FROM: Polusny MA. Mindfulness-based stress reduction for posttraumatic stress disorder among veterans: a randomized clinical trial. JAMA 2015;314:456–65.[OpenUrl][1][CrossRef][2][PubMed][3] Of six major international post-traumatic stress disorder (PTSD) treatment guidelines, only two mention mindfulness-based treatments, and none recommend their routine use.1 ,2 Few mindfulness-based intervention studies exist for PTSD, and all have significant limitations in design, outcome measures and/or data handling.1 However, these interventions remain widely used. A core-component of PTSD treatment addresses autonomic hyperarousal, and many clinicians apply mindfulness techniques for this or in facilitating treatment for patients too avoidant for trauma-focused psychotherapies (TFPs). This was a 17-week RCT involving 116 US Veteran's Association participants, comparing group mindfulness-based psychotherapy against group present-centred psychotherapy. The primary outcome, change in symptom severity, was assessed using the PTSD checklist (PCL; range, 17–85 with higher scores indicating more severe symptoms). As a secondary efficacy … [1]: {openurl}?query=rft.jtitle%253DJAMA%26rft.volume%253D314%26rft.spage%253D456%26rft_id%253Dinfo%253Adoi%252F10.1001%252Fjama.2015.8361%26rft_id%253Dinfo%253Apmid%252F26241597%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/external-ref?access_num=10.1001/jama.2015.8361&link_type=DOI [3]: /lookup/external-ref?access_num=26241597&link_type=MED&atom=%2Febmental%2F20%2F1%2F30.atom

BACKGROUND:Current clinical practice guidelines (CPGs) for posttraumatic stress disorder (PTSD) offer contradictory recommendations regarding use of medications or psychotherapy as first-line treatment. Direct head-to-head comparisons are lacking. METHODS:Systemic review of Medline, EMBASE, PILOTS, Cochrane Central Register of Controlled Trials, PsycINFO, and Global Health Library was conducted without language restrictions. Randomized clinical trials ≥8 weeks in duration using structured clinical interview-based outcome measures, active-control conditions (e.g. supportive psychotherapy), and intent-to-treat analysis were selected for analyses. Independent review, data abstraction, and bias assessment were performed using standardized processes. Study outcomes were grouped around conventional follow-up time periods (3, 6, and 9 months). Combined effect sizes were computed using meta-analyses for medication versus control, medication pre-/posttreatment, psychotherapy versus control, and psychotherapy pre-/posttreatment. RESULTS:Effect sizes for trauma-focused psychotherapies (TFPs) versus active control conditions were greater than medications versus placebo and other psychotherapies versus active controls. TFPs resulted in greater sustained benefit over time than medications. Sertraline, venlafaxine, and nefazodone outperformed other medications, although potential for methodological biases were high. Improvement following paroxetine and fluoxetine treatment was small. Venlafaxine and stress inoculation training (SIT) demonstrated large initial effects that decreased over time. Bupropion, citalopram, divalproex, mirtazapine, tiagabine, and topiramate failed to differentiate from placebo. Aripiprazole, divalproex, guanfacine, and olanzapine failed to differentiate from placebo when combined with an antidepressant. CONCLUSIONS:Study findings support use of TFPs over nontrauma-focused psychotherapy or medication as first-line interventions. Second-line interventions include SIT, and potentially sertraline or venlafaxine, rather than entire classes of medication, such as SSRIs. Future revisions of CPGs should prioritize studies that utilize active controls over waitlist or treatment-as-usual conditions. Direct head-to-head trials of TFPs versus sertraline or venlafaxine are needed.

As the longest war in American history draws to a close, an unprecedented number of service members and veterans are seeking care for health challenges related to transitioning home and to civilian life. Congressionally mandated screening for mental health concerns in the Department of Defense (DoD), as well as screening efforts Veterans Affairs (VA) facilities, has been established with the goal of decreasing stigma and ensuring service members and veterans with depression and posttraumatic stress disorder (PTSD) receive needed treatment. Both the DoD and VA have also developed integrated behavioral health in primary-care based initiatives, which emphasize PTSD screening, treatment, and care coordination. This article discusses the rationale for population-level deployment-related mental health screening, recent changes to screening frequency, commonly used screening instruments such as the primary care PTSD screen (PC-PTSD), PTSD checklist (PCL), and Davidson Trauma Scale (DTS); as well as the strengths/limitations of each, and recommended cut-off scores based on expected PTSD prevalence.