Pharmacologic Interventions VS. Therapy for Veteran’s with Post- Traumatic Stress Disorder.pdf

Running head: PTSD IN VETERANS 1

Pharmacologic Interventions VS. Therapy for Veteran’s with Post- Traumatic Stress Disorder

Regina C. Gibbs

Liberty University

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Did you know that as many as 500,000 veterans who have served in wars over the past 13 years

have been diagnosed with Post-Traumatic Stress Disorder (PTSD) (Reisman, 2016)? While

PTSD is not limited to military veterans, it has been found to have a high prevalence in this

particular community. Reisman (2016, p. 18) describes PTSD as “the development of

characteristic and persistent symptoms along with difficulty functioning after exposure to a life

threatening experience or to an event that either involves a threat to life or serious injury.” The

defenders of our country, and others, are risking not only their lives but also their sanity in order

to keep citizens safe. This research study aims to identify the most beneficial long term treatment

for our heroes.

Significance

War is an element of life that has occurred on this earth since the beginning of time. It goes

without saying that war has a lasting effect on communities and the world as a whole. However,

it also has a large impact on veterans and their family members. We are just now beginning to

understand the lasting effects that war has on an individual and their families. PTSD is an

extremely common anxiety disorder that many veterans suffer from. The core symptoms of

PTSD include re-experiencing traumatic content, persistent avoidance of traumatic content,

negative alterations in cognitions and arousal and reactivity (Haagen, 2015). Many of our

veterans are suffering alone in silence. In many cases, an individual is not even aware that they

are suffering from this disorder. In the United States, 20% of suicides are performed by veterans

(Reisman, 2016). It is incredibly important that we give a voice to those in need. The bible says,

“Speak up for those who cannot speak for themselves, for the rights of all who are destitute.

Speak up and judge fairly; defend the rights of the poor and needy. (Proverbs 31:8-9). It is our

responsibility to find help for our heroes. The best way that we can help these veterans is to find

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a lasting treatment for their PTSD. With significant research, we can find a way to help integrate

our veterans back into society and give them back the life they once had. Not only will they

benefit, but their families will as well.

Research Question

With all of this being said, it is important to determine the best way to treat our veterans. In

veterans with Post-Traumatic Stress Disorder, are pharmacologic interventions more effective

than therapy in sustaining the service member’s transition back to society after five years of

returning home? Is it more beneficial for veterans to receive medication or therapy to help them

adjust back into their lives at home after their traumatic experiences?

There are many medications used to help control the symptoms of PTSD. However, with those

medications come multiple side effects. Fortunately, those side effects can also be treated with

more medications. The cycle continues until the veteran is essentially a walking pharmacy.

“Psychopharmacologic treatment of PTSD is primarily symptomatic and encompasses agents

from all categories of centrally acting drugs” (Birkhimer, 2004). The only problem is, you’re not

actually treating the PTSD, and you’re just controlling the symptoms. The root of the problem is

still there.

Hypothesis

Psychological therapies are more effective in treating veterans with PTSD than pharmacologic

interventions after five years. With CBT, patients are able to use redirect destructive thoughts and

develop personal coping skills without the side effects of multiple medications. The

independent variables in this study will be the medications the veterans receive and CBT. The

dependent variable will be the veteran’s ability to integrate themselves back into society. The

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main goal is to establish a treatment that will help veterans transition back to a normal life and

society after experiencing trauma and suffering from PTSD.

Literature Review

This section will begin by covering the risk factors for PTSD among veterans. Then

research concerning treatment options for these individuals will be reviewed. Lastly, veteran

satisfaction and treatment preferences will be discussed.

Risk Factors

In order to thoroughly treat veterans with PTSD it is important to identify those individuals who

are at risk. While anyone can suffer from PTSD for various reasons, some individuals have a

higher chance of developing this disorder. Some people are able to cope with a higher level of

trauma than others. Xue collected data from 32 different studies to help identify risk factors of

PTSD in veterans. The sample sizes of these studies ranged from 238 to 40,600 (Xue, et al.,

2015). This study breaks down the risk factors found into three groups including: pre trauma

factors, peri-trauma factors and post-trauma factors. The study concluded that the highest

predictor was peri-trauma factors, trauma severity, and adverse life events (Xue et al., 2015).

Peri-trauma factors for veterans include but are not limited to, seeing someone wounded or

killed, injuries to themselves, and firing weapons. Factors such as race and age were originally

thought to play a higher significance in regards to PTSD. However, studies show that they are

unrelated.

When discussing military characteristics it was determined that military rank, occupation, and

length and number of deployments plays a very critical role in developing PTSD (Xue et

al.,2015). Enlisted members of the military are more likely to experience combat than officers in

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the military. Therefore, enlisted veterans have a higher chance of developing PTSD compared to

officers. Enlisted members are also usually left to do grunt work which can potentially lead to

feelings of depression and negativity. Occupation also played a large role in contributing to

PTSD development. It seems fair to say that an infantry man will see more combat than a

military cook. However, it is important to note that anyone in the military can experience

combat and they are all trained to fight. In reality though, infantry men and other combat related

billets will experience more traumatic events than someone that is not in a combat related billet.

The length of time and number of deployments is also a contributing factor. If a veteran is

deployed multiple times over the course of a few years he has a greater chance of being exposed

to trauma than someone that isn’t deployed often. It is also important to take into consideration

the veteran’s personal life. It is possible that veterans are missing important events in their home

life including the birth of a child, the death of a family member, or their best friend’s wedding.

These circumstances are very likely to weigh heavy on an individual’s mind and potential

leading to feelings of sadness. In this case, if a traumatic event did occur it is possible that the

event compiled with their sadness about life situations can lead to PTSD. It has been concluded

from this article that the most attention should be given to the role of personnel and environment

variables in predicting PTSD (Xue et al., 2015).

Treatment Options

There are numerous treatments available for PTSD so it would be beneficial to determine which

are the most effective in veterans. Sharpless and Barber (2011) evaluated psychological and

pharmacological approaches to PTSD in veterans. Psychotherapies such as Prolonged Exposure

(PE), Cognitive Processing Therapy (CPT) and Eye Movement Desensitization and Reprocessing

(EMDR) were found to be the most effective in treating veterans. Relaxation training and stress

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inoculation training were found to be far less effective (Sharpless & Barber, 2011). PE utilizes

imaginal exposure, processing of imaginal exposure, and relaxation training focused on slow

breathing techniques. Sessions are conducted over an 8-15 week period and each session lasts 90

minutes (Sharpless & Barber, 2011). CPT involves 12 weekly, 60 minute, individual sessions.

The goal is to reduce PTSD through emotional processing and cognitive restructuring of trauma-

related emotions and thoughts (Schumm, Walter, Bartone, & Chad, 2015). This form of

treatment is more intense than others. EDMR attempts to use desensitization and reprocessing by

having the veteran imagine distressing images while tracking finger movements by the therapist

(Sharpless &Barber, 2011).

Propranolol (Inderal), a beta-adrenergic antagonist (beta-blocker), is the most effective

medication for reducing symptoms of PTSD. In the end authors found that PE is the

psychotherapy of choice. Many studies note that antidepressants such a Zoloft and Paxil are

considered first- line choices in treating PTSD (Schumm, Walter, Bartone, & Chad, 2015). It is

also noted that paroxetine, sertraline and venlafaxine are the most promising medications used to

treat PTSD symptoms (Sharpless & Barber, 2011). It is also important to note that some of these

treatments are based on the veteran’s willingness to participate. Some individuals may not feel

comfortable talking about their experiences and diving into treatment. The veteran’s preferences

can have a large impact on the type of treatment used. Also, different goals can change the

treatment. Some goals include just symptom relief while other want to dissect what needs to be

done to improve relationships and quality of life. Some beneficial treatments may not be utilized

if individuals don’t see the value in that particular option (Schumm, Walter, Bartone, & Chad,

2015). Many individuals do not like the idea of taking medications and would prefer to be

involved in psychotherapy. Schumm (2015) conducted a study determining that veterans most

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frequently endorse a preference for psychotherapy versus medication when addressing PTSD.

The most popular psychotherapy was CPT and PE.

In light of studies reviewed, there is a need to conduct further studies that determine why

veterans prefer each specific type of treatment. Is there a preference that is more desirable based

on age, race, or gender? Secondly, more research should be conducted on which treatment is

more suitable for long term results. It is possible that some treatments are able to get the patient

through the initial diagnosis of PTSD, but are not beneficial in maintaining results. The goal is to

determine which treatment option will have the most beneficial results for the veteran over the

longest period of time.

Study Setting

This research study will be conducted at a military hospital on the north east coast of the United

States of America. This facility provides care to every branch of the military. Many of the

patients at this facility have experience trauma from combat while serving in the military. It is

one of the largest military hospitals, and also the only joint operations hospital for military

members in the US.

All participants will be outpatient as opposed to inpatient. It is ideal to know how the

patient will act in society during the treatment. Therapeutic services will be held in the

behavioral health clinic of the hospital. The study will be conducted on military veterans

experiencing high levels of PTSD related to combat.

Research Design

The type of design that will be used in this study is the experimental design. The

experimental design is a type of quantitative research. One of the purposes of experimental

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research is to test a null hypothesis by applying an intervention to the experimental subjects but

not to the control subject, and then measuring the effect on a dependent variable (Gray, Grove, &

Sutherland, 2017, p. 38). This is the exact type of research needed for this study. This particular

study will have two independent variables. The first independent group will receive medications

common for treating PTSD such as Propranolol, but will not receive therapy of any kind. The

next independent group will receive therapeutic services including CBT, EMDR, and PE. The

control group will not be given any type of treatment, but they will be given a placebo

medication.

Sample and Sampling Procedure

For this research study, a random sample will be obtained. All subjects will be volunteers from

the joint command military outpatient behavioral health clinic. There will be 150 participants in

this study. Of those, 50 subjects will be part of the independent groups and 50 subjects for the

control group. It would be ideal to have 75 subjects be male and 75 female. This particular study

will not use any veterans that are struggling with gender issues. Often times, individuals that

have gender issues also suffer from other psychiatric issues. Depression, suicidal ideation,

interpersonal trauma exposure, substance abuse, anxiety and general distress are all consistently

elevated among transgender and gender non-conforming individuals (Valentine & Shipher,

2018). We want to ensure that all psychiatric issues and trauma are related to combat received

from military service.

All of the participants in this study will be military members that are no longer serving. While

there are plenty of military members that live in the US, it is very apparent that service members

are part of a unique culture. Being in the military is drastically different than being a normal

member of society. With this being said, it requires a different set of coping skills to integrate

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back into society than it does when staying in the military. This study aims to find a treatment for

veterans returning back to society. Unfortunately, this study will be excluding active military

service members and service members that are part of a Reserves unit.

The participants will range in age from 18-35. Socioeconomic status, ethnicity, and marital status

will not be a factor when determining candidates. All participants will have been discharged

from the military within one year of when the study occurs. Also, each participant has to have

PTSD associated with combat trauma. The combat trauma needs to have occurred within two

years of when the subjects begin the study. Participants can be from any branch of the military

as long as they have experienced combat trauma within two years.

The study will randomly select 150 volunteers that meet all of the criteria. The 150

candidates will be randomly inserted into each group. There will be equal numbers of males and

females in each group. The participants will be unaware of the specific group they are placed in.

Ethical Issues

As with anything, there are potential ethical issues that may arise. With this particular study, it

could be questioned whether or not it is ethical to not include individuals suffering from gender

issues. Just because they have these issues does not mean that they haven’t also experience

PTSD related to combat trauma. There are many transgender individuals that don’t suffer from

any psychological trauma based off of their sexuality. Is it ethical to not include these individuals

in the study? For the purposes of this study, transgender individuals will not be included because

it is important that the study is not tampered with by any extenuating circumstances.

In order to protect the participant’s rights and privacy, the study will follow the Health

Insurance Portability and Accountability Act (HIPAA) of 1966. HIPAA is a federal legislation

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that aims to ensure the privacy of a patient’s healthcare information (Houston, 2009). Each

participant will have an individual record that is kept in a locked file that only direct members of

their medical team can access. The facilitators of this study will have training on confidentiality.

With this study, we are potentially risking veteran’s not receiving treatment at all. There

will be 50 individuals that are only receiving a placebo. However, placebos have been found to

cause clinically relevant changes and are sometimes indistinguishable from what they are being

tested against (Gaab, 2018). This could potentially not be the case and some individuals may

actually experience worse symptoms of PTSD. We are also potentially not giving a participant

that is more suitable for pharmacologic treatment the correct treatment if they are a part of the

therapy group. This is also the same vice versa. If a patient is more suitable to therapy and they

are only receiving medication, it could be a potential risk. However, with great risk comes great

reward.

Data Collection

In order to collect data, this research study will use interviews to gather information. The

study will take place over a one year time frame. Every month, participants will have a one on

one interview for one hour. Each participant will have twelve interviews in total resulting in 120

hours of interviews.

During the interview, participants will be able to discuss their progress. While there will be

a list of standardized questions ( see Appendix A), participants are free to discuss any issues that

are pressing to them. They may discuss their doubts and concerns. The goal is to make the

participant feel as supported as possible during this study. In order to do so, the same

interviewer will interview the same participant during all twelve sessions. This will help with

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the continuity of care and accuracy of the results. The interviewer and the participant will be

able to build a strong and trusting relationship.

It is important that the interview process is not confused with a therapy session. While it

may be therapeutic for the participant to vent to someone, this session is not for advice. The

interviewer will not give the participant any advice or change the plan of care in any way. The

interview is strictly for gaining information on the progress of the participant. The interviewer

will have a specific set of questions that the participant can expound on. They are there to get a

generalized picture of whether or not the prescribed treatment for the participant is being

helpful.

Data Analysis

In this study, analysis of variance (ANOVA) is the procedure that will be used in order to

analyze data. This procedure compares data between two or more groups to investigate the

differences between those groups (Gray, Grove, & Sutherland, 2017, p. 571). There are two

treatment groups and one dependent group in this study. During each interview, the interviewer

will give the participant a score based off of their questionnaire. The variances in the

participant’s scores from the beginning of the study until the end will be used to analyze data.

Strengths and Weaknesses

A strength of this study is the amount of participants being examined. With 150 participants

the size is large enough to solidly analyze data. Using males and females in the study is another

strength. We are able to get a generalized idea of the impact that medications and therapy will

have on both genders. However, in the future it may be beneficial to conduct a study with just

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males and just females. This may give a better idea on what treatment works best on each

gender.

Another strength of this study is the collection method. It will be incredibly beneficial to

directly observe the progress or lack of progress of the participants in such an intimate manner.

This study could have collected measurements from charts and files, but instead chose to sit

down and interview each participant. This will give the best grasp on evaluating the

information.

A weakness of this study could potentially be the financial cost. It is imperative that the

financial responsibilities are evaluated in order to actually conduct the study. The location of the

interviews, the interviewers, and all other participants will need to be compensated.

Another weakness is potentially having participants drop out of the study. It is important

that each participant remains a part of the study until completion. It is also imperative that each

participant is honest about their progress and concerns. If they are not honest during the

questionnaire it could potentially be detrimental to the data analysis.

This study will be incredibly beneficial for veterans. However, in the future it would be

beneficial to have a study that examines the family members of a veteran with PTSD. Which

treatment do they feel is the most effective for the family member with PTSD? How are these

treatments and results affecting the life of their loved ones? This particular study is lacking any

information on this subject. It is recommended that treatment for PTSD include support of the

family for military personnel suffering while healing from trauma (Ray & Vanstone, 2009).

Unfortunately, this study will not include family members in any way.

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While this study will provide great information for PTSD treatment for veterans there are

still weaknesses in the study. An area that is potentially lacking in this research is long term

outcomes. It is possible that the treatment may provide immediate relief from PTSD, but what

about in the future? Will the same treatment still work for the patient 20 years from now?

In summary, this study will be incredibly beneficial to veteran’s who are suffering from

PTSD. A superior treatment will be identified that will make the transition back into society more

manageable for our veterans with PTSD.

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References

Birkhimer, L. J., Devane, L. C., & Muniz, C. E. (2004, April 06). Posttraumatic stress disorder:

Characteristics and pharmacological response in the veteran population. Retrieved

from Posttraumatic stress disorder: Characteristics and pharmacological response in the

veteran population

Gaab, J. (2018, August 03). The placebo and its effects: A psychoneuroendocrinological

perspective. Retrieved from The placebo and its effects: A psychoneuroendocrinological

perspective https://www.sciencedirect.com/science/article/pii/S0306453018305705

Gray, J., Grove, S. K., & Sutherland, S. (2017). Burns and Groves the practice of nursing

research appraisal, synthesis, and generation of evidence. St. Louis, MO: Elsevier.

Haagen, J. F., Smid, G. E., Knipscheer, J. W., & Kleber, R. J. (2015, June 27). The efficacy of

recommended treatments for veterans with PTSD: A metaregression analysis. Retrieved

from The efficacy of recommended treatments for veterans with PTSD: A metaregression

analysis

Houston, M. (2009, November 29). The psychiatric medical record, HIPAA, and the use of

electronic medical records. Retrieved from The Psychiatric Medical Record, HIPAA, and

the Use of Electronic Medical Records

https://www.sciencedirect.com/science/article/pii/S1056499309000911

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Ray, S. L., & Vanstone, M. (2009, February 07). The impact of PTSD on veterans' family

relationships: An interpretative phenomenological inquiry. Retrieved from

https://www.sciencedirect.com/science/article/pii/S0020748909000066

Reisman, M. (2016, October). PTSD treatment for veterans: what's working, what's new, and

what's next. Retrieved March 28, 2019, from PTSD Treatment for Veterans: What’s

Working, What’s New, and What’s Next

Schumm, J. A., Walter, K. H., Bartone, A. S., & Chard, K. M. (2015, April 16). Veteran

satisfaction and treatment preferences in response to a posttraumatic stress disorder

specialty clinic orientation group. Retrieved from

https://www.sciencedirect.com/science/article/pii/S0005796715000649

Sharpless, B. A., & Barber, J. P. (2011). A clinician's guide to PTSD treatments for returning

veterans. Professional Psychology: Research and Practice, 42(1), 8-

15. http://dx.doi.org/10.1037/a0022351

Valentine, S. E., & Shipherd, J. C. (2018, March 28). A systematic review of social stress and

mental health among transgender and gender non-conforming people in the United States.

Retrieved from A systematic review of social stress and mental health among transgender

and gender non-conforming people in the United States

https://www.sciencedirect.com/science/article/pii/S0272735817304208

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Retrieved from A Meta-Analysis of Risk Factors for Combat-Related PTSD among

Military Personnel and Veterans

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Appendix A

Progress Questionnaire for Veteran’s With PTSD

1. The number of nightmares I have had this month have decreased.