PTSD: National Center for PTSD

Complementary and Integrative Health (CIH) for PTSD

Jennifer L. Strauss, PhD, Ariel J. Lang, PhD, & Paula P. Schnurr, PhD

Disclaimer: This article is currently undergoing revisions to reflect a clear conceptualization of complementary and integrative health--rather than complementary and alternative medicine (CAM)--as well as research updates related to the forthcoming revision (2023) of the VA/DoD Clinical Practice Guideline for PTSD.

Key Points

• Use of CIH is widespread for the management of mental health problems, including PTSD.
• Although limited, evidence suggests that some CIH approaches have modest beneficial effects as a treatment for PTSD.
• Most VA mental health programs offer CIH approaches; VA is supporting efforts to study the benefits of CIH for PTSD.

Complementary and Integrative Health (CIH) Approaches

Broadly conceptualized, in the United States (U.S.), "complementary and integrative health (CIH) approaches" refers to products and practices that are not currently part of mainstream, conventional medical practice:

• Complementary refers to the use of these techniques in combination with conventional approaches.
• Integrative health brings conventional and complementary approaches together in a coordinated way, emphasizing treatment of the whole person (1).

In the U.S., and specifically within VA, CIH approaches have gained popularity and research attention. Please visit the National Center for Complementary and Integrative Health (NCCIH) for a complete overview of CIH interventions and a discussion of the shift from "complementary and alternative medicine" to "complementary and integrative health". Within VA, the Integrative Health Coordinating Center (IHCC), Office of Patient Centered Care & Cultural Transformation, serves as a resource for clinical practices and education for Veterans, clinicians, leadership and staff.

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Conventional PTSD Treatment and CIH

Some conventional therapies for PTSD (e.g., exposure-based cognitive behavioral therapies [CBT]) include elements that are consistent with CIH approaches, but they are not conceptualized as the mechanism of change. For example, relaxation techniques may be used to increase adherence to and tolerability of exposure, but repeated confrontation with the feared stimulus is the primary driver of change.

In contrast, the "Third Wave" psychotherapies, such as Acceptance and Commitment Therapy (ACT), Dialectical Behavior Therapy (DBT), and Mindfulness-Based Cognitive Therapy (MBCT), integrate mindfulness with behavioral and cognitive strategies. Mindfulness--one definition of which is "paying attention in a particular way, on purpose, in the present moment, and non-judgmentally" (2)--is seen as an important agent of change in these approaches because it shifts the individual's perspective in a way that counteracts hypothesized psychopathological processes.

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Widespread Use of CIH for PTSD in Veteran and Civilian Populations

In general, reported rates of CIH use are similar in Veteran and civilian samples, ranging from approximately one-quarter to one-half of respondents, depending on the type of CIH and health conditions assessed (3-5). Active military personnel are not captured in nationally representative or Veteran samples, but research suggests rates of CIH use in the military are similar (6,7), if not higher (8) than rates of CIH use among Veterans and civilians.

The use of CIH approaches specifically for management and treatment of mental health problems is common (9) and increasing (10,11). Among a nationally representative sample, rates of CIH increased for managing anxiety (20.2% to 27.9%) and depression (40.9% to 42.7%) between 1990 and 1997 (10). In another nationally representative sample, survey results showed that CIH approaches were used more commonly than conventional therapies to treat self-defined anxiety attacks (51.9% vs. 40.8%) and severe depression (63.9% vs. 36.4%) (11).

Research on use of CIH specific to individuals with PTSD is emerging and suggests extensive utilization:

• A study in Veterans found that those with PTSD were 25% more likely than Veterans without PTSD to report CIH use, in particular, biofeedback and relaxation techniques (3).
• In a sample of older Veterans, some diagnoses, including PTSD, were more common among CIH users.
• One study looked at use of CIH specifically for the management of PTSD symptoms. In a nationally representative sample, 39% of those with PTSD indicated that they had used CIH in the previous year to address self-reported emotional and mental health problems (12).

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Limited Evidence for the Effectiveness of CIH in PTSD

Despite the widespread use of CIH among individuals with PTSD, evidence to support the efficacy of CIH for clinical treatment of PTSD is limited. The current empirical evidence for different CIH approaches in PTSD is described below. This is not an exhaustive list of potential applications of CIH in PTSD. It is limited to those CIH approaches that have been tested in controlled studies in patients with PTSD. For each approach, treatment effects on PTSD symptoms and key limitations are summarized.

Acupuncture

There has been one published randomized clinical trial of acupuncture as a treatment for PTSD. In that study, acupuncture was superior to waitlist and comparable to group CBT for PTSD in a non-Veteran sample (13). Although the effect size was large, the sample was small and there was no control for the nonspecific features of acupuncture (i.e., sham acupuncture). A systematic review described the evidence for the effectiveness of acupuncture for PTSD as encouraging but concluded that further trials are needed (14). Of note, 5 of the 6 studies examined in that review were conducted in China, where acupuncture is a mainstream treatment. Therefore, findings may not generalize to the use of acupuncture as a CIH modality in Western conventional medicine.

Meditation

Several studies have evaluated different meditative practices. A randomized controlled trial found that a 6-week group intervention that provided training in mantram repetition (silent repetition of a spiritually meaningful word) in conjunction with treatment as usual (medication and case management) had a small to moderate effect on PTSD symptoms among Veterans with chronic PTSD as compared to treatment as usual alone. It is difficult to interpret the observed benefits in the mantram repetition group as due only to the intervention because there was no control for the nonspecific treatment effects, such as additional clinical contact, of the group-based mantram repetition intervention (15).

Niles et al. (2012) found that an 8-week mindfulness intervention was superior to psychoeducation, both delivered by telehealth. Those who received the mindfulness condition showed greater improvement in PTSD symptoms, but these improvements were not sustained after treatment ended. It is not clear if the brief nature of the intervention or the modality of delivery (telehealth vs. face-to-face) affected the results (16).

More recently, a randomized controlled pilot study compared Mindfulness Based Stress Reduction (MBSR) plus usual care to usual care alone. Both groups had improved PTSD symptoms at post-treatment, but between-group differences were not observed in intent-to-treat analyses, although the observed within-group effect was larger in the group that received MBSR in addition to usual care. As with the trial of mantram repetition described above, the nonspecific treatment effects of MBSR, such as additional clinical contact and group support, were not controlled for in this pilot study, which leaves the possibility that the few differences that were observed could be attributable to these other factors. (17)

Relaxation techniques

Results are somewhat variable regarding the impact of relaxation techniques on PTSD symptoms. Some studies have found no benefit associated with relaxation techniques as compared to PTSD treatment (18-20). Other trials have shown that relaxation techniques are associated with clinically meaningful, albeit modest, changes in PTSD symptoms (21-23).

Yoga

One small RCT compared an adjunctive, 12-session yoga intervention to an assessment control in a sample of Veteran and civilian women (24). Although there were significant decreases in PTSD symptoms (specifically re-experiencing and hyperarousal symptoms) in both groups, there were no between-group differences. Both treatment arms required weekly, structured group interactions and general behavioral activation, which may have partially contributed to the similar levels of clinical change (small to moderate effect sizes) observed in both study arms.

Other CIH mind-body practices

Research is emerging with preliminary evidence for other CIH mind-body practices, such as energy therapy for PTSD. An initial study of Emotional Freedom Techniques (EFT), in which the patient taps acupuncture points to stimulate energy meridians, compared the approach to Eye Movement Desensitization and Reprocessing ([EMDR]; N = 46, 19 of whom withdrew before post-treatment). EFT and EMDR did not differ statistically, and the effect size observed in both groups was small (25). More recently, EFT plus standard care was compared to standard care alone in a sample of Veterans (N = 59), and EFT was associated with improved PTSD symptoms. Because of methodological limitations of these trials, strong conclusions about Emotional Freedom Techniques cannot be drawn from these findings (26).

Another study compared treatment as usual plus adjunctive healing touch and guided imagery to treatment as usual alone in an active-duty sample who had recently returned from deployment and screened positive for PTSD symptoms (although PTSD diagnosis was not established). There were statistically significant decreases in PTSD symptoms for the group who received adjunctive healing touch plus guided imagery, but not for the treatment as usual control group (27). Here again, controls for the effects of usual treatment were not clearly specified, and adherence to between-session use of guided imagery was not assessed.

These initial studies begin to demonstrate acceptability and feasibility of adjunctive CIH mind-body approaches, but do not provide conclusive information about efficacy.

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Clinical Implications

Based on the available evidence, it is difficult to draw firm conclusions about the efficacy of any type of CIH for PTSD. Acupuncture appears to have benefit but needs to be evaluated relative to sham acupuncture in order to control for the nonspecific benefits of treatment. Mindfulness-based meditation and relaxation appear to have modest benefit; little is known about the effect of other meditative practices and other CIH approaches.

Overall, the current evidence base does not support the use of CIH interventions as an alternative to current empirically-established approaches for PTSD, or as first-line interventions recommended within evidence-based clinical guidelines. Current evidence suggests CIH may be best applied as an adjunct to other PTSD treatments or as a gateway to additional services for patients who initially refuse other approaches.

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VA Facilities Offer CIH

VA is committed to providing patient-centered Whole Health care that includes evidence-based treatments for Veterans with mental health and behavioral health conditions. Recognizing some Veterans' interest in CIH approaches, VA facilities may choose to provide CIH as an adjunct to other established evidence-based therapies and medications to support overall health and well-being.

VA does not have specific policies or guidance related to the provision of CIH approaches for PTSD (28). However, VA does have internal policy that requires various CIH approaches be made available if deemed appropriate by the care team as a part of the Veteran's care plan (29). Currently there are 8 approved CIH approaches covered under this policy: acupuncture, biofeedback, clinical hypnosis, guided imagery, massage therapy, meditation, Tai Chi/Qigong, and yoga. To support this policy, VA has developed mechanisms to track use and effectiveness of CIH among VA patients as a part of the VA Whole Health System, which will continue to inform future clinical guidance, policies, and best practices for use of CIH modalities.

A 2020 report by VA's Complementary and Integrative Health Evaluation Center (CIHEC) examined Veteran use of 9 CIH therapies and chiropractic care from fiscal years 2017-2019. Key findings included (30):

• All VA medical facilities provided some CIH therapies.
• Veterans' use of each of the therapies increased over the assessment period.
• Traditional acupuncture and chiropractic care were the 2 most widely used therapies across all sites.
• Among VA health care users, men were less likely to use CIH than women. Women Veterans accounted for 9% of VA care users and made up 17.3% of CIH therapy users.
• Black Veterans accounted for 17.5% of VA users but made up a higher percentage of those using meditation, yoga, Tai Chi/Qigong, biofeedback, guided imagery and clinical hypnosis.
• Among CIH therapy and chiropractic care users, 33% had PTSD.
• Veterans were more likely to receive acupuncture, massage therapy and chiropractic care from community providers, and those Veterans seeking such care in the community were more likely to have PTSD than the overall VA care population.

Another survey of all 170 VA specialized PTSD treatment programs found (31):

• 96% of the 125 programs that responded reported offering CIH.
• The types of treatments used most often in specialized PTSD programs were mindfulness, stress management/relaxation, progressive muscle relaxation, and guided imagery, all of which were offered in more than 50% of treatment programs.

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VA's Support of Research on CIH for PTSD

VA's Evidence Synthesis Program in the Health Services Research and Development Service conducted a comprehensive literature review of CIH (at the time, CAM) for PTSD (32). In addition, VA's Office of Research and Development undertook a dedicated effort to evaluate CIH in the treatment of PTSD with the solicitation of research applications examining the efficacy of meditative approaches to PTSD treatment; the result was 3 clinical trials examining mindfulness-based stress reduction or mantram repetition. View the Whole Health Evidence Based Research site, VA's ORD information on CIH or clinicaltrials.gov for an updated list of CIH research projects supported by VA.

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References

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29. Department of Veterans Affairs. (2022, December 13; Updated). Provision of Complementary and Integrative Health. https://www.va.gov/VHApublications/ViewPublication.asp?pub_ID=10072
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31. Libby, D. J., Pilver, C. E., & Desai, R. (2012). Complementary and alternative medicine in VA specialized PTSD treatment programs. Psychiatric Services, 63(11), 1134-1136. https://doi.org/10.1176/appi.ps.201100456
32. Strauss, J. L., Coeytaux, R., McDuffie, J., Nagi, A., & Williams, J. W. (2011). Efficacy of complementary and alternative medicine therapies for posttraumatic stress disorder. Department of Veterans Affairs.

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