Running head: REDUCING STRESS AND ANXIETY IN VETERANS WITH PTSD 1

Reducing Stress and Anxiety in Veterans With PTSD

Jayden Dunn

Caitlin O’Hara

Brent Skall

Taylor Watson

Youngstown State University

NURS 3947 Nursing Research

Dr. Patricia Hoyson and Dr. Mary Shortreed

Fall 2018
REDUCING STRESS AND ANXIETY IN VETERANS WITH PTSD 2

Abstract

The intention of this paper is to compare the effects that yoga and selective serotonin reuptake

inhibitors (SSRI’s) have on reducing stress and anxiety in veterans suffering from PTSD.

This review looked at multiple scholarly articles and journals and cross-referenced them to give

an accurate representation of the research on yoga and SSRI’s. The research showed that there is

no significant evidence that yoga or SSRI’s are effective enough to treat PTSD symptoms by

themselves. There was a significant finding that showed that the use of both treatments in

conjuncture with one another provides an effect on PTSD patients that treats the symptoms

effectively. There is a need for more research on this topic and the long-term effects of yoga and

use of SSRI’s together. Overall when comparing the use of yoga and SSRI’s there was no

evidence to support the use of just one treatment over the other, but there was evidence to

support the use of them together.

REDUCING STRESS AND ANXIETY IN VETERANS WITH PTSD 3

Reducing Stress and Anxiety in Veterans With PTSD

PTSD is a mental disorder of the brain that occurs in people that have experienced a

traumatic event. Symptoms of PTSD usually occur within a couple months of the incident and

most last for more than a month and be severe enough to interfere with activities of daily living.

Some common symptoms include flashbacks, bad dreams, or frightening thoughts. The

conventional treatments for PTSD are anti-depressants and anti-anxiety medications such as

SSRI’s. Conventional treatment of this disorder has shown to be effective enough to prevent

suicide in this population and reduce some of the major symptoms, but the use of these drugs do

not treat all the symptoms of PTSD. Yoga and other forms of complementary and alternative

medicine have been on the rise for treatment of anxiety disorders including PTSD. These two

treatment modalities are very different in nature so the research question was asked: Does yoga

or SSRI’s have a stronger effect on reducing stress and anxiety in veterans with PTSD?

Literature Review

Introduction

To obtain a better understanding of PTSD and the effects that yoga and SSRI’s have on

treating this mental disorder, we accessed information from ProQuest Nursing and CINAHL

databases. We found eight reputable and relevant sources to pull information from. The

following pages will include a variety of different studies and knowledge regarding the

effectiveness of both yoga and SSRI’s in the treatment of PTSD for veteran clients.

Yoga

Yoga has been acknowledged as one of the best ways to stay physically fit for many

years, but it is also one of the best ways to keep mentally fit. That is why researchers have begun

to apply yoga intervention in US war veterans that suffer from post-traumatic stress disorder.
REDUCING STRESS AND ANXIETY IN VETERANS WITH PTSD 4

When these heroes come home from war, the battle isn’t always over for them. PTSD is a life-

changing disorder that occurs repetitively after experiencing a traumatic event, which often leads

to risky behaviors and/or suicide. For many years, physicians have tried to treat veterans with

PTSD by using medication, but they have not been completely successful with this method.

Researchers began to look at other alternatives and conjunctive therapies, such as yoga. The hope

behind this was to find a way to give war veterans the best quality of life in a cost-effective way,

and eventually decrease the rate of suicides committed among this population.

These studies looked at several characteristics affected by PTSD like anxiety and

hyperarousal symptoms, which include irritability, startle reflexes, anger, guilt, as well as self-

destructive behaviors such as binge drinking, drugs, and so on. According to these few studies

that have been conducted, yoga does have a positive outcome on veterans. The participants were

to partake in yoga sessions for a specific amount of time and be assessed thoroughly before and

afterwards. The overall outcomes of both studies were very successful and revealed that yoga

does play a role in improving the quality of life in war veterans who suffer from PTSD.

Specifically, in a study done by Seppala, Nitschke, Tudorascu, Hayes, Goldstein, Nguyen,

Perlman, and Davidson, the symptoms were assessed by using PTSD Checklist-Military version

(PCL-M) which concluded in lower rates of PTSD symptoms, anxiety, and respirations (2014).

This study randomly assigned twenty-one veterans to a control group and an ‘active’ group

which implemented Sudarshan Kriya yoga. The individuals in the ‘active’ group showed

significant improvements while the control group stayed the same. From looking at this study,

one can see that most patients who undergo treatment with medication alone still have difficulty

trying to cope with their anxiety. Breathing-based yoga can serve as a strong conjunctive therapy
REDUCING STRESS AND ANXIETY IN VETERANS WITH PTSD 5

to medication because it allows the individual to relax by focusing on purposeful movements and

breathing patterns and result in a reduction of PTSD symptoms.

In a similar study done by Staples, Hamilton, and Uddo (2013), they reported that their

participants not only had a noteworthy decrease in hyperarousal symptoms, but roughly eighty

percent of the participants responded to a program evaluation saying they “extremely” or “very

much” enjoyed the yoga class and felt it was refining their quality of life. This data conflicted

with the Outcome Questionnaire 45.2 (OQ-45.2) scale, which only showed a slight increase. The

researchers then proposed that more investigation be put in the scale because the participants had

reported not only feeling better, but a better quality of life with more mental clarity, which the

scale failed to reflect. This study again reflected that yoga was a helpful intervention in veterans

suffering from PTSD.

After reviewing these studies, it was apparent that yoga intervention did have a positive

result. Even though these studies used different styles of yoga, both approaches resulted in

significantly decreased PTSD hyperarousal symptoms. This is perhaps the most important effect

of both studies because hyperarousal symptoms have the greatest effect on the veteran’s quality

of life. These are the symptoms that disrupt their life, increase anxiety, and send them into deep

depression which often results in suicide. Both studies showed that regardless of which type of

yoga was used, there was a decrease in these PTSD symptoms. This proves that while it still

needs more research and investigation, breathing-based yoga should be integrated in the

treatment of military veterans coming back from war with post-traumatic stress disorder to

decrease suicide rates and give them the best quality of life.

Yoga Trials
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Many health care facilities these days are increasingly becoming open to incorporating

more alternative therapies into their treatments and care plans because of the success they are

proving to demonstrate. Specifically, the Veterans Health Administration is one of the bigger

facilities to take part in an integrative approach. As stated previously, post-traumatic stress

disorder is one of the biggest mental health issues, along with a variety of other issues that

veterans face and is a problem that health care providers are constantly trying to manage.

“Standard medical models often target isolated disease states, such as infection,

headaches, or insomnia, and at times they may miss the more complex, multisystem dysfunction

that has been documented in the veteran population” (Hull, 2015, pg.12) Many researchers are

interested in seeing how relaxation techniques, such as yoga, used in combination with other

approaches affect this condition rather than just using pharmacological treatment and that is what

one study conducted by Sullivan and Hull (2015) intended to find out. They documented the

findings of a complementary and alternative medicine (CAM) program created for veterans to

see how they responded. In the program, a variety of services were offered including chair yoga,

qigong, yoga nidra, and acupuncture. The study was aiming to see how the services affected the

specific population of veterans physical and mental health. The researchers used questionnaires

where the participants rated their experience. The veterans all reported significant decreases in

their symptoms of mental illness such as depression and PTSD along with other issues that

interfered with activities of daily life such as insomnia and pain. Some other benefits noted of

incorporating yoga as a treatment plan is that it is low cost, sustainable, and does not have any

side effects that come along with medicinal treatments.

Another study examined the results of a randomized controlled trial that involved military

veterans with PTSD taking part in Kripalu yoga. Those who chose to participate did a 10 week
REDUCING STRESS AND ANXIETY IN VETERANS WITH PTSD 7

intervention program. The study looked at the effects of yoga on PTSD and trauma related

symptoms and how the practice caused improvements. They found that yoga involved self

regulation, including cognitive, emotional, and behavioral regulation. “Collectively through

these mechanisms, yoga may reduce PTSD symptoms by decreasing physical tension, increasing

relaxation, attenuating automatic thoughts (e.g., rumination) and behaviors (e.g., hyperarousal),

and enhancing awareness and attitudes characterized by nonjudgment” (Reinhardt, 2017). Before

and after the 10-week program, the researchers screened the participants using a Clinician

Administered PTSD Scale, which is a 30-item interview to diagnose the severity of PTSD. The

majority of participants fell into the severe range before beginning the program. “Following the

10 week intervention period, yoga group participants’ PTSD symptom levels dropped into the

moderate PTSD/threshold range” (Reinhardt, 2017). The results of this particular study were

consistent with recent literature signifying that yoga may have potential as a PTSD therapy in

veterans. The study had some issues that hindered the trial including the fact that many of the

participants dropped out before the conclusion of the trial so additional larger trials would need

to be held in order to confirm the hypothesis that yoga reduces PTSD symptoms in veterans.

Overall both of these articles provided positive evidence supporting yoga as a treatment for

trauma-related mental health issues, but recognized that limitations of existing research hinder

clear conclusions about yoga's efficacy.

SSRI’s.

Before we can determine the response of taking Selective Serotonin Reuptake Inhibitors

(SSRI’s) and how it is used in the treatment of posttraumatic stress disorder (PTSD), we must

have a basic understanding of both concepts. According to the American Psychiatric Association

(2002)., PTSD is a neurological disorder of the brain that includes, flashbacks, nightmares,
REDUCING STRESS AND ANXIETY IN VETERANS WITH PTSD 8

restricted range of emotions, and hyperarousal symptoms related to recall of a traumatic event.

Studies have shown that SSRI’s are successful in relieving intrusive, avoidance, and

hyperarousal symptoms as well as depression, anxiety, impulsivity, aggression, and drug and

alcohol use. To measure the effectiveness of the drugs, a Clinician-Administered PTSD Scale

(CAPS) is typically used. This scale establishes a baseline and rates the frequency and severity of

the client’s PTSD symptoms (Blake et al. 1990, 1995). It was noted in a variety of different

studies that with the use of SSRI’s, there were significant reductions in mean CAPS total scores

as well as lower occurrence of re-experiencing symptoms. It is also important to mention that the

medications were also effective in reducing depression and anxiety in veterans with PTSD.

Additionally, it is imperative to mention that patients with post-traumatic stress disorder

are often undiagnosed. Data from a cross-sectional study of 592 adult patients with PTSD helped

to reveal some significant information. Of the adults with PTSD, half received an SSRI in

accordance with mental health treatment. According to the Journal of Behavioral Health Services

& Research, the odds of receiving mental health (MH) treatment were increased 8.2 times for

patients with MH diagnosis. Furthermore, nearly 50% of patients with PTSD received MH

treatment, yet few had this diagnosis documented (Meltzer et al. 2012). It is chief that more

attention in the health care industry be focused on the recognition of PTSD, along with

treatment. SSRI’s are the treatment of choice because they alleviate symptoms, have few side

effects and treat comorbid problems. There is a significant benefit to diagnosing a patient with

PTSD because they can receive focused treatment. Moreover, incomplete treatment leads to less

optimal outcomes and will continue to suffer from symptoms and are at an increased risk of

suicide. This relates to veterans in a very personal way, as a continuing number of patients

continue to commit suicide because of not seeking medical treatment. SSRI’s have been proven
REDUCING STRESS AND ANXIETY IN VETERANS WITH PTSD 9

as an effective type of treatment, it just comes down to whether they are being prescribed and

used. It is recommended that, “future research, focused on strategies to reduce patient and

physician barriers to disclosing trauma aimed at improving the diagnosis and treatment of PTSD,

is essential to advancing the delivery of MH treatment to those suffering from this disabling

condition” (Meltzer et al. 2012). Ultimately, it is vital that health care professionals strive to do

what is in the patient’s best interest and recognize signs of PTSD.

SSRI’s and Yoga

Traditional treatment of PTSD is widely used across health care including SSRI’s.

Complementary and alternative medicine is just now beginning to become a treatment option for

PTSD patients. There are now VA hospitals that utilize forms of medicine like yoga and

mediation to reduce symptoms of PTSD. One study done by Libby, Pilver, and Desai (2012)

inspected 125 of 170 specialized treatment programs determined the use of complementary and

alternative medicine in VA hospitals. They examined 81 mixed format questions covering CAM

treatments. This study had multiple limitations because veterans did not comply with all the

treatment plans. This survey did uncover that many veterans still have symptoms even after the

used of CAM therapies but they found that it would be more beneficial for these veterans to use

conventional PTSD treatments along with programs such as yoga, relaxation therapy, and

meditation (Libby et al. 2012).

A meta-analysis review of 13 articles conducted by Macy, Jones, Graham, and Roach

(2015) focused on the efficacy of yoga as a treatment for traumatic related mental health

disorders. This study looked at the design of 185 distinct studies, yoga interventions,

accessibility of the treatment, it reviewed the strengths and weaknesses of each article, primary

results, types of participants, and recommendations for future research. They also found that the
REDUCING STRESS AND ANXIETY IN VETERANS WITH PTSD 10

use of yoga in treatment is found to be most effective when used with SSRI’s or conventional

treatment of mental health disorders. They determined that yoga does not have enough evidence

to support the use of it as a primary treatment (Jones et al. 2015). All in all both of these studies

that examined VA hospitals and many different studies determined that the best use of yoga is

with the use of medication as well.

Conclusion

After examining the research for the use and efficacy of yoga and SSRI’s as treatment for

veterans with PTSD the results show that these two different forms of medicine do treat some

symptoms of this mental disorder. Yoga helps with relaxation, treats hyperarousal symptoms, and

helps veterans have a better quality of life while SSRI’s help treat the depressive symptoms of

this disorder. The research showed that these two forms of treatment are effective in some ways,

but not in others. Through comparing the two treatments there is little research to determine

which treatment is more effective. The research that has been conducted showed the most

effective treatment is the use of both yoga and SSRI’s together to create a balanced treatment

plan.
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References

Libby, D. J., Pilver, C. E., Desai, R. (2012). Complementary and Alternative Medicine in VA

Specialized PTSD Treatment Programs. Journal of Psychiatric Services, 63(11), 1134-

1136. doi: 10.1176/ appi.ps.201100456)

Macy, R. J., Jones, E., Graham, L. M., Roach, L. (2015). Yoga for Trauma and Related Mental

Health Problems: A Meta-Review With Clinical and Service Recommendations. Journal

of Trauma, Violence, & Abuse, 19(1), 35-57. doi: 10.1177/1524838015620834

Meltzer, E. C., Averbuch, T., Samet, J. H., Saitz, R., Jabbar, K., Lloyd-Travaglini, C., &

Liebschutz, J. M. (2011). Discrepancy in Diagnosis and Treatment of Post-traumatic

Stress Disorder (PTSD): Treatment for the Wrong Reason. The Journal of Behavioral

Health Services & Research, 39(2), 190-201. doi:10.1007/s11414-011-9263-x

Seedat, S., Stein, D. J., Ziervogel, C., Middleton, T., Kaminer, D., Emsley, R. A., & Rossouw, W.

(2002). Comparison of Response to a Selective Serotonin Reuptake Inhibitor in Children,

Adolescents, and Adults with Posttraumatic Stress Disorder. Journal of Child and Adolescent

Psychopharmacology,12(1), 37-46. doi:10.1089/10445460252943551

Seppala, E. M., Nitschke, J. B., Tudorascu, D. L., Hayes, A., Goldstein, M. R., Nguyen, D. T. H.,

Perlman, D., & Davidson, R. J. (2014). Breathing-Based Meditation Decreases

Posttraumatic Stress Disorder Symptoms in U.S. Military Veterans: A Randomized

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DOI:10.1002/jts.21936

Staples, J. K., Hamilton, M. F., Uddo, M. (2013). A Yoga Program for the Symptoms of Post-
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Traumatic Stress Disorder in Veterans. Military Medicine, Vol. 178.

DOI:10.7205/MILMED-D-12-00536