Post-traumatic stress disorder in the context of terrorism and other civil conflict in Northern Ireland: randomised controlled trial
BMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39021.846852.BE (Published 31 May 2007) Cite this as: BMJ 2007;334:1147
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I acknowledge Dr Imran Mushtaq's point about the value of a trial
that would investigate alternative treatment approaches instead of a 'no
treatment' or 'delayed treatment' control. Clinically such a trial would
be expected to make an important contribtuion to our knowledge base in
this area.
From a user and policy perspective there is still value in
demonstrating the impact of the 'no treatment option' as in practice many
people suffering trauma related disorders do not have access to evidence
based interventions, and the reality for them is 'no treatment'.
In the context of the Northern Ireland conflict there has been an
ongoing debate on how best to address the needs of those affected by
violence including those suffering trauma related disorders. Over the
years I have heard views such as 'nothing can be done', 'it is too late',
'it is too politically difficulty to unearth the past' and such like.
This study demonstrates that something can be done (in this case for a
chronic PTSD patient group) and that to offer no treatment is to yield to
a council of despair. This study adds to the body of knowledge which is
clearly pointing us in the direction of needing to develop and put in
place evidence based services for trauma related disorders, and to develop
the service menus and pathways that will enable people to access
appropriate interventions, sooner rather than later. It clearly addresses
the view that offering nothing is not a tenable option.
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor,
Duffy et al (1) describe a very interesting and rigorous randomized
controlled trial which provides evidence for the effectiveness of
cognitive therapy in post-traumatic stress disorder in the context of
terrorism and civil conflict. However, I do think some more information
would have been useful to interpret the results accurately.
My first comment is regarding the effects of medication. Some more
detail about the medication status of the patients would have been
helpful. It is mentioned that no patients were started on medications
during the trial. However, 52% in the immediate therapy group were on
antidepressants already. When were these initiated in relation to the
trial? Also, were any changes to the antidepressant dose allowed during
the trial? Over 70% in the immediate therapy group had comorbid major
depression. It could be argued that the effect of antidepressant
initiation just before the trial or dose changes may be partly responsible
for the improvement in this group’s symptoms.
The authors make it clear that the percentages telling us about the
overall effectiveness of cognitive therapy are the combined scores of the
immediate treatment and waiting list control groups. It is important to
bear in mind that this, in effect, makes them uncontrolled scores. They
are not comparing 2 groups of patients, one receiving therapy and the
other not receiving therapy.
The maintenance of treatment gains is another area of comment. The
follow-up mean scores in Table 3 have been taken at either 4 or 12 months.
As a clinician, I would be particularly interested in information about
the maintenance of gains at 12 months. This is not clear from the table.
If gains demonstrated at 4 months are lost by 12 months, this then raises
questions about whether booster sessions are indicated.
Finally, the therapist effect that the authors bring to our attention
is very significant. After all, in clinical practice, one would want an
effective therapist who brings about the most improvement in one’s
patients. It would be interesting to look at whether this difference in
patient scores is related to the type of qualification in cognitive
therapy that the therapists had. Recent research into this area has shown
that formal post-qualification training in cognitive therapy is associated
with competence in cognitive therapists (2).
I congratulate the efforts of the authors in adding to the evidence
base and look forward with interest to further research in this area.
References:
1. Duffy M, Gillespie K, Clark DM. Post-traumatic stress disorder in
the context of terrorism and other civil conflict in Northern Ireland:
randomised controlled trial. BMJ 2007;334:1147 (2 June), doi:
10.1136/bmj.39021.846852.BE (published 11 May 2007).
2. Brosan L, Reynolds S, Moore RG. Factors associated with competence in
cognitive therapists. Behavioural and Cognitive Psychotherapy 2007;35:
179-90.
Competing interests:
None declared
Competing interests: No competing interests
CBT works for various psychiatric conditions and National Institute
for Health and Excellence (NICE) recommends it as major psychological
treatment for them (1-3). Duffy et al (4) randomised controlled trial is
an
another success story describes use of CBT in PTSD but in the context of
terrorism and other civil conflict in Northern Ireland. We congratulate
the authors for such a nice and important piece of work and would take
this opportunity to raise few points here.
Firstly, they chose delayed treatment group (waiting list) as a
control rather than alternative treatments and gave their reasons. People
who are having treatment, in comparison with control group without any
treatment, are likely to do well, as shown by the study results. Instead,
if they have chosen eye movement desensitisation or other alternatives, as
recommended by NICE (5) for PTSD (although they are largely based on
traumatic events not involving terrorism), results might be more
representative of control group.
Secondly, they have claimed the presence or absence of a comorbid
psychiatric disorder was not related to degree of improvement but we see
contradictory evidence that patients with comorbid conditions, especially
major depression (72% of the treatment group) receive more CBT sessions
and showed similar good results. Therapists in the study were given
flexibility to adapt to different CBT techniques, necessary to treat those
comorbid conditions, which may have been responsible for that overall
effect and not necessarily supports their claim. They have also mentioned
that patients whose initial depression score was over 35 were particularly
difficult to engage in the treatment and one would imagine that their
comorbid illness would affect the degree of improvement.
REFERENCES:
1. National Institute for Health and Clinical Excellence. Anxiety:
management of anxiety (panic disorder, with and without
agoraphobia, and generalized anxiety disorder) in adults in primary,
secondary and community care (clinical guideline 22). London: NICE,
2004.
2. National Institute for Health and Clinical Excellence. Depression:
management of depression in primary and secondary care (clinical
guideline 23). London: NICE, 2004.
3. National Institute for Health and Clinical Excellence. Eating
disorders: core interventions in the treatment and management of
anorexia nervosa, bulimia nervosa and related eating disorders
(clinical guideline 9). London: NICE, 2004.
23 Layard R. The case for psychological treatment centers.
4.Duffy M, Gillespie K, Clark DM. Post-traumatic stress disorder in
the context of terrorism and other civil conflict in Northern Ireland:
randomized
controlled trial. BMJ, doi: 10.1136/bmj.39021.846852.BE (published 11 May
2007).
5.National Institute for Health and Clinical Excellence. Post-traumatic
stress disorder (PTSD): The management of PTSD in adults and
children in primary and secondary care (clinical guideline 26).
London: NICE, 2005.
Competing interests:
None declared
Competing interests: No competing interests
For about 10 years or more it has been proven that the brains of
people with chronic PTSD have been changed biologically in a way that the
adaptation system cannot work appropiately. So there is a distortion in
properly
transferring the signals to meaning and emotion.
Medication can only supress the symptons of PTSD and can make you very
sick in another way in the long run.
Cognitive therapy is not successful in all cases, especially not in
multiple life-threathening incidents in a short time (i.e. 6 months) in
wartime conditions.
EMDR is also not successful in above mentioned cases.
Veterans with PTSD cannot be cured in the same way as civilians.
Civilians are daily living in non-threatening conditions (living in peace-mode) and after one incident they are back in peace time among their
spouse and friends who can help them too.
Military personnel on a mission live every minute of the day
in life-threatening conditions (living in fight mode) and cannot be cured
on mission.
In the Netherlands in WW II many Jews were transported to camps in
Germany and killed. The few who survived and their relatives are still
suffering the consequences of this.
As a veteran with PTSD I consult the Sinai Centre, an institution for
treatment of PTSD and other, and I still meet Jews with PTSD on their way
back home after treatment for their PTSD.
After more then 60 years not cured from PTSD !!!!!
Looking at psychiatry I wonder if these professionals know what they
are doing and how this can be proved.
Looking at the history of psychiatrists and psychiatry there is not much
consensus in treatment over the years.
It looks to me merely as a commercial business where selling baked
air is common.
Competing interests:
None declared
Competing interests: No competing interests
We are grateful to Declan Fox and Stamatia Tzigianni for their
thoughtful
responses to our article. When considering cognitive behaviour therapy
(CBT) it
is important
to realise that the term covers a wide range of specific treatment
programmes
that vary considerably in their effectiveness. There is good evidence that
some
computerized CBT and other types of guided CBT self-help are effective in
a
subset of individuals with mild to moderate depression. For this reason,
the
National Institute of Clinical Excellence (NICE) Treatment Guidelines
suggest they
have an important place in a stepped care approach to depression
management.
In contrast to the depression literature, existing guided self-help
programmes
for PTSD have failed to demonstrate efficacy in randomized controlled
trials. For
this reason, current NICE Guidance does not recommend a stepped care
approach to the treatment of PTSD. (see article for references to NICE
Guidance).
Availability of suitably trained CBT therapists is a problem. The
Government
made a 2005 election manifesto commitment to increase public access to
psychological therapies. This should be honoured by increasing the number
of
trained therapists as well as by making guided self-help available (when
the
latter has been shown to be effective).
Competing interests:
None declared
Competing interests: No competing interests
It was a very interesting study. However, a couple of comments are
all I want to make. Firstly, immediate cognitive therapy can be considered
to be a dream in many (if not all) mental health trusts across the United
Kingdom. Even a 12 week wait is a bit optimistic in certain trusts.
However, this could be partially alleviated by using a computerised
CBT approach since it overcomes the burden of needing waiting lists and
could be done at ones convinience.
A pragmatic trial that compares normal waiting time and then CBT
versus immediate computerised CBT would be an ideal option and could be
looked into.
Competing interests:
None declared
Competing interests: No competing interests
Sir
As GPs in N Ireland, we have seen up close the awful psychological cost of
years of sectarian strife. We have seen multiply-traumatised patients who
have found it impossible to escape from daily risks to their lives,
particularly members of the security forces. It is wonderful, in this week
when our new assembly gets down to business, to see a new hope dawn for
those still suffering PTSD and related disorders.
Duffy et al have done great work here, trumping their previous notable
treatment of Omagh bomb victims.
We now know what works for PTSD here in N Ireland and there can no longer
be any excuses for failure to provide access to the specific CBT routines.
On the wider front, perhaps Ms Hewitt or her successor will now get real
on funding PROPER CBT services---as opposed to telling PCTs to buy
computer programs?
Declan Fox MB MRCGP
Freelance physician
Competing interests:
Various professional and personal contacts with the study authors.
Competing interests: No competing interests
Chronic pain syndrome among young Maoist combatants in Nepal
Sir-
After the peace accord in November 2006, approximately 35,000 Maoist
combatants, People’s Liberation Army (PLA) in Nepal have been disarmed and
settled into seven cantonments in seven rural districts in Southwest Nepal
under the supervision of United Nations. Each cantonment accommodates
approximately 5,000 PLA soldiers.
Kinderberg International, e.V., a German humanitarian NGO under
contract
with GTZ, a German foreign aid agency has been conducting surgical camps
for resettled combatants in the past 6 months to provide reconstructive
surgery service for combatants treated in the field during the war.
From October 29th to November 6th 2007, we provided the surgical camp
to
the 7th battalion division in Talband, Kailali district. The team
consisted of
four surgeons and physicians and six nurses and three logistic staffs. We
provided free medical consultation and reconstructive surgery for
combatants
in this cantonment. We stayed in the camp 24 hours for 7 days and provided
as much surgery and medical consultation as possible for the soldiers.
We examined 622 patients during 7 consecutive days and we conducted all
together 74 operations including stump revision, bullet removal. Average
age
of patients was 23.4 years old and predominantly male (79.7%). The high
demand of surgical intervention was expected considering the nature of the
camp as post-conflict disarmed military encampments.
The most striking finding of this camp was stunningly high prevalence of
chronic pain syndrome developed after bullet and shrapnel wounds (27.7%).
This high prevalence of chronic pain and emotional scars to these young
military recruits urges us the need for comprehensive intervention other
than
surgery. High prevalence of depression and PTSD are reported among victims
of recent conflicts . And somatization as primary symptoms of depression
is
also well known fact in many communities . Considering these trends of
high musculoskeletal pain syndrome several years after active fighting,
the
international relief community should be ready to provide psychosocial
interventions for disarmed combatants.
Masahiro J Morikawa, MD, MPH
Kinderberg International, e.V. Stuttgart, Germany
Case Western Reserve University, Cleveland, OH, USA
Andreas Settje, MD
Kinderberg International, e. V. Kathmandu, Nepal
SKM hospital for reconstructive surgery, Sankhu, Nepal
Competing interests:
None declared
Competing interests: No competing interests