2/2-Optimizing PTSD Treatments

描述(由申请人提供)：虽然公认药物疗法和心理疗法在治疗慢性创伤后应激障碍(PTSD)方面都相对有效，但美国医学研究所(IOM，2007)最近的报告强调了我们目前知识中的巨大差距，指出缺乏关于影响治疗接受和完成的因素、这些药物和心理疗法的综合有效性以及它们在共同亚群(例如诊断为同时出现的人群)中的疗效的知识。为了解决这些差距，我们提出了第一个大规模试验，直接关注几个关键参数的个性化PTSD护理：治疗的选择，心理治疗和药物PTSD联合治疗的效果，以及是否存在共同发生的严重抑郁症。在我们之前关于创伤后应激障碍治疗的心理治疗和药物治疗试验的基础上，我们将进行一项双随机优先试验，在该试验中，患有慢性创伤后应激障碍的女性和男性创伤幸存者将随机分配到选择或不选择治疗条件。在选择条件下，患者将在长期暴露(PE)和长期暴露加舍曲林(PE+SER)之间进行选择。在没有选择的情况下，患者将被随机分配到单独延长暴露(PE)组或长期暴露加舍曲林(PE+SER)组。此外，我们将专门招募和检查共发的严重抑郁障碍(MDD)患者。通过精神病理学和更广泛的功能测量来衡量结果，将在治疗后和24个月的随访中进行评估。我们还将检查生物、心理和社会反应的标志物，心理治疗的变化过程，以及这些治疗的成本效益。具体目标是：1)比较PE和PE+SER的短期和长期疗效；2)系统地比较已选择治疗的患者和没有选择治疗的患者在治疗依从性、治疗完成率和有效性方面的差异；以及3)比较单独患有创伤后应激障碍的患者与患有创伤后应激障碍并同时发生严重抑郁症的患者。根据NIMH的战略计划，这项建议侧重于更个性化的药物，重点放在患者的选择上，并更好地了解个体的结局轨迹。

DESCRIPTION (provided by applicant): Although it is well established that both pharmacological and psychological therapies are relatively effective in treating chronic posttraumatic stress disorder (PTSD), the recent Institute of Medicine (IOM, 2007) report highlights vast gaps in our current knowledge noting a lack of knowledge regarding factors influencing treatment acceptance and completion, the combined effectiveness of these pharmacological and psychological treatment, and their efficacy in common subpopulations (e.g., those with diagnostic co-occurrence). To address these gaps, we propose the first large-scale trial to directly focus on individualizing PTSD care across several key parameters: choice of treatment, the effects of combined psychotherapy and pharmacological PTSD treatment, and the presence of co-occurring major depression. Building on our previous psychotherapy and pharmacotherapy trial on PTSD treatment, we will conduct a doubly randomized preference trial in which female and male trauma survivors with chronic PTSD will be randomly assigned to either choice or no choice treatment conditions. In the choice condition, patients will choose between prolonged exposure (PE) and prolonged exposure plus sertraline (PE + SER). In the no choice condition, patients will be randomly assigned to either prolonged exposure alone (PE) or prolonged exposure plus sertraline (PE + SER). In addition, we will specifically recruit and examine patients with co-occurring major depressive disorder (MDD). Outcome, as measured by both psychopathology and broader functioning measures, will be assessed at post-treatment and through 24-month follow-up. We will also examine biopsychosocial markers of response, psychotherapy change processes, and cost-effectiveness of these treatments. The Specific Aims are: 1) To compare the short-term and long-term effectiveness of PE to that of PE + SER; 2) To systematically compare patients who have chosen their treatment to those who have not in terms of treatment adherence, treatment completion, and effectiveness; and 3) To compare individuals with PTSD alone to those with PTSD and co-occurring major depression. In line with the NIMH's strategic plan, this proposal focuses on more personalized medicine, focusing on patients' choices and better understanding individual trajectories of outcome.