Using the first line of treatment for PTSD
Despite a high percentage of soldiers with Post Traumatic Stress Disorder (PTSD) and increasing rates of suicide, the Department of Veteran Affairs (DVA) has not conducted any research on Eye Movement Desensitization and Reprocessing (EMDR) since 1998. EMDR is an effective, widely recognized trauma treatment, regarded as first line of treatment for PTSD in numerous national and international practice guidelines. In fact, the DVA and the Department of Defense (DoD) Practice Guidelines (2010) list EMDR therapy as an “A” level treatment, described as “A strong recommendation that clinicians provide the intervention to eligible patients.”
According to the recently published practice guidelines of the World Health Organization, trauma-focused cognitive behavioral therapy (CBT) and EMDR are the only therapies recommended for children, adolescents and adults with PTSD. However, major differences exist between the two treatments: “Unlike CBT with a trauma focus, EMDR does not involve (a) detailed descriptions of the event, (b) direct challenging of beliefs, (c) extended exposure, or (d) homework.” (p.1) These factors can make EMDR therapy easier for veteran treatment as seen by the difference in retention rates and outcomes.
Initial research using EMDR with military personnel found that EMDR led to remission of PTSD symptoms in 78 percent of soldiers with positive effects maintained at follow-up (Carlson & colleagues, 1998, Journal of Traumatic Stress). There was a 100 percent retention rate. By comparison, a 2012 Congressional Report found that only 40 percent of soldiers completed the Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE), the therapies used by Veteran’s Administration. A more recent study with 48 Iraq and Afghanistan combat personnel diagnosed with combat PTSD found that after treatment with EMDR, the symptoms of PTSD resolved after only four sessions for non-wounded and eight sessions for wounded personnel (Russell & colleagues, 2007, International Journal of Stress Management). The notoriously high drop out rate for CPT and PE and the positive results reported with the use of EMDR begs the question: Why are there no funded studies of EMDR by the VA?
While a growing body of evidence over the last 20 years has shown that EMDR provides effective trauma treatment for civilians, the VA has not conducted any EMDR research. Instead they have focused on pharmaceuticals, CPT and PE, and alternative therapies for PTSD including pets, acupuncture, transcendental meditation, the “emotional freedom technique,” tai chi, art therapy, Reiki, yoga, and pharmaceutical agents (Government Accountability Office, 2011). Drug studies include derivations of such drugs as marijuana and ecstasy.
Treating PTSD with medications is not effective. In fact, psychoactive prescription drugs have been implicated as one of the causative agents of the high rate of suicide of our troops. Of those with PTSD, 80 percent are given psychoactive drugs with 89 percent of these prescribed antidepressants (Rosenheck, Journal of Clinical Psychiatry, 2008). Antidepressants have been linked to suicidal thoughts and behaviors and black box warnings alert consumers and prescribers to these risks. Meanwhile, the VA has effectively ignored studies showing that psychotherapy is a more effective treatment for PTSD than medication. Five-months after treatment, 60 percent of those on medication and 58 percent of those who received placebo still had PTSD compared to only 20 percent of those who received psychotherapy (Shalev & colleagues, Archives of General Psychiatry, 2012). So why give medications at all when a sugar pill is just as effective without all the side effects? It is time to stop simply prescribing and to start providing evidence-based treatment.
While current suicide prevention activities of the DoD and VA are necessary, they are not sufficient to stem rising suicide rates among soldiers and veterans. Prevention must also focus on one of the most serious risk factors that contribute to depression and suicide, untreated or inadequately treated PTSD. The VA needs to develop a strong research and clinician training program for EMDR on par with current research and training programs for CPT and PE.
A Time magazine cover article (July 23, 2012) reported that more soldiers have committed suicide than have died in the war in Afghanistan. The military/veteran mental health system is being overwhelmed and needs all the evidence-based psychotherapies as treatments to alleviate human suffering and counteract the enormous wave of tragic outcomes owing to PTSD. In 2012, the Surgeon General of the Navy called for more research on EMDR. There is an ethical mandate and a moral responsibility to provide our troops with all the best psychotherapies available. EMDR is one of the evidence-based therapies that should be available for the treatment of PTSD for all veterans and active duty service men and women.
Kate Wheeler Ph.D., APRN-BC, FAAN
Anna Marcel de Hermanas, LPCC, certified EMDR therapist