To The Editor: It is worth noting two misleading conclusions in the otherwise excellent study by Marit Sijbrandij et al. (1), published in the January 2007 issue of the Journal. In their article, they assessed subjects for posttraumatic stress disorder (PTSD) 18 to 92 days after the subjects’ index of traumatic events. Then, approximately one-half of these subjects were randomly assigned to four cognitive behavior therapy (CBT) sessions and reassessed 1 week after treatment and again 4 months after treatment. The remaining subjects were randomly assigned to a waiting list condition (1). A post hoc analysis showed that within the CBT group, those patients who started treatment within the first month after the traumatic event improved more than those patients who started treatment 1 to 3 months after the event. This appears to be a type I error. It has been shown that the majority of individuals, if not all, show some PTSD symptoms following traumatic events, but those who will have enduring symptoms become apparent after the 1-month mark (2). What likely happened in this study was that those patients who started treatment within the first month experienced improvement because of the natural loss of symptoms that would have occurred even without treatment, and they experienced additional improvement from the treatment. It cannot be supported that the CBT treatment alone caused the early treatment group to improve more than the later treatment group (2).
This error is compounded by the penultimate sentence of the discussion that stated that the findings supported recent recommendations from other publications, indicating that for “severe initial traumatic response[,] brief trauma-focused cognitive behavioral therapy may speed recovery and prevent PTSD if treatment begins 2 [to] 3 weeks after trauma exposure” (1, p. 89). This misrepresents the evidence. The evidence is for treating severe PTSD within the first month. There is no evidence that this study involved the treatment of severe PTSD in those patients who received treatment within the first month. The National Institute for Clinical Excellence report that the authors cited clearly stated that watchful waiting is the recommendation for mild symptoms within the first month (3).
1.Sijbrandij M, Olff M, Reitsma J, Carlier I, de Vries M, Gersons B: Treatment of acute posttraumatic stress disorder with brief cognitive behavioral therapy: a randomized controlled trial. Am J Psychiatry 2007; 164:82–902.Rothbaum B, Foa E, Riggs D: A prospective examination of posttraumatic stress disorder in rape victims. J Trauma Stress 1992; 5:455–4753.National Institute for Clinical Excellence (NICE): Post-Traumatic Stress Disorder: The Management of PTSD in Adults and Children in Primary and Secondary Care. London, National Institute for Clinical Excellence, 2005
Dr. Scheeringa reports no competing interests.
This letter (doi: 10.1176/appi.ajp.2007.07030406) was accepted for publication in April 2007.