PTSD: National Center for PTSD

Complementary and Integrative Health (CIH) for PTSD

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

The use of complementary and integrative health (CIH) practices is widespread for the management of mental health problems, including posttraumatic stress disorder (PTSD). This article is focused on mind-body practices that are applied for the treatment of PTSD. Although limited, evidence suggests that some CIH practices have beneficial effects as a treatment for PTSD. Most VA mental health programs offer CIH practices, and VA is supporting efforts to study the benefits of CIH for PTSD.

Complementary and Integrative Health (CIH) Practices

In the United States (U.S.), CIH refers to health care that brings conventional and complementary practices together in a coordinated way, emphasizing treatment of the whole person (1). The term "complementary" refers to the application of non-conventional techniques in combination with conventional approaches. Although VA encourages integrative care, some Veterans choose exclusively nonconventional, or "alternative" strategies for managing their PTSD symptoms.

CIH practices have gained popularity and research attention in the U.S., and specifically within VA. (Please visit the National Center for Complementary and Integrative Health 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, Office of Patient Centered Care & Cultural Transformation, serves as a resource for clinical practices and education for Veterans, clinicians and staff. It is important to note that most studies have contrasted a stand-alone CIH practice with a conventional treatment for PTSD. As such, the current evidence base speaks to CIH practices used outside of a context of integrative care for PTSD, and we will learn more as CIH research evolves.

This article is focused on CIH practices that are applied for the treatment of PTSD. We exclude approaches wherein CIH practices are elements of conventional therapies. For example, some evidence-based therapies for PTSD include elements that are consistent with CIH practices but not considered primary drivers of change. Prolonged Exposure (PE) includes relaxation training, but gradually approaching trauma-related memories, feelings, sensations and situations that the patient has avoided since the trauma is the primary driver of change. Similarly, 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.

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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 (2-4). Active military personnel are not captured in nationally representative or Veteran samples, but research suggests rates of CIH use in the military are similar to (5,6), if not higher (7) than, rates of CIH use among Veterans and civilians.

The use of CIH practices specifically for management and treatment of mental health problems is common (8) and increasing (9). CIH use appears to be more common in younger, college-educated and female individuals and to vary by race (10-12). 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 (13).

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 (14):

• 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% of CIH therapy users.
• Black Veterans accounted for 18% 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.

Another survey of all 170 VA specialized PTSD treatment programs found (15) that 96% of the 125 programs that responded reported offering CIH. The types of treatments used most often in these 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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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 treatment of PTSD is limited. The current empirical evidence for different CIH practices in PTSD, which was the basis for the 2023 VA/DoD Clinical Practice Guidelines for PTSD (16), is described below. This is not an exhaustive list of potential applications of CIH in PTSD. It is limited to those CIH practices that have been tested in controlled studies for the treatment of PTSD symptoms. For each practice, treatment effects on PTSD symptoms and key limitations are summarized.

Recommended practices

No CIH practice achieved the data standards required for a "strong for" recommendation for PTSD in the VA/DoD Clinical Practice Guideline for PTSD. Mindfulness Based Stress Reduction (MBSR), however, reached a "weak for" recommendation. MBSR, which involves instruction in a variety of mindfulness practices, is typically taught in eight 2.5-hour, group-based sessions and a 1-day retreat by a teacher with specialized training. The evidence suggesting that MBSR outperforms both active and inactive controls for reduction of PTSD symptoms comes from a systematic review of 9 studies (17). Among these studies are 2 large randomized controlled trials (RCTs) with Veterans, one that found that MBSR outperformed Present-Centered Group Therapy (PCGT; 18), and one that did not (19). A 4-session version of MBSR also led to greater change in PTSD than treatment as usual in the primary care setting (20).

Continuing Education Course

Clinical Practice Guideline for PTSD 2023: Complimentary, Integrative and Alternative Approaches

This online course reviews the 2023 VA/DoD CPG recommendations for complimentary, integrative and alternative approaches to treating PTSD.

Insufficient evidence to recommend

Practices that are considered promising based on an emerging body of evidence are detailed below in alphabetical order. Practices that are supported by less evidence, often only a single trial, are mentioned at the end in the "Other practices" section.

Acupuncture

Acupuncture is a procedure in which needles are applied to the skin by a trained practitioner for therapeutic effects. Evidence from a systematic review of 7 studies suggests acupuncture improves PTSD symptoms in individuals with PTSD in relation to any comparator (21). Although several studies took place in China, where acupuncture is conventional, results in U.S. populations are similar. Acupuncture was superior to waitlist and comparable to group cognitive behavioral therapy (CBT) for PTSD in a civilian sample (22) and significantly improved PTSD symptoms in when added to usual care in an active-duty military sample (23).

Mantram Repetition Program (MRP)

Mantram repetition program (MRP) is a meditative practice involving silent repetition of a sacred word (i.e., a mantram), 1-pointed attention and slowing down. An RCT 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 greater effect on PTSD symptoms among Veterans with chronic PTSD as compared to treatment as usual alone (24). A second trial showed that MRP outperformed Present Centered Therapy in terms of change in PTSD symptoms and insomnia among Veterans with PTSD (25).

Transcendental Meditation (TM®)

TM involves focus on a silently-used sound called a mantra and is practiced for 15-20 minutes twice per day. Three studies have evaluated TM for treatment of PTSD symptoms in Veterans with PTSD. In the largest study, TM did not differ from PE but outperformed a health education control (26). Additional evidence for TM comes from two smaller studies (27,28).

Yoga

Yoga involves a set of physical, mental and spiritual practices to create a connection between mind and body. In the U.S., practices vary greatly in terms of the degree of emphasis on each of these components. Strategies, such as use of invitatory language and absence of hands-on adjustments, have been developed to improve the experience of those with exposure to trauma (29). Evidence from a systematic review including 7 studies suggests that yoga is associated with more improvement in self-reported PTSD symptoms than no treatment, treatment as usual, or psychoeducation control (30).

Other practices

A single study showed that Loving-Kindness Meditation was not inferior to an evidence-based psychotherapy, Cognitive Processing Therapy (CPT), in terms of change in clinician-rated PTSD symptoms (31). Progressive muscle relaxation led to significant reduction in clinician-assessed PTSD symptoms and did not differ from PE in one low quality RCT involving older adults (32). There are initial studies showing possible benefit of Cognitively Based Compassion Training Veteran version (33), Mindfulness Based Cognitive Therapy (MBCT: 34), integrative exercise (35), Mindfulness Based Exposure Therapy (36), somatic experiencing (37) and visual art therapy (38). No controlled studies have evaluated guided imagery, hypnosis/self-hypnosis, massage therapy, somatic experiencing, or Tai Chi/Qigong.

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Clinical Implications

Based on the available evidence, it is difficult to draw firm conclusions about the efficacy of CIH for PTSD. MBSR has been suggested based on available evidence and several other therapies show promise. The current evidence base does not support the use of CIH practices as a first-line intervention for PTSD. Given the lack of demonstrated harm associated with these practices along with initial positive evidence, CIH practices may be applied for Veterans who prefer these options, as a gateway to additional services or for their ancillary health benefits. As with any PTSD treatment, it is important that the clinician and Veteran work together to establish and evaluate treatment goals to determine whether a selected practice is having a beneficial effect.

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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 concerns. Recognizing some Veterans' interest in CIH practices, VA facilities may choose to provide CIH as an option along with 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 practices for PTSD (39). However, VA does have internal policy that requires various CIH practices be made available if deemed appropriate by the care team as a part of the Veteran's care plan (40). Currently there are 8 approved CIH practices covered under this policy: acupuncture, biofeedback, clinical hypnosis, guided imagery, massage therapy, meditation, Tai Chi/Qigong, and yoga. It should be noted, however, that these are generally approved practice. Care should be taken to evaluate the evidence for Veterans' target conditions when selecting specific practices. Additionally, meditation is a broad term applying to a variety of practices; it is advisable to begin with practices that have some demonstrated benefit for PTSD. 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.

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VA's Support of Research on CIH for PTSD

View the Whole Health Evidence Based Research site, VA's ORD information on CIHM or clinicaltrials.gov for an updated list of CIH research projects supported by VA.

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References

1. National Center for Complementary and Integrative Health. (2021, April). Complementary, alternative, or integrative health: What's in a name? https://www.nccih.nih.gov/health/complementary-alternative-or-integrative-health-whats-in-a-name
2. Micek, M. A., Bradley, K. A., Braddock, C. H., & McDonnell, M. (2007). Complementary and alternative medicine use among Veterans Affairs outpatients. Journal of Alternative and Complementary Medicine, 13(2), 190-193. https://doi.org/10.1089/acm.2006.6147
3. Baldwin, C. M. Long, K., Kroesen, K., Brooks, A. J., & Bell, I. R. (2002). A profile of military Veterans in the southwestern United States who use complementary and alternative medicine: Implications for integrated care. Archives of Internal Medicine 162(15), 1697-1704. https://doi.org/10.1001/archinte.162.15.1697
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19. Davis, L. L., Whetsell, C., Hamner, M. B., Carmody, J., Rothbaum, B. O., Allen, R. S., Bartolucci, A., Southwick, S. M., & Bremner, J. D. (2019). A multisite randomized controlled trial of mindfulness-based stress reduction in the treatment of posttraumatic stress disorder. Psychiatric Research & Clinical Practice, 1(2), 39-48. https://doi.org/10.1176/appi.prcp.20180002
20. Possemato, K., Bergen‐Cico, D., Treatman, S., Allen, C., Wade, M., & Pigeon, W. (2016). A randomized clinical trial of primary care brief mindfulness training for Veterans with PTSD. Journal of Clinical Psychology, 72(3), 179-193. https://doi.org/10.1002/jclp.22241
21. Grant, S., Colaiaco, B., Motala, A., Shanman, R., Sorbero, M., & Hempel, S. (2018). Acupuncture for the treatment of adults with posttraumatic stress disorder: A systematic review and meta-analysis. Journal of Trauma & Dissociation, 19(1), 39-58. https://doi.org/10.1080/15299/732.2017.1289493
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24. Bormann, J. E., Thorp, S. R., Wetherell, J. L., Golshan, S., & Lang, A. J. (2013). Meditation-based mantram intervention for Veterans with posttraumatic stress disorder: A randomized trial. Psychological Trauma: Theory, Research, Practice, and Policy, 5(3), 259-267. https://doi.org/10.1037/a0027522.
25. Bormann, J. E., Thorp, S. R., Smith, E., Glickman, M., Beck, D., Plumb, D., Zhao, S., Ackland, P. E., Rodgers, C. S., Heppner, P., Herz, L. R., & Elwy, A. R. (2018). Individual treatment of posttraumatic stress disorder using mantram repetition: A randomized clinical trial. American Journal of Psychiatry, 175(10), 979-988. https://doi.org/10.1176/appi.ajp.2018.17060611
26. Nidich, S., Mills, P. J., Rainforth, M., Heppner, P., Schneider, R. H., Rosenthal, N., Salerno, J., Gaylord-King, C., & Rutledge, T. (2018). Non-trauma-focused meditation versus exposure therapy in Veterans with posttraumatic stress disorder: A randomized controlled trial. The Lancet, 5(12), 975-986. https://doi.org/10.1016/S2215-0366(18)30384-5
27. Heffner, K. L., Crean, H. F., & Kemp, J. E. (2016). Meditation programs for Veterans with posttraumatic stress disorder: Aggregate findings from a multi-site evaluation. Psychological Trauma: Theory, Research, Practice, and Policy, 8(3), 365-374. https://doi.org/10.1037/tra0000106
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29. Emerson, D. (2015). Trauma-sensitive yoga in therapy: Bringing the body into treatment. WW Norton & Company.
30. Cramer, H., Lauche, R., Anheyer, D., Pilkington, K., de Manincor, M., Dobos, G., & Ward, L. (2018). Yoga for anxiety: A systematic review and meta-analysis of randomized controlled trials. Depression and Anxiety, 35(9), 830-843. https://doi.org/10.1002/da.22762
31. Kearney, D. J., Malte, C. A. Storms, M., & Simpson, T. L. (2021). Loving-Kindness Meditation vs Cognitive Processing Therapy for posttraumatic stress disorder among Veterans. JAMA Open Network, 4(4) e21660. https://doi.org/10.1001/jamanetworkopen.2021.6604
32. Thorp, S. R., Glassman, L. H., Wells, S. Y., Walter, K. H., Gebhardt, H., Twamley, E., Golshan, S., Pittman, J., Penski, K., Allard, C., Morland, L. A., & Wetherell, J. (2019). A randomized controlled trial of Prolonged Exposure therapy versus relaxation training for older Veterans with military-related PTSD. Journal of Anxiety Disorders, 64, 45-54. https://doi.org/10.1016/j.janxdis.2019.02.003
33. Lang, A. J., Malaktaris, A. L., Casmar, P., Baca, S. A., Golshan, S., Harrison, T., & Negi, L. (2019). Compassion meditation for posttraumatic stress disorder in Veterans: A randomized proof of concept study. Journal of Traumatic Stress, 32(2), 299-309. https://doi.org/10.1002/jts.22397
34. King, A. P., Erickson, T. M., Giardino, N. D., Favorite, T., Rauch, S. A. M., Robinson, E., Kulkarni, M., & Liberzon, I. (2013). A pilot study of group Mindfulness-Based Cognitive Therapy (MBCT) for combat Veterans with posttraumatic stress disorder (PTSD). Depression and Anxiety, 30(7), 638-645. https://doi.org/10.1002/da.22104
35. Goldstein, L. A., Mehling, W. E., Metzler, T. J., Cohen, B. E., Barnes, D. E., Choucroun, G. J., Silver, A., Talbot, L. S., Maguen, S., Hlabin, J. A., Chesney, M. A., & Neylan, T. C. (2017). Veterans group exercise: A randomized pilot trial of an integrative exercise program for Veterans with posttraumatic stress. Journal of Affective Disorders, 227, 345-352. https://doi.org/10.1016/ j.jad.2017.11.002
36. King, A. P., Block, S. R., Sripada, R. K., Rauch, S., Giardino, N., Favorite, T., Angstadt, M. S., Kessler, D., Welsh, R., & Liberzon, I. (2015). Altered Default Mode Network (DMN) resting state functional connectivity following a mindfulness-based exposure therapy for posttraumatic stress disorder (PTSD) in combat Veterans of Afghanistan and Iraq. Depression and Anxiety, 33(4), 289-299. https://doi.org/10.1002/da.22481
37. Brom, D., Stokar, Y., Nuriel-Porat, V., Ziv, Y., Lerner, K., & Ross, G. (2017). Somatic experiencing for posttraumatic stress disorder: A randomized controlled outcome study. Journal of Traumatic Stress, 30(3), 304-312. https://doi.org/10.1002/jts.22189
38. Wu, C., & Lee, S. Y. (2020). After the interventionafter the intervention an evaluation and analysis of visual art therapy in the treatment of PTSD. International Journal of Clinical and Experimental Medicine, 13(10), 7646-7653.
39. Zeliadt, S. B., DeFaccio, R., Resnick, A., Toyama, J., McGinty, N., Douglas, J., Schult, T., Whitehead, A., & Taylor, S. L. (2022, February). Compendium on the use of core Whole Health services, complementary and integrative health therapies, and chiropractic care at the VA. Volume 2: Transitions in care due to the COVID-19 pandemic, 2017-2020. Available at: https://www.va.gov/WHOLEHEALTH/professionalresources/clinician-tools/Evidence-Based-Research.asp
40. 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

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