A Review of the Literature: Efficacy of Complementary and Alternative Medicine Therapies for Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) is often chronic and may be associated with significant comorbidities and functional impairments. Among OEF/OIF Veterans who received VA care between 2002 and 2008, 22% were diagnosed with PTSD. In addition to increased mental health service use among this newest generation of Veterans, VA also has witnessed a significant increase among Vietnam-era Veterans. The current VA/DoD Clinical Practice Guideline for the Management of PTSD recommends the following evidence-based, first-line therapies: trauma-focused cognitive behavioral psychotherapies, stress inoculation training, and pharmacotherapies. Complementary and alternative medicine (CAM) interventions include a range of therapies that are not considered standard to the practice of medicine in the U.S. However, studies in military and non-military populations show that more than one-third of U.S. adults use CAM approaches to manage a range of physical and emotional health concerns.

Investigators at the VA Evidence-based Synthesis Program in Durham, NC conducted a review of the literature from database inception through December 22, 2010 to examine the evidence on the effect of CAM therapies (e.g., acupuncture, mind-body, meditation) in treating PTSD. After screening 1,776 articles, manuscripts describing 7 randomized controlled trials (RCT) and 2 non-RCT studies were chosen in order to answer the four key questions:

Question #1
For adults with PTSD, are mind-body complementary and alternative medicine therapies (e.g., acupuncture, yoga, meditation) more efficacious than control for PTSD symptoms and health-related quality of life?

• Meditation techniques are associated with small-to-moderate, but statistically non-significant improvements in PTSD severity and health-related quality of life compared to usual care only (one fair-quality study) and individual psychotherapy (one poor-quality study). Both studies examined relatively brief, group therapy formats in male Veterans.
• For acupuncture (one good-quality study), change in PTSD symptoms and health-related quality of life was similar to that observed for group cognitive behavioral therapy and was greater than wait-list control in a predominantly male, non-Veteran cohort.
• In three poor-quality RCTs, relaxation was not associated with significant clinical improvement relative to active comparators.

Supplementary report
To supplement the primary report, the investigators also searched ClinicalTrials.gov for ongoing studies and the Cochrane Database of Systematic reviews (CDSR) for evidence synthesis of CAM treatments for closely related disorders. This search produced four systematic reviews that evaluated mind-body CAM therapies. Investigators found no synthesized evidence of acceptable quality for manipulative and body-based CAM therapies, movement-based CAM therapies, or energy therapies. Limited evidence does support the use of meditation and relaxation training for anxiety and acupuncture for depression.

Question #2
For adults with PTSD, are manipulative and body-based complementary and alternative medicine therapies (e.g., spinal manipulation, massage) more efficacious than control for PTSD symptoms and health-related quality of life?

• There was insufficient evidence to answer this question.

Question #3
For adults with PTSD, are complementary and alternative medicine therapies that are movement-based or involve energy therapies more efficacious than control for PTSD symptoms and health-related quality of life?

• Investigators did not identify any published, ongoing, or unpublished/completed RCTs of movement-based or energy therapies for PTSD.

Question #4
For treatments evaluated in Questions 1-3 that lack randomized controlled trials, is there evidence from other study designs that suggests the potential for treatment efficacy?

• Two non-randomized, prospective studies of CAM therapies for PTSD were identified, which provided little additional evidence of potential efficacy of PTSD for any CAM interventions of interest.

Limitations
This limited evidence base suggests that CAM treatments -- including forms of meditation, acupuncture, relaxation, and mind-body interventions -- can be feasibly administered, appear to be well-tolerated, and may hold promise as adjunctive or mono-therapies for PTSD. However, while the limitations of the current evidence preclude investigators from drawing strong conclusions to inform clinical practice or public policy regarding the optimal use of CAM therapies for PTSD, they do point to numerous opportunities for future research.

Suggestions for Future Research
Designing rigorous tests of some CAM modalities may be difficult since sham procedures that are both truly inert and appear sufficiently similar to the active intervention are challenging to devise. Thus, future research may want to test these strategies in small exploratory trials, if there is sufficient theoretical rationale for a beneficial treatment effect.

Authors' note
VA's Office of Mental Health Services has funded several projects to explore the use of meditation for PTSD, and the results of this evidence synthesis will be used to inform project design and evaluation efforts. In addition, VA's Office of Research and Development has supported three projects focusing on meditative treatment for PTSD.

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This report is a product of the HSR&D Evidence-based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers -- and to disseminate these reports throughout VA.

Reference
Strauss J, Coeytaux R, McDuffie J, Nagi A, and Williams J, Jr. Efficacy of Complementary and Alternative Therapies for Posttraumatic Stress Disorder. VA-ESP Project #09-010;2011.

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This report is a product of the HSR&D Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers - and to disseminate these reports throughout VA.

See the full reports online.