Two treatments for post-traumatic stress that are considered the gold standard for treating the condition in combat veterans are not significantly more effective than some other approaches, including medication, stress management therapy and mindfulness, according to a new study.

Two types of therapy that focus on confronting and dealing with trauma — cognitive processing therapy and prolonged exposure therapy — are largely considered front-line treatments for PTSD.

But a review of PTSD treatment studies dating back to 1989 found that while the two therapies reduce symptoms, they also have high dropout rates and low follow-through, making them less effective and less likely to completely alleviate symptoms.

According to the research, published in the Journal of the American Medical Association on Aug. 4, nearly a quarter of patients who tried CPT or PE dropped out.

Still, nearly 70 percent of those who received one of the two front-line therapies saw a decrease in symptoms, even as two-thirds still met the criteria for having PTSD after treatment.

"When we looked hard at how effective these two treatments were, as well as some other psychotherapies, we found they are reasonably effective — but they are not as definitively helpful as we would like," said Dr. Charles Marmar, a psychiatrist at NYU Langone and one of the article's authors.

According to the review, conducted by Marmar and other researchers at the Cohen Veterans Center for Post-Traumatic Stress and Traumatic Brain Injury and NYU Langone Medical Center, medications, as well as therapies that teach personal skills and coping strategies or focus on relaxation, mindfulness, yoga and exercise, were nearly as effective as the CPT and PE therapy.

Roughly 13 percent of Iraq and Afghanistan veterans have been diagnosed with PTSD, while 10 percent of Persian Gulf War veterans and 11 percent of Vietnam veterans still have symptoms, according to the study.

To treat the disorder — characterized by intrusive thoughts such as anxiety and nightmares, feeling "on edge" or hyper-aroused, or being detached or disconnected, among other symptoms — clinical practice guidelines used by the Veterans Affairs and Defense departments recommend trauma-related exposures like CPT and PE to treat PTSD.

But other therapies, including conventional medications like antidepressants and some complementary and alternative treatments, appear to help many affected veterans nearly as much as those frontline treatments and could help those who have tried either but failed to respond, according to the study authors.

Marmar recalled two World War II veterans whom he treated while working at the San Francisco VA Health System: One had experienced daily nightmares for 40 years with medication, the other sought marriage counseling with his wife for marital problems that began as soon as he returned from the war.

Neither therapy cured the veterans' PTSD. But they helped eliminate symptoms, Marmar said.

A dose of medication let the first veteran sleep peacefully, with the intrusive nightmares retreating to twice a month. The couple embraced coping strategies that improved their marriage, even after nearly 50 years together.

"My experience is one of great optimism," Marmar said. "Don't give up if the first treatment or second treatment doesn't work. ... It's a lot of trial-and-error work, but with persistence, flexibility and compassionate commitment for the veteran, every patient should to be able to get the assistance they need."

For some veterans, treatment may mean group therapy in a structured mindfulness session. Another study published in the same JAMA edition found that in a group of 116 veterans with PTSD, those treated with mindfulness-based stress reduction experienced a greater reduction of symptoms than those treated with "present-centered" therapy, which focuses on managing current problems in a patient's life.

That study was conducted by the Minneapolis Veterans Affairs Health Care System,

Dr. David Kearney and psychologist Tracy Simpson with the VA Puget Sound Health System, said the two articles indicate that proven alternative therapies could be beneficial to veterans.

"Given the large number of individuals with PTSD, not all of whom will opt for or benefit sufficiently from existing approaches, additional treatments suitable for broad implementation are needed," wrote the two in an editorial accompanying the studies.

Patricia Kime is a senior writer covering military and veterans health care, medicine and personnel issues.

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