Progress Notes: Clinical Practice Guideline on the Treatment of PTSD

Lynn F. Bufka, PhD, joined the American Psychological Association in 2002 and is currently the associate executive director of Practice Research and Policy. Previously, she was associate director of clinical training and an assistant research professor at Boston University.

Joan Cook, PhD, is an associate professor in the Yale School of Medicine Department of Psychiatry. She has nearly 100 publications in the areas of traumatic stress, geriatric mental health and dissemination fields. Dr. Cook has worked clinically with a range of trauma survivors. She has also served as the principal investigator on six federal grants, was a member of the APA Guideline Development Panel for PTSD and was the 2016 President of APA’s Division of Trauma Psychology.

Howard Kurtzman, PhD, joined the American Psychological Association in 2007 and is currently the acting executive director of the APA Science Directorate. Previously, he was a program director at the National Institute of Mental Health and was on the faculty of the psychology department at Cornell University.

Hannah Calkins: This is Progress Notes: a podcast keeping tabs on the practice of psychology. I’m Hannah Calkins, and today, we’re going to be talking about an exciting new initiative here at APA: the development of clinical practice guidelines. Earlier this year, APA released a guideline on the treatment of Posttraumatic Stress Disorder in adults — the culmination of seven years of rigorous review and development. 

I spoke to three psychologists involved in the development of the guideline. In the first half we’ll talk to Dr. Lynn Bufka and Dr. Howard Kurtzman, who are staffers here at APA, and in the second half we’ll hear from Dr. Joan Cook, who is an expert in treating PTSD, uses clinical practice guidelines regularly, and was a member of the guideline development panel.  Here we go! 

Lynn Bufka: I’m Lynn Bufka. I am the associate executive director for Practice Research and Policy within the Practice Directorate at APA. I am the lead staff person in the Practice Directorate for the clinical practice guideline initiative, which includes not only the advisory steering committee; it also includes the panels that develop the clinical practice guidelines.

Howard Kurtzman: And I’m Howard Kurtzman. I’m the acting executive director for Science.  I am the lead staff person from the Science Directorate working on clinical practice guidelines for APA.

Lynn Bufka: The clinical practice guideline on PTSD is about, what do we know about the treatments that are efficacious for treatment of PTSD in adults? And do we know anything about how those treatments compare to one another? So ultimately, it’s a series of recommendations about what treatments are known to work, and taking into account both the benefits and potential adverse effects of those treatments. And the guideline is really intended for anybody who interacts with individuals with PTSD, whether they’re the primary clinician who’s going to provide the intervention, or a person who’s referring someone for care, or a person with PTSD, or a family member or loved one, or even a policymaker who is trying to figure out what are good practices for treating PTSD.

Howard Kurtzman: An additional use of the PTSD guideline is to identify gaps in the research — questions that we don’t have clear answers for about the efficacy and comparative effectiveness of particular treatments.

Hannah Calkins: Let’s back up a second. What exactly are clinical practice guidelines, who uses them, and how are they used?

Lynn Bufka: Clinical practice guidelines…What they do is synthesize the research evidence around a particular question. Typically it’s going to be around a particular kind of disorder or health condition but it could be around particular kinds of interventions or practices in a clinical setting or health care setting. But what it does is — based on a systematic review of the literature that has addressed particular questions—synthesizes that evidence in a way that makes decision-making much easier for the end user because the person who is providing care or making referrals or making decisions about what kind of care should be provided or seeking care…they can’t read all the research that’s out there. So a clinical practice guideline brings all that together in a systematic way, ultimately has a series of recommendations about what is known about the research so that individuals can make more informed decisions about their care or the care that they are providing. And they’re used across all kinds of settings. They’re used in primary care, they’re used across different kinds of medical disciplines. Institutions use them and embed them into their electronic health records, so they’ll use the information in clinical practice guidelines to prompt individuals to think about offering different kinds of interventions or to consider certain assessments or to provide certain information to patients. They get translated into materials that are appropriate for patients and family members to ask questions about what kind of care is necessary. So they have a wide variety of uses.

Howard Kurtzman: And I would add that the methods and procedures for guideline development have evolved in a very impressive fashion over the last 10 or 20 years. And at APA, we followed what are the current best practices in guideline development.

Hannah Calkins: The process for developing the guideline on PTSD started in 2010. One reason why APA chose PTSD as its first topic for guideline development was that members were asking for it. Some guidelines on treat PTSD already exist, including guidelines from the American Psychiatric Association and VA and Department of Defense. But members were looking to APA for its recommendations.

The interdisciplinary, 12-person panel that developed the guideline was formed in 2012. Dr. Bufka and Dr. Kurtzman helped oversee the process.

Howard Kurtzman: The advisory steering committee developed a call for nominations which we distributed widely, and the goal was to bring on people who have worked in a variety of approaches, theoretical approaches, worked in a variety of settings, worked with a variety of populations; people who could assess evidence fairly, and could work in a collegial manner with other panel members. And we ended up with a panel composed of academic scientists, people who work in practice full-time, including independent practitioners, and people who’ve written and published in a variety of areas. And I think the panel represents the full range of providers who have expertise in PTSD. We also had community members, who have had treatment for PTSD themselves. So it’s a pretty broad panel.

Lynn Bufka: And it’s important to note that the panel members were not all psychologists. We had a social worker, a general practice physician, a couple of psychiatrists. So it was a pretty diverse group of individuals from a variety of backgrounds that all agreed to work on this very intense project.

It’s really important for guidelines to be developed independently. They should not be influenced by special interests or political processes or an individual’s allegiance to particular treatments. It’s really intended to be an objective evaluation of the research evidence and a compilation into recommendations for how to proceed with care.    

Hannah Calkins: The next step was an external systematic review of the literature. It was funded by the federal government through the Agency for Healthcare Quality and Research, and to keep it independent, it was conducted by an evidence-based practice center in North Carolina.

But before the review could begin, the panel had to determine its scope. They identified core questions about what they wanted to know about the efficacy and comparative effectiveness of psychological and medication treatments for PTSD. Then they had to decide on what basis they would include or exclude studies — for example, saying that they would only include studies conducted in English, done within a certain time frame, and involving specific populations. Then, they went to the research databases, pulled the articles that met the criteria, and sent them off for review.

Finally, at that point, the external systematic review team evaluated and reported on the evidence in each study.

Howard Kurtzman: One of the challenges in guideline development is that you’re always a little bit behind. The systematic review may not capture the very latest research that was released at the time it was published, and then by the time the guideline panel looks at the systematic review, perhaps additional research has come out. The APA panel, though, made an additional effort to examine the more recent literature, not in a full-fledged systematic review, which would have taken a lot of time and expense, frankly, but to do an assessment of whether the literature that we did find, using the same criteria as the original systematic review, would result in any change in the recommendations they would make. They determined that was not the case. But this is a question that we do get, how do you maintain currency with the literature? I think the panel did a reasonable job on that, but it is a challenge that every panel, in every field, not just APA, faces.

Hannah Calkins: Dr. Raquel Halfond, APA’s director of Clinical Practice Guidelines, worked with the panel to methodically assess the findings of the review and make recommendations. That involved coming up with another set of questions.

Lynn Bufka: As a clinician, what outcomes do I want to think about in terms of trying to impact change? Am I most interested in loss of diagnosis, am I most interested in reduction of symptoms, am I most interested in quality of life? So the panel — and the community members were critical in this part of the process — debated what outcomes were important; they selected what they decided were critical outcomes, they look at the evidence for each, look at the benefits of care, look at the possible risks and harms, make a determination, hopefully you’re not going to recommend something in which the benefits don’t outweigh the harms. Make that kind of decision. And then they’re also looking at what do we know about patient values and preferences? Do patients really not want particular kinds of treatments? What do we know about the applicability of that across different kinds of populations? So all of those factors get considered before a recommendation is made about a particular intervention. So that was the decision-making process. And then once they got the decisions about the recommendations done, then they have to put it together into a guideline document to explain what they did and what they’re recommending.

Hannah Calkins: Then, the provisional guideline document was released and distributed for a comment period.

Lynn Bufka: We received almost 900 comments in the process, but every comment was reviewed and considered when thinking about how to revise the document. When individuals presented evidence for supporting particular kinds of interventions, the panel did look at that to make sure that they felt they had evaluated it carefully in their initial process. So, while there were not that many changes in terms of recommendations as a result of comments, the panel certainly considered all the comments. The context around the recommendations certainly changed somewhat too in response to comments, as people suggested potentially making it clear that guideline recommendations are not mandates and standards, but they’re really an opportunity to synthesize the best evidence.

Hannah Calkins: By this point, you’re probably curious about what’s actually in the final guideline. What did the panel recommend?

Lynn Bufka: Sure, there’s two kinds of recommendations that are made. There are recommendations which are strong recommendations and there are conditional recommendations. They sometimes might say “suggest” or “recommend” and what that reflects is the strength of the evidence behind it. A strong recommendation indicates that there’s really good evidence that you should do this particular intervention or that it’s got good outcomes. A conditional recommendation says, yes, there’s evidence for good outcomes but it’s not perhaps as strong, or maybe there are some concerns about applicability or patient values and preferences. But, having said that, all of the interventions, the treatments that are recommended in the guideline, have evidence supporting their benefit in the treatment of PTSD.

Howard Kurtzman: In the guideline development world, or discipline, people struggle with how to characterize different levels of recommendations, so we use the terms strong and then conditional or suggested. That doesn’t mean that the conditional or suggested are somehow second class treatments. As Lynn said, the current evidence just may not be as strong or there just may not be as much evidence one way or the other. In other areas of health care, other guidelines have used things like A level and B level or 5 stars, 4 stars, things like that, which have conveyed…you know, no one wants to get a B-level treatment, right? So we struggle with what the correct terminology should be, but those treatments that in this guideline are labeled as conditional or suggested are useful treatments and clinicians should consider using them.

Lynn Bufka: The ones that received a strong recommendation would be Cognitive Behavioral Therapy, Cognitive Processing Therapy, Cognitive Therapy, and Prolonged Exposure and the latter three are really more specialty kinds of interventions that come from Cognitive Behavioral Therapy. So they all have their roots in looking at thoughts and behaviors and trying to get people to do things perhaps that they’ve been reluctant to do as a result of their trauma experience. So each of those interventions received a strong recommendation.

The conditional, or the suggested, psychological recommendations…there were three of them. Brief Eclectic Psychotherapy, EMDR (Eye Movement Desensitization Reprocessing Therapy) and NET (or Narrative Exposure Therapy). And they all had evidence supporting their efficacy, but perhaps did not have as strong of evidence or had not been studied as widely or been used with as broad a number of populations. In addition, four medications received a conditional recommendation; that was fluoxetine, sertraline, paroxetine, and venlafaxine. Medications are a little trickier than, say, psychological treatments, because there’s more likely to be side effects with medications than there are with psychological treatments.

Hannah Calkins: Dr. Bufka and Dr. Kurtzman encourage all providers who work with people PTSD to read the guideline document, which is available online. But they also emphasized again that this guideline isn’t just for practitioners.

Howard Kurtzman: And of course by making information about treatment of PTSD more widely available to the public, we’re hoping that more people who have PTSD will see that there are effective treatments and they will seek out those treatments.

Hannah Calkins: Dr. Joan Cook is a clinical psychologist and researcher who has worked with a range of trauma survivors, from combat survivors and prisoners of war, to people who have been sexually assaulted and abused, to survivors of terrorism.

Not only was Dr. Cook a member of the panel that developed APA’s clinical practice guideline on PTSD, she and her colleagues also conducted additional research to supplement the panel’s recommendations. 

Joan Cook: My name is Dr. Joan Cook, and I’m an associate professor in the Yale School of Medicine’s Department of Psychiatry.

Like many busy healthcare professionals, I don’t have time to read every single original research article on every particular disorder, so I really trust guidelines to do an excellent synopsis for me.

I think for years there was a discomfort, or a dislike of clinical practice guidelines — maybe a fear. Maybe some practitioners found them constraining, or condescending, or were otherwise turned off by the process or the product of clinical practice guidelines. I get that. I get that some people might fear they would be micromanaged or mandated. But I love that our guideline is aspirational. I see it as being informative, illuminating, and a heavy burden lifted off providers that don’t have to do this kind of synthesis themselves. A lot of front-line psychologists and other mental health providers, who aren’t in organizations, who are in private practice, may have very little time to keep up with the literature. And I think our guidelines are a wonderful synopsis for them to be informed in the incredible advancements that have happened in the field of traumatic stress. Some of us psychologists and other mental health professionals or medical health care professionals may have one style when working with patients, and may be less open to learning new things. And as a lifelong learner, I believe and advocate that it’s in every practitioner and patient’s best interest that this guideline be taken into account.

One of the things that’s so nice about our guideline too, and one of the reasons why I’m so proud of our work, is that it was comprehensive and thoughtful, it was balanced and transparent, and one thing that made it unique was that we had panel members from an interdisciplinary group so we weren’t just psychologists. We were all in the work together, reviewing the systematic review and coming up with the evidence-based recommendations. So I think we clearly acknowledge that there are limitations, as with any clinical guidelines, and the clinical practice guidelines that we put together are based on the best-available evidence at the time, and shouldn’t be construed as a standard of care prescribing a specific course of action.  

So, in addition to being a member of the APA development guideline panel for PTSD, my research team — Drs. Vanessa Simiola and Amy Ellis and I — conducted two separate systematic reviews that the panel considered as supplemental material. One was a review on mental health treatment preferences for survivors of trauma, and the other was on evidence-based relationship variables in trauma treatment. And the findings of these additional reviews were used to make the treatment recommendations more comprehensive, with regard to the risk of harm or adverse events associated with various interventions, as well as the patient values and preferences.

So my group found that trauma survivor participants in the empirical literature had expressed a preference for psychotherapy over medication, and for talking about the trauma. And in the other review we did, it’s quite well-known, and there’s a theoretical rationale, for believing that patient and therapy relationship factors may be especially important in the psychotherapy of PTSD, especially when the trauma the person experienced was interpersonal in nature. And so those with PTSD commonly have difficulties trusting others, and that’s a stance that could negatively impact the development of relationships, both within and outside of psychotherapy. We found that the therapeutic relationship, the alliance, was predictive of or associated with a reduction in symptomatology. So I think that practitioners need to be cognizant of that issue.

At minimum, I’d encourage providers to be familiar with these guidelines and to get trained in some of these treatments. And perhaps, if they have the time and resources, to receive supervision or consultation in effective delivery of some of these treatments. I think it’s important that we provide patients with information about these treatments and participate with them in shared decision-making, so I’d encourage practitioners to discuss these treatments — the process, the procedures, the effectiveness, the associated emotional and practical demands of these treatments — with their patients. Of course, some of our community members reminded us that all practitioners in clinical practice should have an awareness of and be knowledgeable about trauma, and offer information about these treatments, and as well as teach coping skills, and work from a personalized approach and be sensitive to cultural and sociodemographic differences. So for me, all of that resonates for being an evidence-informed psychologist and practitioner.

You know, there’s a sentence in the International Society for Traumatic Stress Studies’ guidelines that particularly resonated for me, and it resonated for me throughout the process of putting our guidelines together. And it was that, patients with PTSD pose unique problems, and require flexible decision-making and solutions, including when to amend, modify, or alter the course of a treatment protocol. So it’s not just a generic PTSD that one treats, but a particular patient with PTSD, who presents with life situations and circumstances unique to them. And so I say to providers using these guidelines, please use them, but never forget that our patients are unique and deserve a personalized approach.

You know, it’s an exciting time for the field of clinical psych, and it’s a really exciting time for trauma psychology. We’ve made incredible progress in our research on PTSD in how we treat adults with PTSD, and it’s more than time, it’s past time, that APA share these consolidated findings with a wider audience. I’m really excited because I think the push to develop and disseminate effective PTSD treatments is great news not just for practitioners but so many of our patients, who have suffered in silence for years. Thousands of people can now benefit from the PTSD treatments that have been developed and tested. That’s news to celebrate.

There’s limits with any guideline, and this guideline is no exception. It’s evolving. The research literature for the efficacy of treatment in adults with PTSD is strong, and I’m glad that we got this out there and that health care providers and the public are going to learn about that. But there are several limitations, and they include we don’t have as much good data on comparing various psychotherapies; we don’t have good data on an evaluation of moderators of treatment effects; we need to include more participants with complicated comorbidities; we have patients in these trials with some complicated comorbidities—depression, anxiety, substance misuse and abuse — we don’t have as great of data on people who are currently engaging in what could be called self-injurious behaviors or self-harm.

We also acknowledge that although the research evidence is strong for the particular treatments for adults with PTSD, there are many other treatments that are being used or are under development, and we haven’t studied those rigorously. There’s also important clinical questions we still have, like how do patients’ needs dictate the choices among the treatments, what’s the timing of the use of these treatments, should we be integrating some of these treatments to promote patient engagement or to decrease the chances they’ll drop out or to increase the benefits they  receive… So we’re also not at a point where we can predict which treatments are most suitable for which patients. But we’ve come a long way and I have confidence that we’re going to get there.  

Hannah Calkins: APA’s clinical practice guideline on PTSD is a living document. It will be reviewed in five years. The guideline, as well as additional resources for practitioners, for the public and for policymakers, are all available online.

In addition, APA is currently developing two new guidelines: one on obesity and overweight in children and adolescents, and another on depression. Both are expected to be released in 2018.

Thanks for listening to Progress Notes. This episode was produced by me, Hannah Calkins, with help from Madeline Stoltz and Jewel Edwards-Ashman. Next month, Jewel returns with an episode on prescriptive authority for psychologists. Don’t miss it: subscribe to Progress Notes on iTunes or SoundCloud, and follow us on Twitter @APAPractice.