Academic journal article European Journal of Psychotraumatology

What I Have Changed My Mind about and Why: Public Health and Technology Perspectives in the Field of Trauma Studies

Academic journal article European Journal of Psychotraumatology

What I Have Changed My Mind about and Why: Public Health and Technology Perspectives in the Field of Trauma Studies

Article excerpt

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Science, by its very nature, is a process of discovery that inevitably - if not always uniformly or quickly - leads to change in the understanding of natural and biological phenomena. The title of the book, The Half-Life of Facts: Why Everything We Know Has An Expiration Date (Arbesman, 2012), nicely captures this expectation of change and even argues that the 'expiration' of facts can be understood quantitatively.

The field of traumatic stress studies has undergone remarkable change, particularly since the formalization of the diagnostic criteria for posttraumatic stress disorder (PTSD) in 1980 (Schnurr, 2010). In 2015, a panel of experts in the neurobiology of PTSD who spoke at the annual meeting of the International Society for Traumatic Stress Studies (ISTSS) was asked to address the topic: 'What I changed my mind about and why' (Yehuda et al., 2016). For the ISTSS meeting in 2016, the organizers asked us to address this same topic from the perspectives of public health and technology, discussing what we have changed our mind about and the rationale for the change. Below we summarize our comments, in the order they were presented at the meeting.

1.Professor Dr. Paula Schnurr

My primary focus is in clinical trials of treatment for PTSD. My particular interest is in research to help us understand the effects of treatment in clinical practice - practical clinical trials of established treatments - and in promoting the use of evidence to guide policy and decision-making.

Since the first ISTSS Practice Guideline was published 16 years ago (Foa, Keane, & Friedman, 2000), we have learned even more convincingly about how to treat PTSD and other trauma-related problems. Simply put, treatment works. It works well for a range of people in a range of environments, and for a range of associated problems. We can offer real hope to trauma survivors around the world. We also can offer choice in the type of treatments and even in modalities for treatment.

What I have changed my mind about is how well treatments work. Please do not think that I am saying, 'Treatments for PTSD don't work.' They do. The best treatments for PTSD meaningfully reduce PTSD and other comorbid symptoms and increase functioning and quality of life. What I am saying is that we have very effective treatments, but we need to learn how to make more people more better.

My colleague Dr. Juliette Harik has been leading an effort to develop an online decision aid for PTSD in order to enhance patients' knowledge about treatment and support shared decision-making about treatment choice. We have been looking at loss of diagnosis following evidence-based treatment in order to optimally communicate information about treatment effectiveness. Loss of diagnosis is actually a very good way to measure clinically meaningful change; in one of my studies, it was associated with an average 40-point decrease on the Clinician Administered PTSD Scale and in achieving a good endpoint on measures of functioning and quality of life (Schnurr & Lunney, 2016). In the analyses performed to develop the decision aid (Harik, Grubbs, & Schnurr, 2016), we found that loss of diagnosis occurs for 53 out of every 100 patients who receive Prolonged Exposure (PE), Cognitive Processing Therapy, or Eye Movement Desensitization and Reprocessing, first-line psychotherapies recommended in practice guidelines (Forbes et al., 2010). For first-line medications, the selective serotonin reuptake inhibitors, the estimate was 42 out of 100. The effectiveness of these psychotherapies and medications is good, but why can't it be better?

There have been critiques of the treatment literature that use numbers such as these to argue that PTSD treatments are ineffective and that we need new treatments. I disagree. We have so many good trauma-focused and non-trauma-focused treatments. There may be a role for novel approaches, but I think the primary way forward is to improve the treatments we have. …

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