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APPENDIX A. Search Strategies

Step Goal Terms Resulta

1 PTSD terms Stress Disorders, Traumatic[MeSH] OR stress disorders, posttraumatic[MeSH] OR (post AND traumatic AND stress AND disorder[All 

Fields]) OR (post-traumatic AND stress AND disorder [All Fields]) OR 

(post traumatic stress disorder[All Fields]) or (post-traumatic stress 

disorders[All Fields]) OR ptsd[All Fields]

AND

1069

2 Interventions Acupuncture Therapy[Mesh:noexpl] OR Acupuncture Analgesia[Mesh] 

OR Acupuncture, Ear[Mesh] OR Electroacupuncture[Mesh] OR 

Acupuncture[Mesh] OR Acupressure[Mesh] OR Auriculotherapy[Mesh] 

OR acupuncture[All Fields] OR (acupuncture[All Fields] AND therapy[All 

Fields]) OR (acupuncture therapy[All Fields]) OR acupressure[All Fields] 

OR auriculotherapy[All Fields] OR Mind-Body Therapies[Mesh:noexpl] 

OR Breathing Exercises[Mesh] OR Hypnosis[Mesh] OR Imagery 

(Psychotherapy)[Mesh] OR Meditation[Mesh] OR Mental 

Healing[Mesh] OR Relaxation Therapy[Mesh] OR Tai Ji[Mesh] OR 

Therapeutic Touch[Mesh] OR Yoga[Mesh] OR Mind-Body Relations, 

Metaphysical[Mesh] OR breath[All Fields] OR breath[All Fields:expl] 

OR Complementary Therapies[Mesh:noexpl] OR Holistic Health[Mesh] 

OR Medicine, East Asian Traditional[Mesh] OR Reflexotherapy[Mesh] 

OR Spiritual Therapies[Mesh] OR acoustics[MeSH] OR acoustics[All 

Fields] OR acoustic[All Fields] OR aromatherapy [MeSH] OR sensory[All 

Fields] OR aromatherapy[All Fields] OR art[MeSH] OR art[All Fields] 

OR colour[All Fields] OR color[MeSH] OR color[All Fields] OR 

dance[All Fields] OR music[MeSH] OR music[All Fields] OR play and 

playthings[MeSH] OR (play AND playthings[All Fields]) OR play and 

playthings[All Fields] OR play[All Fields] OR sensory art therapies[MeSH] 

OR reflexotherapy[All Fields] OR craniosacral[All Fields] OR magnet[All 

Fields] OR light[MeSH ] OR light[All Fields] OR feldenkrais[Tiab] 

OR Alexander[Tiab] OR pilates[All Fields] OR trager[All Fields] OR 

movement therapeutic[All Fields] OR movement therapies[All Fields] 

OR movement therapy[All Fields] OR healers[All Fields] OR energy[All 

Fields] OR therapeutic touch[MeSH] OR (therapeutic[All Fields] AND 

touch[All Fields]) OR therapeutic touch[All Fields] OR reiki[All Fields]) OR 

ayurvedic[All Fields]

AND

83692

3 Study designs Randomized controlled trial[publication type] OR clinical trial[publication 

type] OR Comparative study[Publication type] OR clinical trials as 

topic[MeSH] OR (randomized AND controlled AND trial[Tiab]) OR (clinical 

AND trial[Tiab] OR trial[Tiab:expl]

AND

13973

4 Combine results 

and apply limits

#1 AND #2 AND #3

LIMITS: English and Human and Adult

353

a

Numbers reflect the result of the PubMed search only.
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APPENDIX B. Study Selection Form

Citation Screening Instructions: Turn on revision marks and label each citation with your 

decision. For studies that you can definitively exclude (≥ 90%), mark with “E.” For studies 

that are relevant to CAM for PTSD but not eligible (e.g., a review article), mark with a “B” for 

background. For an article that appears to meet eligibility criteria, mark with “IN” for include. 

We will need to be able to identify comparative studies that appear to meet our eligibility criteria 

but are excluded because they are not RCTs. Mark these studies with “F” for flag, and in the 

absence of RCTs for a therapy, we will give these studies further scrutiny. 

Inclusion criteria: 

•	 Study must be an RCT

•	 Sample population must have diagnosis of PTSD using DSM criteria, validated severity 

measures (e.g., PTSD Checklist), or clinical diagnosis by a physician

•	 Sample population is ≥ 19 years of age

•	 Setting: Patients are recruited from community or outpatient mental health or general 

medical settings

•	 Any of the following eligible treatments:

o Mind-body therapies: Acupuncture, meditation, yoga, deep-breathing exercises, 

guided imagery, mindfulness-based stress reduction, hypnotherapy, progressive 

relaxation, qi gong, and tai chi

o Manipulative and body-based therapies: spinal manipulation, massage therapy

o Other CAM therapies:

	Movement-based therapies: Feldenkrais method, Alexander technique, 

Pilates, Rolfing Structural Integration, and Trager psychophysical 

integration

o Manipulation of various energy fields to affect health: magnet therapy, light 

therapy, qi gong, Reiki, and healing touch

•	 Comparative studies:

o Studies that compare an eligible treatment to a control condition—such as usual 

care (including no treatment, supportive therapy), an attention control, sham 

intervention, or a waitlist—will be included

o Studies that compare an eligible treatment to an empirically based treatment such 

as CBT, PE, or antidepressant medication

•	 Outcome is reported at ≥ 6 weeks after treatment initiation

•	 Patients are in acute phase treatment (i.e., not selected for treatment-resistant PTSD)

•	 Study must be published in a peer-reviewed publication

Exclusion criteria:

•	 Study is a non–English language publication

•	 Study is conducted outside of North America, Western Europe, Australia, or New 

Zealand. Studies conducted outside of these countries are unlikely to be applicable to a 

VA population because of important differences in culture and the health care system.

•	 Study populations are patients with complicated PTSD: psychosis or acute suicidality
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•	 Studies in which the eligibility criteria require a diagnosis of PTSD comorbid with 

another mental illness (e.g., PTSD and substance abuse)

•	 Intervention is used in a continuation phase or maintenance phase

•	 Excluded interventions:

o cognitive processing therapy 

o eye movement desensitization and reprocessing (EMDR) 

o generic counseling

o life review therapy

o psychoeducational therapy

o social support or supportive therapy 

o standard psychodynamic therapy 

o “third wave” cognitive and behavioral therapies: mindfulness-based cognitive 

therapy, dialectical behavioral therapy, and acceptance and commitment therapy

o other treatments that are a direct extension of an established conventional therapy 

(e.g., Imagery Rehearsal Therapy)

o incident stress debriefing, psychological debriefing

o trauma-focused therapy

o present-focused therapy

o seeking-safety treatment

o relaxation therapy used as a control arm or not described in sufficient detail to 

understand the key components
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APPENDIX C. Sample Data Extraction Form

Study Information (Author/Year/EN#): ___________________________________________

Other linked studies? (1) No (2) Yes: ___________________________________________

1. Study objective: ____________________________________________________________

__________________________________________________________________________

2. Study location (1-4 sites): ☐ NA

a. Location 1: City______________________ Country:___________________

b. Location 2: City______________________ Country:___________________

c. Location 3: City______________________ Country:___________________

d. Location 4: City______________________ Country:___________________

3. Study location (If > 4 sites): ☐ NA Sites (#): ________ Countries/regions(#): ________ 

Names of regions (e.g. Western Europe) ________________________________________

4. Treatment setting (all that apply): 

(1) Mental Health (2) Gen. Medical (3) Non-Medical (4) NR

5. VA settings: (1) Yes (2) No (3) Mixed (4) NR

6. Active duty military settings: (1) Yes (2) No (3) Mixed (4) NR

7. Academic affiliation: (1) Yes (2) No (3) Mixed (4) NR

8. Study design:

(1) Patient level RCT (2) Non-randomized controlled trial (3) Cross-over trial

(4) Prospective cohort study (5) Case Series (6) Other: _______________________

9. Subject recruitment (all that apply): (1) Screening (2) Clinician referral

(3) Advertisement (paid) (4) Other (list):______________________ (5) NR
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Characteristics of the participants 1. Total enrolled: _________________

Characteristic Total Enrolled Intervention Control

2. Mean age (SD)

3. Sex: Men (n)

4. Sex: Women (n)

5. Race: White (n)

6. Race: African American (n)

7. Race: Latino (n)

8. Race: Asian (n)

9a. Mean (SD) education (years) or

9b. ≥ High school education (n)

10. Mean (SD) PTSD severity: __________

11. Mean (SD) Functional status: _________

12. Mean (SD) Years since trauma

1. Eligibility Criteria:

a. Diagnosis: (1) DSM3R (2) DSMIV (3) ICD (4) Clinical-nonstandardized

(5) Severity measure (e.g., PCL) (6) Patient self-reports diagnosis

b. Trauma exposure (all that apply): (1) Combat (2) Natural disaster

(3) Rape/sexual assault (4) Childhood abuse (5) Physical assault (6) Transportation 

accident (7) Other_____________________________

c. Age range: _______________________________

d. Suspend other psychological treatment: (1) Yes (2) No

e. Keep psychotropic medications stable: (1) Yes (2) No

f. Other 1: ________________________________________________________________

g. Other 2:_________________________________________________________________
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2. Exclusion Criteria:

a. Alcohol or substance abuse: (1) Yes (2) No (3) Not reported

b. Psychotic disorder: (1) Yes (2) No (3) Not reported

c. Reason 1: _______________________________ Reason 2:______________________

d. Reason 3:________________________________ Reason 4: _____________________

Intervention 

1. Intervention:________________________________________________________________

2. Sessions planned (#):____________ Mean (SD) Sessions delivered:___________

3. Duration planned (minutes/session): ______________

4. Discipline: (1) Physician (2) PhD MH professional (3) Masters train MH professional

[All that apply] (4) Physical therapist (5) Chiropractor (6) Trained research assistant

(7) Trained acupuncturist (8) Other: ______________________________

5. Mean years of experience (SD):_____________________

6. Study-specific training: _______________________________________________________

7. Intervention components:

a. Component 1:_____________________________________________ (allowed | given)

b. Component 2:_____________________________________________ (allowed | given)

c. Component 3:______________________________________________(allowed | given)

d. Component 4:_____________________________________________ (allowed | given)

e. Component 5:_____________________________________________ (allowed | given)

8. Is the intervention described in sufficient detail for a trained practitioner to replicate? 

(1) Yes (2) No

Comparator (If active comparator choose PE or CPT > EMDR>Other)

9. Basic descriptor: (1) Usual Care (2) Sham (3) Attention Control (4) Waitlist 

(5) CPT (6) Exposure therapy (7) Other: ___________________________________

10. Sessions planned (#):____________ Mean (SD) Sessions delivered:___________

11. Duration planned (minutes/session):______________________

12. Clinician same discipline as for the intervention? (1) Yes (2) No (3) NR
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13. Comparator Components:

f. Component 1: ____________________________________________ (allowed | given)

g. Component 2: ____________________________________________ (allowed | given)

h. Component 3: ____________________________________________ (allowed | given)

i. Component 4: ____________________________________________ (allowed | given)

j. Component 4: ____________________________________________ (allowed | given)

14. If 3-arm trial, other comparator: _______________________________________________

Outcomes

1. Subjects randomized:_________ Number Analyzed:___________

2. Time 1 f/u (weeks): _______ Time 1 f/u (n): ________

3. Time 2 f/u (weeks): _______ Time 2 f/u (n): ________

4. Other time points reported: (1) No (2) Yes (weeks): a. ____ b. ____ c.___

5. Response definition (% change):______________________________________

6. Remission definition:_______________________________________________

7. Symptom measure 1: ____________________________□ Self-report □ Interviewer rated

8. Symptom measure 2: ____________________________□ Self-report □ Interviewer rated

9. HRQOL measure: ______________________________ □ Self-report □ Interviewer rated

10. Outcome measure 4: ____________________________ □ Self-report □ Interviewer rated

11. Adherence measured: (1) sessions completed (2) homework (3) both

12. Outcomes reported as dichotomous results – time point 1 (weeks):____________

 OR □ No dichotomous results reported

Outcome NR Intervention Comparator

Events (n) At risk (n) Events (n) At risk (n)

AE: Discontinuation

AE: Any

Clinical response

Clinical remission

Completer
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13. Time point 2 Results (weeks):________________OR □ No time point 2 dichotomous results

Outcome NR Intervention Comparator

Events (n) At risk (n) Events (n) At risk (n)

AE: Discontinuation

AE: Any

Clinical response

Clinical remission

Completer

14. Continuous results – time point 1 (weeks)______ give mean (SD) or mean (95% CI; x to y) 

□ No continuous results reported

Outcome Intervention 

baseline

Comparator 

baseline

Intervention

followup

Int

“n”

Comparator 

followup

Comp

“n”

F/U 

Code

Adherence NA NA

Sx score 1

Sx Score 2

HRQOL

Patient 

satisfaction

Social 

functioning

F/U Code: U=Unadjusted Mean (e.g., ANOVA); A=Adjusted mean (e.g, ANCOVA); C1=Change 

score for treatment arm (T2-T1); C2=Change score for treatment arm (T1-T2); D1 = Difference 

in means between groups at followup (intervention – comparator, e.g., estimate from mixed 

model); D2 = Difference in means between groups at followup (comparator - intervention); 

P=only a p value given (record p value in the Intervention f/u field)
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15. Continuous results – time point 2 (weeks):______ give mean (SD) or mean (95% CI; x to y)

□ No Dichotomous results reported at time point 2

Outcome Intervention 

baseline

Comparator 

baseline

Intervention

followup

Int

“n”

Comparator 

followup

Comp

“n”

F/U 

Code

Adherence NA NA

Sx score 1

Sx Score 2

HRQOL

Patient 

satisfaction

Social 

functioning

F/U Code: U=Unadjusted Mean (e.g., ANOVA); A=Adjusted mean (e.g, ANCOVA); C1=Change 

score for treatment arm (T2-T1); C2=Change score for treatment arm (T1-T2); D1 = Difference 

in means between groups at followup (intervention – comparator, e.g., estimate from mixed 

model); D2 = Difference in means between groups at followup (comparator - intervention); 

P=only a p value given (record p value in the Intervention f/u field)
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APPENDIX D. Criteria Used in Quality Assessment

General Instructions:

For each risk of bias item, rate as “Yes,” “No,” or “Unclear.” After considering each of the 

quality items, give the study an overall quality rating of good, fair or poor.

Detailed Quality Items:

If an item is rated as “No,” describe why in the comments column.

1. Randomization adequate? Was the allocation sequence adequately generated? Yes/No/Unclear

2. Allocation concealment adequate? Was allocation adequately concealed? Yes/No/Unclear

3. Incomplete outcome data adequately addressed? Yes/No/Unclear

Consider Attrition bias: Were there systematic differences between groups in withdrawals from a 

study or high overall loss to followup? (Even small differences could be important when rates are 

low.) Were subjects excluded from the analysis – if so, were the exclusions sensible?

4. Subjects Blinded? Were subjects blind to treatment assignment? Yes/No/Unclear

5. Outcome assessor blinded? (This may be recorded separately for each critically important 

outcome.) Were Outcome assessors blind to treatment assignment? Yes/No/Unclear

6. Provider (treating clinician) blinded? Were providers blind to treatment assignment?

Yes/No/Unclear

7. All outcomes reported? Are reports of the study free of suggestion of selective outcome reporting 

(systematic differences between reported and unreported findings)? Yes/No/Unclear

8. Intention-to-treat analysis? All eligible patients that were randomized are included in analysis; 

note- mixed models and survival analyses are in general ITT Yes/No/Unclear

9. Adequate power for main effects? Yes (if power analysis or sample size calculation given and 

recruitment met needs or if post-hoc power calculation shows adequate power)/No (did not meet 

projected sample size needs) /Unclear (no power or sample size calculation given)

10. Other Selection bias? Were there methods that could lead to differences or were there systematic 

differences observed in baseline characteristics and prognostic factors of the groups compared?(e.g., 

failure of randomization): Yes/No/Unclear

11. Comparable groups maintained? (Includes crossovers, adherence, and contamination.) Consider 

issues of crossover (e.g., from one intervention to another), adherence (major differences in adherence 

to the interventions being compared), contamination (e.g., some members of control group get 

intervention) Yes/No/Unclear

12. Lack of Performance bias? Were there no important systematic differences in the care that was 

provided, other than the intervention of interest? Yes/No/Unclear

13. Lack of Measurement bias? Were the measures used reliable and valid – and therefore, “yes” no 

important measurement bias? Yes/No/Unclear

14. Absence of Detection bias? Were there systematic differences between groups in how outcomes are 

determined? If no systematic differences answer “yes” – no important detection bias.

Yes/No/Unclear

15. Was there the absence of potential important conflict of interest? The focus here is financial 

conflict of interest. Therefore if no financial conflict of interest (e.g. funded by government or 

foundation and authors do not have financial relationships with drug/device manufacturer), then 

answer “yes.” Yes/No/Unclear
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Overall rating

Please assign each study an overall quality rating of “Good,” “Fair,” or “Poor” based on the 

following definitions:

A “Good” study has the least bias, and results are considered valid. A good study has a clear 

description of the population, setting, interventions, and comparison groups; uses a valid 

approach to allocate patients to alternative treatments; has a low dropout rate; and uses 

appropriate means to prevent bias, measure outcomes, and analyze and report results. 

A “Fair” study is susceptible to some bias but probably not enough to invalidate the results. 

The study may be missing information, making it difficult to assess limitations and potential 

problems. As the fair-quality category is broad, studies with this rating vary in their strengths and 

weaknesses. The results of some fair-quality studies are possibly valid, while others are probably 

valid. 

A “Poor” rating indicates significant bias that may invalidate the results. These studies have 

serious errors in design, analysis, or reporting; have large amounts of missing information; or 

have discrepancies in reporting. The results of a poor-quality study are at least as likely to reflect 

flaws in the study design as to indicate true differences between the compared interventions.
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eer Review Comments/Author Responses

Response

ves, scope, and methods for this review clearly described?

Acknowledged

Acknowledged

excellent review and evidence synthesis. Thank you.

Acknowledged

 clearly and well-defined project. The authors are to be 

 the organization of the report which made for easy reading.

ould appreciate a formal definition of CAM (if there is 

e introductory material.

hat natural products such as nutritional supplements were 

eview, but there was no convincing rationale for this 

 the paucity of information from other CAM approaches, it 

reconsidering this decision.

Thank you.This definition is provided on the first page of the Executive Summary and in the background section of the Introduction of the report.The decision to exclude nutritional supplements was made by the stakeholders, not the research team.

Acknowledged

dication of bias in our synthesis of the evidence?

Acknowledged

sion criteria listed on p 12-13 show a clear bias toward 

ne centric locations. Given the paucity of studies, inclusion 

tion of studies particularly from countries where CAM is 

would be warranted. This would also involve non-English 

ations.

The reviewer raises a valid point. Our conceptual framework was to review settings and subjects similar to the VA and Veterans—thus the focus on studies conducted in the U.S. and economically similar countries. Our staff is not resourced to include non-English publications. We note this limitation in the discussion.

Acknowledged

Acknowledged

Acknowledged

o evidence of intentional bias. The authors have done a 

reporting the evidence. However, I believe the selection 

e limited what can be learned from the existing evidence, 

ave created an unintentional bias in the conclusions. 

See response to Question 7, Reviewer 6
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Response

studies of interest to the VA that we have overlooked?

 (2011). Military Medicine, 176:626-630

Thank you for making us aware of this article. Although it was published after our literature search date (Dec 22, 2010) and thus excluded from our formal literature synthesis, we now include a description of this study in our Results section, Key Question 4.

ents above on excluded studies. since PTSD is commonly 

ubstance abuse, exclusion of studies requiring both 

 applicability of findings 

e references for the excluded studies is a plus, as the reader 

wn conclusions. Shore 2004 is missing from that list. 

Operation Iraqi Freedom and Operation Enduring Freedom 

terans Health Administration chiropractic clinic: a case 

ournal of Rehabilitation Research & Development. 47(1):1-

AcknowledgedShore 2004 is included in the excluded studies table in Appendix F.Thank you for bringing this article to our attention. However, it does not meet our inclusion criteria since PTSD diagnosis was not a study inclusion criteria, nor was change in PTSD a reported outcome.

 am aware of, but this is not my field Acknowledged

 am aware of Acknowledged

Acknowledged

n RCT of mindfulness meditation by Barbara Niles that is 

ve that the authors attempted to get a copy of the paper but 

me reason. However, the trial was well-done and positive, 

elpful to try to include it if at all possible.

We have obtained a prepublication draft of this manuscript but do not include it in the current report since our literature review strategy stipulates that included studies be published in peer-reviewed journals. 

linical performance measures, programs, quality improvement measures, patient care services, or conferences 

d by this report? If so, please provide detail.

this report will be used while designing demonstration 

eld, in an attempt to address some of the methodological 

ified in the report.

Acknowledged

e base is too limited Acknowledged
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Response

mitations of current scientific evidence to review and the 

n for investment in adequately powered trials may affect and 

rch trials. This could result in positive results for patient care 

Acknowledged

tate health services research in this area I the VA, it would 

 some procedure codes that could be universally adopted that 

arious CAM approaches.

Thank you for this suggestion. We have added it to our Future Research section.

think of Acknowledged

any recommendations on how this report can be revised to more directly address or assist implementation needs.

o immediately be able to provide the draft version of this 

luation team from the University of Rochester, who will be 

aluation structure of our demonstration projects. Please advise 

, or if not, when the report can be available to them. This 

very soon, so this is time sensitive.

Acknowledged

ent report and I have only a few suggestions for how to 

ove it. 

e description of the data synthesis is somewhat difficult to 

ecially the last couple of lines. It may not be to experts in 

er. It would be nice if this could be a little clearer.

ld be very helpful to include the quality ratings on Table 4 as 

entence or 2 interpreting the important findings in the study 

ng on the reader either understanding the measurements or 

o them to understand what the findings mean. 

clarify that the study by Echeburua is a study of CBT/coping 

n (if I understand it correctly)

Thank you.We revised the data synthesis section to more clearly describe the standardized mean difference.We added the quality ratings for each study in Table 4. Outcomes are summarized in text. There was not adequate space to summarize the results narratively in the table.Echeburúa and colleagues conducted a comparative effectiveness study of relaxation training (progressive muscle relaxation; PMR) to an intervention that included cognitive behavioral therapy, coping, and PMR. We have updated the description of the study and Table 4 to better describe the two treatment arms. 
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Response

paragraph----why so much discussion about Vujanovic and 

is there data on mindfulness to support this contention? 

this much space in this report if no data and only opinion? 

We agree. In the final report, we have markedly streamlined this portion of the discussion.

pread use of CAM across the VA, clinicians, researchers, 

ors may find the report to be useful in helping them 

vidence base on CAM for PTSD.

Thank you.

us with contact details of any additional individuals/stakeholders who should be made aware of this report.

wal, info in VA Outlook Thank you. We will be sure Dr. Agarwal is made aware 

of the report.

ditional suggestions or comments below. If applicable, please indicate the page and line numbers from the draft 

hat the number who have deployed in the current conflicts is 

lion

t sure why nonscientific “energy therapies” are included 

based therapies, but since you didn’t find any efficacy, I 

matter.

Thank you for this comment. The report introduction now reflects an estimated 2.2 million deployed.We included energy therapies and movement therapies within the same category, consistent with NCCAM’s classification system for these modalities.

dentify some features of this report that are very helpful in 

his literature synthesis and might be applicable to other ESP 

nclude:

ellent and a nice model for our reports. It is very clear. 

ly nice. Very helpful. 

at! again, an interpretation of the findings might be helpful 

ledgeable reader

Thank you!
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Response

fic if there could be a parallel review of CAM therapies 

depression and some of the non-PTSD anxiety disorders. 

 tend to be comorbid with PTSD as well as share some 

 More importantly, there are many treatments that are identical 

ons and PTSD (e.g., SSRI’s, sleep medications), so it would 

some CAM approaches that are successful for these conditions 

ccessful for PTSD. Thus, it would be extremely useful to have 

n addition to the efficacy results, such a review could also point 

al considerations as well as touch on patient acceptability.

ful to include a brief description of the AHRQ study quality 

ext.

the statement on page 4 (and elsewhere in the text) that lower 

dence may be applicable when CAM treatments are offered 

nventional, evidence-based PTSD therapies. Even in the 

d-on therapy, it is important to conduct high quality studies.

blematic to omit mention of veterans of previous wars (e.g., 

etnam, etc.). Vietnam veterans are by far the most numerous 

m, so they and other previous war era veterans should be 

introductory paragraph.

 the paper (perhaps when discussing future research?), it may 

o discuss some of the complexities of PTSD research. These 

 of traumas (e.g., natural disasters, combat, rape, etc) which 

ferentially to treatments, time since trauma (which may impact 

erity), and comorbidity (both psychiatric and medical).

he opportunity to review this report. I hope these comments 

 increase the report’s utility.

We thank the reviewer for this suggestion. This supplementary report has already been commissioned, is underway, and should be available in the fall of 2011.A brief description of the AHRQ quality methods is presented in the Methods section under Quality Assessment.We appreciate this reviewer’s comment. The Future Research section has been revised substantially and this statement has been omitted from the discussion. Thank you for this suggestion. We have expanded the introductory text to acknowledge Veterans of all service eras.We thank the reviewer for this observation. A full discussion of the complexities of PTSD research was beyond the scope of this report, but we have highlighted some key challenges and referred the reader to more in-depth discussions.Thank you!
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Response

did a very careful job in preparing this document. The 

and thorough. However, I feel that the document could be 

he authors made several revisions. 

which is very strict about inclusion and exclusion, would be 

a literature that was more evolved, in which there were more e definitive studies. With such a small and underdeveloped 

uld have been informative to include a broader range of 

so could have influenced the conclusions about what appears 

—even if those conclusions were not definitive.

tant example of this concerns the exclusion of studies that 

as a comparison treatment but did not provide an adequate 

e relaxation protocol. At least a couple of these studies 

arks) found that relaxation was less effective than treatments 

n the VA/DoD PTSD practice guideline. The Marks study, 

shed in the Archives of General Psychiatry, would be 

 at least good or better quality. Although the statement about 

29 is not very favorable, by not reviewing studies such as 

rks, it might appear that relaxation is an intervention in need 

However, its performance in the 3 studies reviewed and these 

dies suggests that it may not have promise. Of course, this 

s to be tempered by the absence of detail about what study 

ually received. However, the information could be presented 

this caveat mentioned.

ow the criteria that caused other studies to be excluded might 

e results. The point is a more inclusive review that extracted 

n from the existing literature could provide useful guidance 

ections. 

Thank you.The research team understands this observation by the reviewer. However, our conceptual framework was to review settings and subjects similar to the VA and Veterans for ease of implementation if there was strong evidence for a therapy. We have added text to the Limitation section to acknowledge this important point.Acknowledged
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Response

nd that the authors revise content in the section on Future 

, and carry these revisions into the more extensive summary 

sing the p. 4 content as a reference:

raph discusses usual care and no care interventions as if they 

hen they are not. The inferences drawn from a usual care 

ent and stronger than the inferences drawn from a no care 

ragraph suggests that “evidence of benefit from less rigorous 

y be sufficient” for CAM treatments for PTSD that are los e to patient preferences, and have few adverse effects. There 

 review to support this suggestion. Low cost, low risk 

t patients like may not be a good use of resources at a system 

interfere with the delivery of effective care. Except for the 

ness of this suggestion, I do not think it fits with VA’s model 

Furthermore, why would a lower standard of evidence be a 

y case?

graph concludes that medication, acupuncture, relaxation, 

interventions are feasible and acceptable to patients and 

ise as adjunctive of monotherapies for PTSD.” Based on 

view, it is not possible to draw such a broad, if suggestive, 

t the benefits of monotherapy and adjunctive therapy 

reatments. None of them were tested in both formats. 

e tone of the conclusion does not fit with the summary of 

p. 29 or the table on pp. 39-40. Findings based on small, 

r fair quality studies (for which the strength of evidence 

/comparator combinations is rated as low or insufficient 

uncture), are not an adequate basis for concluding that the 

ted may be promising. There is only one good-quality study, 

as monotherapy (although study participants were allowed to 

and receive supportive therapy).

The text has been revised to refer to no care (waitlist) controls.The Future Research section has been revised substantially, and the endorsement of lower quality evidence and discussion of costs have been removed.We agree that the conclusions were overly broad. The conclusions have been modified and reflect the concerns raised by this reviewer.
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Response

dations for future research should include recommendations 

ness of reporting and fidelity monitoring, both of which 

the literature reviewed. Testing CAM interventions as 

rsus adjunctive therapies also would be helpful. There could 

that CAM as monotherapy should use EBT as a comparator 

th of data now available for the EBTs.

mindfulness on pp. 41-42 seems out of place in a section on 

s content is not about the limitations of the report.

at the authors standardize the level of detail provided about 

. For example, in the section on relaxation (pp. 26-29), F 

e reported for the Watson study, p-values are reported for the 

nd Ms and SDs are reported for the Echeburúa study. 

nd that the authors try to reduce jargon when possible. 

he 3rd bullet on 0. 29 are difficult to understand. 

Recommendations about fidelity monitoring and completeness of outcomes reporting have been specifically addressed in the revised Future Research section.We concur and now omit this content from the limitations section.Thank you for this observation. We have attempted to standardize this section.Thank you for this observation. We have attempted this where possible.
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ess Disorder Evidence-based Synthesis Program

xcluded Studies

reviewed in their full-text version and excluded for the reason indicated. An alphabetical reference list follows the table.

Population

not PTSD

Setting not 

outpatient, PC, 

MH, or community

Intervention 

not eligible 

CAM treatment

Control or 

comparator not 

eligible condition

Location not 

US/Europe/New 

Zealand/Australia

Language not 

English

Not peer 

reviewed/not 

primary data

XXX

X

X

X

X

X

XX

X

X

X

X

X

X

X

XXX

XX

X

XXXX

X

X
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Therapies for Posttraumatic Stress Disorder Evidence-based Synthesis Program

LIST OF EXCLUDED STUDIES 

Bob P. Psychophysiology of hypnotic abreaction. 

Homeost Health Dis. 2004;43(2):109-111.

Branstrom R, Kvillemo P, Brandberg Y, et al. Selfreport mindfulness as a mediator of psychological 

well-being in a stress reduction intervention for 

cancer patients--a randomized study. Ann Behav Med. 

2010;39(2):151-61.

Bryant RA, Moulds ML, Guthrie RM, et al. The 

additive benefit of hypnosis and cognitive-behavioral 

therapy in treating acute stress disorder. J Consult Clin 

Psychol. 2005;73(2):334-40.

Cardena E. Hypnosis in the treatment of trauma: 

A promising, but not fully supported, efficacious 

intervention. Int J Clin Exp Hypn. 2000;48(2):225-238.

Carlson JG, Chemtob CM, Rusnak K, et al. Eye 

movement desensitization and reprocessing (EDMR) 

treatment for combat-related posttraumatic stress 

disorder. J Trauma Stress. 1998;11(1):3-24.

Carter JJ. Evaluation of a multi-component yoga 

intervention as adjunct to psychiatric treatment for 

Vietnam veterans with posttraumatic stress disorder 

(PTSD): A randomized controlled trial (RCT). 

controlled-trials.com; 2006.

Descilo T, Vedamurtachar A, Gerbarg PL, et al. Effects 

of a yoga breath intervention alone and in combination 

with an exposure therapy for post-traumatic stress 

disorder and depression in survivors of the 2004 SouthEast Asia tsunami. Acta Psychiatr Scand; 2010:289-

300.

Dunn AS, Passmore SR, Burke J, et al. A crosssectional analysis of clinical outcomes following 

chiropractic care in veterans with and without posttraumatic stress disorder. Mil Med. 2009;174(6):578-

583.

Echeburua E, de Corral P, Zubizarreta I, et al. 

Psychological treatment of chronic posttraumatic stress 

disorder in victims of sexual aggression. Behav Modif. 

1997;21(4):433-56.

Frueh BC, Monnier J, Yim E, et al. A randomized trial 

of telepsychiatry for post-traumatic stress disorder. J 

Telemed Telecare. 2007;13(3):142-147.

Gordon JS, Staples JK, Blyta A, et al. Treatment of 

posttraumatic stress disorder in postwar Kosovo high 

school students using mind-body skills groups: a pilot 

study. J Trauma Stress. 2004;17(2):143-7.

Hiley-Young B. Facilitating Cognitive-Emotional 

Congruence in Anxiety Disorders During SelfDetermined Cognitive Change: An Integrative Model J 

Cogn Psychother. 1990;4(2):225-236.

Kraft K, Telles S. Yoga practice may be useful after 

post-traumatic stress. Focus on Alternative and 

Complementary Therapies. 2010;15(3):255-256.

Marks I, Lovell K, Noshirvani H, et al. Treatment 

of posttraumatic stress disorder by exposure and/or 

cognitive restructuring: a controlled study. Arch Gen 

Psychiatry. 1998;55(4):317-25.

Nakamura Y, Lipschitz DL, Landward R, et al. Two 

sessions of sleep-focused mind-body bridging improve 

self-reported symptoms of sleep and PTSD in veterans: 

A pilot randomized controlled trial. J Psychosom Res. 

2010.

Peeke PM, Frishett S. The role of complementary 

and alternative therapies in women’s mental 

health. Primary Care - Clinics in Office Practice. 

2002;29(1):183-197.

Salerno N. The Use of Hypnosis in the Treatment 

of Post-traumatic Stress Disorder in a Female 

Correctional Setting. Australian Journal of Clinical & 

Experimental Hypnosis. 2005;33(1):74-81.

Shore A. Long-term effects of energetic healing 

on symptoms of psychological depression and 

self-perceived stress. Altern Ther Health Med 

2004;10(3):42-8.

Short A. Theme and variations on quietness: 

Relaxation-focused music and imagery in aged care. 

Australian Journal of Music Therapy. 2007;18:39-61.

Spira JL, Pyne JM, Wiederhold B, et al. Virtual reality 

and other experiential therapies for combat-related 

posttraumatic stress disorder. Primary Psychiatry. 

2006;13(3):58-64.

Stapleton JA, Taylor S, Asmundson GJ. Effects of three 

PTSD treatments on anger and guilt: exposure therapy, 

eye movement desensitization and reprocessing, and 

relaxation training. J Trauma Stress. 2006(1):19-28.
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Stapleton JA, Taylor S, Asmundson GJG. Efficacy of 

various treatments for PTSD in battered women: Case 

studies. J Cogn Psychother. 2007;21(1):91-102.

Tacón AM, McComb J. Mindful exercise, quality 

of life, and survival: A mindfulness-based exercise 

program for women with breast cancer. The Journal 

of Alternative and Complementary Medicine. 

2009;15(1):41-46.

Tarrier N, Pilgrim H, Sommerfield C, et al. A 

randomized trial of cognitive therapy and imaginal 

exposure in the treatment of chronic posttraumatic 

stress disorder. J Consult Clin Psychol. 1999;67(1):13-

8.

Taylor S, Thordarson DS, Maxfield L, et al. 

Comparative efficacy, speed, and adverse effects 

of three ptsd treatments: exposure therapy, emdr, 

and relaxation training. J Consult Clin Psychol. 

2003(2):330-8.

Taylor S. Outcome Predictors for Three PTSD 

Treatments: Exposure Therapy, EMDR, and 

Relaxation Training. J Cogn Psychother. 

2003;17(2):149-161.

Trzepacz AM, Luiselli JK. Efficacy of Stress 

Inoculation Training in a Case of Posttraumatic 

Stress Disorder (PTSD) Secondary to Emergency 

Gynecological Surgery. Clinical Case Studies. 

2004;3(1):83-92.

Valentine PV, Smith TE. Evaluating traumatic incident 

reduction therapy with female inmates: a randomized 

controlled clinical trial. Research on Social Work 

Practice. 2001;11(1):40-52.

Waelde LC, Uddo M, Marquett R, et al. A pilot study 

of meditation for mental health workers following 

Hurricane Katrina. J Trauma Stress. 2008;21(5):497-

500.
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APPENDIX G. Glossary

Acupuncture

A family of procedures involving stimulation of anatomical points on the body by a variety of 

techniques. American practices of acupuncture incorporate medical traditions from China, Japan, 

Korea, and other countries. The acupuncture technique that has been most studied scientifically 

involves penetrating the skin with thin, solid, metallic needles that are manipulated by the hands 

or by electrical stimulation. 

Alexander technique

A movement therapy that uses guidance and education about ways to improve posture and 

movement. The intent is to teach a person how to use muscles more efficiently in order to 

improve the overall functioning of the body. 

Ayurvedic medicine

A system of medicine that originated in India thousands of years ago. Ayurveda is based on 

theories of health and illness and on ways to prevent, manage, or treat health problems. A chief 

aim of Ayurvedic practices is to cleanse the body of substances that can cause disease, and this is 

believed to help reestablish harmony and balance. 

Biofeedback

A technique that uses simple electronic devices to teach clients how to consciously regulate 

bodily functions, such as breathing, heart rate, and blood pressure, in order to improve overall 

health. Biofeedback is used to reduce stress, eliminate headaches, recondition injured muscles, 

control asthmatic attacks, and relieve pain. 

Chiropractic care

A type of care that involves the adjustment of the spine and joints to influence the body’s nervous 

system and natural defense mechanisms to alleviate pain and improve general health. It is 

primarily used to treat back problems, headaches, nerve inflammation, muscle spasms, and other 

injuries and traumas.

Cognitive behavioral therapy (CBT)

A psychotherapeutic approach that aims to solve problems concerning dysfunctional emotions, 

behaviors, and cognitions through a goal-oriented, systematic procedure. The term is used in 

diverse ways to designate behavior therapy, cognitive therapy, or therapy based on a combination 

of the two.

Cognitive processing therapy (CPT)

A cognitive behavioral therapy for PTSD and related conditions. CPT conceptualizes PTSD as 

a disorder of “nonrecovery” in which erroneous beliefs about the causes and consequences of 

traumatic events produce strong negative emotions and prevent accurate processing of the trauma 

memory and natural emotions emanating from the event.

Complementary and alternative medicine (CAM)

A group of diverse medical and health care systems, practices, and products that are not generally 
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considered part of conventional medicine. Complementary medicine is used together with 

conventional medicine, and alternative medicine is used in place of conventional medicine. 

Energy therapy

A practice that involves channeling of energy through the hands of a practitioner into the 

patient’s body to restore a normal energy balance and health. It is often used in conjunction with 

alternative and conventional medical treatments.

Eye movement desensitization and reprocessing (EMDR)

A form of psychotherapy developed to resolve symptoms resulting from disturbing and 

unresolved life experiences. EMDR uses a structured approach to address past, present, and 

future aspects of disturbing memories. 

Exposure therapy

A type of behavior therapy in which the patient confronts a feared situation, object, thought, or 

memory. Sometimes exposure therapy involves reliving a traumatic experience in a controlled, 

therapeutic environment. The goal is to reduce the distress, physical or emotional, felt in certain 

situations. 

Feldenkrais

A movement therapy that uses a method of education in physical coordination and movement. 

The intent is to help the person become more aware of how the body moves through space and to 

improve physical functioning.

Frontalis muscle tension

Tension or pain in the muscle tissues that run vertically on the forehead.

Guided imagery

A mind-body approach involving a series of relaxation techniques followed by visualization of 

detailed images, usually calm and peaceful in nature. If used for treatment, the individual will 

visualize their body free of the specific problem or condition. 

Health-related quality of life (HRQOL)

Aspects of overall quality of life that can be clearly shown to affect health—either physical or 

mental.

Image habituation training (IHT)

A form of exposure therapy that involves the patient in generating verbal descriptions of the 

traumatic event and recording these onto an audiotape.

Intent-to-treat analysis

A method of analyzing results of a randomized controlled trial that includes in the analysis 

all cases that should have received a treatment regimen but for some reason did not. All cases 

allocated to each arm of the trial are analyzed together as representing that treatment arm, 

regardless of whether they received or completed the prescribed regimen.
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Magnet therapy

An approach that applies a magnetic field to the body for purported health benefits including pain 

control. Magnets in products such as magnetic patches and disks, shoe insoles, bracelets, and 

mattress pads are used for pain in the foot, wrist, back, and other parts of the body.

Manipulative and body-based practices

Practices that focus primarily on the structures and systems of the body, including the bones and 

joints, soft tissues, and circulatory and lymphatic systems. Two commonly used therapies in this 

category are spinal manipulation and massage therapy.

Mantram

A sound, syllable, word, or group of words used in meditation practice to focus attention and 

achieve a state of greater calmness, physical relaxation, and psychological balance.

Massage therapy

A practice where therapists manipulate muscle and connective tissue to enhance function of those 

tissues and promote relaxation and well-being.

Mind-body medicine

Practices that focus on the interactions among the brain, mind, body, and behavior, with the 

intent to use the mind to affect physical functioning and promote health. 

Mindfulness-based stress reduction (MBSR)

A type of meditation with origins in religious and spiritual traditions. Mindfulness meditation 

focuses attention on breathing to develop increased awareness of the present. The intent is to 

reduce stress and control emotions in order to improve health. 

Movement-based therapy

The psychotherapeutic use of movement to promote emotional, cognitive, physical, and social 

integration of individuals.

Musculoskeletal manipulation

Manipulation of the bones and joints, soft tissues, and circulatory and lymphatic systems.

National Center for Complementary and Alternative Medicine (NCCAM) 

An agency of the NIH dedicated to exploring complementary and alternative healing practices 

in the context of rigorous science; training CAM researchers; and disseminating authoritative 

information to the public and professionals.

National Institutes of Health (NIH) 

An agency of the U.S. Department of Health and Human Services that is responsible for 

biomedical and health-related research.

Olfactory hypnotherapy

A technique that uses scents to arouse potent emotional reactions in the patient. During hypnosis, 

the patient learns to associate pleasant scents with a sense of security and self-control to 

overcome phobias and prevent panic attacks.
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Pilates

A movement therapy that uses a method of physical exercise to strengthen and build control 

of muscles, especially those used for posture. Awareness of breathing and precise control of 

movements are integral components of this approach. 

Posttraumatic stress disorder (PTSD)

A severe anxiety disorder that can develop after exposure to any event that results in 

psychological trauma. 

Progressive relaxation

A technique used to relieve tension and stress by systematically tensing and relaxing successive 

muscle groups.

Prolonged exposure

A form of behavior therapy and cognitive behavioral therapy for PTSD characterized by 

reexperiencing a traumatic event through remembering it and engaging with reminders of the 

trauma (triggers).

Qi gong

A practice with origins in Chinese philosophy involving gentle physical movement, mental 

focus, and deep breathing directed toward specific parts of the body. 

Reflexotherapy

A treatment method that uses fingers, needles, and magnet applicators to influence biologically 

active spots on a human body that are situated where nerve terminals and vessels are 

concentrated. 

Reiki

An energy medicine practice that originated in Japan. In Reiki, the practitioner places hands on 

or near the person receiving treatment, with the intent to transmit “ki,” believed to be life-force 

energy.

Relaxation therapy

A practice that focuses on using a combination of breathing and muscle relaxation to deal with 

stress. 

Rolfing Structural Integration

A form of deep tissue massage used to realign the tissues that cover and connect all muscles and 

body organs (fascia). Bringing the body back into proper alignment is thought to reduce pain, 

improve flexibility and energy, and reduce muscle tension.

Sensory arts therapy

An expressive arts therapy that encourages the patient to express and understand emotions 

through artistic expression and the creative process.
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Serotonin norepinephrine reuptake inhibitors (SNRI)

A class of antidepressant drugs used in the treatment of major depression and other mood 

disorders. They are sometimes also used to treat anxiety disorders. SNRIs act upon and increase 

the levels of two neurotransmitters in the brain that are known to play an important part in mood, 

serotonin and norepinephrine.

Serotonin reuptake inhibitor (SSRI) 

A class of medications used to treat psychological conditions including depression and anxiety 

disorders. SSRIs help increase levels of serotonin in the brain, thus improving mood. 

Spinal manipulation

A practice performed by chiropractors and other health care professionals such as physical 

therapists, osteopaths, and some conventional medical doctors. It involves the use of hands or a 

device to apply a controlled force to a joint of the spine, moving it beyond its passive range of 

motion; the amount of force applied depends on the form of manipulation used. 

Stress inoculation therapy (SIT)

A cognitive behavioral treatment for PTSD where the goal is to help a patient gain confidence in 

his or her ability to cope with anxiety and fear stemming from trauma-related reminders. In SIT, 

the client becomes more aware of reminders for anxiety and fear and learns coping skills that are 

useful in managing anxiety, such as muscle relaxation and deep breathing. 

Tai chi

A mind-body practice, originated in China as a martial art, that involves moving the body in a 

slow, relaxed, and graceful series of movements. Many practitioners believe that tai chi helps the 

flow throughout the body of a vital energy called “qi.”

Trager Psychophysical Integration

A movement therapy in which practitioners apply a series of gentle, rhythmic rocking 

movements to the joints. The intent is to release physical tension and increase the body’s range of 

motion.

Trauma-focused therapy

A therapy designed to reduce negative emotional and behavioral responses following child sexual 

abuse and other traumatic events. The treatment addresses distorted beliefs and attributions 

related to the abuse and provides a supportive environment in which the patient is encouraged to 

talk about their traumatic experience. 

Whole medical system

A complete system of theory and practice that has evolved over time in different cultures and 

apart from conventional medicine. Examples of whole medical systems include traditional 

Chinese medicine, Ayurvedic medicine, homeopathy, and naturopathy.

Yoga

A system of physical postures, breathing techniques, and meditation practiced to promote bodily 

or mental control and well-being.