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

An evaluation of the associations among posttraumatic stress disorder, depression, and complicated grief in active duty military personnel with traumatic loss

Between 44% and 87% of active duty service members and veterans who deployed following the September 11, 2001, terrorist attacks know someone who was killed or seriously injured in combat. Considering the high frequency and known impact of traumatic loss, it is important to understand if and how traumatic loss may impede posttraumatic stress disorder (PTSD) treatment progress in military personnel. Additionally, experiencing a traumatic loss elevates the risk of developing prolonged grief disorder (PGD), which is associated with higher levels of PTSD symptoms, more functional impairment, and more lifetime suicide attempts among military personnel. Given what is known about the association between PGD and PTSD in treatment-seeking service members and veterans, it is also important to understand whether grief-related symptom severity negatively impacts PTSD treatment response. The current study examined associations among traumatic loss, complicated grief, depressive symptoms, and PTSD treatment response among military personnel (N = 127) who participated in variable-length cognitive processing therapy (CPT). There was no direct, F(2, 125) = 0.77, p = .465, or indirect, β = .02, p = .677, association between a traumatic loss index event and PTSD treatment response compared with other trauma types. Prior assessments of depressive symptom severity were directly related to PTSD at later assessments across two models, ps < .001-p = .021 Participants with a traumatic loss index trauma demonstrated significant reductions in complicated grief, depressive symptoms, and PTSD following CPT, ps < .001, ds = -0.61--0.83. Implications, study limitations, and suggestions for future research are presented.

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.

Differential posttraumatic stress disorder symptom cluster response to stellate ganglion block: secondary analysis of a randomized controlled trial

Empirically supported treatments for posttraumatic stress disorder (PTSD) exist, but research suggests these therapies are less effective, acceptable, and feasible to deliver to active duty service members (SMs) compared to civilians. Stellate ganglion block (SGB) procedure, in which a local anesthetic is injected around the cervical sympathetic chain or stellate ganglion to temporarily inhibit sympathetic nervous activity, is gaining popularity as an alternative PTSD treatment in military settings. However, it is unknown whether certain PTSD symptoms are more responsive to SGB than others. The current study involved a secondary analysis of data collected from a previous randomized controlled trial of SGB compared to sham (normal saline) injection (N = 113 SMs). PTSD symptoms were assessed via clinical interview and self-report at baseline and 8 weeks post-SGB or sham. Logistic regression analyses showed that the marked alterations in arousal and reactivity PTSD symptom cluster demonstrated the greatest symptom severity reductions after SGB, relative to sham. The reexperiencing cluster also showed pronounced response to SGB in clinician-rated but not self-reported outcomes. Post-hoc item-level analyses suggested that arousal and reactivity cluster findings were driven by reductions in hypervigilance, concentration difficulties, and sleep disturbance, whereas clinician-rated reexperiencing cluster findings were driven by reductions in physiological reactions to trauma cues, emotional reactions to trauma cues, and intrusions. Our findings align with a burgeoning literature positioning SGB as a potential novel or adjunctive PTSD treatment. Results could guide future hypothesis-driven research on mediators of therapeutic change during SGB for PTSD symptoms in SMs.

Systematic review and meta-analysis of neurofeedback and its effect on posttraumatic stress disorder

Background

To date, only one systematic review and meta-analysis of randomized controlled trials (RCTs) has evaluated the effect of neurofeedback in PTSD, which included only four studies and found an uncertainty of the effect of EEG-NF on PTSD symptoms. This meta-analysis is an update considering that numerous studies have since been published. Additionally, more recent studies have included fMRI-NF as well as fMRI-guided or -inspired EEG NF.

Methods

Systematic literature searches for RCTs were conducted in three online databases. Additional hand searches of each study identified and of systematic reviews and meta-analyses published were also undertaken. Outcomes evaluated the effect of neurofeedback vs. a control (active, sham, and waiting list) on their effects in reducing PTSD symptoms using various health instruments. Meta-analytical methods used were inverse variance random-effects models measuring both mean and standardized mean differences. Quality and certainty of the evidence were assessed using GRADE. Adverse events were also evaluated.

Results

A total of 17 studies were identified evaluating a total of 628 patients. There were 10 studies used in the meta-analysis. Results from all studies identified favored neurofeedback's effect on reducing PTSD symptoms including BDI pretest-posttest [mean difference (MD): 8.30 (95% CI: 3.09 to 13.52; P = 0.002; I 2 = 0%)]; BDI pretest-follow-up (MD: 8.75 (95% CI: 3.53 to 13.97; P < 0.00001; I 2 = 0%); CAPS-5 pretest-posttest [MD: 7.01 (95% CI: 1.36 to 12.66; P = 0.02; I 2 = 86%)]; CAPS-5 pretest-follow-up (MD: 10 (95% CI: 1.29 to 21.29; P = 0.006; I 2 = 77%); PCL-5 pretest-posttest (MD: 7.14 (95% CI: 3.08 to 11.2; P = 0.0006; I 2 = 0%); PCL-5 pretest-follow-up (MD: 14.95 (95% CI: 7.95 to 21.96; P < 0.0001; I 2 = 0%). Other studies reported improvements using various other instruments. GRADE assessments of CAPS, PCL, and BDI demonstrated a moderate/high level in the quality of the evidence that NF has a positive clinical effect.

Conclusion

Based on newer published studies and the outcomes measured, NF has demonstrated a clinically meaningful effect size, with an increased effect size at follow-up. This clinically meaningful effect appears to be driven by newer fMRI-guided NF and deeper brain derivates of it.

Heart Rate Variability Biofeedback as a Treatment for Military PTSD: A Meta-Analysis

INTRODUCTION

Emerging research has provided tentative support for the use of heart rate variability biofeedback (HRVB) as a treatment for several psychological disorders, with meta-analyses providing compelling evidence for HRVB as a promising treatment for anxiety, depression, and PTSD. Given the prevalence of PTSD in military veterans and the comparatively lower benefit and higher attrition rate of traditional psychological treatment for PTSD relative to civilian counterparts, it is important to examine complementary and alternative treatment approaches such as HRVB in this population. Although studies of HRVB for PTSD have been conducted with military veterans, they have involved relatively small sample sizes, limiting interpretation. To address this, the current article presents a comprehensive meta-analysis, consolidating existing literature to more accurately evaluate the efficacy of HRVB in reducing PTSD symptoms within military populations.

MATERIALS AND METHODS

This meta-analysis was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, and our protocol was registered with PROSPERO to increase review transparency. A literature search of HRVB interventions was conducted using PubMed, PsycINFO, Military Database, PTSDPubs, and EBSCO's Psychological and Behavioral Sciences Collection.

RESULTS

Five studies met eligibility criteria, providing a combined sample size of 95 military services members. For all studies, effect sizes were negative, indicating a reduction in PTSD symptoms. Effect sizes ranged from -1.614 to -0.414, resulting in an overall moderate to large mean effect for HRVB (Hedges's g = -0.557; 95% confidence interval = -0.818 to -0.296; P < .001). Additionally, cumulative attrition was 5.8%, significantly lower than commonly reported rates for evidence-based treatments (16%-36%).

CONCLUSIONS

The present study is the first meta-analysis to examine HRVB as a treatment for military service members with PTSD. Results indicate that HRVB may be a viable treatment approach to reduce PTSD symptomatology. Low attrition rates, ease of accessibility, and favorable participant outlook serve as additional benefits for the use of HRVB.

Comparison of behavioral activation-enhanced cognitive processing therapy and cognitive processing therapy among U.S. service members: A randomized clinical trial

Posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) frequently co-occur and can cause significant impairment. Data are lacking as to whether interventions targeting both PTSD and MDD may improve treatment outcomes among individuals with this comorbidity compared with existing evidence-based PTSD treatments alone. This randomized trial compared the effectiveness of cognitive processing therapy (CPT) enhanced with behavioral activation (BA+CPT) versus CPT among 94 service members (52 women and 42 men; age M = 28.5 years) with comorbid PTSD and MDD. The primary outcome was clinician-administered depression symptom severity on the Montgomery-Åsberg Depression Rating Scale (MADRS) from pretreatment through 3-month follow-up. Intent-to-treat analyses using multilevel models showed statistically and clinically significant decreases in MADRS scores for both conditions over time, with no significant differences between BA+CPT and CPT. Secondary depression and PTSD symptom outcomes followed a similar pattern of results. For diagnostic MDD and PTSD outcomes using available data, no statistically significant differences between treatments emerged at posttreatment or 3-month follow-up. Sessions attended, dropout rate, and treatment satisfaction did not significantly differ between treatments. Outcomes were comparable for both treatments, suggesting that BA+CPT and CPT were similarly effective psychotherapy options for comorbid PTSD and MDD.

A systematic review and meta-analysis of individual and couple therapies for posttraumatic stress disorder: Clinical and intimate relationship outcomes

The association between symptoms of posttraumatic stress disorder (PTSD) in adults and difficulties in intimate relationships is well documented. Growing literature suggests that interpersonally-oriented therapies, such as couple and family interventions, may lead to improvements in both PTSD symptoms and intimate relationship functioning. However, it is unknown how individual PTSD treatments compare to couple/family interventions in relational outcomes. The present study was a systematic review and meta-analysis of individual and couple/family treatments to examine changes in PTSD symptoms and intimate relationship functioning. Twelve couple treatment studies with 13 unique samples and 7 individual treatment studies with 9 unique samples met inclusion criteria. No family-based treatments were identified. Meta-analytic findings indicated moderate to large reductions in PTSD symptoms for both couple and individual studies. Small but significant improvements in intimate relationship functioning across individual and couple studies were observed. Moderation analysis suggested that across both individual and couple treatment formats, trauma-focused treatments had larger effects on PTSD symptoms. Trauma-focused treatments had larger effects on intimate relationship functioning for individual studies. Military status did not moderate outcomes. This study supports the utility of both individual and couple treatment formats for treating PTSD and provides preliminary support for these modalities for also enhancing intimate relationship functioning.

Neuromodulation as an Augmenting Strategy for Behavioral Therapies for Anxiety and PTSD: a Narrative Review

PURPOSE OF REVIEW

Post-traumatic stress disorder (PTSD) is a prevalent problem. Despite current treatments, symptoms may persist, and neuromodulation therapies show great potential. A growing body of research suggests that transcranial magnetic stimulation (TMS) is effective as a standalone treatment for PTSD, with recent research demonstrating promising use when combined synergistically with behavioral treatments. In this review, we survey this literature including data suggesting mechanisms involved in anxiety and PTSD that may be targeted by neurostimulation.

RECENT FINDINGS

Evidence suggests the mechanism of action for TMS that contributes to behavioral change may be enhanced neural plasticity via increased functionality of prefrontal and subcortical/limbic structures and associated networks. Some research has demonstrated a behavioral change in PTSD and anxiety due to enhanced extinction learning or improved ability to think flexibly and reduce ruminative tendencies. Growing evidence suggests TMS may be best used as a therapeutic adjunct, at least acutely, for extinction-based exposure therapies in patients by accelerating therapy response.

SUMMARY

While TMS has shown promise as a standalone intervention, augmentation with psychotherapy is one avenue of interest. Non-responders to current EBPs might particularly benefit from this sort of targeted approach, and it may shorten treatment length, which would help the successful completion of a course of therapy.