Psychological treatment for symptoms of posttraumatic stress disorder in vulnerable populations
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The lifetime prevalence of posttraumatic stress disorder (PTSD) ranges from 1 to 14 percent in the general population. Diagnosis is based on criteria that address hallmark symptoms of the disorder from re-experiencing the trauma to hyperarousal, emotional numbing, and avoidance of memories, thoughts, or feelings associated with the event. PTSD is particularly prevalent in vulnerable populations and comorbid with substance use disorders, serious mental illness, or both. Psychological treatment options are more strongly recommended than pharmacological treatment by the American Psychological Association (APA); however, the efficacy of psychotherapy is less studied in vulnerable populations for fear that substance use or mental health outcomes will worsen. Prolonged exposure (PE) therapy and cognitive processing therapy (CPT) are the most investigated forms of cognitive behavioral therapy (CBT) in vulnerable populations and involve overcoming the trauma through repeated exposure for PE or processing with a clinician for CPT. A review of all randomized controlled trials (RCTs) that have evaluated the effect of either form of CBT on non-combat PTSD, substance use disorder (SUD), and mental health outcomes found that PE administered alongside SUD treatment had the greatest positive impact on PTSD and SUD outcomes. PE also had a better impact than CPT on PTSD outcomes in individuals with PTSD and serious mental illness (SMI); however, neither form of CBT performed substantially better than the other with respect to mental health outcomes. In future studies, the impact of psychological treatments on PTSD and other health outcomes needs to be assessed on the same variables in larger populations of vulnerable individuals that are inclusive and representative of those receiving care for SUD and SMI in community health care settings.