November 30, 2022

Treating PTSD in Accordance with New APA Guidelines Requires Measurement-Based Care

The APA strongly recommends four treatments for PTSD. All of them require the use of measurement-based care.

Recent guidelines put forth by the American Psychological Association (APA) highlight four treatments that garnered APA’s strongest support for treatment of posttraumatic stress disorder (PTSD). 

All four treatments require the use of measurement-based care. Yet, today, only 20% of clinicians routinely practice measurement-based care.

APA generated these guidelines to help clinicians choose treatment approaches that have empirical support so that patients have the best chance at recovery. But treatment selection is only half the battle. It is critical to measure progress along the way.

Let’s dive into what these guidelines could mean for your practice, and how measurement-based care can help facilitate this transition: 

Why did the APA start with PTSD? 

In a given year, about 50-60% of the US population will experience a trauma, and about 8-20% will go on to develop PTSD. It is important to note here, as not all patients with trauma will develop PTSD, that the guidelines are meant to inform treatment selection for those with PTSD specifically. Prevalence rates vary by context, with one recent meta-analysis estimated the rates of PTSD in veterans of Operation Enduring Freedom/Operation Iraqi Freedom at about 23%. Moreover, untreated PTSD is associated with increased risk for development of more chronic conditions, like substance use and being unhoused

Swift intervention for those who need it has the capacity to improve quality of life rather drastically. And, on a larger scale, high-quality intervention might help equilibrate the growing imbalance of the number of individuals who need mental healthcare and the number for whom the healthcare system is equipped to provide it. 

Why did the APA establish treatment guidelines? 

Psychology is one of the only health fields for which centralized treatment guidelines of common conditions are the exception and not the rule. Perhaps this is because, for many years, there has been much debate about whether psychology, as a field, ought to be considered a science at all. However, the past few decades have brought more alignment between psychology and other areas of healthcare through an increased focus on evidence-based practice. This advancement has highlighted the need to develop standardized treatment guidelines, including when and how clinicians should use measurement-based care.

And, this endeavor is well underway. Since their publication in 2017, the PTSD guidelines are in the company of two additional APA clinical practice guidelines for 1) the behavioral treatment of overweight and obesity in children and adolescents (published in 2018) and 2) depression across the lifespan (published in 2019). With additional guidelines (i.e., for treating chronic pain in adults) are currently under development, it is almost certain that guideline-driven measurement-based care is here to stay. 

So, what four treatments have strong empirical support for PTSD? 

The panel considered three key factors when making their recommendations: 1) strength and quality of evidence supporting each treatment, including how treatments hold up when compared to wait list controls versus active treatment, 2) patient factors and preferences that might influence treatment effectiveness, and 3) any harmful or iatrogenic outcomes that might inform guidelines advising against certain treatments. 

The four psychotherapies receiving strongest support (listed in alphabetical order) are: 

  1. cognitive behavioral therapy
  2. cognitive processing therapy
  3. cognitive therapy
  4. prolonged exposure. 

Furthermore, the panel concluded that there is insufficient evidence to recommend relaxation-based therapy. 

These four treatments all rely on the use of initial and repeated assessment to measure symptoms. And, because they are designed to be time-limited, all rely on between-session practice, like daily thought and behavior logs and worksheets, to ensure maximum effectiveness. 

What does this mean for clinicians?

Routinely offering empirically-supported treatments for PTSD can help get patients off your waitlist and back to living their lives. To ensure that you are set up to practice measurement-based care, here are two steps to take:

  1. It’s important to have an easy and reliable way of assessing PTSD. Not every trauma survivor will meet criteria for PTSD, so relying on disclosure of trauma is insufficient. On the other hand, those who do meet criteria for PTSD might avoid disclosure due to shame, or might not even attribute their current symptoms to their trauma experience. Consider a treatment like prolonged exposure, which relies on imaginal exposure to trauma as a direct antidote to the intrusive, re-experiencing symptoms that are common in PTSD. The consequences of using such an approach with a trauma survivor who does not meet criteria for PTSD could cause symptoms to worsen, not improve. A brief semi-structured interview, such as the PTSD Symptom Scale Interview for DSM-5 (PSSI-5), can help you deliver these interventions with confidence. 
  2. Once treatment has begun, it’s helpful to measure whether symptoms are improving. Indeed, both prolonged exposure and cognitive-processing therapy strongly recommend the use of weekly or biweekly symptom assessment via self-report questionnaire. The PTSD Checklist for DSM-5 (PCL-5) or the Posttraumatic Diagnostic Scale (PDS-5) are two widely-used options. 

To ensure that your practice is offering the highest quality care in accordance with these guidelines, measurement-based care is key.