policies derived from this CPG,” according to the Viewpoint. ‘No treatment is effective or acceptable for everyone, and we need as many options for effective treatment as possible, not fewer. VA and DoD clinicians need accurate information that keeps them up to date with the latest tools for treating veterans and service members, not reification of a limited status quo. Until these issues are addressed, we recommend continuing to rely on the 2017 version.’
The VA and DoD Evidence-Based Practice Work Group (EBPWG) was established and first chartered in 2004. “In 2017, VA and DoD published a CPG for Management of Posttraumatic Stress Disorder and Acute Stress Disorder (2017 VA/DoD PTSD CPG), which was based on evidence reviewed through March 2016,” the panel wrote. “Since the release of that CPG, the evidence base on PTSD has expanded. Consequently, the EBPWG initiated the update of the 2017 VA/DoD PTSD CPG in 2022. This updated CPG’s use of Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach reflects a more rigorous application of the methodology than previous iterations. Therefore, the strength of some recommendations might have been modified because of the confidence in the quality of the supporting evidence.”
The new guideline points out that, in the 2023 CPG, the evidence on trauma-focused psychotherapies was reviewed for each treatment individually, rather than as a class, for comparison with medications. The updated algorithm allowed “greater attention to discussing the generalizability of evidence to subgroups based on gender identity, sexuality, race, ethnicity, age, and other patient characteristics and clearer delineation of complementary, integrative, and alternative health treatment,” according to the CPG developers.
The CPG makes a strong recommendation for individual psychotherapies over pharmacologic interventions for the treatment of PTSD. Among the recommended psychotherapies for the treatment of PTSD are Cognitive Processing Therapy, Eye Movement Desensitization and Reprocessing, or Prolonged Exposure.
Other recommendations are in the accompanying graphic.
- Hoge CW, Chard KM, Yehuda R. US Veterans Affairs and Department of Defense 2023 Clinical Guideline for PTSD—Devolving Not Evolving. JAMA Psychiatry. Published online January 10, 2024. doi:10.1001/jamapsychiatry.2023.4920
- US Department of Veterans Affairs and Department of Defense. VA/DoD clinical practice guideline for management of posttraumatic stress disorder and acute stress disorder.. https://www.healthquality.va.gov/guidelines/MH/ptsd/VA-DoD-CPG-PTSD-Full-CPGAug242023.pdf
- Rauch SAM, Kim HM, Powell C, Tuerk PW,et. al. Efficacy of Prolonged Exposure Therapy, Sertraline Hydrochloride, and Their Combination Among Combat Veterans With Posttraumatic Stress Disorder: A Randomized Clinical Trial. JAMA Psychiatry. 2019 Feb 1;76(2):117-126. doi: 10.1001/jamapsychiatry.2018.3412. PMID: 30516797; PMCID: PMC6439753.