Therapy for PTSD – Drugs, counselling, and…yoga?

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Post-traumatic stress disorder, widely known as , has received increased attention over the past few years. Although a relatively new medical term, many claim that the concept has been known since ancient times. The Greek historian Herodotus described in his writings the psychological fatigue Spartan commander Leonidas recognized in his soldiers during the war at the Thermopylae Pass (480 BC). Others claim that descriptions of psychological symptoms due to war were also mentioned by Hippocrates, who talked about “frightening battle dreams,” and by other Greek, Roman, and Egyptian writers centuries ago. Much later, Charles Dickens also wrote about his own PTSD-like symptoms after he experienced a traumatizing railway accident in 1865.

In 1980, PTSD was recognized as a diagnosable mental health disorder with specific symptoms, and it was added to the third edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-III). Prior to this, PTSD was known as, among other things, “shell shock” (to describe a psychological condition of combat veterans who were “shocked” by their experiences on the battle field), “combat fatigue,” and “soldier’s heart” (to describe symptoms of rapid heartbeat, anxiety, and shortness of breath).

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Today, in the fifth edition of the DSM (DSM-V), PTSD is classified as a trauma- and stress-related disorder that is characterized by intrusive or distressing thoughts, nightmares, and flashbacks of past exposure to traumatic events such as the sudden death of a loved one, serious accidents, natural disasters, sexual or physical assault, child sexual or physical abuse, combat exposure, and torture. The symptoms of PTSD tend to last for more than a month, and women are generally more likely to develop PTSD after exposure to traumatic events than men.

While PTSD is often associated with war and members of the military, emergency workers and first responders (i.e., police, firefighters, and other emergency workers) are also highly vulnerable for experiencing “critical incident stress” or “operational stress injury”, broader terms that include PTSD symptoms.

The evolution in the diagnosis for PTSD has been followed by an evolution in treatments for the disorder. Today, an array of options that include pharmacotherapy (treatment using medications), psychotherapy (counselling), and other alternative and complementary interventions are available for people with PTSD. Psychological treatments such as cognitive behavioral therapy or pharmacological treatment with antidepressant medications (such as selective serotonin reuptake inhibitors, or SSRIs, and serotonin norepinephrine reuptake inhibitors, or SNRIs) are recommended as first choice treatment options for PTSD by Canadian and international clinical practice guidelines. While there is strong evidence indicating clinically meaningful improvements for many patients with PTSD as a result of these approaches, some individuals continue to have symptoms.

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In the last two years, the Rapid Response Service at — an independent agency that finds, assesses, and summarizes the research on drugs, medical devices, and procedures — has received an increasing number of requests by health decision-makers across Canada on the clinical effectiveness of alternative treatment approaches to PTSD. These have included yoga, meditation, mindfulness, and energy balance methods. We often associate these methods with relaxation and stress reduction, but what is the evidence about their impact in the treatment of PTSD?

Yoga is an ancient eastern practice that has been widely adopted by western populations and is often associated with stress reduction and enhanced well-being. It is believed to enhance the interaction between the body and the mind and can take on many forms, but it generally consists of poses or postures, breathing techniques, and/or meditation. Yoga has previously been studied in a number of therapeutic areas including low-back pain, falls prevention, insomnia and mental illness. While there is some evidence for the use of yoga in treating depression, there is limited evidence on its use as a treatment for PTSD so its effectiveness is currently not known. However, some clinical practice guidelines recommend that yoga may be useful in combination with other treatments for PTSD.

Another CADTH review on the effectiveness of transcendental meditation as a treatment for PTSD also revealed a lack of evidence.In transcendental meditation,a word or a phrase (called a mantra) is silently repeateduntil the mind is free of thought. It is practised for 15 to 20 minutes twice daily, in a sitting position. Whether or not it is effective in the treatment of PTSD is not known at this time.*

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Mindfulness is an integrative, mind–body based approach that helps people change the way they think and feel about their experiences. It is a way of paying attention to the present moment by using meditation, breathing techniques, and yoga. It involves consciously bringing awareness to thoughts and feelings, without making judgments, thereby allowing the individual to become less enmeshed in their thoughts and feelings and better able to manage them. The CADTH review of mindfulness found that while the strongest evidence base exists for the use of mindfulness in treating depression, the effectiveness of mindfulness for treating PTSD is unclear. However, one clinical practice guideline recommends that mindfulness be considered in conjunction with other treatments for hyperarousal symptoms (increased psychological and physiological tension) in patients with PTSD.

The Emotional Freedom Technique (EFT) is based on the idea that imbalances in the body’s energy system have an effect on an individual’s psychology. The technique aims to correct these energy imbalances by having the patient recall a traumatic memory while repeating a self-acceptance statement and tapping on a sequence of points on his or her body. The CADTH review on EFT found that while the evidence is limited, available studies have shown that EFT may be effective for reducing the symptoms of PTSD.*

Further research into alternative therapies that may be used instead of current standard care or to complement existing PTSD treatments is needed. A review of the clinical evidence on such alternative, non-drug treatments will help to inform treatment decisions for people with PTSD.

*The review of the evidence on these technologies was performed in 2013. The evidence base may have changed since then.

If you like to find more evidence on treatments for PTSD from CADTH, you can find it at: https://www.cadth.ca/search?keywords=PTSD.

If you like to learn more about the CADTH Rapid Response service, please visit www.cadth.ca/RapidResponse. And if you like to see what other drugs, devices, or procedures have been covered by the Rapid Response service at CADTH, visit www.cadth.ca/RapidResponseReports. Here you’ll find all of the freely available reports listed chronologically as they are completed. To learn more about CADTH, visit www.cadth.ca, follow us on Twitter: @CADTH_ACMTS, or talk to our Liaison Officer in your region: https://www.cadth.ca/contact-us/liaison-officers.