Evidence-based Synthesis Program Department of Veterans Affairs

Health Services Research & Development Service Evidence-based Synthesis Program 

Efficacy of Complementary and 

Alternative Medicine Therapies

for Posttraumatic Stress Disorder

Department of Veterans Affairs

Health Services Research & Development Service

August 2011

Investigators:

Principal Investigator:

Jennifer L. Strauss, Ph.D.

Co-Investigators:

Remy Coeytaux, M.D., Ph.D.

Jennifer McDuffie, Ph.D.

John W. Williams Jr., M.D., M.H.Sc

Research Associate:

Avishek Nagi, M.S.

Medical Editor:

Liz Wing, M.A.

Prepared for:

Department of Veterans Affairs

Veterans Health Administration

Health Services Research & Development Service

Washington, DC 20420

Prepared by:

Evidence-based Synthesis Program (ESP) Center 

Durham Veterans Affairs Healthcare System

Durham, NC

John W Williams Jr., M.D., M.H.Sc, Director
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Efficacy of Complementary and Alternative Medicine 

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PREFACE

Health Services Research & Development Service’s (HSR&D’s) Evidence-based Synthesis 

Program (ESP) was established to provide timely and accurate syntheses of targeted healthcare 

topics of particular importance to Veterans Affairs (VA) managers and policymakers, as they 

work to improve the health and healthcare of Veterans. The ESP disseminates these reports 

throughout VA.

HSR&D provides funding for four ESP Centers and each Center has an active VA affiliation. The 

ESP Centers generate evidence syntheses on important clinical practice topics, and these reports 

help:

• develop clinical policies informed by evidence,

• guide the implementation of effective services to improve patient outcomes and to 

support VA clinical practice guidelines and performance measures, and 

• set the direction for future research to address gaps in clinical knowledge.

In 2009, the ESP Coordinating Center was created to expand the capacity of HSR&D Central 

Office and the four ESP sites by developing and maintaining program processes. In addition, 

the Center established a Steering Committee comprised of HSR&D field-based investigators, 

VA Patient Care Services, Office of Quality and Performance, and Veterans Integrated Service 

Networks (VISN) Clinical Management Officers. The Steering Committee provides program 

oversight, guides strategic planning, coordinates dissemination activities, and develops 

collaborations with VA leadership to identify new ESP topics of importance to Veterans and the 

VA healthcare system.

Comments on this evidence report are welcome and can be sent to Nicole Floyd, ESP 

Coordinating Center Program Manager, at nicole.floyd@va.gov.

Recommended citation: Strauss JL, Coeytaux R, McDuffie J, Nagi A, Williams JW Jr. Efficacy 

of Complementary and Alternative Therapies for Posttraumatic Stress Disorder. VA-ESP Project 

#09-010; 2011.

This report is based on research conducted by the Evidence-based Synthesis 

Program (ESP) Center located at the Durham VA Medical Center, Durham, NC, 

funded by the Department of Veterans Affairs, Veterans Health Administration, 

Office of Research and Development, Health Services Research and Development. 

The findings and conclusions in this document are those of the author(s) who are 

responsible for its contents; the findings and conclusions do not necessarily represent 

the views of the Department of Veterans Affairs or the United States government. 

Therefore, no statement in this article should be construed as an official position of 

the Department of Veterans Affairs. No investigators have any affiliations or financial 

involvement (e.g., employment, consultancies, honoraria, stock ownership or options, 

expert testimony, grants or patents received or pending, or royalties) that conflict with 

material presented in the report.
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Efficacy of Complementary and Alternative Medicine 

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TABLE OF CONTENTS

EXECUTIVE SUMMARY

Background.................................................................................................................................................... 1

Methods......................................................................................................................................................... 1

Data Synthesis............................................................................................................................................... 2

Peer Review................................................................................................................................................... 2

Results ........................................................................................................................................................... 2

Future Research............................................................................................................................................. 3

Abbreviations Table....................................................................................................................................... 4

INTRODUCTION

Background.................................................................................................................................................... 5

METHODS

Topic Development........................................................................................................................................ 9

Analytic Framework.................................................................................................................................... 10

Search Strategy............................................................................................................................................ 10

Study Selection............................................................................................................................................ 11

Data Abstraction .......................................................................................................................................... 13

Quality Assessment ..................................................................................................................................... 13

Data Synthesis............................................................................................................................................. 13

Rating the Body of Evidence....................................................................................................................... 14

Peer Review................................................................................................................................................. 14

RESULTS

Literature Search ......................................................................................................................................... 15

Study Characteristics................................................................................................................................... 16

KQ 1: In adults with PTSD, are mind-body complementary and alternative medicine therapies (e.g., 

acupuncture, yoga, meditation) more efficacious than control for PTSD symptoms and healthrelated quality of life?...................................................................................................................... 19

KQ 2: In adults with PTSD, are manipulative and body-based complementary and alternative medicine 

therapies (e.g., spinal manipulation, massage) more efficacious than control for PTSD symptoms 

and health-related quality of life?.................................................................................................... 31

KQ 3: In adults with PTSD, are complementary and alternative medicine therapies that are movementbased or involve energy therapies more efficacious than control for PTSD and health-related 

quality of life?.................................................................................................................................. 32

KQ 4: For treatments evaluated in KQs 1–3 that lack randomized controlled trials, is there evidence 

from other study designs that suggests the potential for treatment efficacy?.................................. 33

SUMMARY AND DISCUSSION

Summary of Evidence by Key Question ..................................................................................................... 37

Limitations................................................................................................................................................... 39

Recommendations for Future Research....................................................................................................... 40

Conclusions ................................................................................................................................................. 42
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REFERENCES ................................................................................................................................................... 43

APPENDIX A. SEARCH STRATEGIES................................................................................................ 49

APPENDIX B. STUDY SELECTION FORM...................................................................................... 50

APPENDIX C. SAMPLE DATA EXTRACTION FORM................................................................ 52

APPENDIX D. CRITERIA USED IN QUALITY ASSESSMENT............................................... 58

APPENDIX E. PEER REVIEW COMMENTS/AUTHOR RESPONSES................................ 60

APPENDIX F. EXCLUDED STUDIES .................................................................................................. 68

APPENDIX G. GLOSSARY......................................................................................................................... 71

FIGURES

Figure 1. Analytic framework for CAM therapies for PTSD...................................................................... 10

Figure 2. Literature flow diagram................................................................................................................ 16

TABLES

Table 1. Summary of inclusion and exclusion criteria ................................................................................ 11

Table 2. Summary of study characteristics.................................................................................................. 17

Table 3. Summary of outcome measures..................................................................................................... 18

Table 4. Characteristics of mind-body interventions (KQ 1) ...................................................................... 20

Table 5. Ongoing RCTs of mind-body interventions (KQ 1)...................................................................... 29

Table 6. Characteristics of manipulative and body-based interventions (KQ 2)......................................... 31

Table 7. Characteristics of nonrandomized CAM treatment studies (KQ 4)............................................... 34

Table 8. Nonrandomized studies (KQ 4)..................................................................................................... 36

Table 9. Summary of the strength of evidence for KQs 1–3 ....................................................................... 37
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EVIDENCE REPORT

INTRODUCTION

Posttraumatic stress disorder (PTSD) is among the most common Axis I disorders, with an 

estimated lifetime prevalence in the U.S. of approximately 7 percent.1 PTSD is often chronic and 

is associated with significant adverse consequences, including high rates of depression and other 

psychiatric comorbidities; substance abuse; suicidality; impaired social, occupational, and family 

functioning; decreased quality of life; and increased rates of medical morbidity, health risk 

behaviors, and health service use.1-9 PTSD is the emotional disorder most frequently associated 

with combat and other potentially traumatic experiences that may occur during the course of 

military service (e.g., sexual assault, motor vehicle injury). Over 2.2 million U.S. troops have 

deployed in Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF).10 One 

anticipated consequence of this sustained period of military operations is the increased incidence 

of PTSD among Veterans. Among OEF/OIF Veterans who received Department of Veterans 

Affairs (VA) care between 2002 and 2008, 22 percent were diagnosed with PTSD.11 In addition 

to increased mental health service use among this newest generation of Veterans, the VA has 

witnessed the sharpest increase in mental health service use among Vietnam-era Veterans.12 As 

the VA strives to anticipate and serve the treatment needs of the Veteran population, including 

those returning from current Middle East conflicts as well as Veterans of previous service eras, 

identifying and implementing effective PTSD treatment approaches remains a critical priority. 

Complementary and alternative medicine (CAM) interventions are popular among consumers 

and are widely employed to treat diverse physical and mental health conditions.13 The results 

of a recent national survey show that nearly 38 percent of U.S. adults use CAM approaches 

to manage a range of physical and emotional health concerns, including pain, anxiety, and 

depression.14,15 Such widely used practices deserve careful evaluation and may hold promise as 

either adjunctive or primary PTSD therapies. Thus, this evidence synthesis was requested by VA 

Research and Development to inform decisions on the need for research in this area. This report 

reviews the evidence for common CAM approaches for PTSD—excluding natural products such 

as nutritional supplements—and examines mind-body therapies, manipulative and body-based 

practices, and practices that are movement-based or involve energy therapies.

BACKGROUND

The current VA/Department of Defense (DoD) Clinical Practice Guideline for the Management 

of Posttraumatic Stress (October 2010)16 recommends the following evidence-based, firstline therapies for PTSD: (1) trauma-focused cognitive behavioral psychotherapies, (2) stress 

inoculation training (SIT), and (3) pharmacotherapies. These recommendations are largely 

consistent with previously published practice guidelines and systematic reviews (e.g., Bisson and 

Andrew,17 Foa and colleagues,18 Institute of Medicine19). 
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Overview of Current Evidence-based PTSD Therapies 

Trauma-focused psychotherapies

The category of trauma-focused psychotherapies incorporates several multicomponent, PTSDspecific interventions that share a theoretical foundation in cognitive behavioral principles. 

Consistent with a cognitive behavioral framework, the key components of trauma-focused 

psychotherapies may include in vivo and narrative/imaginal exposure as well as cognitive 

restructuring exercises. These treatments are designed to decrease emotional response through 

habituation and to modify maladaptive thoughts, behaviors, and emotions associated with PTSD. 

Most trauma-focused psychotherapy protocols combine administration of these exercises with 

psychoeducation and training in relaxation and anxiety-management techniques. Of note, several 

commonly employed relaxation techniques, such as breathing and muscle relaxation, are also 

consistent with CAM approaches. However, in the case of trauma-focused psychotherapies, these 

strategies are not hypothesized to be core mechanisms of change. Rather, they are introduced 

early in treatment to support the patient’s later engagement in key trauma-focused elements of 

treatment (e.g., exposure techniques and cognitive exercises). 

The most well established of the trauma-focused psychotherapies are prolonged exposure 

therapy, cognitive processing therapy, and eye movement desensitization and reprocessing 

(EMDR). Although the comparative efficacy of these interventions has not yet been established,17

collectively the category of trauma-focused therapies has a strong empirical base. On average, 

56 percent of patients who enter treatment (intent-to-treat) and 67 percent of patients who 

complete treatment no longer meet criteria for PTSD at posttreatment.20 In clinical trials, traumafocused therapies show large effects compared to waitlist control (average effect size = 1.11) and 

moderate effects compared to supportive therapy (average effect size = 0.82).20

Stress inoculation training approaches

SIT protocols for PTSD provide training in anxiety management and coping skills to “inoculate” 

against heightened stress responses that are presumed central to the maintenance of PTSD. 

SIT protocols provide a tool kit of cognitive behavioral and mind-body stress management 

techniques, including progressive muscle relaxation, breathing retraining, positive thinking and 

self-talk, assertiveness training, and thought stopping.16 As with trauma-focused psychotherapies, 

several CAM techniques (e.g., release of muscle tension and breathing techniques to invoke 

relaxation) are common components of these interventions. However, SIT approaches (like 

trauma-focused psychotherapies) are theoretically grounded in cognitive behavioral theories of 

change and impart training in cognitive behavioral stress management techniques. Hence, for this 

review, and consistent with the theoretical basis of this treatment approach, SIT is considered a 

cognitive behavioral intervention.

Pharmacotherapies

First-line, evidence-based pharmacotherapies for PTSD include selective serotonin reuptake 

inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs), administered 

as monotherapies.16,18,21 Both SSRIs and SNRIs are presumed to improve psychobiological 

dysfunction believed to be characteristic of the syndrome of PTSD. Of the SSRIs, the strongest 

evidence base currently exists for paroxetine and sertraline, for which response rates are near 60 

percent.21,22
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Among the SNRIs, venlafaxine has the strongest support.16 For example, one recent randomized 

controlled trial (RCT) found that 78 percent of patients treated with venlafaxine experienced a 

positive clinical response (i.e., > 30% decrease in symptom severity) although only 40 percent 

achieved remission.23 In contrast to current clinical practice guideline recommendations, it should 

be noted that the Institute of Medicine’s recent review of PTSD therapies (2007)19 concluded 

that there is insufficient evidence to support the use of pharmacotherapies for PTSD. In response 

to this controversial recommendation, one committee member appended19 an alternative 

conclusion in support of SSRIs as well as novel antipsychotics. Despite current controversies, 

pharmacotherapies—particularly SSRIs and SNRIs—are widely accepted as standard first-line 

treatment. 

Limitations of Current Evidence-based PTSD Therapies

Despite mounting empirical support for the treatments summarized above and tremendous 

efforts within the clinical research community to refine and optimize these approaches, each 

is associated with limitations and potential barriers to broad dissemination and uptake. Issues 

of access, patient preference/acceptability, and suitability are the primary limiting factors. 

For example, trauma-focused psychotherapies may provoke emotional responses, and some 

patients may have difficulty managing these reactions, or may choose not to engage in therapies 

that can cause emotional (albeit short-term) discomfort. Thus, the current VA/DoD Clinical 

Practice Guideline recommends careful screening of patients’ suitability for these modalities 

and recommends against their use with certain patients (e.g., those with current substance abuse, 

psychosis, or health problems for which intense physiological arousal is contraindicated).16 Also, 

all current evidence-based psychotherapies require specialized training and frequent provider 

contact, which may limit their accessibility. This potential limitation is of particular relevance 

for patients located in areas in which clinical resources are limited (e.g., rural) and those whose 

schedules cannot readily accommodate frequent sessions (e.g., because of work constraints or 

lack of childcare). Finally, psychotherapies are typically delivered in mental health specialty 

clinics, which may present a barrier for those concerned about perceived stigma associated with 

receiving care in a mental health setting, or for those who distrust mental health providers.24

In contrast to psychotherapies for PTSD, pharmacotherapies generally require less frequent and 

shorter contact with a provider and are routinely administered in both mental health and primary 

care clinics. However, some patients are not amenable to pharmacological interventions,25 and 

current evidence indicates that nearly 27 percent of patients will prematurely discontinue SSRIs 

due to treatment failure or adverse side effects, including sexual dysfunction, weight gain, 

and sleep disturbance.26 Finally, existing studies suggest that medications alone are often not 

sufficient to relieve symptoms, and there is some evidence that men are less likely than women to 

benefit from pharmacological PTSD treatments.27 Therefore, current evidence-based treatments 

for PTSD are not always appropriate, well-tolerated, accessible, adequate, or congruent with 

patient preferences.

Complementary and Alternative Medicine

CAM is commonly used to describe a wide range of therapies that are not generally considered 

standard components of modern medicine as practiced by physicians in the U.S. Yet, many 

CAM treatments, such as acupuncture, are part of traditional medical practices in other parts 
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of the world. The National Center for Complementary and Alternative Medicine (NCCAM) in 

the National Institutes of Health (NIH) has proposed a classification system for CAM therapies 

that includes natural products (e.g., dietary supplements, herbal remedies, probiotics), mindbody medicine (e.g., meditation, yoga, acupuncture), manipulative and body-based practices 

(e.g., spinal manipulation, massage therapy), whole medical systems (e.g., traditional Chinese 

medicine, Ayurvedic medicine), and other alternative practices (e.g., light or magnet therapy, 

movement therapies). Although this definition and classification system is helpful, it is imperfect 

since some treatments, such as biofeedback, are considered conventional treatment by some 

experts and CAM treatment by others. For some CAM therapies, such as acupuncture, there 

is a growing body of scientific literature evaluating efficacy or possible mechanisms of action. 

However, for many CAM therapies there remains a lack of scientific evidence on efficacy, harms, 

indications, appropriate dosing, or mechanisms of action.

Rationale for an Evidence-based Synthesis of CAM Therapies for PTSD

CAM interventions are widely requested and used by mental health consumers including 

Veterans and active duty personnel; mental health–related concerns are among the most common 

reasons for seeking care from a CAM provider.13-15,28,29 If efficacious, these treatments may 

merit consideration as either first-line or adjunctive PTSD treatments. Most CAM treatments 

considered in this report are noninvasive or minimally invasive; considered unlikely to result 

in adverse side effects; and in some cases may be more congruent with individual treatment 

preferences than currently recommended traditional treatment options. Numerous stakeholders 

have expressed strong interest in fostering the evidence base for these approaches in PTSD.16,30

Consistent with these directives, this evidence synthesis was requested by VA Research and 

Development to inform decisions on the need for further research in this area. This report thus 

reviewed the evidence for common CAM approaches for treating PTSD.
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METHODS

TOPIC DEVELOPMENT

This review was commissioned by the Department of Veterans Affairs’ Evidence-based 

Synthesis Program. The key questions (KQs) were developed after a topic refinement process 

that included a preliminary review of published, peer-reviewed literature and consultations with 

content experts and key stakeholders in the treatment of PTSD. During this topic refinement 

process, selected CAM therapies were prioritized for the report; natural products (e.g., dietary 

supplements) were excluded. CAM therapies were classified using categories proposed by the 

NCCAM, and the KQs reflect this classification. 

The final KQs were:

KQ 1. In adults with PTSD, are mind-body complementary and alternative medicine therapies 

(e.g., acupuncture, yoga, meditation) more efficacious than control for PTSD symptoms and 

health-related quality of life? 

KQ 2. In adults with PTSD, are manipulative and body-based complementary and alternative 

medicine therapies (e.g., spinal manipulation, massage) more efficacious than control for PTSD 

symptoms and health-related quality of life?

KQ 3. In adults with PTSD, are complementary and alternative medicine therapies that are 

movement-based or involve energy therapies more efficacious than control for PTSD symptoms 

and health-related quality of life? 

KQ 4. For treatments evaluated in KQs 1–3 that lack randomized controlled trials, is there 

evidence from other study designs that suggests the potential for treatment efficacy?
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ANALYTIC FRAMEWORK

We developed and followed a standard protocol for all steps of this review. Our approach was 

guided by the analytic framework shown in Figure 1.

Figure 1. Analytic framework for CAM therapies for PTSD

Examples of interventions:

•	 Mind-body therapies: acupuncture, meditation, yoga, deep-breathing exercises, guided imagery, hypnotherapy, 

progressive relaxation, and tai chi

•	 Manipulative and body-based therapies: spinal manipulation and massage therapy

•	 Movement-based therapies: Feldenkrais method, Alexander technique, Pilates, Rolfing Structural Integration, and 

Trager Psychophysical Integration

•	 Energy therapies: magnet therapy, light therapy, qi gong, Reiki, and healing touch

SEARCH STRATEGY

We searched English-language publications in MEDLINE® (via PubMed®), Embase®, 

PsycINFO®, Cumulative Index to Nursing and Allied Health Literature® (CINAHL), and the 

Cochrane Controlled Trials Registry from database inception through December 22, 2010. 

Search terms included terms for CAM therapies (acupuncture, mind-body, sensory art, yoga, 

reflexotherapy, musculoskeletal manipulation), PTSD, and RCTs. We used these limit terms: 

all adults ≥ 19 years of age, humans, and English. In addition, we searched the Published 

International Literature on Traumatic Stress (PILOTS) database (April 26, 2011), a specialized 

PTSD database maintained by the National Center for Posttraumatic Stress Disorder, to identify 

existing systematic reviews and studies of relaxation treatments. 

KQ4

Other prospective study 

designs when no published 

RCTs available

Randomized controlled trials: KQs 1-3

Mind-body

therapies*

Manipulative and

body-based

therapies*

Movement-based

and energy

therapies*

KQ1 KQ2 KQ3 KQs 1-3

Adverse

effects

Population

Adults with PTSD

Comparators

Usual care,

empirically-based treatments

Primary Outcomes

• PTSD symptoms

• Health-related quality 

of life

Secondary Outcomes

• Patient statisfaction

• Treatment adherence

• Functional status
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We supplemented electronic searching by examining the bibliographies of included studies and 

review articles. When RCTs were not identified, we searched for prospective studies by adapting 

the sensitive “therapy filter” contained in PubMed clinical queries. To assure completeness, 

search strategies were developed in consultation with a master librarian. The search terms and 

MeSH headings for the search strategies appear in Appendix A. In addition to searching the 

published literature, we searched ClinicalTrials.gov (www.clinicaltrials.gov) (April 7, 2011) 

to identify studies in progress or completed studies that have not been published in the peerreviewed literature.

STUDY SELECTION

Using prespecified inclusion/exclusion criteria, two reviewers assessed the list of titles and 

abstracts. Full-text articles identified by either reviewer as potentially relevant were retrieved for 

further review. Each article retrieved was reviewed by two reviewers using the eligibility criteria 

in Appendix B; disagreements were resolved by discussion or by a third reviewer. To be included 

in the evidence synthesis, a study had to (1) be an RCT, (2) compare an eligible treatment to 

an empirically-based treatment or to a control condition, and (3) include a sample diagnosed 

with PTSD. Because relaxation is often used as a placebo control in trials of psychotherapy, 

we further specified that relaxation interventions must be presented as an active treatment and 

described in sufficient detail to understand the key components. As noted earlier, studies that 

included relaxation training introduced within the context of a standard PTSD therapy, such as 

prolonged exposure or SIT, were conceptualized as non-CAM and thus ineligible for this review. 

In the absence of any RCT for a given treatment, we examined other prospective study designs. In 

response to a request from stakeholders, we categorized reasons for exclusion in a subsample of 

600 studies excluded during the initial abstract review. Detailed eligibility criteria are described in 

Table 1.

Table 1. Summary of inclusion and exclusion criteria

Study 

characteristic Inclusion criteria Exclusion criteria

Study design KQs 1–3: RCTs

KQ 4: Other study designs when no RCTs were 

identifieda

Non–English language publication

Non–peer-reviewed publication

Population Adults ≥ 19 diagnosed with PTSD using DSM criteria, 

validated severity measures (e.g., PTSD checklist), or 

clinical diagnosis

Patients in acute-phase treatment (i.e., not selected 

for treatment-resistant PTSD)

Patients with complicated PTSD or 

acute suicidality

Studies with eligibility criteria 

requiring a diagnosis of PTSD 

comorbid with another mental or 

physical illness (e.g., PTSD and 

substance abuse)
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Study 

characteristic Inclusion criteria Exclusion criteria

Interventions Any of the following eligible treatments:

•	 Mind-body therapies: acupuncture, meditation, 

yoga, deep-breathing exercises, guided imagery, 

hypnotherapy, progressive relaxation, and tai chi

•	 Manipulative and body-based therapies: spinal 

manipulation and massage therapy

•	 Movement-based therapies: Feldenkrais method, 

Alexander technique, Pilates, Rolfing Structural 

Integration, and Trager Psychophysical Integration

•	 Energy therapies: magnet therapy, light therapy, qi 

gong, Reiki, and healing touch

Interventions used in a continuation 

or maintenance phase

Dietary supplements

Standard psychotherapies 

(e.g., prolonged exposure) and 

extensions of these therapies 

(e.g., mindfulness-based cognitive 

therapy)

Relaxation used as a control arm or 

reported without describing the key 

components

Biofeedback

Comparators Studies comparing an eligible treatment to a 

control condition such as usual care (including no 

treatment), supportive therapy, attention control, sham 

intervention, or a waitlist 

Studies comparing an eligible treatment to an 

empirically based treatment, prolonged exposure, 

cognitive processing therapy, or antidepressant 

medication

None

Outcomes Change in level of PTSD symptoms (i.e., on selfreport and/or clinician-administered measures, 

including remission rates) or change in quality of life 

(i.e., functional status and health-related quality of life)

Social functioning, patient satisfaction with treatment, 

treatment adherence/retention (e.g., proportion of 

prescribed sessions that are completed, completion 

of between-session assignments), and adverse 

treatment effects

Reported at ≥ 6 weeks after treatment initiation

None

Setting Patients recruited from community or outpatient 

mental health or general medical settings 

Studies conducted outside North 

America, Western Europe, Australia, 

or New Zealand. Studies conducted 

outside of these countries were 

unlikely to be applicable to VA 

populations because of important 

differences in culture and health 

care systems.

a

The eligibility criteria for nonrandomized controlled trials matched the criteria for KQs 1–3 except for study design. For each 

intervention that lacked eligible RCTs, we included prospective studies (nonrandomized controlled trials, controlled before-andafter studies, and prospective cohort studies and case series).

Abbreviations: DSM = Diagnostic and Statistical Manual of Mental Disorders, PTSD = posttraumatic stress disorder, RCT = 

randomized controlled trial, VA = Veterans Affairs 

Studies identified from the ClinicalTrials.gov search were included if they were an RCT of an 

eligible CAM intervention and evaluated adults with PTSD. In addition, we included completed 

studies when a MEDLINE search (April 2011) using the name of the principal investigator did 

not identify a published study reporting clinical outcomes. 
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DATA ABSTRACTION

A trained researcher abstracted data from published reports into a data abstraction form 

(Appendix C); a second reviewer overread the abstracted data. We resolved disagreements by 

consensus among the first and second reviewer or by obtaining a third reviewer’s opinion when 

consensus could not be reached. We abstracted the following data for each included study: 

•	 study design

•	 setting

•	 population characteristics

•	 subject eligibility and exclusion criteria

•	 number of subjects and providers

•	 intervention(s)

•	 comparison(s)

•	 length of followup

•	 outcome(s)

For studies identified in ClinicalTrials.gov with no identified peer-reviewed publication of study 

results, we abstracted a limited set of data: study title, intervention, comparator, funding agency, 

funding dates, and study status.

QUALITY ASSESSMENT

We assessed the risk of bias pertaining to the key questions using the quality criteria described in 

the Agency for Healthcare Research and Quality (AHRQ) Methods Guide for Effectiveness and 

Comparative Effectiveness Reviews (hereafter referred to as the Methods Guide),31 adapted for 

this specific topic. For RCTs, we abstracted data on adequacy of randomization and allocation 

concealment, comparability of groups at baseline, blinding, completeness of followup and 

differential loss to followup, whether incomplete data were addressed appropriately, validity of 

outcome measures and completeness of outcomes reporting, and conflict of interest. Using these 

data elements, we assigned a summary quality score of Good, Fair, or Poor to individual RCTs. 

Because non-RCT studies were included for descriptive purposes, we did not assess their quality.

We assessed studies for applicability to U.S. Veterans. In addition to the quality rating for 

individual studies, we evaluated the overall quality of the evidence for each KQ as proposed by 

the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) Working 

Group (Appendix D).32

DATA SYNTHESIS

We critically analyzed studies to compare their characteristics, methods, and findings. We 

compiled a summary of findings for each KQ or clinical topic and drew conclusions based on 

a qualitative synthesis of the findings. There were not sufficient studies to perform quantitative 

meta-analyses. When the evidence was sufficient to estimate an effect, we computed the 

standardized mean difference (SMD) using Hedges g for continuous outcomes, to facilitate 

comparisons across studies. The SMD is useful when studies assess the same outcome, but with 

different measures. In this circumstance, it is necessary to standardize the results for the studies 
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to a uniform scale to facilitate comparisons and to combine in meta-analysis. We calculated the 

SMD for each study by subtracting (at posttest) the average score of the control group from the 

average score of the experimental group and dividing the result by the pooled standard deviations 

(SDs) of the experimental and control groups. A negative SMD indicates a greater effect in the 

intervention group. For example, an effect size of -0.5 indicates that the mean decline in PTSD 

symptom severity for the experimental group is half an SD greater than the mean decline in the 

control group. SMD is commonly interpreted as small (0.2), moderate (0.5), or large (≥ 0.80).33,34

RATING THE BODY OF EVIDENCE

We assessed the overall body of evidence for outcomes using a method developed by the 

GRADE Working Group, which classified the grade of evidence across outcomes according to 

the following criteria:

•	 High—Further research is very unlikely to change our confidence on the estimate of 

effect.

•	 Moderate—Further research is likely to have an important impact on our confidence in 

the estimate of effect and may change the estimate.

•	 Low—Further research is very likely to have an important impact on our confidence in 

the estimate of effect and is likely to change the estimate.

•	 Insufficient—Evidence on an outcome is absent or too weak, sparse, or inconsistent to 

estimate an effect.

PEER REVIEW

A draft version of the report was reviewed by technical experts and clinical leadership, and their 

comments are provided in Appendix E.
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RESULTS

LITERATURE SEARCH

We identified 1776 unique citations from a combined search of MEDLINE® (via PubMed®, n = 

353), Embase® (n = 451), CINAHL® (n = 429), PsychINFO® (n = 390), Cochrane Database of 

Systematic Reviews (n = 32), and the PILOTS database (n = 121). By manual examination of 

the bibliographies of included studies and review articles, we identified four additional citations. 

Of these, 1738 were excluded at the title-and-abstract level. Of the 1738 studies excluded at the 

title-and-abstract level, we reevaluated and categorized the reason for exclusion in a subsample 

of 600 citations. The most common reasons for exclusion were review article (23%); a drug or 

a non-CAM intervention (22%); a “standard treatment” (e.g., EMDR or CBT) without a CAM 

comparator (14%); a sample under 19 years of age (13%); a sample that did not have PTSD 

(10%); and evaluation of therapies that were neither standard for PTSD nor for CAM (10%).

An additional 29 studies were excluded following full-text review. The question of what type 

of relaxation study was applicable to our report was a complicated one. Our literature search 

identified six citations that included a relaxation treatment arm but did not meet full eligibility 

criteria. Of these, one did not evaluate a population with PTSD;35 one was determined not 

to be CAM because the relaxation was delivered in conjunction with biofeedback;36 two 

conceptualized the relaxation as a control group rather than an active treatment;37,38 and one study 

with three citations did not describe the key components of the relaxation intervention such that 

it could not be categorized as CAM or otherwise.39-41

Nine published studies were retained and abstracted for this evidence synthesis, including 7 

RCTs (described in 12 articles) and 2 non-RCTs. Five articles contained previously described 

demographic or descriptive data for the seven RCTs; these studies are referred to as “companion” 

studies.

Additionally, our search of www.clinicaltrials.gov identified 438 potentially relevant, 

unpublished trials. Of these, 16 were RCTs of an eligible CAM therapy for PTSD and are 

described in the applicable KQ sections that follow. There were also three non-RCTs, described 

in the KQ 4 section.

Figure 2 illustrates each step of our literature search process. Appendix F provides a complete 

listing of articles excluded at the full-text stage, with reasons for exclusion.
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Figure 2. Literature flow diagram

Excluded = 29 references

Population not PTSD = 10

Setting not of interest = 2

Intervention not complementary medicine = 11

Comparator not appropriate = 1

Not Westernized culture = 1

Language not English = 1

Not primary data = 3

KQ 2 (RCT manipulative 

and body-based CAM) 

1 trial + 1 companion 

study

Pulled for full text review = 38 

references

KQ 1 (RCT mindbody CAM) 

6 trials + 4 companion 

studies

Search results = 1776 references

Included = 9 trials and 5 companion 

studies*

Excluded = 1738 references

Excluded at the title/abstract level

KQ 4 (non-RCT CAM) 

2 trial + 0 companion 

studies

KQ 3 (RCT movementbased or energy-based 

CAM) 

0 trials + 0 companion 

studies

*Reference list includes additional references cited for background and methods plus Web sites relevant to KQs.

Abbreviations: KQ = key question, CAM = complementary and alternative medicine, PTSD = posttraumatic stress disorder, RCT 

= randomized controlled trial

STUDY CHARACTERISTICS

Basic characteristics of these studies are summarized in Table 2. A total of 7 RCTs (296 subjects) 

and 2 non-RCTs (41 subjects) met eligibility criteria. Of the RCTs, three evaluated relaxation, 

two evaluated meditation, and one each evaluated acupuncture and massage interventions. There 

were no RCTs identified that examined movement-based or energy therapies. To be eligible for 

participation, all studies required patients to meet DSM criteria for PTSD, and four of the seven 

RCTs included military Veterans. All studies reported PTSD symptom outcomes, but healthrelated quality of life (HRQOL), patient satisfaction, social functioning, and adverse effects were 

reported less frequently. Only one RCT was good quality.

Common study limitations included (1) a lack of power to draw meaningful conclusions, (2) the 

absence of explanations for missing data and dropouts, and (3) analyses that were performed 

on completers rather than intent-to-treat samples. In addition, important aspects of the study 
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design and sample characteristics were frequently unclear in the fair- and poor-quality articles. 

For example, it was difficult in every case to discern whether the groups being compared were 

truly comparable at baseline. The nonrandomized studies used prospective cohort and case series 

designs. 

Table 2. Summary of study characteristics

Study Study design (n) Qualitya Intervention vs. comparator Outcome measuresb

RCTs of mind-body interventions: KQ 1

Bormann et al., 

200842

RCT (n = 29) Fair Mantram repetition vs. usual 

care

CAPS, PCL, Q-LES-Q-SF, 

FACIT-SpEx4, CSQ

Brooks and 

Scarano, 198543

RCT (n = 25) Poor Transcendental meditation vs. 

psychotherapy

PVSDS, individual items to 

assess employment status 

and family problems 

Echeburúa et al., 

199644

RCT (n = 20) Poor Progressive muscle relaxation 

vs. cognitive behavioral 

therapy

SS-PTSD, SOA

Hollifield et al, 

200745

RCT (n = 84) Good Acupuncture vs. group 

cognitive behavioral therapy 

vs. waitlist

PSS-SR, SDI

Vaughan et al., 

199446

RCT (n = 36) Fair Applied muscle relaxation vs. 

image habituation training vs. 

EMDR

SI-PTSD, IES

Watson et al., 199747 RCT (n = 90) Poor Simple relaxation instruction 

vs. relaxation instruction + 

deep breathing vs. relaxation 

instruction + deep breathing 

and thermal biofeedback

PTSD-I

M-PTSD

RCT of manipulative and body-based interventions: KQ 2

Price, 200648,49 RCT (n = 8) Poor Body-oriented therapy 

(massage) vs. waitlist

CR-PTSD

Non-RCTs of CAM therapies for PTSD: KQ 4

Abramowitz and 

Lichtenberg, 201050

Prospective cohort 

(n = 36)

NA Hypnotherapeutic olfactory 

conditioning 

IES-R

Hossack and 

Bentall, 199651

Case series (n 

= 5); 17 and 29 

weeks

NA Relaxation and visual 

kinesthetic dissociation

IES

a

Study quality assessed via key quality criteria described in Agency for Healthcare Research and Quality’s (AHRQ’s) Methods 

Guide for Effectiveness and Comparative Effectiveness Reviews.31

b

Outcomes limited to those with direct relevance to KQs 1–4 (i.e., PTSD severity/diagnosis, HRQOL).

Abbreviations: CAPS = Clinician-Administered PTSD Scale, CR-PTSD = Crime-Related Post Traumatic Stress Disorder 

Scale, EMDR = eye movement desensitization and reprocessing, FACIT-SpEx4 = Functional Assessment of Chronic Illness 

Therapy–Spirituality-Expanded Version 4, IES = Impact of Events Scale, IES-R = Impact of Events Scale–Revised, M-PTSD = 

Mississippi Scale for Combat-Related PTSD, NA = not applicable, PCL = Posttraumatic Stress Disorder Checklist (-M is military 

version), PSS-SR = Posttraumatic Symptom Scale–Self Report, PTSD-I = Posttraumatic Stress Disorder Interview, PVSDS = 

Post-Vietnam Stress Disorder Scale, Q-LES-Q-SF = Quality of Life Enjoyment and Satisfaction Questionnaire–Short Form, RCT 

= randomized controlled trial, SI-PTSD = PTSD Structured Interview, SOA = Scale of Adaptation, SS-PTSD = Scale of Severity 

of Posttraumatic Stress Disorder, SDI = Sheehan Disability Inventory
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Table 3 summarizes the outcome measures included in this evidence synthesis, listing the abbreviated 

and full name of each instrument, format, number of items, score range, and interpretation of scoring. 

Table 3. Summary of outcome measures

Abbreviation Name of instrument Format # of 

items Range Interpretation

CAPSa Clinician-Administered PTSD 

Scale

Semistructured 

interview 17 0–136 Higher score = more severe PTSD symptoms

CR-PTSDb Crime-Related Post Traumatic 

Stress Disorder Scale Self-report scale 28 0–112 Higher score = more severe PTSD symptoms

CSQ Client Satisfaction 

Questionnaire Self-report scale 8 8–36

Higher score = more 

satisfaction with 

treatment

FACIT-SpEx4

Functional Assessment of 

Chronic Illness Therapy–

Spirituality-Expanded Version 4

Self-report scale 23 0–184 Higher score = better 

quality of life

IESc Impact of Events Scale Self-report scale 15 0–75 Higher score = more 

severe PTSD symptoms

IES-R Impact of Events Scale–Revised Self-report scale 22 0–88 Higher score = more 

severe PTSD symptoms

M-PTSD Mississippi Scale for CombatRelated PTSD Self-report scale 35 35–175 Higher score = more 

severe PTSD symptoms

PCL PTSD Checklist Self-report scale 17 17–85 Higher score = more 

severe PTSD symptoms

PSS-SR Posttraumatic Symptom Scale–

Self-Report Self-report scale 17 0–51 Higher score = more 

severe PTSD symptoms

PTSD-I Posttraumatic Stress Disorder 

Interview

Structured 

interview 17 17–119 Higher score = more severe PTSD symptoms

PVSDS Post-Vietnam Stress Disorder 

Scale (unpublished) NR NR NR Higher score = more severe PTSD symptoms

Q-LES-Q-SF Quality of Life Enjoyment and 

Satisfaction–Short Form Self-report scale 14 14–70 Higher score = better quality of life

SDI Sheehan Disability Inventory Self-report scale 3 0–30 Higher score = greater 

functional impairment

SI-PTSD PTSD Structured Interview Structured 

interview 17 0–68 Higher score = more severe PTSD symptoms

SOA Scale of Adaptation Self-report scale 6 6–36

Lower score = better 

adaption to impact of 

sexual aggression on 

daily life

SS-PTSDS

Scale of Severity of 

Posttraumatic Stress Disorder 

Symptoms

Structured 

interview 51 0–51 Higher score = more 

severe PTSD symptoms

a

Numerous scoring strategies exist. The number of items/range of scores presented here refer only to the interview items that 

assess DSM-IV diagnostic criteria. Additional CAPS items may administered to assess functioning, response validity, and 

presence of associated symptoms. 

b

Score is typically calculated and interpreted as the average item score. 

c

The IES does not assess Cluster D/hyperarousal PTSD symptoms, whereas the IES-R does include items to assess this symptom 

cluster.

Abbreviations: NR = not reported, PTSD = posttraumatic stress disorder
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KEY QUESTION 1: In adults with PTSD, are mind-body complementary 

and alternative medicine therapies (e.g., acupuncture, yoga, meditation) 

more efficacious than control for PTSD symptoms and health-related 

quality of life?

Published literature

We identified six published RCTs that met our criteria for KQ 1. Of these, two examined 

meditation,42,43 one examined acupuncture,45 and three examined breathing/relaxation 

training.44,46,47 These studies are summarized in Table 4 and discussed in this section. 

In addition to the published literature, our search of ClinicalTrials.gov identified 16 unpublished 

or ongoing studies relevant to this question (Table 5). 
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 Alternative Medicine 

ess Disorder Evidence-based Synthesis Program

body interventions (KQ 1)

ation Design details Intervention Comparator Outcomesa

at

): 56 (6.57)

%)

ns: 29 

PTSD diagnosis: DSM-IV by CAPSKey exclusions: Psychotic disorder Severe suicidality Inability to participate in a 

group

Recruitment: PTSD orientation groups, fliers, brochures

6 weekly, 90-minute group sessions of mantram repetition + home practiceLed by psychiatric nurses

Usual care Remission: NR

Response:  ES = between group differences NR HRQOL: ES = between group differences NRAE: NRFollowup duration: 6 weeks (end of treatment)

at

): 33.3 (NR)

%)

ns: 25 

PTSD diagnosis: DSM-III (means of assessment not specified)Key exclusions: Substance abuse Major tranquilizers Psychiatric hospitalization Suicidal or homicidal Currently practicing TMRecruitment: from mental health clinic

4-day workshop on transcendental meditation (TM), then weekly 60-minute sessions for 11 weeks + home practice 20 minutes/day, twice daily)Led by Maharishi-trained leader

Individual psychotherapy

Remission: NRResponse:  decreased PTSD symptom severity, p < .05; emotional numbness, p < .025HRQOL:  decreased family problems, p < .05 AE: NRFollowup duration: 12 weeks (end of treatment)

sex assault

): 22 (6.9)

00%)

e

PTSD diagnosis: DSM-IIIR by SS-PTSDSKey exclusions: Other serious mental illness Time since trauma > 3 monthsRecruitment: Consecutive patients seeking 

treatment

Progressive muscle relaxation (PMR)Five 1-hour sessionsIntervention not well described 

Cognitive restructuring, coping skills training, and PMR 

Remission:  5 of 10 treatments vs. 8 of 10 control had no symptomsResponse:  no between group differencesHRQOL: NRAE: NRFollowup duration: 5 weeks (end of treatment) and 2,4,7, 13 months
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Population Design details Intervention Comparator Outcomesa

4

ma: childhood sexual/

cal abuse

 age (SD): 42.2 (NR)

 27 (32.14%) 

ans: none

PTSD diagnosis:  DSM-IV by SCID Key exclusions: substance abuse, psychosis, current other active treatment for PTSDRecruitment: clinical referral, advertisement, flyers, other media, professional contacts, word of mouth

Acupuncture (traditional Chinese medicine) with 11 to 14 solid needles placed for 25–40 minutes with manipulation + 15 minutes/day of homebased therapy (ear seeds)

Cognitive behavioral therapy or waitlist

Remission: NRResponse (PSS-SR < 16): Acupuncture = 15 (63%), maintained at 24 weeks CBT = 9 (36%), increased to 13 (52%) at 24 weeks Waitlist = 4 (17%), NR at 24 weeksHRQOL: acupuncture and CBT groups improved compared to WL controlAE: 1 in acupuncture groupFollowup duration: 12 weeks (end of treatment) and 24 weeks

6

ma: childhood abuse, 

al/physical assault, 

portation

 age (SD): 32 (14.7)

 13 (36.11%)

ans: none

PTSD diagnosis:DSM-IIIR by SI-PTSDKey exclusions: severe personality disorder, psychosisRecruitment: from mental health clinic

Applied muscle relaxation (early recognition of anxiety, progressive muscle relaxation, passive muscle (“releaseonly”) relaxation, cuecontrolled relaxation

EMDR or exposure therapy 

Remission: no between group differencesResponse: no between group differencesHRQOL: NRAE: NRFollowup duration: 2 to 3 weeks (end of treatment) and 24 weeks

0

ma: combat

 age (SD): 45.6 (NR)

 90 (100%)

ry Veterans: 90 

%)

PTSD diagnosis: DSM-IIIR by PTSD-IKey exclusions: NRRecruitment: NR

10 weekly, 30-minute sessions of relaxation instruction (RI) or RI + deep breathing instruction

10, weekly, 30-minute sessions of RI, deep breathing + thermal biofeedback

Remission: NRResponse: NRHRQOL: NRAE: NRFollowup duration: NR

n for intervention versus comparator.

 effects, CAPS = Clinician-Administered PTSD Scale, DSM = Diagnostic and Statistical Manual, EMDR = eye movement desensitization and 

, HRQOL = health-related quality of life, PCL = PTSD Checklist, PSS-SR = Posttraumatic Symptom Scale–Self Report, PTSD-I = Post-traumatic 

LES-Q-SF = Quality of Life Enjoyment and Satisfaction Questionnaire–Short Form, NR = not reported, NS = not significant, RI = relaxation 

d Clinical Interview for DSM, SD = standard deviation, SI-PTSD = PTSD Structured Interview
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Meditation

Although various typologies of meditation practice exist, meditation may be broadly classified 

as concentrative or nonconcentrative (e.g., mindfulness meditation), depending on the manner in 

which mental attention is entrained. Concentrative techniques are those in which the practitioner 

intensely focuses on a particular object (e.g., a candle flame, the sensation of breathing, a word 

or sound) and tries to repeatedly bring focus back to the object if attention falters. In contrast, 

nonconcentrative techniques encourage practitioners to cultivate awareness and acceptance of 

all mental events. The goal is to observe moment-to-moment shifts in one’s internal experiences 

without controlling or judging their content. 

In this evidence synthesis, we identified two studies42,43 involving a total of 54 patients that 

compared concentrative meditation to control (1 study) or to an active comparator (1 study). 

Both studies enrolled samples of male combat Veterans into group-based interventions and 

encouraged regular home practice. Sample sizes were relatively modest (n = 25 to 29), treatment 

length was brief (6 to 12 weeks), and outcomes were assessed at posttreatment only. We did not 

identify any published studies of nonconcentrative meditative techniques for PTSD.

Bormann and colleagues (2008)42 conducted a fair-quality RCT of 29 male combat Veterans who 

met DSM-IV criteria for PTSD. Participants were recruited from a VA medical center via clinical 

orientation groups or flyers and brochures. Participants randomized to the mantram intervention 

received six, 90-minute, weekly group sessions co-led by two psychiatric nurses. Session content 

included the use of mantram repetition (i.e., the spiritual practice of repeating a sacred word 

or phrase) to manage PTSD symptoms, slow down thinking to decrease reactivity, and foster 

mindfulness to train attention. Home practice and self-monitoring were encouraged. Participants 

randomized to this condition were allowed to maintain usual care, including medications. Patients 

allocated to the control condition received “usual care” that was not described further. Key inclusion 

criteria were male VA participants diagnosed with combat-related PTSD. Those with current 

psychosis or severe suicidality or those deemed unable to participate in a group were excluded. 

Outcomes were assessed at posttreatment (6 weeks). PTSD severity was assessed with the 

Clinician-Administered PTSD Scale (CAPS) and PTSD checklist (PCL). HRQOL was assessed 

with the Functional Assessment of Chronic Illness Therapy–Spirituality-Expanded Version 4 

(FACIT-SpEx4) and Quality of Life Enjoyment and Satisfaction Questionnaire–Short Form 

(Q-LES-Q-SF). Satisfaction with the mantram intervention was assessed with the Client 

Satisfaction Questionnaire (CSQ). Adverse effects and treatment adherence (i.e., group session 

adherence, home practice) were not reported. Steps to ensure treatment fidelity included the use 

of a treatment manual and expert review of randomly selected session recordings. This trial was 

conceptualized as a feasibility study, and some of its limitations were consistent with a preliminary 

effort, including nonblinding of group assignment, failure to report or address missing data, and 

a lack of followup assessments. In addition, the authors did not report or account for potential 

baseline between-group differences (e.g., PTSD severity) that may have influenced the findings. 

Participants were randomized to the mantram intervention (n = 14) or control (n = 15). Change 

scores and effect sizes were provided for all outcome measures. However, because no inferential 

analyses were conducted, the statistical significance of reported differences was unclear. 

Posttreatment decreases in the severity of PTSD symptoms were larger in the intervention group 
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compared to control. For the CAPS, mean change was -4.79 (SD = 7.45) versus -2.64 (SD = 

5.44); effect size: -0.33. For the PCL, mean change was -8.79 (SD = 12.64) versus -1.20 (SD 

= 7.95); effect size: -0.72. A similar pattern of improvement was observed on both measures of 

HRQOL. For the Q-LES-Q-SF, mean change was 0.64 (SD = 0.93) versus 0.07 (SD = 0.70); 

effect size: 0.70. For the FACIT-SpEx4, mean change was 10.14 (SD = 9.49) versus 2.64 (SD 

= 12.62); effect size: 0.67. Eighty-six percent of participants who completed the mantram 

intervention, including those initially randomized to the waitlist control, rated their treatment 

satisfaction as “moderate to high” on the CSQ (mean scores not provided).

Brooks and Scarano (1985)43 conducted a poor-quality RCT that allocated 25 patients to either 

a 12-week transcendental meditation (TM) group (n = 13) or individual psychotherapy (n = 12). 

TM is a spiritually-based form of mantram. All potential participants were seeking treatment for 

combat-related trauma symptoms at the Denver Vet Center. No specific inclusion criteria were 

listed, and it was not clear if all participants met full diagnostic criteria for PTSD. Exclusion 

criteria included history of psychiatric hospitalization, current suicidal or homicidal ideation, 

or currently practicing TM. With the exception of the study treatments, the authors did not 

specify whether participants were able to begin or continue other behavioral or pharmacological 

therapies during the study period. 

TM was taught in a 4-day workshop that included daily 90-minute sessions led by an individual 

who was trained by Maharishi Mahesh Yogi (TM developer), followed by 11, 1-hour, weekly 

followup meetings. Home practice for 20 minutes twice daily was recommended. No additional 

information about the TM trainer was provided. Therapists providing psychotherapy to 

participants randomized to the comparison condition held a minimum of a master’s degree in 

social work or psychology. The primary study outcomes, measured at baseline and posttreatment 

(12 weeks), were the “degree” of PTSD and emotional numbness assessed with the Post-Vietnam 

Stress Disorder Scale (PVSDS), an unpublished measure. Additional items assessed aspects 

of HRQOL, including employment status and family problems. Adverse effects (except for 

discontinuation) were not reported. 

Several significant design flaws limited interpretability of study findings, including the use of 

unpublished and unvalidated measures; failure to describe subject characteristics (although 

the authors indicated that there were no between-group differences at baseline); no measure of 

adherence (group attendance, home practice) or treatment fidelity; and failure to measure or report 

other treatments received during the study period. Because a single interventionist delivered the 

TM intervention, treatment and therapist effects were confounded. Finally, although not specifically 

addressed by the authors, this preliminary study enrolled a relatively modest sample size and 

certainly was not adequately powered for equivalence hypothesis testing (nor was it intended to be).

Comparable proportions of participants in each study arm completed 12 weeks of treatment: 10 

(77%) completed TM and 8 (67%) completed individual therapy. Reasons for discontinuation 

were not reported. Mean pretreatment and posttreatment scores were provided for the PVSDS. 

However, no information was provided about possible range and interpretation of scores, which 

largely limited their interpretability. Controlling for pretreatment values, greater reduction in PTSD 

severity was observed for the TM group (9.70 ± 2.98 to 5.80 ± 4.26) versus psychotherapy group 

(11.71 ± 2.63 to 10.86 ± 2.85, p < .05). This was also true for the Emotional Numbness Scale for 
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TM versus psychotherapy (3.70 ± 1.64 to 1.70 ± 1.95 versus 3.75 ±1.03 to 3.50 ± 1.41, p < 0.05, 

respectively). At posttreatment, those in the TM group were also more likely to report fewer family 

problems (p < 0.05), whereas no between-group difference in employment status was observed. 

Within-group, paired t-tests showed significant improvement on all self-reported measures for the 

TM group and no significant changes at posttreatment for the psychotherapy group.

To summarize, the findings of two short-term RCTs provided limited support for two forms 

of concentrative meditation for combat-related PTSD. Both studies examined relatively brief 

group therapy formats in all-male Veteran samples, with demonstrated effects on PTSD severity 

and HRQOL. However, both were preliminary inquiries, and design limitations compromised 

interpretability and generalizability of reported findings. Yet, together these studies demonstrate 

the feasibility of enrolling and retaining male Veterans into meditation group interventions, and 

both recorded improvement in posttreatment symptoms relative to baseline levels. 

Acupuncture

Acupuncture, a branch of traditional Chinese medicine, has been used to treat mental illness in 

other countries for centuries. It comprises a varied group of procedures that can include needle 

placement in preselected or individually chosen points; in subcutaneous tissue or muscle; with 

or without manipulation, electrical stimulation or the use of “ear seeds” in addition to needle 

placement. However, it is unknown whether acupuncture can be used to treat PTSD successfully.

We identified a single, good-quality RCT by Hollifield and colleagues (2007)45 that allocated 84 

patients who met DSM-IV criteria for PTSD either to acupuncture (n = 29); cognitive behavioral 

therapy (CBT) sessions (n = 28); or a waitlist control (n = 27). The intervention period was 12 

weeks and comprised 24 acupuncture sessions or weekly group CBT sessions. Participants in the 

study were recruited by clinician referrals and advertisements in the local media; no VA or DoD 

settings were included. Key exclusions were comorbid psychotic disorder or substance abuse or 

current engagement in a PTSD-specific treatment. However, participants could continue stable 

supportive therapy or prescribed medication for another psychiatric disorder, such as depression. 

Biweekly acupuncture treatments were 60 minutes each and included a symptom interview; 

pulse and tongue evaluation; needle insertion, manipulation, and retention; and Vaccaria seed 

(or “ear seed”) placement. Participants were instructed to massage the seeds, which were 

taped to specific points on the ear, for 15 minutes every day between sessions. Treatment was 

administered by an experienced, licensed acupuncturist trained in traditional Chinese medicine. 

Weekly, 2-hour group CBT sessions followed a manualized protocol. To equalize amount of 

attention to the problem the two groups experienced, home practice of CBT methods for 15 

minutes/day was also encouraged, but adherence was not measured. The training and experience 

level of the therapist who led the CBT groups were not specified. Only one interventionist was 

assigned to each intervention; thus, treatment and therapist effects were confounded.

Assessments were conducted at baseline, 12 weeks (end of treatment), and 6 months (3-month 

followup). PTSD severity was measured with the Posttraumatic Symptom Scale–Self Report 

(PSS-SR), and HRQOL was measured with the Sheehan Disability Inventory (SDI). Treatment 

satisfaction was assessed among those randomized to acupuncture or CBT with a 10-item scale 

developed by the authors (α = 0.87). Neither treatment adherence nor treatment fidelity was 

reported. Among the 29 participants randomized to acupuncture, 65.5 percent were retained. Five 
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withdrew before initiation of treatment and thus were not included in the analyzed sample (i.e., 

no baseline data). An additional five participants withdrew during treatment for the following 

reasons: incarceration (n = 1); conflicting medical treatments (n = 2); perceived adverse effects 

of acupuncture (n = 1); and difficulty keeping appointments (n = 1). Of the 28 participants 

randomized to CBT, 75 percent were retained. Three withdrew before treatment, and 4 withdrew 

during treatment due to difficulty keeping appointments (n = 2) and unknown reasons (n = 2). 

Among the 27 participants randomized to waitlist control, 77.8 percent were retained. Three 

withdrew before treatment, and three withdrew during the study period for unstated reasons. 

Intent-to-treat analyses included all participants for whom baseline data were available: 

acupuncture (n = 24); CBT (n = 25); and waitlist control (n = 24). Missing data were estimated 

using the last-observation-carried-forward method. 

Mean PSS-SR scores decreased from baseline to the 12-week assessment in both the acupuncture 

group (31.3 ± 10.1 to 15.6 ± 13.9) and CBT group (32.5 ± 6.6 to 20.0 ± 10.6; p < .05) but 

remained essentially unchanged in the waitlist group (30.8 ± 9.5 to 27.9 ± 12.3). At 6 months, the 

treatment effects on PTSD symptoms persisted (PSS-SR scores =15.4, acupuncture; 16.7, CBT; 

and 27.9, waitlist control). Pairwise contrasts from 0 to 12 weeks were not statistically different 

between acupuncture and CBT (p = 0.29). Pairwise contrasts were statistically significant 

between both waitlist and acupuncture (p < 0.01) and CBT (p < 0.01). 

Similar findings were observed for all three study arms on the SDI: scores decreased from 

baseline to the 12-week assessment in both acupuncture (3.8 ± 0.8 to 3.0 ± 1.3) and CBT (4.1 ± 

0.8 to 3.3 ± 1.2; p < .05) but were again essentially unchanged in the waitlist control. SDI scores 

remained relatively stable across all three groups at 6 months. As with the PSS-SR, pairwise 

contrasts from baseline to posttreatment for the SDI were not statistically different between 

acupuncture and CBT (p = .83); However, there were statistically significant differences between 

waitlist and both acupuncture (p = .01) and CBT(p < .01). Global satisfaction with care was high, 

and there was no significant difference between groups in both acupuncture and CBT.

In summary, the findings from a single, good-quality RCT suggested that a 12-week course 

of acupuncture treatments was similar to group CBT (although not powered for equivalence 

hypothesis testing) and more effective than no acupuncture in reducing PTSD symptoms and 

improving HRQOL. The clinical improvement associated with acupuncture or CBT persisted for 

at least 3 months after completion of treatment.

Relaxation 

Three studies involving 146 patients44,46,47 compared forms of relaxation training to active 

comparators; one also included a third, attention control arm47 Study quality ranged from poor44,47

to fair.46

The RCT by Echeburúa and colleagues (1996)

44 randomly assigned 20 women who had 

experienced sexual aggression in the past 3 months to a CBT-based intervention that 

included cognitive restructuring plus coping skills training and progressive muscle relaxation 

(PMR)—or to PMR alone. In this comparative effectiveness design, both interventions 

consisted of five, 60-minute, weekly sessions administered by a doctoral-level therapist with 

5 years’ experience conducting CBT for sexual assault-related PTSD. The therapist also 

was responsible for conducting all study assessments. Participants were recruited from three 
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psychological counseling centers for women in Spain. All met DSM-IIIR criteria for acute 

PTSD (i.e., symptoms had persisted for > 1 month and < 3 months) per the Scale of Severity of 

Posttraumatic Stress Disorder Symptoms (SS-PTSDS). Severe psychiatric comorbidity (e.g., 

schizophrenia, mental deficiency) was the primary exclusion criteria.

The cognitive restructuring plus specific coping skills training intervention included:

•	 psychoeducation about sexual trauma and PTSD

•	 introduction of CBT techniques for modifying maladaptive thoughts and feelings related 

to sexual trauma

•	 coping skills training including PMR, thought stopping, and distraction

•	 instructions for self-guided exposure to avoided situations and stimuli 

The PMR alone intervention provided psychoeducation and training in progressive muscle 

relaxation. For both conditions, PMR followed methods proposed by Bernstein and Borkovec.52

This study was considered poor quality because of nonblinding of subjects or the assessor/

therapist, unclear randomization and allocation concealment, and no intent-to-treat analysis. 

Power was not calculated a priori and clearly was inadequate for comparative analyses. There 

was no measure of treatment fidelity, and adherence was unclear. Finally, inclusion of PMR in 

both intervention arms complicated interpretation of study findings in the absence of a clearer 

description of how applying this technique may have differed between treatment conditions.

Outcomes were assessed at baseline; posttreatment (5 weeks after baseline); and at 

approximately 2, 4, 7, and 13 months after baseline (i.e., 1, 3, 6, and 12 months after the end 

of treatment). It appears that all 20 patients completed treatment and remained in the study 

through the 13-month assessment. At baseline, mean score on the SS-PTSDS, the primary 

outcome measure, was 35.5 (SD = 7.96). Within groups, mean scores decreased from baseline 

to posttreatment, from 36.7 (SD = 8.59) to 12 (SD = 6.94) for the cognitive restructuring plus 

coping skills group, and from 34.3 (SD = 7.54) to 18.7 (SD = 9.20) for the PMR group. Scores 

decreased slightly in subsequent assessments in both groups. There were no statistically 

significant between-group differences. At posttreatment, 8 out of 10 patients (80%) in the 

cognitive restructuring plus coping skills group and 5 out of 10 (50%) in the PMR group no 

longer met criteria for PTSD. Additional improvements were observed at the 2-month followup 

(100% remission in the cognitive restructuring plus coping skills group versus 80% remission 

in the PMR group), which were retained at the 13-month followup. Results of the Scale of 

Adaptation (SOA), a measure of functional adaptation to the experience of sexual aggression, 

reflected significant reductions in both treatment groups, which were retained at the 13-month 

followup.

In the RCT by Vaughan and colleagues (1994),46 applied muscle relaxation (AMR) was 

compared to eye movement desensitization (EMD) and image habituation training (IHT), a 

form of exposure therapy. Thirty-six patients with PTSD referred to an outpatient PTSD clinic 

were randomly assigned to AMR (n = 11), EMD (n = 12), or IHT (n = 13). Participants’ trauma 

histories included violent crime, rape, child abuse, and motor vehicle accident. Schizophrenia and 

severe personality disorders were exclusions. At baseline, 22 percent reported subclinical levels 

of Category C (avoidance/numbing) symptoms and thus did not meet full DSM-IIIR criteria for 

PTSD. 
27

Efficacy of Complementary and Alternative Medicine 

Therapies for Posttraumatic Stress Disorder Evidence-based Synthesis Program

Patients were scheduled to attend four sessions over a 2- to 3-week period. The AMR treatment, 

adapted from Ost (1987),53 taught participants to recognize early signs of anxiety and to apply 

relaxation techniques to manage and quell anxiety. During the treatment sessions, three increasingly 

brief, relaxation techniques were sequentially introduced: progressive muscle relaxation, releaseonly relaxation (i.e., passive muscle relaxation), and cue-controlled relaxation, in which selfinstruction to “relax” was paired with the state of relaxation. Participants were expected to practice 

these techniques between sessions, 40 minutes per day. In the EMD condition (now known as 

eye movement desensitization and reprocessing [EMDR]), saccadic eye movements (induced by 

asking the patient to track the therapist’s hand as it moved rapidly across the visual field) were 

paired with associative elements of the traumatic memory, including imagery, cognition, affect, 

and physiological sensations. No between-session work was assigned to participants in the EMD 

group. Patients in the IHT group were required to listen to continuous-loop, audiotaped descriptions 

of their trauma and to record cognitions and anxiety levels on a homework sheet for 60 minutes 

per day. The level of education and training of the therapists was not reported, but all were trained 

in EMD by Francine Shapiro, the originator of the technique. This study was considered fair 

quality because of ambiguous reporting of methods (including lack of clarity about the adequacy 

of randomization, nonblinded assessments, inadequate treatment of missing data, lack of intent-totreat analyses) and inadequate statistical power.

The primary PTSD-related outcome measure was the PTSD Structured Interview (SI-PTSD), 

assessed by a blinded rater at baseline, posttreatment (2 to 3 weeks), and 3 months. All three 

treatment groups were associated with significant improvement (p < 0.001) in SI-PTSD scores at 

the posttreatment and 3-month followup. There were no between-group differences in SI-PTSD 

scores at the baseline, posttreatment, or 3-month assessments. Adverse effects were not reported.

In a 3-arm, 10-week trial, Watson and colleagues (1997)47 randomized 90 male Vietnam-era Veterans 

to 1 of 3 relaxation training conditions: simple relaxation instruction (RI), RI plus deep breathing, or 

RI plus deep breathing plus thermal biofeedback. All were recruited by a technician at the St. Cloud, 

Minnesota VA Medical Center; additional details about recruitment procedures were not reported. 

All met DSM-IIIR criteria for PTSD, per the Posttraumatic Stress Disorder Interview (PTSD-I). 

Additional details about diagnostic procedures or specific inclusion/exclusion procedures were not 

provided. The technician, who was trained by a doctoral-level psychologist with 7 years’ experience 

in biofeedback and relaxation therapies, was responsible for recruitment, administration of all study 

treatments, and all study assessments—and thus was not blinded to treatment group assignment. 

All 3 treatment conditions consisted of 10, 30-minute sessions conducted in a quiet, dimly 

lit laboratory in which participants were seated in a reclining chair and provided 10 minutes 

to adapt to room temperature before beginning each session. Regardless of treatment group 

assignment, each participant was attached to a biofeedback apparatus that monitored finger 

temperature and frontalis muscle tension. Participants randomized to the RI group were 

instructed to “relax as much as possible” during the sessions. Those in the RI plus deep breathing 

condition were also given instruction in deep breathing prior to each session and instructed to 

practice relaxing and deep breathing throughout the 30-minute session. Those in the RI plus 

deep breathing plus thermal biofeedback condition were additionally told that they would hear a 

tone, indicating their level of relaxation, and instructed to increase their finger temperature and 

lower the tone as much as possible by relaxing during the session. Thus, the three treatment arms 
28

Efficacy of Complementary and Alternative Medicine 

Therapies for Posttraumatic Stress Disorder Evidence-based Synthesis Program

could be conceptualized as an attention control (RI), relaxation/CAM intervention (RI + deep 

breathing), and biofeedback/traditional treatment. 

Outcomes included PTSD-I total and individual item scores, Mississippi Scale for CombatRelated PTSD (M-PTSD), finger temperature, and frontalis muscle tension. This study was 

considered poor quality. Key limitations included unclear randomization and allocation 

concealment; inadequate treatment of incomplete outcome data; nonblinding of subject, provider, 

and assessor; no intent-to-treat analysis; and no power or sample size calculation/underpowered 

for comparative analyses. Adverse effects were not reported. 

In the completer sample, significant pretreatment versus posttreatment (Week 10) differences 

were observed for two PTSD symptoms assessed by individual items on the PTSD-I: intrusive 

memories (p < .01) and exaggerated startle response (p < .05), as well as M-PTSD total scores (p 

< .05) and middle-finger skin temperature, reported as degrees Fahrenheit p < .05). However, no 

time-by-treatment group differences were noted. Analysis of outcome data was limited to those 

who completed at least 9 of the 10 treatment sessions. Those who missed more than one session 

were replaced by other volunteers; intent-to-treat results were not reported. 

To summarize, the findings of three RCTs provided limited support for relaxation interventions for 

PTSD. However, none of these relatively small studies was adequately powered for comparisons of 

active treatment groups, and significant design flaws limited interpretability of study findings.

Overall, the findings from six published RCTs that included a mind-body complementary and 

alternative medicine therapy as an intervention demonstrated the following:

•	 Meditation techniques were associated with moderate improvements in symptoms and 

HRQOL compared to usual care only (one fair-quality study) and decreased symptom 

severity compared to individual psychotherapy (one poor-quality study).

•	 The clinical effectiveness of a course of acupuncture as a treatment for PTSD was similar 

to that of group CBT and greater than waitlist control (one good-quality RCT).

•	 Relaxation training was associated with moderate clinical improvement, but studies were 

small and favored the active comparator. Because 95 percent confidence intervals were 

large, an important clinical benefit for active comparators versus relaxation treatment was 

possible (three poor-quality RCTs).

Unpublished literature

Our search of ClinicalTrials.gov identified 16 RCTs relevant to KQ 1. These studies are 

summarized in Table 5, organized alphabetically by trial name. We identified eight ongoing trials 

that are examining the following CAM interventions: acupuncture, emotional freedom techniques, 

guided imagery/imagery modification, mind-body skills, mindfulness meditation, relaxation, and 

yoga. In addition, we identified six completed studies for which we could not identify a publication 

that reported clinical outcomes; they included these interventions: acupuncture, emotional freedom 

techniques, guided imagery, mindfulness-based stress reduction, and yoga. There was also one trial 

on yoga with status listed as “unknown.” Of the completed studies, two had funding stop dates of 

April 2009 or earlier, raising the possibility of publication bias for these interventions. The authors 

of these two studies were contacted, and for one study (Acupuncture for Posttraumatic Stress 

Among Military Personnel), a manuscript is in development.
29

 Alternative Medicine 

ess Disorder Evidence-based Synthesis Program

ody interventions (KQ 1) 

VA/DoD population? Intervention Comparator Sponsor and clinicaltrials.gov ID Funding start and stop date Status

Y Yoga breathing 

technique; single group assignment

Not clearly specified The University of 

QueenslandNCT00256477

Mar 2005–Oct 2005 Completedb

Y Acupuncture Waitlist Henry M. Jackson 

FoundationNCT00320138

Mar 2006–Oct 2007 Completed

N Interpersonal 

psychotherapy 

1. Prolonged exposure2. Relaxation 

NIMHNCT00739765

Apr 2008–Mar 2013 Recruiting

Y Emotional Freedom 

Techniques 

Standard care Soul Medicine 

InstituteNCT0074341

Dec 2008- May 2010

Completed

N Yoga Women’s health 

education

Justice Resource InstituteNCT00839813

Nov 2008–May 2011

Recruiting

Y Yoga Usual care The University of 

QueenslandNCT00256464

Jun 2007–Jan 2008 Unknown

Y Mindfulness 

Telehealth Intervention

Self Samueli Institute for 

Information Biology NCT00350584

Feb 2007–Apr 2008 Completed

Y Acupuncture 1. Sham 

acupuncture2. No intervention

Department of Veterans AffairsNCT00868517

Oct 2009–Sep 2011 Recruiting

Y Guided imagery Music Duke University

NCT00635635

Oct 2007–Mar 2010 Completed
30

 Alternative Medicine 

ess Disorder Evidence-based Synthesis Program

VA/DoD population? Intervention Comparator Sponsor and clinicaltrials.gov ID Funding start and stop date Status

Y 1. Slow breathing 

2. Meditation 3. Meditation + slow breathing 

Sitting quietly Oregon Health and 

Science UniversityNCT00778960

Jan 2009–Sep 2013 Recruiting

Y Mind-body skills Standard treatment The Center for MindBody Medicine

NCT01093053

Sep 2010–Aug 2012

Recruiting

Y Mindfulness-based 

stress reduction 

Usual care Seattle Institute 

for Biomedical and Clinical ResearchNCT00880152

Sep 2008–Dec 2009

Completed

Y Mindfulness-based 

stress reduction

Supportive therapy Department of 

Veterans AffairsNCT01058031

Jan 2007–Nov 2010 Completed

Y Acupuncture Standard care Department of 

Veterans AffairsNCT01060553

Jul 2010–Jun 2011 Recruiting

Y Emotional Freedom 

Technique

Waitlist Soul Medicine 

InstituteNCT01117545

May 2010–Jun 2013

Recruiting

N Imagery modification Waitlist Goethe University

NCT00976859

Sep 2009–Dec 2011

Recruiting

in peer-reviewed journal as of May 2011.

nter for Complementary and Alternative Medicine, NIMH = National Institute of Mental Health, PTSD = posttraumatic stress disorder, RCT = randomized 
31

Efficacy of Complementary and Alternative Medicine 

Therapies for Posttraumatic Stress Disorder Evidence-based Synthesis Program

KEY QUESTION 2: In adults with PTSD, are manipulative and bodybased complementary and alternative medicine therapies (e.g., spinal 

manipulation, massage) more efficacious than control for PTSD 

symptoms and health-related quality of life?

Published literature

We identified one poor-quality RCT by Price (2006)48,49 of body-oriented therapy in eight adult 

female subjects with histories of childhood sexual trauma (Table 6). 

Table 6. Characteristics of manipulative and body-based interventions (KQ 2)

Study Population Design details Intervention Comparator Outcomesa

Price, 

200648,49

N = 8

Trauma: rape, 

childhood physical/

sexual abuse

Mean age (SD): 38 

(NR)

Women: 8 (100%)

Veterans: none

PTSD diagnosis:

Severity of PTSD by PCL

Key exclusions: 

Substance abuse, 

currently involved in a 

violent relationship,

Not currently in active 

psychotherapy,

Not able to pay 50% of 

the cost for massage

Recruitment: clinical 

referral

8 weekly 

60-minute 

sessions of 

body-oriented 

therapy 

(massage) + 

body awareness 

education and 

body-mind 

integration

Waitlist Remission: 

Score below 

clinical cut-off— 

intervention 

group, 2 of 4 vs. 

waitlist group, 1 

of 4

Response: 

symptom 

improvement, 

intervention 

group, p < .01

HRQOL = NR

AE = NR

Followup 

duration: 9 weeks 

(end of treatment)

a

If comparator, outcomes given for intervention versus comparator.

Abbreviations: AE = adverse effect, NR = not reported, HRQOL = health-related quality of life, PCL = PTSD Checklist

Although formal PTSD diagnosis was not a study inclusion criterion, six of the eight women 

screened positive for PTSD at study inception, as indicated by baseline administration of the 

Crime-Related Post Traumatic Stress Disorder Scale (CR-PTSD)—the primary outcome variable. 

Participants were recruited through clinician referral, free advertisements on women’s groups’ 

Web sites, and emails to select graduate students; no VA or DoD settings were included. To be 

included, women had to be in active psychotherapy; be willing to stop any current bodywork one 

month prior to entering the study; and agree to pay 50 percent of the cost for the study-related 

bodywork sessions. Exclusion criteria were current substance abuse, involvement in a violent 

relationship, or psychiatric hospitalization within the last year. There was no requirement to 

maintain stable dosages of psychotropic medications. Four subjects were randomly allocated 

to eight, 1-hour sessions of Swedish-type massage, body awareness education, and “bodymind integration” (i.e., exploration of links between internal experiences and physiological 

sensations). The other four subjects were allocated to a waitlist control. The primary outcome 

measure, assessed at 9 weeks, was the CR-PTSD. 
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Efficacy of Complementary and Alternative Medicine 

Therapies for Posttraumatic Stress Disorder Evidence-based Synthesis Program

Pretreatment and posttreatment (Week 9) changes in scores were presented graphically, 

but axis labels were unclear, which hampered interpretation. Study limitations included 

incomplete descriptions of study participants, small sample size, and the potential for differing 

cointerventions across groups. In addition, the principal investigator collected and analyzed all 

data, and was not blinded to treatment condition. Although not explicitly stated, it appeared that 

the principal investigator also was the sole interventionist; her level of experience providing 

bodywork was not stated. This limitation introduces potential bias and confounds treatment and 

therapist effects. As is common for a small preliminary study, treatment adherence and fidelity 

were not assessed. 

The sample was relatively homogeneous: 89 percent were white; 71 percent reported incomes 

equal to or greater than $25,000; and all had at least a bachelor-level education. Sexual 

orientation was fairly varied—nearly half reported homosexual or bisexual orientations. All 

subjects had been in psychotherapy at least 1 year (range 1 to 20), and five of eight women were 

taking psychotropic medications. By Week 9, clinical remission (per recommended screening 

cutoffs on the CR-PTSD) had occurred in two of four women in the intervention group and 

one of four women in the waitlist control group. Pretreatment and posttreatment within-group 

comparisons showed significant improvements for the intervention group but not for the control 

group on the CR-PTSD; between-group comparisons were not significant. 

In summary, the findings from one small, poor-quality RCT in a relatively homogeneous sample 

provided modest support for the application of body-oriented therapy as an adjunctive treatment 

for women survivors of childhood sexual assault. We found no RCTs of manipulative or bodybased CAM interventions in men, military or Veteran samples, or individuals with PTSD 

related to more recent traumatic stressors (versus childhood abuse). We were unable to identify 

published RCTs of other manipulative or body-based CAM interventions, such as chiropractic 

medicine and naturopathy, or of alternative applications and forms of massage therapy.

Unpublished literature

Our search of ClinicalTrials.gov did not identify any RCTs relevant to KQ 2. 

KEY QUESTION 3: In adults with PTSD, are complementary and 

alternative medicine therapies that are movement-based or involve 

energy therapies more efficacious than control for PTSD and healthrelated quality of life? 

Our literature search identified no published RCTs of movement-based or energy therapies for 

PTSD. 

Unpublished literature

Our search of ClinicalTrials.gov did not identify any RCTs relevant to KQ 3. 
33

Efficacy of Complementary and Alternative Medicine 

Therapies for Posttraumatic Stress Disorder Evidence-based Synthesis Program

KEY QUESTION 4: For treatments evaluated in KQs 1–3 that lack 

RCTs, is there evidence from other study designs that suggests the 

potential for treatment efficacy? 

Published literature

We identified two nonrandomized, prospective studies (Table 7) that assessed clinical outcomes 

over time among patients with PTSD who received a CAM intervention as defined in the 

Methods section. 

Table 7. Characteristics of nonrandomized CAM treatment studies (KQ 4)

Study Population Design details Intervention Comparator Outcomes

Abramowitz 

and 

Lichtenberg, 

201050

Israeli combat 

Veterans with 

PTSD by DSM-IV.

Mean age: 41.2 

(12.2)

Women: 0%

Veterans: 100%

Prospective 

cohort (N = 36)

Outcomes: 

1. Immediately 

posttreatment (6 

weeks)

2. 6 months

3. 1 year

Hypnotherapeutic 

olfactory 

conditioning

Six 1.5-hour 

sessions over 6 

weeks

NA Remission: NR

Response: IES-R; 

improvement was 

significant at the 

6-week posttreatment 

assessment and 

remained improved 

at 6 and 12 months

Hossack and 

Bentall, 199651

Male volunteers 

who met DSMIII-R criteria for 

PTSD

Mean age: 34.8 

(10.26)

Women: 0%

Veterans: 0%

Multiple baseline 

design across 

subjects (N = 5)

Outcome: 

Subjects 1 

and 2 received 

intervention at 

3 weeks from 

baseline; subject 

3 received 

intervention at 

6 weeks from 

baseline; subjects 

4 and 5 received 

intervention at 

9 weeks from 

baseline

4 therapy sessions 

including 

Relaxation: 

Jacobson’s method 

and guided imagery

Two sessions

Visual kinesthetic 

dissociation

Two sessions

Baseline Response:

3 patients reported 

decrease in intrusive 

imagery, 1 reported 

“less clear cut 

improvement,” 

and 1 showed “no 

improvement”

Abbreviations: DSM = Diagnostic and Statistical Manual of Mental Disorders, IES-R = Impact of Events Scale-Revised, NA = 

not applicable, NR = not reported, PTSD = posttraumatic stress disorder 

A prospective cohort study by Abramowitz and Lichtenberg (2010)50 involved 36 Israeli veterans 

with combat-related PTSD and treatment-resistant, olfactory-induced flashbacks. DSM-IV

diagnostic criteria were determined by semistructured, clinical interview. Participants underwent 

a form of brief hypnotherapy that entailed six, 90-minute, weekly hypnotherapeutic olfactory 

conditioning sessions in addition to standard CBT and stress management strategies (including 

imaginal exposure to the traumatic event). The core components of the intervention included:

• Session 1: repeated pairing of pleasant memories with a pleasant-smelling essential oil 

(i.e., classical conditioning)

• Session 2: hypnotic induction, imaginal reexperiencing of functioning well under stress, 
34

Efficacy of Complementary and Alternative Medicine 

Therapies for Posttraumatic Stress Disorder Evidence-based Synthesis Program

paired with hypnotic suggestion that the participant can manage PTSD-related intrusive 

memories and flashbacks

• Session 3: use of guided imagery, hypnosis, and suggestion around themes of mastery, 

control, and safety, paired with the pleasant scent identified in the initial session

• Sessions 4 and 5: repeated imaginal exposure to traumatic memories under hypnosis, 

paired with the pleasant scent

• Session 6: review of treatment gains, new skills, and plans to maintain and use new skills, 

particularly when triggered by olfactory stimuli 

Compared to baseline, the Impact of Events Scale-Revised (IES-R) scores were significantly 

improved at 6 weeks, 6 months, and 12 months. The investigators also reported significant 

decreases at 12 months, relative to baseline, in dosage and use of SSRIs, benzodiazepine, and 

neuroleptic medications.

The multiple baseline case series by Hossack and Bentall (1996)51 examined a visual-kinesthetic 

dissociation intervention in five male U.K. residents who reported severe intrusive imagery and 

met DSM-IIIR criteria for PTSD. Study diagnoses were determined by forensic psychiatrists 

and confirmed by brief clinical interview by the lead author. Participants’ trauma histories 

included surviving an industrial helicopter crash (n = 1) and witnessing a crowd surge at a 

football stadium that resulted in 95 deaths (n = 4). In addition to the five participants who 

completed treatment, a sixth participant enrolled but dropped out during the baseline phase and 

was not included in study analyses. The Impact of Events Scale (IES), which assesses Cluster 

B (“reexperiencing”) and Cluster C (“avoidance and numbing”) symptoms, was the primary 

measure of PTSD severity. Participants also completed daily diaries of duration, clarity, and 

related distress. The four-session intervention was administered in two phases:

• Relaxation: In the first two individual sessions, participants were taught to apply 

progressive muscle relaxation and guided imagery techniques to promote relaxation. 

Instruction in guided imagery emphasized incorporation of multiple sensory modalities 

(visual, kinesthetic, auditory, olfactory, and gustatory) in preparation for the next 

treatment phase.

• Visual-kinesthetic dissociation: In the final two sessions, participants were taught to 

apply relaxation skills and multisensory imagery techniques to imagine themselves at 

the cinema and to switch vantage points between being within a film of their trauma 

(first person), watching the film (second person), and watching themselves watch the 

film (third person). Using a manualized protocol, participants were then taught to 

manipulate the color and speed of the film and to run it backward and forward while 

repeatedly rotating their experience of the image from the first-, second-, and third-person 

perspectives. 

In addition to daily diaries of intrusive events, assessments were conducted at regular intervals 

across the 17 weeks in which this multiple baseline design study was conducted, as well as 

3-month followup (29-week assessment). No descriptive or inferential statistical analyses 

were conducted. However, visual plots of each participant’s symptom change over time were 

presented and discussed. The authors report “substantial” reductions in IES scores for four of the 

five participants (although two showed evidence of some posttreatment increase in avoidance). 
35

Efficacy of Complementary and Alternative Medicine 

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Daily diary results indicated that four participants reported sizable decreases in the experience of 

intrusive imagery (maintained at 3-month followup), whereas one experienced a modest increase. 

The authors noted that daily diary results suggested important (albeit preliminary) differences in 

how participants responded to the different treatment components: for one participant, relaxation 

seemed the most potent; for another, visual-kinesthetic dissociation had the greatest impact; and 

two others seemed to respond to both interventions. 

In summary, the two published, nonrandomized studies identified by our systematic search 

provided little evidence of broad potential efficacy in PTSD for any of the CAM interventions 

of interest. One study50 presented initial pilot findings of a multimodal intervention that included 

both CAM (hypnotherapy, guided imagery) and imaginal exposure techniques. Although initial 

findings are promising, the study appears most applicable to the subgroup of combat Veterans 

who are particularly sensitive to olfactory triggers. Because the study sample was limited to men, 

it provided no additional information about the potential efficacy of CAM modalities in women. 

Likewise, a second study in five males provided limited initial information about the feasibility 

and potential utility of brief CAM intervention that included instruction in relaxation skills and 

imagery techniques including imaginal exposure. 

In addition to these studies, one additional nonrandomized study,

54 which was published after 

we conducted our literature search, was identified during the peer review process. In a study by 

Rosenthal and colleagues (2011), five OEF/OIF Veterans who met DSM-IV diagnostic criteria 

for combat-related PTSD were instructed in transcendental meditation (TM) by a certified 

instructor and asked to practice the technique for 20 minutes, twice daily, during the 12-week 

study period. Clinician support was provided through the study duration via biweekly, faceto-face meetings, as well as telephone, email, and text message contacts. At 8-week followup, 

patients showed improvements in the clinician-rated PTSD symptom severity (CAPS: M change 

score = 31.4, p = 0.02), self-reported PTSD symptom severity (PCL: M change score = 24.00, p

< .02), and self-reported quality of life (Q-LES-Q-SF: M change score = -13.00, p < 0.01). The 

results of this small, uncontrolled study provide additional preliminary support for applications 

of meditation in Veterans with PTSD.54 

Unpublished literature

Our search of ClinicalTrials.gov identified two non-RCTs relevant to KQ 4. These studies are 

summarized in Table 8, organized alphabetically by trial name. Both trials examined yoga. One 

is still recruiting, but the other is completed with a funding stop date of April 2009 or earlier, 

raising the possibility of publication bias for this intervention.
36

 Alternative Medicine 

ess Disorder Evidence-based Synthesis Program

KQ 4)

VA/DOD population? Intervention Comparator Sponsor and clinicaltrials.gov ID Funding start and stop date Status

Y Yoga None

Brigham and Women’s Hospital NCT00962403

Aug 2009–Dec 2010 Recruiting

Y Yoga None

Samueli Institute for Information BiologyNCT00269490

Dec 2005–Aug 2007 Completed
37

Efficacy of Complementary and Alternative Medicine 

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SUMMARY AND DISCUSSION

This evidence synthesis was requested by VA Research and Development to review and 

summarize the empirical evidence for applications of common CAM therapies to the treatment 

of PTSD. Four KQs were identified to examine the efficacy of mind-body therapies (KQ 1), 

manipulative and body-based therapies (KQ 2), movement-based therapies (KQ 3), and relevant 

evidence derived from nonrandomized trials of CAM interventions for PTSD (KQ 4). 

Our systematic literature search yielded six RCTs relevant to KQ 1, one relevant to KQ 2, 

and none to KQ 3. For KQ 4, which enabled us to expand our search beyond RCTs to include 

nonrandomized trials, two additional studies were identified. Most studies reviewed appeared to 

be preliminary investigations and were underpowered, limited by significant design flaws, and 

often provided inadequate descriptions of the intervention to permit replication. For each KQ, the 

evidence reviewed was limited. Indeed, perhaps our most striking finding overall was the relative 

dearth of available evidence on CAM applications for PTSD, despite clear consumer interest and 

widespread use of these treatments. 

SUMMARY OF EVIDENCE BY KEY QUESTION

For each KQ, we summarize the strength of evidence (SOE) and magnitude of treatment 

effects in Table 9. Interventions are compared to control or usual care and to active treatments 

separately. When the strength of evidence was rated insufficient, we did not calculate a treatment 

effect.

Table 9. Summary of the strength of evidence for KQs 1–3

Number 

of studies 

(subjects)

Domains pertaining to strength of evidence Magnitude of effecta and SOE

Risk of bias:

design/quality

Consistency Directness Precision PTSD symptoms: Effect estimate (95% CI)

KQ 1: Meditation vs. usual care Low SOE

1 (29) RCT/Fair Not 

applicable

Direct Imprecise SMD: -0.32 (-1.46 to 0.05), self-report PCL; 

-0.70 (-1.06 to 0.41), interviewer-based 

CAPS

KQ 1: Meditation vs. active treatment Insufficient SOE

1 (25) RCT/Poor Not 

applicable

Direct Imprecise Not estimated

KQ 1: Acupuncture vs. control Moderate SOE

1 (84) RCT/Good Not 

applicable

Direct Imprecise SMD: -0.92 (-1.51 to -0.32), self-report 

PSS-SR

KQ 1: Acupuncture vs. group CBT Low SOE

1 (84) RCT/Good Not 

applicable

Direct Imprecise SMD: -0.35 (-0.91 to 0.22), self-report PSSSR

KQ 1: Relaxation vs. control Insufficient SOE

1 (90) RCT/Poor Not 

applicable

Direct Imprecise Not estimated
38

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Number 

of studies 

(subjects)

Domains pertaining to strength of evidence Magnitude of effecta and SOE

KQ 1: Relaxation vs. other active treatment Insufficient SOE

2 (56) RCT/Fair to 

Poor

Consistent Direct Imprecise Lowb

SMD: 0.41 (-0.42 to 1.24), interviewer 

based SI-PTSD

SMD: 0.79 (-0.13 to 1.71), interviewer 

based SS-PTSD

KQ 2: Massage vs. control Insufficient SOE

1 (8) RCT/Fair Not 

applicable

Direct Imprecise Not estimated

KQ 3: Movement-based and energy therapies vs. control Insufficient SOE

None NA NA NA NA NA

a

A negative SMD indicates a greater effect for the CAM therapy.

b

SMDs were are reported separately for the two studies because a summary estimate was not indicated.

Abbreviations: CI = confidence interval, OR = odds ratio, NA = not applicable, RCT = randomized controlled trial, SMD = 

standardized mean difference, SOE = strength of evidence

Considered in sum, the highest quality evidence exists for acupuncture. However, strong 

conclusions cannot reliably be drawn on the basis of a single RCT; replication of findings is 

required. In addition, the active comparator in this study was group CBT, which is generally 

considered to be less potent than individual CBT therapies.55 The greatest breadth of evidence 

exists for relaxation interventions—we identified three RCTs that examined forms of breathing 

and muscle relaxation. In each case, the trials were preliminary and design flaws limited 

interpretation of study findings, which were positive overall. Further conclusions cannot be made 

in the absence of well-designed investigations of these modalities. 

The evidence base for meditation therapies is similarly limited by a paucity of well-designed 

trials, although early evidence is promising. In addition to a lack of scientific rigor and the need 

to replicate preliminary findings, the current literature is limited to concentrative meditative 

techniques. No RCTs of other common mind-body interventions, including mindfulness 

meditation and yoga, were identified in our review of the published, peer-reviewed literature. 

However, we identified 16 ongoing and/or unpublished studies registered with ClinicalTrials.gov, 

suggesting that this is a growing area of research. Approximately half of these trials are ongoing, 

and the majority are recruiting active military and/or Veteran samples. Thus, a significantly larger 

and broader evidence base may be anticipated within the next several years. 

For manipulative and body-based CAM therapies, the evidence base is extremely limited, and for 

movement-based and energy therapies, we identified no RCTs, published or in progress. Thus, 

the current and developing evidence bases for these therapies are likely to remain insufficient for 

clinical or policy recommendations in the near future. 

More broadly, the limitations of the current evidence preclude conclusions about specific 

interventions, populations, formats, settings, appropriate treatment length or “dosing,” or other 

refinements to the development of these approaches. We found little evidence addressing adverse 

effects, and retention rates, when reported, were comparable to current evidence-based treatments.
39

Efficacy of Complementary and Alternative Medicine 

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LIMITATIONS

Several limitations of the current review merit mention. First, we limited our literature search 

to clinical trials published in peer-reviewed, English-language journals. We also searched 

ClinicalTrials.gov for ongoing and unpublished trials, which served as a proxy “snapshot” of 

additional evidence that may be anticipated in the near future. However, our search did not 

extend to the “gray literature,” and thus excluded technical reports, white papers, and other 

evidence streams and formats that would not have been identified through standard database 

searches. In addition, we limited our literature search to CAM trials conducted in PTSD samples. 

Thus, the current review did not consider evidence of CAM applications in other anxiety 

disorders, major depression, or sleep disorders, for which there is symptom overlap and frequent 

comorbidity with PTSD. For example, in their review of CAM and self-help treatments for 

all anxiety disorders (generalized anxiety disorder was most frequently described), Jorm and 

colleagues56 found evidence from at least one well-designed RCT in support of acupuncture, 

aromatherapy, massage, dance and movement, meditation, relaxation training, and yoga. 

Other recent evidence reviews and meta-analyses have examined applications of massage in 

depression;57 energy therapies for health and mental health conditions;58 mindfulness-based stress 

reduction for anxiety, depression, pain, and chronic medical conditions;59-61 meditation therapy in 

anxiety disorders;62 and vipassana (mindfulness) meditation in a broad range of presentations.63

Evidence of effectiveness in closely related mental illnesses could provide indirect evidence of 

effectiveness for PTSD. 

The current review also did not include applications of CAM treatments in nonclinical 

populations or noninterventional designs. Because relaxation training has been employed as a 

placebo control condition in PTSD treatment trials, our inclusion criteria specified that relaxation 

interventions be presented as active treatment and that the key components be described in 

sufficient detail. These criteria led to the exclusion of five RCTs of relaxation interventions for 

PTSD, which otherwise would have met criteria for inclusion in the current review. Of these, 

two were excluded because relaxation was a control rather than an active comparator,37,38 and 

three were excluded due to lack of detail about the relaxation condition, such that we could not 

confidently categorize the interventions as CAM.39-41 It merits mention that in these studies, 

relaxation showed modest effects and performed less favorability than active comparators. 

Thus, a wider set of inclusion criteria for the current review may have yielded a larger evidence 

base, and tempered enthusiasm for applications of relaxation-based monotherapies for PTSD. 

Likewise, we did not examine, or attempt to examine, issues of symptom overlap or comorbidity 

of PTSD and traumatic brain injury or other unique presentations that may be anticipated among 

OEF/OIF Veterans. In addition, the scope of our literature search excluded natural products 

(e.g., nutritional supplements), as was our charge. Finally, our review did not examine thirdwave psychotherapies (e.g., mindfulness-based cognitive therapy, dialectical behavior therapy, 

and acceptance and commitment therapy) and related approaches. Despite some conceptual 

overlap with CAM and incorporation of CAM techniques such as meditation, these approaches 

are theoretically grounded in cognitive behavioral theory. They are understood to be extensions 

of mainstream approaches—and thus are distinct from CAM. Although outside of the scope of 

the current review, consideration of these strategies may inform broader understanding of the 

utility of CAM approaches for PTSD. It also merits mention that numerous forms and practices 

of mindfulness practice exist, such as seated meditation, movement-based practices, and even 
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the occasional mindful enjoyment of a single raisin. The field may be best served at this stage of 

treatment development by considering a range of different approaches to cultivating mindfulness 

skills.

In addition to the above limitations, there are important strengths of our methodological 

approach as well. First, limiting our review to evidence gleaned from published, peer-reviewed 

trials allowed us to focus on quality over quantity when examining this relatively undeveloped 

body of research. Although many CAM approaches have been in practice for thousands of years, 

the application of rigorous methods to standardize and evaluate the efficacy of these treatments 

is a relatively new development in the field of interventional PTSD research. In addition, our 

evidence synthesis was guided by a carefully designed standardized protocol, including a 

systematic search of research databases and relevant bibliographies, double data abstraction, 

and use of AHRQ criteria to assess the quality of identified studies. Our multidisciplinary team 

included expertise in internal medicine, clinical psychology, epidemiology, acupuncture research, 

and integrative medicine. In sum, this was a highly structured and systematic review of the extant 

evidence. 

RECOMMENDATIONS FOR FUTURE RESEARCH

The limitations of the current evidence preclude our ability to draw strong conclusions to 

inform clinical practice or public policy regarding optimal use of CAM therapies for PTSD, yet 

the limitations in the available evidence point to numerous opportunities for future research. 

Questions remain about the efficacy, effectiveness, safety, cost-effectiveness, comparative 

effectiveness, mechanisms of actions, dosing, indications and contraindications, and differential 

response among subgroup populations. There are also unanswered questions about patient and 

provider preferences and expectations, optimal outcome, adherence and fidelity measures, and 

resource utilization patterns.

One of the most pertinent questions regarding CAM therapies for PTSD is, What effects might 

one expect of a given intervention relative to no intervention? This clinically relevant question 

is best addressed by a randomized clinical trial with a no-treatment (waitlist) comparator. This 

trial design controls for many threats to internal validity and is particularly appropriate when 

there are no or few controlled trials. However, study designs that withhold or delay treatment to 

those with PTSD may not be institutionally feasible or ethically defensible.64 In their thoughtful 

discussion of the methodological challenges inherent in this area of research, Devilly and 

McFarlane (2009)65 question the value and appropriateness of waitlist and placebo-controlled 

PTSD intervention trials given potential risks (e.g., greater chronicity, comorbidities, suicidality, 

functional impairments, and financial burden) that may be incurred when available evidencebased treatments are withheld or delayed. As an alternative to the standard RCT design, the 

authors demonstrate a means of deriving statistical estimates of waitlist control and placebo 

treatment effect sizes from existing data and applying these estimates to interpret the effects of 

future treatment innovations. Although this statistical approach has not been used widely, such 

strategies merit consideration as an alternative to the use of nonactive controls. 

Another pertinent question is, To what extent might placebo, or nonspecific effects account 

for observed clinical outcomes? This question can be hard to answer for CAM therapies, for 
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which it may be difficult to design a sham procedure that is both truly inert and that appears 

sufficiently similar to the active intervention to isolate the specific effect of the intervention. 

The fields of surgical and psychotherapy research have long grappled with similar issues. Strong 

recommendations and methodological guidelines now exist to guide these efforts. 66,67 Of the 

many CAM therapies with potential to serve as a therapeutic option in the treatment of PTSD, 

acupuncture is arguably the one with the most plausible placebo control. For example, it is 

possible, in the context of a clinical trial, to administer sham acupuncture such that research 

subjects are unable to determine with certainty whether they are receiving the true or sham 

treatment. The current standard in acupuncture research is to compare an active acupuncture 

intervention to both a sham acupuncture intervention and a no-acupuncture control. This threearm RCT design makes it possible to simultaneously assess the efficacy or effectiveness and 

safety of a course of acupuncture while also partially addressing the extent to which nonspecific 

effects may contribute to observed outcomes. 

Although more costly and challenging to conduct, comparative effectiveness designs also may 

be indicated to give patients and clinicians the most direct evidence about competing treatment 

options. These trials may be most appropriate and informative after additional preliminary work 

has fostered a stronger evidence base for CAM treatments of interest. Finally, practical clinical 

trials, which combine aspects of efficacy and effectiveness designs, merit consideration as a 

potentially more efficient and actionable alternative to traditional explanatory trials.68

Ultimately, the choice of which research strategy to employ should be determined by the 

key questions and the plausibility and estimates of benefit based on prior research.66,69-71 For 

example, explanatory trials are best suited to address the question, Can this intervention work? 

and pragmatic trials to address the question, Does this intervention work?69 For most CAM 

treatments, the basic question of “Can it work?” for PTSD has not been answered. Observational 

studies can provide good evidence about the feasibility of interventions and adverse effects that 

require large studies or long followup durations to detect. Smeeding and colleagues (2010)72

conducted a longitudinal evaluation of the effectiveness of an integrative health clinic and 

program within the Veterans Affairs Health Care System (VAHCS) for PTSD, chronic pain, 

stress-related depression, and anxiety. Observational studies of this kind can provide a rich 

source of information about the feasibility and acceptability of CAM treatments delivered within 

a VA setting. In addition, high-quality observational studies that show very large treatment 

effects can provide good evidence of treatment effect. For example, we do not need an RCT to 

prove the benefits of a good parachute when stepping out of an airplane at altitude. However, 

our review did not identify observational studies showing very large treatment effects for any 

of the CAM treatments evaluated. Thus, randomized, placebo (or sham intervention) controlled 

trials— the gold standard for evaluating intervention effects—will be the most logical design for 

the majority of studies planned to evaluate CAM interventions. Small exploratory trials would be 

a logical next step for the CAM interventions that lack any studies of treatment effect.67

Whether evaluated in RCTs or observational studies, evaluating CAM therapies is 

challenging.73,74 A complete description of the challenges is beyond the scope of this report, but 

issues of blinding patients and treating clinicians to the intervention assignment, accounting for 

the learning curve of procedural-based interventions, identifying the appropriate comparator, 

procedures to minimize attrition, and monitoring fidelity to the planned intervention are all key 
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challenges. In addition, research on PTSD has important challenges, including the variety of 

traumas (e.g., combat, rape), the time since trauma, and the presence of medical or psychiatric 

comorbidity, all of which may impact treatment response. In addition to these more general 

challenges, we observed important variability in the completeness and consistency of PTSD 

outcome reporting. The evidence base for CAM treatments, and PTSD more generally, would be 

strengthened by a more uniform approach to outcome assessment. For our review, we prioritized 

PTSD symptom response, HRQOL, and adverse effects as the most important outcomes. 

Secondary outcomes included patient satisfaction, treatment adherence, and functional status. 

This prioritization of outcomes should be confirmed with stakeholders and then assessed more 

consistently across studies. To this end, the PROMIS initiative, an AHRQ-funded effort to 

develop a common battery of measures for many different conditions, may be a useful resource. 

Another important limitation of the current evidence base was the descriptions of treatment 

interventions, which were usually inadequate to permit replication. Glasziou and colleagues75

have recently proposed standards for intervention reporting to include sufficient detail to guide 

replication, including descriptions of the interventionists, the content of the intervention, the 

treatment setting, how and when the intervention was delivered, and the degree of flexibility 

permissible. Finally, health services research in the VA could be facilitated by developing 

procedure codes to capture CAM approaches used in the VA.

CONCLUSIONS

Our systematic review identified seven RCTs and two nonrandomized studies of CAM 

interventions for PTSD. Our review of relevant studies registered with ClinicalTrials.gov further 

suggests that this modest empirical foundation is growing. The term CAM encompasses a broad 

range of treatments—not all of which may hold the same level of promise as applications for 

PTSD. The current absence of a strong signal pointing to any one CAM approach over others 

argues for investment in a set of adequately powered trials to evaluate the most promising 

therapies, rather than a single large trial for any one treatment. Given the current state of 

evidence, a two-pronged approach may be most appropriate at this stage to move the field 

forward. That is, a series of adequately powered RCTs may be indicated for select CAM 

interventions for which there is clear and strong preliminary signal, either based on good-quality, 

early empirical evidence (e.g., acupuncture), a sound theoretical rationale for efficacy in the 

absence of strong pilot findings (e.g., meditation), and/or promising data gleaned from the bench 

sciences (e.g., compelling animal models). For other CAM modalities for which the science 

and theory are even less well developed, such as energy therapies, more prudence is indicated, 

suggesting the utility of exploratory pilot studies as the appropriate next step. In addition, the 

efficiency and ultimate yield of future efforts may be further optimized by consensus agreement 

about, and concerted efforts to address, limitations identified in the current literature. Broadly, 

these limitations concern issues of appropriate design, outcome, and replication strategies. There 

is an opportunity for strategic, well-designed studies to address the substantial gaps in evidence 

identified in this review. 
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