drugs (for example, psychopharmacologic agents available in generic form) or psychotherapies. Researchers and their funding sources tend to be more inspired by novelty, leading to a certain inertia about actual treatments in use that are not investigated empirically (Branscomb et al., 2001: 51). Some studies test head-to-head comparisons of interventions that clinicians find irrelevant to actual practice, especially for veterans. Finally, the population of veterans is heterogeneous, including older veterans with chronic PTSD and younger returning veterans; they also include women and members of various ethnic and racial groups. Little is known from systematic research on the potential response to various treatments or the acceptability of various treatment modalities across the groups identified. VA is in a unique position to help bring order and direction to the research enterprise regarding PTSD.

Finding 5. The committee found that studies of PTSD interventions have not systematically and comprehensively addressed the needs of veterans with respect to efficacy of treatment and the comparative effectiveness of treatments in clinical use.

Recommendation 5. The committee recommends that VA take an active leadership role in identifying research priorities for addressing the most important gaps in evidence in clinical efficacy and comparative effectiveness.2 Potential areas for future research include:

  • Comparisons of psychotherapy (e.g., CBT) and medication

  • Evaluation of the comparative effectiveness of individual and group formats for psychotherapy modalities

  • Evaluations of the efficacy of combined psychotherapy and medication, compared with either alone, and compared with


The committee has noted with interest research on effectiveness in other areas of mental health. For example, the STAR*D (Sequenced Treatment Alternatives to Relieve Depression) study aimed to reproduce some real-life settings in allowing participants choice and offering alternatives when a course of treatment did not work, and used an outcome measure of “remission” meaning becoming symptom free. Another study brought to the committee’s attention is the CATIE (Clinical Antipsychotic Trials of Intervention Effectiveness) Schizophrenia study, which compares newer atypical antipsychotics with each other and with conventional antipsychotics in regard to long-term effectiveness and tolerability, and also in identifying antipsychotics that work for patients who have not had success with that class of drugs. Finally, STEP-BD (Systematic Treatment Enhancement Program for Bipolar Disorder) is a long-term study of manic-depressive illness that studied treatment (both pharmacologic and psychosocial) of affected individuals on two “pathways”—one a naturalistic, best practices pathway that allowed patients and clinicians to choose the best course of treatment, and the other a “randomized care pathway” that involved patients in multi-site randomized controlled trials. Program participation lasted for up to 5 years to facilitate adequate follow-up.

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