在这项研究中，加拿大瑞尔森大学的Candice M. Monson博士及其同事将40对夫妻随机分成2组：3个月PTSD治疗组和对照(等待名单)组。主要终点为CAPS(临床医生发放的PTSD量表)的评分改变。次要终点包括PTSD检查表、DAS(婚姻适应量表)、BDI(贝克抑郁问卷)和状态-特质焦虑问卷的评分改变。
波士顿大学精神病学教授Lisa M. Najavits博士指出，治疗组和对照组纳入的夫妻都经过了仔细选择，并且基线时均较为健康(例如无严重合并症)，同时还有愿意参与治疗的配偶支持，因此比临床上的典型患者更易治疗。此外，受试者主要为白人且均有工作，而临床上遇到的患者夫妻则可能缺乏这种工作稳定性。综上所述，虽然该研究观察到夫妻行为疗法能够改善配偶的症状及对感情关系的满意度，但研究结果不具有普遍意义(JAMA 2012;308:714-6)。
By: MICHELE G. SULLIVAN, Internal Medicine News Digital Network
A cognitive-behavioral couples therapy specially targeted at posttraumatic stress disorder helped improve symptoms and increased patient satisfaction within the relationship.
"There is increasing recognition that intimate relationships play a potent role in recovery from PTSD, its comorbid symptoms, and the psychosocial impairments that accompany it," Candice M. Monson, Ph.D., and her colleagues wrote in the Aug. 15 issue of JAMA. "Cognitive behavioral conjoint therapy may be used to efficiently address individual and relational dimensions of traumatization and might be indicated for individuals with PTSD who have stable relationships and partners who are willing to engage in treatment with them."
Dr. Monson, professor of psychology at Ryerson University in Toronto, examined the efficacy of an intervention called cognitive-behavioral conjoint therapy, which stressed education, communication, and conflict resolution. She and her associates randomized 40 couples to either the 3-month PTSD program or a wait list. The primary end point was change on the CAPS (Clinician-Administered PTSD Scale). Secondary end points included change on the PTSD Checklist, the DAS (Dyadic Adjustment Scale), the BDI (Beck Depression Inventory), and the State-Trait Anxiety Inventory (JAMA 2012;308:700-9).
The participants were a mean of 40 years old and had been married for 5-8 years. Causes of PTSD included adult or childhood sexual trauma, noncombat physical assault, motor vehicle collision, witnessing or learning about death or illness, and combat-related issues. Time since the trauma ranged from 44 years to fewer than 12 months. Many of the partners with PTSD also had at least one comorbid condition, including mood disorder (up to 90%), anxiety disorder (50%), and substance abuse or dependence (45%).
The intervention consisted of 15 sessions covering three psychosocial realms; the sessions were held twice a week. Phase 1 targeted learning about PTSD and its relational effects. Phase 2 focused on enhanced communication. Phase 3 challenged couples to actively improve their relationships by putting these new skills to work. Couples also were followed for an additional 3 months to determine whether improvements could be maintained.
At the conclusion of the treatment period, PTSD symptom severity had decreased almost three times as much as it did in the control arm. Partner relationship satisfaction had improved four times more. There were also gains in the secondary end points of depression, anger, and anxiety.
After the 3-month follow-up period, 81% of couples reported sustained gains in PTSD symptoms and 81% no longer met the criteria for a PTSD diagnosis. All of the couples reported satisfaction with their relationship.
The investigators cautioned, however, that the relatively high partner satisfaction reported at baseline might have skewed the results somewhat. There was "little evidence of differences between the [intervention group] and the wait list in partner-reported relationship satisfaction, and partners’ ratings of PTSD symptom improvements were not as consistent with the clinicians’ ratings," they said.
Past research in this area yielded more partner-rated benefits, which were similar to those observed by clinicians, wrote Dr. Monson and her coauthors.
The study was sponsored by the National Institute of Mental Health. Dr. Monson had no financial declarations. Dr. Najavits reported no financial disclosures.
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Couples Therapy Might Help - But Whom?
Although the couples therapy program described in Dr. Monson’s paper did improve patients’ symptoms and their perspectives on their intimate relationships, it’s hard to fit those changes into the context of other research data, Lisa M. Najavits, Ph.D., said in an accompanying editorial (JAMA 2012;308:714-6).
Couples in both the active and investigational groups were carefully selected and were already somewhat healthy at baseline, noted Dr. Najavits.
"From a clinical perspective, the study sample appeared ‘easier to treat’ than is typical in community settings, as indicated by baseline measurements of relationship satisfaction, a general lack of severe comorbidities and the support of an intimate partner who was willing to participate in the treatment," she wrote.
The groups also were mostly white and employed, which added a measure of stability that many struggling couples lack, she noted.
"Although the results of this trial were positive, study participants were carefully selected and thus, the applicability of this intervention to a wide range of clinical settings and patients characteristics remains unclear."
Because of this, it’s hard to generalize the results to other couples, who might have already experienced more stresses resulting from PTSD. The trial "cannot be interpreted as being applicable to couples with these additional challenges," who may be the couples in greatest need of help, she said.
DR. NAJAVITS is professor of psychiatry at Boston University, a lecturer at Harvard Medical School in Boston, a clinical psychologist at the Veterans Affairs Boston Healthcare System, and a clinical associate at McLean Hospital in Belmont, Mass. She reported no financial disclosures.