Design of VA Cooperative Study #591: CERV-PTSD, comparative effectiveness research in veterans with PTSD

CERV-PTSD is a randomized controlled trial of two of the most effective treatments for PTSD, Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT). Despite solid evidence that both treatments are effective, there is limited evidence about their effectiveness relative to one another. The primary objective is to compare the effectiveness of PE and CPT for reducing PTSD symptom severity in a healthcare system that offers both treatments. The secondary objective is to compare the effectiveness of PE and CPT for reducing the severity of comorbid mental health problems and service utilization as well as improving functioning and quality of life. The tertiary objective is to examine whether discrepancy between patient preferences and treatment assignment reduces the effectiveness of each treatment. Exploratory analyses will examine whether demographic and clinical characteristics predict differential response to PE and CPT. The study is designed to randomize 900 male and female veterans with PTSD due to any traumatic military event to receive PE or CPT. The standard dose of treatment is 12 weekly sessions but veterans who improve more rapidly may finish in fewer sessions and veterans who improve more slowly may have additional sessions. The primary outcome is improvement in PTSD symptoms, measured during and after treatment and then 3 and 6 months later. As a large multi-site trial with men and women, CERV-PTSD is designed to advance the delivery of care for PTSD by providing conclusive information about whether one treatment is better than the other, overall, and for different types of patients.

Comparison of clinician- and self-assessments of posttraumatic stress symptoms in older versus younger veterans

Assessment of posttraumatic stress disorder (PTSD) in older adults has received limited investigation. The purpose of this study was to compare the severity of PTSD symptoms in treatment-seeking older and younger U.S. veterans with PTSD. Participants were 360 male and 284 female veterans enrolled in 2 separate clinical trials of psychotherapy for PTSD. About 4% of the participants were age 60 years or older. Symptoms were assessed before treatment using clinician-rated and self-report measures. For men, only numbing symptoms were lower in older veterans; this was so in clinician ratings, d = 0.76, and self-reports, d = 0.65. For women, clinician-rated hyperarousal symptoms were lower in older veterans, d = 0.57. Clinician-rated and self-reported symptoms were strongly related, Bs = 0.95 and 0.80 in the male and female samples, respectively. Among men, clinician-rated and self-reported reexperiencing and hyperarousal symptoms were associated only in younger veterans. Accurate assessment of PTSD symptoms in older adults is essential to identifying and implementing effective treatment. Our findings suggest that some symptoms may be lower in older men, and that some symptoms of PTSD may be underdetected in older women. Future research should assess the combined effect of gender and age on PTSD symptom presentation.

Changes in implementation of two evidence-based psychotherapies for PTSD in VA residential treatment programs: a national investigation

There has been little investigation of the natural course of evidence-based treatments (EBTs) over time following the draw-down of initial implementation efforts. Thus, we undertook qualitative interviews with the providers at 38 U.S. Department of Veterans Affairs' residential treatment programs for posttraumatic stress disorder (PTSD) to understand implementation and adaptation of 2 EBTs, prolonged exposure (PE), and cognitive processing therapy (CPT), at 2 time points over a 4-year period. The number of providers trained in the therapies and level of training improved over time. At baseline, of the 179 providers eligible per VA training requirements, 65 (36.4%) had received VA training in PE and 111 (62.0%) in CPT with 17 (9.5%) completing case consultation or becoming national trainers in both PE and CPT. By follow-up, of the increased number of 190 eligible providers, 87 (45.8%) had received VA training in PE and 135 (71.1%) in CPT, with 69 (36.3%) and 81 (42.6%) achieving certification, respectively. Twenty-two programs (57.9%) reported no change in PE use between baseline and follow-up, whereas 16 (42.1%) reported an increase. Twenty-four (63.2%) programs reported no change in their use of CPT between baseline and follow-up, 12 (31.6%) programs experienced an increase, and 2 (5.2%) programs experienced a decrease in use. A significant number of providers indicated that they made modifications to the manuals (e.g., tailoring, lengthening). Reasons for adaptations are discussed. The need to dedicate time and resources toward the implementation of EBTs is noted.

VA Residential Provider Perceptions of Dissuading Factors to the Use of Two Evidence-Based PTSD Treatments

Providers (N = 198) from 38 Department of Veterans Affairs residential posttraumatic stress disorder treatment programs across the United States completed qualitative interviews regarding implementation of 2 evidence-based treatments: prolonged exposure and cognitive processing therapy. As part of this investigation, providers were asked how they decide which patients are appropriate for these treatments. Many indicated that they did not perceive any patient factors that dissuade their use of either evidence-based treatment. However, 3 broad categories emerged surrounding reasons that patients were perceived to be less suitable candidates for the treatments: the presence of psychiatric comorbidities, cognitive limitations, and low levels of patient motivation. Interestingly, providers' perceived reasons for limited or nonuse of a treatment did not correspond entirely to those espoused by treatment developers. Possible solutions to address provider concerns, including educational and motivational interventions, are noted.

Do benzodiazepines reduce the effectiveness of exposure therapy for posttraumatic stress disorder?

OBJECTIVE

Benzodiazepines, other anxiolytics, or sedative hypnotics are prescribed for 30%-50% of posttraumatic stress disorder (PTSD) patients. Prior data and theory suggest that these medications may inhibit response to exposure therapy, one of the most effective PTSD treatments. The present post hoc study reanalyzed results from a psychotherapy trial to assess whether benzodiazepine use was associated with reduced response to exposure therapy.

METHOD

Between August 2002 and October 2005, 283 female veterans and soldiers meeting DSM-IV criteria for PTSD were randomly assigned to 10 weekly 90-minute sessions of either prolonged exposure (n = 140) or present-centered psychotherapy (n = 143). Benzodiazepine use (n = 57) or non-use (n = 226) at intake was not randomly assigned. Multilevel modeling was used to assess the effects of benzodiazepine status, psychotherapy condition, and their interaction on changes on the Clinician-Administered PTSD Scale and the PTSD Checklist during the treatment and 6-month follow-up periods.

RESULTS

Consistent with prior reports from these data, prolonged exposure psychotherapy produced greater reductions per week in PTSD symptoms than did present-centered psychotherapy (b = -0.48, P = .02). Patients prescribed benzodiazepines did not have weaker response to prolonged exposure, but demonstrated poorer posttreatment maintenance of gains from present-centered psychotherapy (b = -0.78, P < .001).

CONCLUSIONS

Prolonged exposure is a sufficiently robust treatment that patients who are taking benzodiazepines can benefit from it. It is unclear whether benzodiazepine use or other patient factors accounted for benzodiazepine recipients' poorer maintenance of gains in present-centered psychotherapy.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00032617.

Prevalence of physical and sexual assault and mental health disorders in older women: findings from a nationally representative sample

OBJECTIVES

This study presents prevalence and characteristics of physical and sexual assaults, and their relationship to posttraumatic stress disorder (PTSD), and mood and anxiety disorders in a nationally representative sample of older women.

DESIGN AND SETTING

Face-to-face interviews conducted with adult participants from wave 2 of the National Epidemiological Survey on Alcohol and Related Conditions.

PARTICIPANTS

A total of 3,354 community-residing women of age 65 years and older.

MEASUREMENT

Alcohol Use Disorder and Associated Disabilities Interview Schedule for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, current mood and anxiety disorders.

RESULTS

Almost 14% of participants reported a history of physical or sexual assault or both during their lifetimes. Assaults were often repeated rather than isolated events. Although the majority of participants did not identify interpersonal violence as their "worst" traumatic event, those who experienced interpersonal violence were generally more likely than those without such history to meet the criteria for past-year and lifetime PTSDs, depression, and anxiety.

CONCLUSIONS

Some women who have been physically or sexually assaulted decades earlier continue to report significant levels of mood and anxiety disorders into late adulthood. Several ways to increase the identification and treatment of older female trauma survivors by healthcare providers are suggested.

Gender differences in prescribing among veterans diagnosed with posttraumatic stress disorder

OBJECTIVE

The Department of Veterans Affairs (VA) and Department of Defense (DoD) issued a revised posttraumatic stress disorder (PTSD) Clinical Practice Guideline (CPG) in 2010 with specific pharmacotherapy recommendations for evidence-based quality care. The authors examined prescribing frequencies over an 11-year period prior to the release of the new guideline to determine gender differences in pharmacotherapy treatment in veterans with PTSD.

METHOD

National administrative VA data from 1999 to 2009 were used to identify veterans with PTSD using ICD-9 codes extracted from inpatient discharges and outpatient clinic visits. Prescribing of antidepressants, antipsychotics and hypnotics was determined for each year using prescription drug files.

RESULTS

Women were more likely than men to receive medication across all classes except prazosin where men had higher prescribing frequency. The proportion of women receiving either of the first-line pharmacotherapy treatments for PTSD, selective serotonin reuptake inhibitors (SSRI) and serotonin-norepinephrine reuptake inhibitors (SNRI), increased from 56.4 % in 1999 to 65.7 % in 2009, higher rates than seen in men (49.2 % to 58.3 %). Atypical antipsychotic prescriptions increased from 14.6 % to 26.3 % and nonbenzodiazepine hypnotics increased from 3.8 % to 16.9 % for women, higher frequencies than seen in men for both medications (OR = 1.31, 1.43 respectively). The most notable gender discrepancy was observed for benzodiazepines where prescriptions decreased for men (36.7 % in 1999 to 29.8 % in 2009) but steadily increased for women from 33.4 % to 38.3 %.

CONCLUSION

A consistent pattern of increased prescribing of psychotropic medications among women with PTSD was seen compared to men. Prescribing frequency for benzodiazepines showed a marked gender difference with a steady increase for women despite guideline recommendations against use and a decrease for men. Common co-occurring disorders and sleep symptom management are important factors of PTSD pharmacotherapy and may contribute to gender differences seen in prescribing benzodiazepines in women but do not fully explain the apparent disparity.

Meta-analysis of the efficacy of treatments for posttraumatic stress disorder

OBJECTIVE

Posttraumatic stress disorder (PTSD) is an important mental health issue in terms of the number of people affected and the morbidity and functional impairment associated with the disorder. The purpose of this study was to examine the efficacy of all treatments for PTSD.

DATA SOURCES

PubMed, MEDLINE, PILOTS, and PsycINFO databases were searched for randomized controlled clinical trials of any treatment for PTSD in adults published between January 1, 1980, and April 1, 2012, and written in the English language. The following search terms were used: post-traumatic stress disorders, posttraumatic stress disorder, PTSD, combat disorders, and stress disorders, post-traumatic.

STUDY SELECTION

Articles selected were those in which all subjects were adults with a diagnosis of PTSD based on DSM criteria and a valid PTSD symptom measure was reported. Other study characteristics were systematically collected. The sample consisted of 137 treatment comparisons drawn from 112 studies.

RESULTS

Effective psychotherapies included cognitive therapy, exposure therapy, and eye movement desensitization and reprocessing (g = 1.63, 1.08, and 1.01, respectively). Effective pharmacotherapies included paroxetine, sertraline, fluoxetine, risperidone, topiramate, and venlafaxine (g = 0.74, 0.41, 0.43, 0.41, 1.20, and 0.48, respectively). For both psychotherapy and medication, studies with more women had larger effects and studies with more veterans had smaller effects. Psychotherapy studies with wait-list controls had larger effects than studies with active control comparisons.

CONCLUSIONS

Our findings suggest that patients and providers have a variety of options for choosing an effective treatment for PTSD. Substantial differences in study design and study participant characteristics make identification of a single best treatment difficult. Not all medications or psychotherapies are effective.

Telephone monitoring and support after discharge from residential PTSD treatment: a randomized controlled trial

OBJECTIVE

This study assessed whether adding a telephone care management protocol to usual aftercare improved the outcomes of veterans in the year after they were discharged from residential treatment for posttraumatic stress disorder (PTSD).

METHODS

In a multisite randomized controlled trial, 837 veterans entering residential PTSD treatment were assigned to receive either standard outpatient aftercare (N=425) or standard aftercare plus biweekly telephone monitoring and support (N=412) for three months after discharge. Symptoms of PTSD and depression, violence, substance use, and quality of life were assessed by self-report questionnaires at intake, discharge, and four and 12 months postdischarge. Treatment utilization was determined from the Department of Veterans Affairs administrative data.

RESULTS

Telephone case monitors reached 355 participants (86%) by phone at least once and provided an average of 4.5 of the six calls planned. Participants in the telephone care and treatment-as-usual groups showed similar outcomes on all clinical measures. Time to rehospitalization did not differ by condition. In contrast with prior studies reporting poor treatment attendance among veterans, participants in both telephone monitoring and treatment as usual completed a mental health visit an average of once every ten days in the year after discharge. Many participants had continuing problems despite high utilization of outpatient care.

CONCLUSIONS

Telephone care management had little incremental value for patients who were already high utilizers of mental health services. Telephone care management could potentially be beneficial in settings where patients experience greater barriers to engaging with outpatient mental health care after discharge from inpatient treatment.

Review of group treatment for PTSD

The purpose of this article is to provide a brief review of group treatment for posttraumatic stress disorder (PTSD). This review includes a description of group-based treatments for PTSD and the available data on the efficacy of group treatment for PTSD. The literature review indicates that group treatment for PTSD is efficacious compared with no treatment. However, specific types of group treatment are not efficacious when compared with a nonspecific group treatment, such as psychoeducation or supportive counseling. Recommendations for practice and research are made in light of the available literature.

Impact of evidence-based standardized assessment on the disability clinical interview for diagnosis of service-connected PTSD: a cluster-randomized trial

Posttraumatic stress disorder (PTSD) is one of the fastest growing compensated medical conditions. The present study compared usual disability examiner practices for PTSD with a standardized assessment that incorporates evidence-based assessments. The design was a multicenter, cluster randomized, parallel-group study involving 33 clinical examiners and 384 veterans at 6 Veterans Affairs medical centers. The standardized group incorporated the Clinician Administered PTSD Scale and the World Health Organization Disability Assessment Schedule-II into their assessment interview. The main outcome measures were completeness and accuracy of PTSD diagnosis and completeness of functional assessment. The standardized assessments were 85% complete for diagnosis compared to 30% for nonstandardized assessments (p < .001), and, for functional impairment, 76% versus 3% (p < .001). The findings demonstrate that the quality of PTSD disability examination would be improved by using evidence-based assessment.

Work-related outcomes among female veterans and service members after treatment of posttraumatic stress disorder

OBJECTIVE

This study examined the effect of treatment for posttraumatic stress disorder (PTSD) on work-related quality-of-life outcomes and the relationship between clinically significant change during treatment and work-related outcomes. Additional analyses explored whether current depression and employment status moderated the effects of treatment and clinically significant change.

METHODS

Participants were 218 female veterans and soldiers with current PTSD who participated in a randomized clinical trial of treatment for PTSD. They received ten weekly sessions of prolonged exposure or present-centered therapy and were assessed before and after treatment and at three- and six-month follow-ups. Outcomes were clinician-rated and self-rated occupational impairment and self-rated satisfaction with work.

RESULTS

Both treatment groups had improvements in occupational impairment, and the degree of improvement by the two groups was similar. There was no pre- to posttreatment change in work satisfaction. At the end of treatment, participants who no longer met diagnostic criteria for PTSD had greater improvements in all domains of work-related quality of life than participants who still had PTSD.

CONCLUSIONS

Although prolonged exposure resulted in better PTSD symptom outcomes than present-centered therapy in the randomized clinical trial, it did not result in better work-related quality-of-life outcomes. The improvement in occupational impairment associated with loss of diagnosis suggests the importance of continuing treatment until clinically meaningful change has been attained.

Effect of cognitive-behavioral couple therapy for PTSD: a randomized controlled trial

CONTEXT

Posttraumatic stress disorder (PTSD) is a prevalent condition associated with intimate relationship problems, and intimate relationship factors have been shown to affect individual PTSD treatment outcomes.

OBJECTIVE

To compare cognitive-behavioral conjoint therapy for PTSD (a manualized couple therapy delivered to patients with PTSD and their significant others to simultaneously treat PTSD symptoms and enhance relationship satisfaction) with a wait-list condition.

DESIGN, SETTING, AND PARTICIPANTS

Randomized controlled trial of heterosexual and same-sex couples (n = 40 couples; n = 80 individuals) in which one partner met criteria for PTSD according to the Clinician-Administered PTSD Scale, conducted from 2008 to 2012 in a Department of Veterans Affairs outpatient hospital setting in Boston, Massachusetts, and a university-based research center in Toronto, Ontario, Canada. Symptoms of PTSD, comorbid conditions, and relationship satisfaction were collected by blinded assessors at baseline, at mid treatment (median, 8.00 weeks [range, 1.71-20.43 weeks] after baseline), and at posttreatment (median, 15.86 weeks [range, 7.14-38.57 weeks] after baseline). An uncontrolled 3-month follow-up (median, 38.21 weeks [range, 28.43-50.57 weeks] after baseline) was also completed.

INTERVENTION

Couples were randomly assigned to take part in the 15-session cognitive-behavioral conjoint therapy for PTSD protocol immediately (n = 20) or were placed on a wait list for the therapy (n = 20).

MAIN OUTCOME MEASURES

Clinician-rated PTSD symptom severity was the primary outcome and was assessed with the Clinician-Administered PTSD Scale. Intimate relationship satisfaction, assessed with the Dyadic Adjustment Scale, patient- and partner-rated PTSD symptoms, and comorbid symptoms were secondary outcomes.

RESULTS

PTSD symptom severity (score range, 0-136) was significantly more improved in the couple therapy condition than in the wait-list condition (mean change difference, -23.21; 95% CI, -37.87 to -8.55). Similarly, patients' intimate relationship satisfaction (score range, 0-151) was significantly more improved in couple therapy than in the wait-list condition (mean change difference, 9.43; 95% CI, 0.04-18.83). The time × condition interaction effect in the multilevel model predicting PTSD symptoms (t37.5 = -3.09; P = .004) and patient-reported relationship satisfaction (t68.5 = 2.00; P = .049) revealed superiority of the couple therapy compared with the wait list. Treatment effects were maintained at 3-month follow-up.

CONCLUSION

Among couples in which one partner was diagnosed as having PTSD, a disorder-specific couple therapy, compared with a wait list for the therapy, resulted in decreased PTSD symptom severity and patient comorbid symptom severity and increased patient relationship satisfaction.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00669981.

The dissociative subtype of PTSD: a replication and extension

BACKGROUND

The nature of the relationship between dissociation and posttraumatic stress disorder (PTSD) has clinical and nosological importance. The aim of this study was to evaluate the evidence for a dissociative subtype of PTSD in two independent samples and to examine the pattern of personality disorder (PD) comorbidity associated with the dissociative subtype of PTSD.

METHODS

Latent profile analyses were conducted on PTSD and dissociation items reflecting derealization and depersonalization in two samples of archived data: Study 1 included 360 male Vietnam War Veterans with combat-related PTSD; Study 2 included 284 female Veterans and active duty service personnel with PTSD and a high base rate of exposure to sexual trauma.

RESULTS

The latent profile analysis yielded evidence for a three-class solution in both samples: the model was defined by moderate and high PTSD classes and a class marked by high PTSD severity coupled with high levels of dissociation. Approximately 15% of the male sample and 30% of the female sample were classified into the dissociative class. Women (but not men) in the dissociative group exhibited higher levels of comorbid avoidant and borderline PD diagnoses.

CONCLUSIONS

Results provide support for a dissociative subtype of PTSD and also suggest that dissociation may play a role in the frequent co-occurrence of PTSD and borderline PD among women. These results are pertinent to the on-going revisions to the DSM and suggest that consideration should be given to incorporating a dissociative subtype into the revised PTSD criteria.

Measurement of a model of implementation for health care: toward a testable theory

Background

Greenhalgh et al. used a considerable evidence-base to develop a comprehensive model of implementation of innovations in healthcare organizations [1]. However, these authors did not fully operationalize their model, making it difficult to test formally. The present paper represents a first step in operationalizing Greenhalgh et al.’s model by providing background, rationale, working definitions, and measurement of key constructs.

Methods

A systematic review of the literature was conducted for key words representing 53 separate sub-constructs from six of the model’s broad constructs. Using an iterative process, we reviewed existing measures and utilized or adapted items. Where no one measure was deemed appropriate, we developed other items to measure the constructs through consensus.

Results

The review and iterative process of team consensus identified three types of data that can been used to operationalize the constructs in the model: survey items, interview questions, and administrative data. Specific examples of each of these are reported.

Conclusion

Despite limitations, the mixed-methods approach to measurement using the survey, interview measure, and administrative data can facilitate research on implementation by providing investigators with a measurement tool that captures most of the constructs identified by the Greenhalgh model. These measures are currently being used to collect data concerning the implementation of two evidence-based psychotherapies disseminated nationally within Department of Veterans Affairs. Testing of psychometric properties and subsequent refinement should enhance the utility of the measures.

Work-related quality of life and posttraumatic stress disorder symptoms among female veterans

BACKGROUND

Posttraumatic stress disorder (PTSD) can have pervasive, negative effects on multiple aspects of quality of life. We investigated the relationship between PTSD symptom clusters and work-related quality of life among female veterans. Although prior studies have shown that PTSD symptom clusters are differentially related to work-related quality of life, no study has assessed these relationships in women specifically.

METHODS

Participants were 253 female veterans with current PTSD. We assessed three components of work-related quality of life (employment status, clinician-rated occupational impairment, and self-rated occupational satisfaction) and performed analyses with and without adjusting for self-reported depression symptoms.

RESULTS

None of the PTSD symptom clusters were associated with employment status. All PTSD symptom clusters had significant independent associations with occupational impairment. All PTSD symptom clusters except avoidance were significantly associated with lower occupational satisfaction, but none had independent associations with occupational satisfaction. No single PTSD symptom cluster emerged as most strongly associated with occupational outcomes. Symptoms of depression had substantial associations across all occupational outcomes, independent of PTSD symptoms.

CONCLUSION

Knowledge about how PTSD relates to occupational outcomes in women veterans is important for addressing the needs of this growing segment of the VA patient population, in which PTSD is a prevalent condition. Because PTSD had differential relationships with the three components of work-related quality of life, measuring only one component, or using an aggregate measure, may obscure important distinctions. Resolving depression symptoms also may be integral to achieving meaningful recovery.

Variation in practices and attitudes of clinicians assessing PTSD-related disability among veterans

One hundred thirty-eight Veterans Affairs mental health professionals completed a 128-item Posttraumatic Stress Disorder (PTSD) Practice Inventory that asked about their practices and attitudes related to disability assessment of PTSD. Results indicate strikingly wide variation in the attitudes and practices of clinicians conducting disability assessments for PTSD. In a high percentage of cases, these attitudes and practices conflict with best-practice guidelines. Specifically, 59% of clinicians reported rarely or never using testing, and only 17% indicated routinely using standardized clinical interviews. Less than 1% of respondents reported using functional assessment scales.

Development and initial validation of the Response to Stressful Experiences Scale

This report describes the development and initial validation of the Response to Stressful Experiences Scale (RSES), a measure of individual differences in cognitive, emotional, and behavioral responses to stressful life events. We validated this instrument with active-duty and reserve components of military and veterans samples (N = 1,014). The resulting 22-item scale demonstrated sound internal consistency (alpha = 0.91-0.93) and good test-retest reliability (r = 0.87). Factor analysis suggested 5 protective factors: (a) meaning-making and restoration, (b) active coping, (c) cognitive flexibility, (d) spirituality, and (e) self-efficacy. Associations with other measures supported convergent, discriminant, and concurrent validity. In separate military samples, the RSES accounted for unique variance in posttraumatic stress disorder symptoms above and beyond existing scales measuring resilience-related constructs, thereby demonstrating incremental validity. The RSES provides a brief, reliable, and valid measure of individual differences in cognitive, emotional, and behavioral responses to life's most stressful events.

Cognitive-behavioral conjoint therapy for PTSD: pilot results from a community sample

Seven couples participated in an uncontrolled trial of cognitive-behavioral conjoint therapy for posttraumatic stress disorder (PTSD). Among the 6 couples who completed treatment, 5 of the patients no longer met criteria for PTSD and there were across-treatment effect size improvements in patients' total PTSD symptoms according to independent clinician assessment, patient report, and partner report (d = 1.32-1.69). Three of the 4 couples relationally distressed at pretreatment were satisfied at posttreatment. Partners reported statistically significant and large effect size improvements in relationship satisfaction; patients reported nonsignificant moderate to large improvements in relationship satisfaction. Patients also reported nonsignificant, but large effect size improvements in depression and state anger symptoms. Future directions for research and treatment of traumatized individuals and close others are offered.

Sensitivity of the SF-36 to PTSD symptom change in veterans

The authors examined the relationship between changes in symptoms of posttraumatic stress disorder (PTSD) and functioning as measured by the Medical Outcomes Study Short Form-36 (SF-36) among 167 veterans in a primary care clinic. Those who reported at least moderate baseline symptoms were categorized as better, unchanged, or worse at reassessment. The SF-36 was used to examine concordance between change in functioning and symptoms. Veterans with reliable changes in symptoms of PTSD showed corresponding statistically significant changes in functioning across health domains. Moreover, these changes in functioning were clinically significant on several SF-36 subscales and on one summary scale.