Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
An end to the suffering??
- Declan P Fox (11 May 2007)
-
Practical problems regarding immediate cognitive therapy
- Stamatia Tzigianni, Vivek Furtado (16 May 2007)
-
Authors Reply
- David M Clark, Michael Duffy, Kate Gillespie (18 May 2007)
-
the fiction of curing PTSD
- g van brussel (18 May 2007)
-
PTSD in the context of terrorism and Cognitive Behaviour Therapy (CBT)
- Imran Mushtaq, John Kamara Senior House Officer-Old Age Psychiatry and Nabeela Majid-Senior House Officer-General Adult Psychiatry (21 May 2007)
-
Some more information would be useful
- Adarsh Shetty, Derby DE22 3NE. (3 June 2007)
-
Treatment or not treatment
- David Bolton (19 July 2007)
-
Chronic pain syndrome among young Maoist combatants in Nepal
- Masahiro J Morikawa, MD, MPH, Andreas Settje, MD (19 November 2007)
|
|
|||
|
Declan P Fox, Freelance physician with interest in basic CBT skills for GPs Based in Newtownstewart, N Ireland, BT78 4NP
Send response to journal:
|
Sir As GPs in N Ireland, we have seen up close the awful psychological cost of years of sectarian strife. We have seen multiply-traumatised patients who have found it impossible to escape from daily risks to their lives, particularly members of the security forces. It is wonderful, in this week when our new assembly gets down to business, to see a new hope dawn for those still suffering PTSD and related disorders. Duffy et al have done great work here, trumping their previous notable treatment of Omagh bomb victims. We now know what works for PTSD here in N Ireland and there can no longer be any excuses for failure to provide access to the specific CBT routines. On the wider front, perhaps Ms Hewitt or her successor will now get real on funding PROPER CBT services---as opposed to telling PCTs to buy computer programs? Declan Fox MB MRCGP
Competing interests: Various professional and personal contacts with the study authors. |
|||
|
|
|||
|
Stamatia Tzigianni, SHO - Leeds Mental Health Trust Leeds, Vivek Furtado
Send response to journal:
|
It was a very interesting study. However, a couple of comments are all I want to make. Firstly, immediate cognitive therapy can be considered to be a dream in many (if not all) mental health trusts across the United Kingdom. Even a 12 week wait is a bit optimistic in certain trusts. However, this could be partially alleviated by using a computerised CBT approach since it overcomes the burden of needing waiting lists and could be done at ones convinience. A pragmatic trial that compares normal waiting time and then CBT versus immediate computerised CBT would be an ideal option and could be looked into. Competing interests: None declared |
|||
|
|
|||
|
David M Clark, Professor of Psychology Institute of Psychiatry at Kings College London, Michael Duffy, Kate Gillespie
Send response to journal:
|
We are grateful to Declan Fox and Stamatia Tzigianni for their thoughtful responses to our article. When considering cognitive behaviour therapy (CBT) it is important to realise that the term covers a wide range of specific treatment programmes that vary considerably in their effectiveness. There is good evidence that some computerized CBT and other types of guided CBT self-help are effective in a subset of individuals with mild to moderate depression. For this reason, the National Institute of Clinical Excellence (NICE) Treatment Guidelines suggest they have an important place in a stepped care approach to depression management. In contrast to the depression literature, existing guided self-help programmes for PTSD have failed to demonstrate efficacy in randomized controlled trials. For this reason, current NICE Guidance does not recommend a stepped care approach to the treatment of PTSD. (see article for references to NICE Guidance). Availability of suitably trained CBT therapists is a problem. The Government made a 2005 election manifesto commitment to increase public access to psychological therapies. This should be honoured by increasing the number of trained therapists as well as by making guided self-help available (when the latter has been shown to be effective). Competing interests: None declared |
|||
|
|
|||
|
g van brussel, pedagogic/educational technologist helmond
Send response to journal:
|
For about 10 years or more it has been proven that the brains of people with chronic PTSD have been changed biologically in a way that the adaptation system cannot work appropiately. So there is a distortion in properly transferring the signals to meaning and emotion. Medication can only supress the symptons of PTSD and can make you very sick in another way in the long run. Cognitive therapy is not successful in all cases, especially not in multiple life-threathening incidents in a short time (i.e. 6 months) in wartime conditions. EMDR is also not successful in above mentioned cases. Veterans with PTSD cannot be cured in the same way as civilians. Civilians are daily living in non-threatening conditions (living in peace-mode) and after one incident they are back in peace time among their spouse and friends who can help them too. Military personnel on a mission live every minute of the day in life-threatening conditions (living in fight mode) and cannot be cured on mission. In the Netherlands in WW II many Jews were transported to camps in Germany and killed. The few who survived and their relatives are still suffering the consequences of this. As a veteran with PTSD I consult the Sinai Centre, an institution for treatment of PTSD and other, and I still meet Jews with PTSD on their way back home after treatment for their PTSD. After more then 60 years not cured from PTSD !!!!! Looking at psychiatry I wonder if these professionals know what they are doing and how this can be proved. Looking at the history of psychiatrists and psychiatry there is not much consensus in treatment over the years. It looks to me merely as a commercial business where selling baked air is common. Competing interests: None declared |
|||
|
|
|||
|
Imran Mushtaq, Senior HouseOfficer-Old Age Psychiatry Princess Marina Hospital, Kent Close Northampton, John Kamara Senior House Officer-Old Age Psychiatry and Nabeela Majid-Senior House Officer-General Adult Psychiatry
Send response to journal:
|
CBT works for various psychiatric conditions and National Institute for Health and Excellence (NICE) recommends it as major psychological treatment for them (1-3). Duffy et al (4) randomised controlled trial is an another success story describes use of CBT in PTSD but in the context of terrorism and other civil conflict in Northern Ireland. We congratulate the authors for such a nice and important piece of work and would take this opportunity to raise few points here. Firstly, they chose delayed treatment group (waiting list) as a control rather than alternative treatments and gave their reasons. People who are having treatment, in comparison with control group without any treatment, are likely to do well, as shown by the study results. Instead, if they have chosen eye movement desensitisation or other alternatives, as recommended by NICE (5) for PTSD (although they are largely based on traumatic events not involving terrorism), results might be more representative of control group. Secondly, they have claimed the presence or absence of a comorbid psychiatric disorder was not related to degree of improvement but we see contradictory evidence that patients with comorbid conditions, especially major depression (72% of the treatment group) receive more CBT sessions and showed similar good results. Therapists in the study were given flexibility to adapt to different CBT techniques, necessary to treat those comorbid conditions, which may have been responsible for that overall effect and not necessarily supports their claim. They have also mentioned that patients whose initial depression score was over 35 were particularly difficult to engage in the treatment and one would imagine that their comorbid illness would affect the degree of improvement. REFERENCES: 1. National Institute for Health and Clinical Excellence. Anxiety: management of anxiety (panic disorder, with and without agoraphobia, and generalized anxiety disorder) in adults in primary, secondary and community care (clinical guideline 22). London: NICE, 2004. 2. National Institute for Health and Clinical Excellence. Depression: management of depression in primary and secondary care (clinical guideline 23). London: NICE, 2004. 3. National Institute for Health and Clinical Excellence. Eating disorders: core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders (clinical guideline 9). London: NICE, 2004. 23 Layard R. The case for psychological treatment centers. 4.Duffy M, Gillespie K, Clark DM. Post-traumatic stress disorder in the context of terrorism and other civil conflict in Northern Ireland: randomized controlled trial. BMJ, doi: 10.1136/bmj.39021.846852.BE (published 11 May 2007). 5.National Institute for Health and Clinical Excellence. Post-traumatic stress disorder (PTSD): The management of PTSD in adults and children in primary and secondary care (clinical guideline 26). London: NICE, 2005. Competing interests: None declared |
|||
|
|
|||
|
Adarsh Shetty, Specialist Registrar in General Adult Psychiatry Psychiatric Unit, Derby City Hospital, Uttoxeter New Road, Derby DE22 3NE.
Send response to journal:
|
Dear Editor, Duffy et al (1) describe a very interesting and rigorous randomized controlled trial which provides evidence for the effectiveness of cognitive therapy in post-traumatic stress disorder in the context of terrorism and civil conflict. However, I do think some more information would have been useful to interpret the results accurately. My first comment is regarding the effects of medication. Some more detail about the medication status of the patients would have been helpful. It is mentioned that no patients were started on medications during the trial. However, 52% in the immediate therapy group were on antidepressants already. When were these initiated in relation to the trial? Also, were any changes to the antidepressant dose allowed during the trial? Over 70% in the immediate therapy group had comorbid major depression. It could be argued that the effect of antidepressant initiation just before the trial or dose changes may be partly responsible for the improvement in this group’s symptoms. The authors make it clear that the percentages telling us about the overall effectiveness of cognitive therapy are the combined scores of the immediate treatment and waiting list control groups. It is important to bear in mind that this, in effect, makes them uncontrolled scores. They are not comparing 2 groups of patients, one receiving therapy and the other not receiving therapy. The maintenance of treatment gains is another area of comment. The follow-up mean scores in Table 3 have been taken at either 4 or 12 months. As a clinician, I would be particularly interested in information about the maintenance of gains at 12 months. This is not clear from the table. If gains demonstrated at 4 months are lost by 12 months, this then raises questions about whether booster sessions are indicated. Finally, the therapist effect that the authors bring to our attention is very significant. After all, in clinical practice, one would want an effective therapist who brings about the most improvement in one’s patients. It would be interesting to look at whether this difference in patient scores is related to the type of qualification in cognitive therapy that the therapists had. Recent research into this area has shown that formal post-qualification training in cognitive therapy is associated with competence in cognitive therapists (2). I congratulate the efforts of the authors in adding to the evidence base and look forward with interest to further research in this area. References: 1. Duffy M, Gillespie K, Clark DM. Post-traumatic stress disorder in the context of terrorism and other civil conflict in Northern Ireland: randomised controlled trial. BMJ 2007;334:1147 (2 June), doi: 10.1136/bmj.39021.846852.BE (published 11 May 2007). 2. Brosan L, Reynolds S, Moore RG. Factors associated with competence in cognitive therapists. Behavioural and Cognitive Psychotherapy 2007;35: 179-90. Competing interests: None declared |
|||
|
|
|||
|
David Bolton, Director of the Northern Ireland Centre for Trauma & Transformation 2 Retreat Close, Omagh, Northern Ireland BT79 0HW
Send response to journal:
|
I acknowledge Dr Imran Mushtaq's point about the value of a trial that would investigate alternative treatment approaches instead of a 'no treatment' or 'delayed treatment' control. Clinically such a trial would be expected to make an important contribtuion to our knowledge base in this area. From a user and policy perspective there is still value in demonstrating the impact of the 'no treatment option' as in practice many people suffering trauma related disorders do not have access to evidence based interventions, and the reality for them is 'no treatment'. In the context of the Northern Ireland conflict there has been an ongoing debate on how best to address the needs of those affected by violence including those suffering trauma related disorders. Over the years I have heard views such as 'nothing can be done', 'it is too late', 'it is too politically difficulty to unearth the past' and such like. This study demonstrates that something can be done (in this case for a chronic PTSD patient group) and that to offer no treatment is to yield to a council of despair. This study adds to the body of knowledge which is clearly pointing us in the direction of needing to develop and put in place evidence based services for trauma related disorders, and to develop the service menus and pathways that will enable people to access appropriate interventions, sooner rather than later. It clearly addresses the view that offering nothing is not a tenable option. Competing interests: None declared |
|||
|
|
|||
|
Masahiro J Morikawa, MD, MPH, Kinderberg International, e.V. Stuttgart, Germany, D-70499, Andreas Settje, MD
Send response to journal:
|
Sir- After the peace accord in November 2006, approximately 35,000 Maoist combatants, People’s Liberation Army (PLA) in Nepal have been disarmed and settled into seven cantonments in seven rural districts in Southwest Nepal under the supervision of United Nations. Each cantonment accommodates approximately 5,000 PLA soldiers. Kinderberg International, e.V., a German humanitarian NGO under contract with GTZ, a German foreign aid agency has been conducting surgical camps for resettled combatants in the past 6 months to provide reconstructive surgery service for combatants treated in the field during the war. From October 29th to November 6th 2007, we provided the surgical camp to the 7th battalion division in Talband, Kailali district. The team consisted of four surgeons and physicians and six nurses and three logistic staffs. We provided free medical consultation and reconstructive surgery for combatants in this cantonment. We stayed in the camp 24 hours for 7 days and provided as much surgery and medical consultation as possible for the soldiers. We examined 622 patients during 7 consecutive days and we conducted all together 74 operations including stump revision, bullet removal. Average age of patients was 23.4 years old and predominantly male (79.7%). The high demand of surgical intervention was expected considering the nature of the camp as post-conflict disarmed military encampments. The most striking finding of this camp was stunningly high prevalence of chronic pain syndrome developed after bullet and shrapnel wounds (27.7%). This high prevalence of chronic pain and emotional scars to these young military recruits urges us the need for comprehensive intervention other than surgery. High prevalence of depression and PTSD are reported among victims of recent conflicts . And somatization as primary symptoms of depression is also well known fact in many communities . Considering these trends of high musculoskeletal pain syndrome several years after active fighting, the international relief community should be ready to provide psychosocial interventions for disarmed combatants. Masahiro J Morikawa, MD, MPH Kinderberg International, e.V. Stuttgart, Germany Case Western Reserve University, Cleveland, OH, USA Andreas Settje, MD Kinderberg International, e. V. Kathmandu, Nepal SKM hospital for reconstructive surgery, Sankhu, Nepal Competing interests: None declared |
|||