Letters
often presents with an initial depressive episode. The conclusion to treat with a selective serotonin reuptake inhibitor risks manic activation. They also fail to consider the deep brain structures, such as the thalamus, that have been shown to aid in differentiating those with unipolar vs bipolar depression.5 Theodore Henderson, MD, PhD Robert Tarzwell, MD, FRCPC Author Affiliations: The Synaptic Space, Centennial, Colorado (Henderson); University of British Columbia, Vancouver, British Columbia, Canada (Tarzwell). Corresponding Author: Theodore Henderson, MD, PhD, Child, Adolescent, and General Psychiatry, The Synaptic Space, 3979 E Arapahoe Rd, Ste 200, Centennial, CO 80122 ([email protected]). Conflict of Interest Disclosures: Dr Henderson is the president and principal owner of The Synaptic Space, a neuroimaging consulting firm. He is also co-owner of Neuro-Luminance Corporation. No other disclosures were reported. 1. McGrath CL, Kelley ME, Holtzheimer PE III, et al. Toward a neuroimaging treatment selection biomarker for major depressive disorder. JAMA Psychiatry. 2013;70(8):821-829. 2. Brockmann H, Zobel A, Joe A, et al. The value of HMPAO SPECT in predicting treatment response to citalopram in patients with major depression. Psychiatry Res. 2009;173(2):107-112. 3. Saxena S, Brody AL, Maidment KM, et al. Localized orbitofrontal and subcortical metabolic changes and predictors of response to paroxetine treatment in obsessive-compulsive disorder. Neuropsychopharmacology. 1999;21(6):683-693. 4. Cho SC, Hwang JW, Kim BN, et al. The relationship between regional cerebral blood flow and response to methylphenidate in children with attention-deficit hyperactivity disorder: comparison between non-responders to methylphenidate and responders. J Psychiatr Res. 2007;41(6):459-465. 5. Mena I, Correa, R, Nader A, Boehme, V. Bipolar affective disorders: assessment of functional brain changes by means of Tc-99m HMPAO NeuroSPECT. Alasbimn J. 2004;6(23).
Prolonged Exposure Therapy in Veterans Affairs: The Full Picture To the Editor The Eftekhari et al study1 on the effectiveness of prolonged exposure therapy (PE) in the Department of Veterans Affairs (VA) demonstrates the vast strides that have been made in testing and disseminating evidence-based treatments for military-related posttraumatic stress disorder (PTSD). We applaud attempts to make PTSD care uniformly rigorous and systematically applied throughout the VA. However, Eftekhari et al fail to acknowledge an unfortunate reality: PE is rarely used in actual VA practice.2 Prolonged exposure therapy is a highly emotionally demanding “trauma-focused therapy” that requires significant patient buy-in, motivation, and readiness to disclose traumatic experiences in vivid detail. Its dissemination in the VA occurred with little patient or line-clinician input, and the veterans’ perspective of PE treatment has not been
evaluated. Studies show that, despite significant dissemination efforts, only a small minority of VA patients are selected for or choose trauma-focused treatment. For example, in a recent study of the Northeast region (conducted after national dissemination rollouts), only 6.3% of VA patients with PTSD had received at least 1 session of trauma-focused therapy and most of the PTSD treatment they received was nontrauma focused.3 The dissemination evaluation of Eftekhari et al does not represent the full spectrum of treatment-seeking veterans with PTSD, but instead a small subset of self-or clinicianselected patients. Eftekhari et al, for example, state that clinicians in their study “used their clinical judgment in determining which patients were suitable candidates for PE”1(p951) but do not elaborate on what determined this suitability or, importantly, what portion of patients were deemed “suitable” for PE by clinicians. The broader problem is that, because VA PTSD psychotherapy outcome research has focused almost exclusively on trauma-focused therapies, almost no data are available on the experiences and outcomes of the vast majority of patients with PTSD not engaging in these therapies. The PTSD treatments commonly used in real-world VA practice have not been systematically evaluated (treatment-as-usual comparison conditions in randomized trials do not suffice and may at any rate be misnomers given that existing studies do not reveal what is “happening on the ground” nationally). Nationally representative, ecologically valid studies of actual PTSD care provided in the VA are sorely needed, as are studies of the reasons for treatment decisions by patients and clinicians. Studies such as the one by Eftekhari et al are spearheading broad improvements in VA PTSD care but further progress cannot be made until the full spectrum of patients and clinicians are represented in effectiveness research. Maria M. Steenkamp, PhD Brett T. Litz, PhD
Author Affiliations: VA Boston Healthcare System, Jamaica Plain, Massachusetts. Corresponding Author: Maria Steenkamp, PhD, Boston VA Medical Center, 150 S Huntington Ave, 13B-73, Jamaica Plain, MA 02130 ([email protected]). Conflict of Interest Disclosures: None reported. 1. Eftekhari A, Ruzek JI, Crowley JJ, Rosen CS, Greenbaum MA, Karlin BE. Effectiveness of national implementation of prolonged exposure therapy in Veterans Affairs care. JAMA Psychiatry. 2013;70(9):949-955. 2. Steenkamp MM, Litz BT. Psychotherapy for military-related posttraumatic stress disorder: review of the evidence. Clin Psychol Rev. 2013;33(1):45-53. 3. Shiner B, D’Avolio LW, Nguyen TM, et al. Measuring use of evidence based psychotherapy for posttraumatic stress disorder. Adm Policy Ment Health. 2013;40(4):311-318.
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often presents with an initial depressive episode. The conclusion to treat with a selective serotonin reuptake inhibitor risks manic activation. They also fail to consider the deep brain structures, such as the thalamus, that have been shown to aid in differentiating those with unipolar vs bipolar depression.5 Theodore Henderson, MD, PhD Robert Tarzwell, MD, FRCPC Author Affiliations: The Synaptic Space, Centennial, Colorado (Henderson); University of British Columbia, Vancouver, British Columbia, Canada (Tarzwell). Corresponding Author: Theodore Henderson, MD, PhD, Child, Adolescent, and General Psychiatry, The Synaptic Space, 3979 E Arapahoe Rd, Ste 200, Centennial, CO 80122 ([email protected]). Conflict of Interest Disclosures: Dr Henderson is the president and principal owner of The Synaptic Space, a neuroimaging consulting firm. He is also co-owner of Neuro-Luminance Corporation. No other disclosures were reported. 1. McGrath CL, Kelley ME, Holtzheimer PE III, et al. Toward a neuroimaging treatment selection biomarker for major depressive disorder. JAMA Psychiatry. 2013;70(8):821-829. 2. Brockmann H, Zobel A, Joe A, et al. The value of HMPAO SPECT in predicting treatment response to citalopram in patients with major depression. Psychiatry Res. 2009;173(2):107-112. 3. Saxena S, Brody AL, Maidment KM, et al. Localized orbitofrontal and subcortical metabolic changes and predictors of response to paroxetine treatment in obsessive-compulsive disorder. Neuropsychopharmacology. 1999;21(6):683-693. 4. Cho SC, Hwang JW, Kim BN, et al. The relationship between regional cerebral blood flow and response to methylphenidate in children with attention-deficit hyperactivity disorder: comparison between non-responders to methylphenidate and responders. J Psychiatr Res. 2007;41(6):459-465. 5. Mena I, Correa, R, Nader A, Boehme, V. Bipolar affective disorders: assessment of functional brain changes by means of Tc-99m HMPAO NeuroSPECT. Alasbimn J. 2004;6(23).
Prolonged Exposure Therapy in Veterans Affairs: The Full Picture To the Editor The Eftekhari et al study1 on the effectiveness of prolonged exposure therapy (PE) in the Department of Veterans Affairs (VA) demonstrates the vast strides that have been made in testing and disseminating evidence-based treatments for military-related posttraumatic stress disorder (PTSD). We applaud attempts to make PTSD care uniformly rigorous and systematically applied throughout the VA. However, Eftekhari et al fail to acknowledge an unfortunate reality: PE is rarely used in actual VA practice.2 Prolonged exposure therapy is a highly emotionally demanding “trauma-focused therapy” that requires significant patient buy-in, motivation, and readiness to disclose traumatic experiences in vivid detail. Its dissemination in the VA occurred with little patient or line-clinician input, and the veterans’ perspective of PE treatment has not been
evaluated. Studies show that, despite significant dissemination efforts, only a small minority of VA patients are selected for or choose trauma-focused treatment. For example, in a recent study of the Northeast region (conducted after national dissemination rollouts), only 6.3% of VA patients with PTSD had received at least 1 session of trauma-focused therapy and most of the PTSD treatment they received was nontrauma focused.3 The dissemination evaluation of Eftekhari et al does not represent the full spectrum of treatment-seeking veterans with PTSD, but instead a small subset of self-or clinicianselected patients. Eftekhari et al, for example, state that clinicians in their study “used their clinical judgment in determining which patients were suitable candidates for PE”1(p951) but do not elaborate on what determined this suitability or, importantly, what portion of patients were deemed “suitable” for PE by clinicians. The broader problem is that, because VA PTSD psychotherapy outcome research has focused almost exclusively on trauma-focused therapies, almost no data are available on the experiences and outcomes of the vast majority of patients with PTSD not engaging in these therapies. The PTSD treatments commonly used in real-world VA practice have not been systematically evaluated (treatment-as-usual comparison conditions in randomized trials do not suffice and may at any rate be misnomers given that existing studies do not reveal what is “happening on the ground” nationally). Nationally representative, ecologically valid studies of actual PTSD care provided in the VA are sorely needed, as are studies of the reasons for treatment decisions by patients and clinicians. Studies such as the one by Eftekhari et al are spearheading broad improvements in VA PTSD care but further progress cannot be made until the full spectrum of patients and clinicians are represented in effectiveness research. Maria M. Steenkamp, PhD Brett T. Litz, PhD
Author Affiliations: VA Boston Healthcare System, Jamaica Plain, Massachusetts. Corresponding Author: Maria Steenkamp, PhD, Boston VA Medical Center, 150 S Huntington Ave, 13B-73, Jamaica Plain, MA 02130 ([email protected]). Conflict of Interest Disclosures: None reported. 1. Eftekhari A, Ruzek JI, Crowley JJ, Rosen CS, Greenbaum MA, Karlin BE. Effectiveness of national implementation of prolonged exposure therapy in Veterans Affairs care. JAMA Psychiatry. 2013;70(9):949-955. 2. Steenkamp MM, Litz BT. Psychotherapy for military-related posttraumatic stress disorder: review of the evidence. Clin Psychol Rev. 2013;33(1):45-53. 3. Shiner B, D’Avolio LW, Nguyen TM, et al. Measuring use of evidence based psychotherapy for posttraumatic stress disorder. Adm Policy Ment Health. 2013;40(4):311-318.
jamapsychiatry.com
JAMA Psychiatry February 2014 Volume 71, Number 2
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpsyc.jamanetwork.com/ by a Universite Laval User on 11/24/2015
211
