Treatment of pharmacotherapy-refractory posttraumatic stress disorder among Cambodian refugees: a pilot study of combination treatment with cognitive-behavior therapy vs sertraline alone

Abstract

Cambodian refugees with posttraumatic stress disorder (PTSD) represent a cohort in severe need of treatment, but little information is available to guide treatment choices. We selected a sample of pharmacotherapy-refractory individuals to test the efficacy of combination treatment with sertraline and cognitive-behavior therapy (CBT) for treating PTSD. Participants in this pilot study were ten Khmer-speaking women who had been at a mean age of 22–26 years during the Pol Pot period (1975–1979). These patients were randomly assigned to either sertraline alone or combined treatment. We found that combined treatment offered additional benefit in the range of medium to large effect sizes for PTSD and associated symptoms. Our findings indicate that substantial gains can be achieved by adding CBT to pharmacotherapy for PTSD, and that a program of CBT emphasizing information, exposure, and cognitive-restructuring can be successfully modified for Khmer-speaking refugees.

Introduction

An estimated 1.5 million Cambodians died during the 4-year Pol Pot period due to starvation, overwork, illness, or execution. In addition many survivors were subjected to the constant threat of death, torture, severe physical deprivation, physical and sexual violence, and physical displacement (Mollica, Poole, & Tor, 1998). Accordingly, studies have documented high rates of both PTSD and major depression in these individuals. For example, in a sample of 50 Cambodian refugees in Greensboro, N.C., 86% met criteria for PTSD, and 80% met criteria for depression (Carlson & Rosser-Hogan, 1994).

Few studies have examined treatment outcome for PTSD in Cambodian refugees. Boehnlein, Kinzie, Ben and Fleck (1985) studied 12 patients and reported 42% no longer met criteria for PTSD after one year of open treatment with medication and long-term psychotherapy. Less success was evident in a smaller sample of Cambodian refugees who received longer-term treatment with imipramine and clonidine (Kinzie & Leung, 1989).

Notably absent are investigations using the treatment modalities associated with the highest effect sizes in empirical reviews: cognitive-behavior therapy (CBT, e.g., Foa, Dancu, Hembree, Jaycox, Meadows and Street, 1999, Resick, Nishith, Weaver, Astin and Feuer, 2002) and treatment with serotonin selective antidepressants (for review see Foa, Keane and Friedman, 2000, Otto, Penava, Pollock and Smoller, 1996). Also absent are investigations of strategies for patients who fail initial interventions. The goal of this pilot study was to provide estimates (effect sizes) for the efficacy of sertraline (Brady et al., 2000) compared to sertraline plus CBT for the treatment of PTSD in a sample of Cambodian refugees. This issue was addressed in a sample of patients unique for two reasons: (1) they had failed to respond to initial pharmacotherapy, and (2) they represented a distinct and severely traumatized cultural group living in the United States.