The Impact of Military Status on Cognitive Processing Therapy Outcomes in the Community

Why Do Veterans Not Respond as Well as Civilians to Trauma-Focused Therapies for PTSD?

ABSTRACT

This column first reviews evidence that veterans have poorer response to trauma-focused therapies for PTSD compared to civilians. We then consider several explanations for this trend, starting with gender as a possible confounding variable. We also examine other hypotheses, including the effects of the military acculturation process, the unique influences of military traumas, such as combat and military sexual traumas, and the roles of traumatic brain injuries (TBIs) and moral injury. Future research, we conclude, must determine whether gender explains the differences in trauma-focused therapy response. If so, then the underlying reasons must be further explored. If not, then we must determine the unique characteristics of the veteran population that make it more resistant to treatment. Mining these elements will help us adapt our trauma-focused therapies to better help this population and close the response-rate gap.

Impact of morally injurious traumatic event exposure on cognitive processing therapy outcomes among Veterans and service members

LAY SUMMARY

Military personnel frequently report actions taken by themselves or others that violate deeply held moral beliefs, which can be experienced as a kind of moral injury. Some have questioned whether existing treatments for posttraumatic stress disorder (PTSD), such as cognitive processing therapy, are effective for those who have been exposed to a morally injurious traumatic event. These analyses demonstrate that active duty service members and Veterans seeking treatment for PTSD who reported potentially morally injurious trauma had PTSD and depression outcomes that were as good as those whose traumas were not primarily seen as morally injurious, suggesting that cognitive processing therapy is an efficacious treatment for PTSD in the context of morally injurious trauma.

Effectiveness and comparative effectiveness of evidence-based psychotherapies for posttraumatic stress disorder in clinical practice

BACKGROUND

While evidence-based psychotherapy (EBP) for posttraumatic stress disorder (PTSD) is a first-line treatment, its real-world effectiveness is unknown. We compared cognitive processing therapy (CPT) and prolonged exposure (PE) each to an individual psychotherapy comparator group, and CPT to PE in a large national healthcare system.

METHODS

We utilized effectiveness and comparative effectiveness emulated trials using retrospective cohort data from electronic medical records. Participants were veterans with PTSD initiating mental healthcare (N = 265 566). The primary outcome was PTSD symptoms measured by the PTSD Checklist (PCL) at baseline and 24-week follow-up. Emulated trials were comprised of 'person-trials,' representing 112 discrete 24-week periods of care (10/07-6/17) for each patient. Treatment group comparisons were made with generalized linear models, utilizing propensity score matching and inverse probability weights to account for confounding, selection, and non-adherence bias.

RESULTS

There were 636 CPT person-trials matched to 636 non-EBP person-trials. Completing ⩾8 CPT sessions was associated with a 6.4-point greater improvement on the PCL (95% CI 3.1-10.0). There were 272 PE person-trials matched to 272 non-EBP person-trials. Completing ⩾8 PE sessions was associated with a 9.7-point greater improvement on the PCL (95% CI 5.4-13.8). There were 232 PE person-trials matched to 232 CPT person-trials. Those completing ⩾8 PE sessions had slightly greater, but not statistically significant, improvement on the PCL (8.3-points; 95% CI 5.9-10.6) than those completing ⩾8 CPT sessions (7.0-points; 95% CI 5.5-8.5).

CONCLUSIONS

PTSD symptom improvement was similar and modest for both EBPs. Although EBPs are helpful, research to further improve PTSD care is critical.

Who improves in trauma-focused treatment: A cluster analysis of treatment response in VA patients undergoing PE and CPT

BACKGROUND

Although most veterans with posttraumatic stress disorder (PTSD) benefit from evidence-based treatments, questions persist concerning the profiles of those at risk for poor outcomes. To help address these gaps, this study analyzed a large clinical cohort of veterans receiving prolonged exposure (PE) or cognitive processing therapy (CPT).

METHODS

Cluster analysis using Ward's method with Euclidian distances identified clinically meaningful subgroups of veterans in a national cohort (n = 20,848) using variables maintained in the electronic medical record. The clusters were then compared via one-way analysis of variance and Tukey's HSD on indicators of treatment progress including PTSD symptom change, clinical recovery, clinically significant change, remission, and treatment completion.

RESULTS

Effect size differences on clinical outcome measures for PE and CPT were negligible. Less than half of veterans achieved at least a 15-point reduction in PCL-5 score and half completed treatment. We identified 10 distinct clusters. Higher rates of PTSD service-connected disability were linked to poorer outcomes across multiple clusters, especially when combined with Post-Vietnam service era. Non-White race was also linked with poorer clinical outcomes. Factors associated with better outcomes included a greater proportion of female veterans, especially when combined with recent service era, and longer PTSD diagnosis duration.

CONCLUSIONS

This study suggests the need to improve PTSD treatment outcomes for non-White and male veterans, examine treatment response in Post-Vietnam era veterans, and consider ways in which the service connection process could hinder treatment response. The results from this study also indicate the benefits of integrating elements of clinical complexity into an analytic approach.

Four profiles of symptom change in residential Cognitive Processing Therapy

A significant portion of veterans do not respond to evidence-based treatments for PTSD. Therefore, researchers have sought to predict who will respond well to trauma-focused treatment. The present study examined pre- and posttreatment symptom profiles, session-by-session change, as well as demographic and additional diagnostic information to better understand PTSD treatment response. Participants included 332 veterans undergoing residential Cognitive Processing Therapy. Latent profile analyses were computed, and four meaningful profiles emerged: Fast Responders, Steady Responders, Partial Responders, and Minimal Responders. Each profile demonstrated symptom reduction at approximately the same rate in the first half of treatment. Two specific profiles, Steady Responders and Minimal Responders, showed key clinically important differences. Both profiles demonstrated severe pretreatment PTSD symptom severity; however, in the second half of treatment, Steady Responders saw the steepest decrease in symptoms of any of the profiles while Minimal Responders saw less symptom reduction compared to all other profiles. Via a thorough examination, membership in Steady Responders compared to Minimal Responders was not associated with demographic or health variables. Results suggest that pretreatment symptom severity does not necessarily determine a client's posttreatment symptom severity. Pretreatment symptom severity did not determine outcome, though some veterans (Minimal Responders) did not experience the same symptom change and treatment effectiveness. Further identifying the factors that lead to the separation of these groups will add important information for determining treatment selection and potential obstacles to effectiveness.

Evidence-based posttraumatic stress disorder treatment in a community sample: Military-affiliated versus civilian patient outcomes

Posttraumatic stress disorder (PTSD) is a significant mental health issue among military service members and veterans. Although the U.S. Department of Veterans Affairs (VA) provides crucial resources for behavioral health care, many veterans seek mental health services through community clinics. Previous research illustrates that military and veteran patients benefit less from evidence-based treatments (EBTs) for PTSD than civilians. However, most PTSD treatment outcome research on military and veteran populations is conducted in VA or military settings. Little is known about outcomes among military-affiliated patients in community settings. The primary aim of this study was to directly compare civilian versus military-affiliated patient outcomes on PTSD and depression symptoms using the PTSD Checklist for DSM-5 (PCL-5) and the nine-item Patient Health Questionnaire (PHQ-9) in a community setting. Participants (N = 502) included military-affiliated (veteran, Guard/Reservist, active duty) and civilian patients who engaged in cognitive processing therapy (CPT) or prolonged exposure (PE) for PTSD in community clinics. Both groups demonstrated significant reductions on the PCL-5, military-affiliated: d = -0.91, civilian: d = -1.18; and PHQ-9, military-affiliated: d = -0.65, civilian: d = -0.88, following treatment. However, military-affiliated patients demonstrated smaller posttreatment reductions on the PCL-5, M_diff = 5.75, p = .003, and PHQ-9, M_diff = 1.71, p = .011, compared to civilians. Results demonstrate that military-affiliated patients benefit from EBTs for PTSD, albeit to a lesser degree than civilians, even in community settings. These findings also highlight the importance of future research on improving EBTs for military personnel with PTSD.

Variable-length Cognitive Processing Therapy for posttraumatic stress disorder in active duty military: Outcomes and predictors

Cognitive Processing Therapy (CPT) is an evidence-based therapy recommended for posttraumatic stress disorder (PTSD). However, rates of improvement and remission are lower in veterans and active duty military compared to civilians. Although CPT was developed as a 12-session therapy, varying the number of sessions based on patient response has improved outcomes in a civilian study. This paper describes outcomes of a clinical trial of variable-length CPT among an active duty sample. Aims were to determine if service members would benefit from varying the dose of treatment and identify predictors of treatment length needed to reach good end-state (PTSD Checklist-5 ≤ 19). This was a within-subjects trial in which all participants received CPT (N = 127). Predictor variables included demographic, symptom, and trauma-related variables; internalizing/externalizing personality traits; and readiness for change. Varying treatment length resulted in more patients achieving good end-state. Best predictors of nonresponse or needing longer treatment were pretreatment depression and PTSD severity, internalizing temperament, being in precontemplation stage of readiness for change, and African American race. Controlling for differences in demographics and initial PTSD symptom severity, the outcomes using a variable-length CPT protocol were superior to the outcomes of a prior study using a fixed, 12-session CPT protocol. CLINICALTRIALS.GOV IDENTIFIER: NCT023818.

Cognitive Processing Therapy for Veterans with Posttraumatic Stress Disorder: What is the Median Effective Dose?

OBJECTIVE

Cognitive Processing Therapy (CPT) has been disseminated in the Veterans Health Administration (VHA) to treat posttraumatic stress disorder (PTSD). Identifying the median effective dose (MED) of CPT, the number of sessions at which the probability of experiencing clinically meaningful improvement (CMI) is 50%, can assist with treatment.

METHOD

From a cohort of Iraq and Afghanistan war veterans who received PTSD psychotherapy in VHA between 2001-2017, veterans who received CPT with available PTSD symptom outcomes (PTSD Checklist; PCL) were identified using natural language processing (n=26,189). Cox proportional hazards regression was used to examine how number of CPT sessions, together with covariates, influenced CMI (10-point PCL reduction). Kaplan-Meier curves were plotted to determine MED.

RESULTS

At eight sessions, there was a 50% probability of experiencing CMI. The Cox proportional hazard regression indicated a greater likelihood of CMI in fewer sessions for veterans who received individual-only CPT versus any group CPT (HR:1.31, 95%CI:1.23-1.39). Kaplan-Meier curves indicated a 50% probability of experiencing CMI at seven sessions for veterans who received individual-only CPT versus ten sessions for veterans receiving any group CPT.

LIMITATIONS

PCL data was not available for all veterans who received CPT or at each potential assessment point. Not all veterans continued in CPT until CMI was observed.

CONCLUSIONS

The MED of CPT was eight sessions. Fewer sessions were needed to reach MED for veterans who received individual versus group CPT. These results may help those who treat, research, and are recovering from PTSD through accurately anchoring treatment expectations and providing a marker of initial treatment response.