Treatment of pharmacotherapy-refractory posttraumatic stress disorder among Cambodian refugees: a pilot study of combination treatment with cognitive-behavior therapy vs sertraline alone
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.
Section snippets
Participants
The study was approved by the Institutional Review Boards at both Massachusetts General Hospital and the North Suffolk Mental Health. Patients provided written consent after a translator read the consent form in Khmer (all participants were illiterate in Khmer and English). Treatment services were provided in Khmer.
Participants had to meet criteria for current PTSD despite ongoing pharmacotherapy as determined by the Structured Clinical Interview for DSM-IV. All patients in this study were
Results
Pretreatment levels of symptom severity and symptom change across treatment are presented in Table 1. Because random assignment did not fully equate groups, we evaluated the impact of treatment by examining differences between groups in the change in symptoms across treatment. Effect sizes (Cohen’s d) comparing differences between groups on these change scores were calculated:These effect sizes were indicative of consistent advantages for
Acknowledgements
Work on this project was supported by a grant from Pfizer Pharmaceuticals to Dr. Pollack and a grant from the van Ameringen Foundation for Dr. Hinton’s contributions to this project.
References (14)
- et al.
Cognitive-behavior therapy for patients failing to respond to pharmacotherapy for panic disorder: A clinical case series
Behaviour Research and Therapy
(1999) - et al.
How does anxiety sensitivity vary across the anxiety disorders?
Journal of Anxiety Disorders
(1992) - et al.
A clinician rating scale for assessing current and lifetime PTSD: the CAPS-1
Behavior Therapist
(1990) - et al.
One-year follow-up study of posttraumatic stress disorder among survivors of Cambodian concentration camps
American Journal of Psychiatry
(1985) - et al.
Efficacy and safety of sertraline treatment of posttraumatic stress disorder: a randomized controlled trial
Journal of the American Medical Association
(2000) - et al.
Cross-cultural response to trauma: a study of traumatic experiences and posttraumatic symptoms in Cambodian refugees
Journal of Traumatic Stress
(1994) - et al.
A comparison of exposure therapy, stress inoculation training, and their combination for reducing posttraumatic stress disorder in female assault victims
Journal of Consulting and Clinical Psychology
(1999)
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