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McLean CP, Foa EB. State of the Science: Prolonged exposure therapy for the treatment of posttraumatic stress disorder. J Trauma Stress 2024; 37:535-550. [PMID: 38652057 DOI: 10.1002/jts.23046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 03/06/2024] [Accepted: 03/08/2024] [Indexed: 04/25/2024]
Abstract
Prolonged exposure therapy (PE) is a well-established first-line treatment for posttraumatic stress disorder (PTSD) that is based on emotional processing theory. PE has been rigorously evaluated and tested in a large number of clinical trials in many countries covering a wide range of trauma populations. In this review, we summarize the evidence base supporting the efficacy of PE across populations, including adults with sexual assault-related PTSD and mixed trauma-related PTSD, military populations, and adolescents. We highlight important strengths and gaps in the research on PE with individuals from marginalized communities. We discuss the efficacy of PE on associated psychopathology and in the presence of the most commonly comorbid conditions, either alone or integrated with other treatments. In addition, we provide an overview of research examining strategies to augment PE. Much of this work remains preliminary, but numerous trials have tested PE in combination with other psychological or pharmacological approaches, interventions to facilitate extinction learning, and behavioral approaches, in the hopes of further increasing the efficiency and efficacy of PE. There are now several trials testing PE in novel formats that may have advantages over standard in-person PE, such as lower dropout and increased scalability. We examine this recent work on new models of delivering PE, including massed treatment, telehealth, and brief adaptations for primary care, all of which have the potential to increase access to PE. Finally, we highlight several promising areas for future research.
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Affiliation(s)
- Carmen P McLean
- Dissemination and Training Division, National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, California, USA
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Stanford University, Stanford, California, USA
| | - Edna B Foa
- Department of Psychiatry, Perlman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Kline AC, Otis NP, Norman SB, Hunt WM, Walter KH. Dropout in a clinical trial for comorbid PTSD and MDD among US service members: Are pretreatment characteristics predictive? Psychother Res 2024:1-13. [PMID: 38497740 DOI: 10.1080/10503307.2024.2325519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 02/26/2024] [Indexed: 03/19/2024] Open
Abstract
OBJECTIVE Despite effective treatment options for posttraumatic stress disorder (PTSD), many patients do not complete therapy. This includes U.S. active duty service members, yet factors linked to attendance in this population remain understudied and dropout remains difficult to predict. Additionally, most studies have not examined samples with PTSD and co-occurring major depressive disorder (MDD) despite high rates of comorbidity. METHOD The current study explored predictors of dropout among service members with comorbid PTSD and MDD (N = 94) randomized to cognitive processing therapy enhanced with behavioral activation (BA + CPT) or CPT as part of a clinical trial. RESULTS Using the Fournier approach, only two predictors were associated with lower dropout risk among over 20 examined: shorter duration between pretreatment assessment and Session 1 (p = .041) and past 3-month PTSD treatment engagement (p = .036). CONCLUSION Results suggest the possible utility of early momentum in starting therapy and leveraging recent treatment to improve attendance. However, this study also highlights the possible limitations of commonly assessed pretreatment factors in predicting attendance and current challenges in measuring dropout risk. Strategies to improve prediction, such as shifting focus to assess modifiable factors and processes more proximal to dropout during treatment, may be needed.Trial registration: ClinicalTrials.gov identifier: NCT02874131.
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Affiliation(s)
- Alexander C Kline
- Psychological Health and Readiness, Naval Health Research Center, San Diego, CA, USA
- Leidos, Inc., San Diego, CA, USA
| | - Nicholas P Otis
- Psychological Health and Readiness, Naval Health Research Center, San Diego, CA, USA
- Leidos, Inc., San Diego, CA, USA
| | - Sonya B Norman
- Department of Psychiatry, University of California San Diego, San Diego, CA, USA
- National Center for PTSD, Executive Division, White River Junction, VT, USA
- VA San Diego Healthcare System, San Diego, CA, USA
| | - W Michael Hunt
- Directorate of Mental Health, Naval Medical Center San Diego, San Diego, CA, USA
| | - Kristen H Walter
- Psychological Health and Readiness, Naval Health Research Center, San Diego, CA, USA
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Bowker H, Saxon D, Delgadillo J. First impressions matter: The influence of initial assessments on psychological treatment initiation and subsequent dropout. Psychother Res 2024:1-11. [PMID: 38289694 DOI: 10.1080/10503307.2024.2308164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 01/02/2024] [Indexed: 02/01/2024] Open
Abstract
OBJECTIVE This study investigated if patients' experience of an initial assessment may be associated with outcome expectations, and with subsequent treatment attendance. METHOD The sample comprised n = 6051 patients with depression/anxiety disorders, nested within k = 148 assessing therapists. Multilevel modelling (MLM) was used to examine therapist effects on treatment initiation and subsequent dropout, adjusting for patient-level characteristics. We tested associations between early outcome expectancy measured at an initial assessment with attendance at a first therapy session, and with dropout after initiation. Variability in mean expectancy ratings in the caseloads of assessing therapists was examined using the intracluster correlation coefficient (ICC). RESULTS Therapist effects partly explained the variance in treatment initiation and dropout. Pre-treatment outcome expectations significantly predicted treatment initiation but not dropout for the subgroup of patients who started treatment. Approximately 16% of variability in mean expectancy ratings was explained by therapist effects (ICC = 0.159) after controlling for patient-level covariates. CONCLUSIONS Patients assessed by some therapists are more likely to have higher outcome expectations, which influences their decision to initiate treatment thereafter. Once patients start therapy, early expectancy measured at assessment no longer influences their attendance, but the "first impression" from an initial assessment does influence their subsequent likelihood of dropout.
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Affiliation(s)
- Hannah Bowker
- Clinical and Applied Psychology Unit, Department of Psychology, University of Sheffield, Sheffield, UK
| | - David Saxon
- Clinical and Applied Psychology Unit, Department of Psychology, University of Sheffield, Sheffield, UK
| | - Jaime Delgadillo
- Clinical and Applied Psychology Unit, Department of Psychology, University of Sheffield, Sheffield, UK
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Wachen JS, Morris KL, Galovski TE, Dondanville KA, Resick PA, Schwartz C. Massed cognitive processing therapy for combat-related posttraumatic stress disorder: Study design and methodology of a non-inferiority randomized controlled trial. Contemp Clin Trials 2024; 136:107405. [PMID: 38056624 DOI: 10.1016/j.cct.2023.107405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 11/20/2023] [Accepted: 12/02/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND Posttraumatic stress disorder (PTSD) is prevalent among military personnel. Cognitive processing therapy (CPT) is identified as one of the most effective treatments for PTSD, although smaller effects have been found in military populations. High rates of dropout from treatment may contribute to reduced efficacy, and military personnel may face unique barriers to treatment completion. One method of improving efficacy may be to reduce dropout by decreasing the time required to receive a full dose of treatment. This paper describes the design and methodology of the first randomized clinical trial testing whether CPT delivered in an intensive format is non-inferior to standard delivery of CPT. METHOD Participants are 140 active duty service members randomized to receive CPT in a 5-day combined group and individual intensive outpatient format (MCPT) or standard CPT (delivered individually twice weekly over 6 weeks). Participants are assessed at baseline, and 1 month, 4 months, and 1 year following the conclusion of the therapy. Reduction in PTSD symptomatology is the primary outcome of interest. Secondary outcomes include comorbid psychological symptoms, health, and functioning. A secondary objective is to examine predictors of treatment outcome to determine which service members benefit most from which treatment modality. CONCLUSION If determined to be non-inferior, MCPT would provide an efficient and accessible modality of evidence-based PTSD treatment. This therapy format would improve access to care by reducing the amount of time required for treatment and improving symptoms and functioning more rapidly, thereby minimizing interference with work-related activities and disruption to the mission.
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Affiliation(s)
- Jennifer Schuster Wachen
- Women's Health Sciences Division, National Center for PTSD, VA Boston Healthcare System, 150 South Huntington Ave. (116B-3), Boston, MA 02130, USA; Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, 720 Harrison Ave., Boston, MA 02118, USA..
| | - Kris L Morris
- Alexander T. Augusta Military Medical Center, 9300 DeWitt Loop, Fort Belvoir, VA 22060, USA
| | - Tara E Galovski
- Women's Health Sciences Division, National Center for PTSD, VA Boston Healthcare System, 150 South Huntington Ave. (116B-3), Boston, MA 02130, USA; Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, 720 Harrison Ave., Boston, MA 02118, USA
| | - Katherine A Dondanville
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229-3901, USA
| | - Patricia A Resick
- Department of Psychiatry and Behavioral Sciences, Duke University, 2400 Pratt St., Durham, NC 27710, USA
| | - Carey Schwartz
- Alexander T. Augusta Military Medical Center, 9300 DeWitt Loop, Fort Belvoir, VA 22060, USA
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Zaccari B, Higgins M, Haywood TN, Patel M, Emerson D, Hubbard K, Loftis JM, Kelly UA. Yoga vs Cognitive Processing Therapy for Military Sexual Trauma-Related Posttraumatic Stress Disorder: A Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2344862. [PMID: 38064219 PMCID: PMC10709771 DOI: 10.1001/jamanetworkopen.2023.44862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 10/14/2023] [Indexed: 12/18/2023] Open
Abstract
Importance First-line treatment for posttraumatic stress disorder (PTSD) in the US Department of Veterans Affairs (VA), ie, trauma-focused therapy, while effective, is limited by low treatment initiation, high dropout, and high treatment refraction. Objective To evaluate the effectiveness of Trauma Center Trauma-Sensitive Yoga (TCTSY) vs first-line cognitive processing therapy (CPT) in women veterans with PTSD related to military sexual trauma (MST) and the hypothesis that PTSD outcomes would differ between the interventions. Design, Setting, and Participants This multisite randomized clinical trial was conducted from December 1, 2015, to April 30, 2022, within 2 VA health care systems located in the southeast and northwest. Women veterans aged 22 to 71 years with MST-related PTSD were enrolled and randomized to TCTSY or CPT. Interventions The TCTSY intervention (Hatha-style yoga focusing on interoception and empowerment) consisted of 10 weekly, 60-minute group sessions, and the CPT intervention (cognitive-based therapy targeting modification of negative posttraumatic thoughts) consisted of 12 weekly, 90-minute group sessions. Main Outcome and Measures Sociodemographic data were collected via self-report survey. The primary outcome, PTSD symptom severity, was assessed using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and PTSD Checklist for DSM-5 (PCL-5). Assessments were conducted at baseline, midintervention, 2 weeks post intervention, and 3 months post intervention. Results Of 200 women veterans who consented to participate, the intent-to-treat sample comprised 131 participants (mean [SD] age, 48.2 [11.2] years), with 72 randomized to TCTSY and 59 randomized to CPT. Treatment was completed by 47 participants (65.3%) in the TCTSY group and 27 (45.8%) in the CPT group, a 42.6% higher treatment completion rate in the TCTSY group (P = .03). Both treatment groups improved over time on the CAPS-5 (mean [SD] scores at baseline: 36.73 [8.79] for TCTSY and 35.52 [7.49] for CPT; mean [SD] scores at 3 months: 24.03 [11.55] for TCTSY and 22.15 [13.56]) and the PCL-5 (mean [SD] scores at baseline: 49.62 [12.19] for TCTSY and 48.69 [13.62] for CPT; mean [SD] scores at 3 months: 36.97 [17.74] for TCTSY and 31.76 [12.47]) (P < .001 for time effects). None of the group effects or group-by-time effects were significant. Equivalence analyses of change scores were not significantly different between the TCTSY and CPT groups, and the two one-sided test intervals fell within the equivalence bounds of plus or minus 10 for CAPS-5 for all follow-up time points. Conclusions and Relevance In this comparative effectiveness randomized clinical trial, TCTSY was equivalent to CPT in reducing PTSD symptom severity, with both groups improving significantly. The higher treatment completion rate for TCTSY indicates its higher acceptability as an effective and acceptable PTSD treatment for women veterans with PTSD related to MST that could address current VA PTSD treatment limitations. Trial Registration ClinicalTrials.gov Identifier: NCT02640690.
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Affiliation(s)
- Belle Zaccari
- Research and Development Service, Veterans Affairs Portland Health Care System, Portland, Oregon
- Department of Mental Health and Clinical Neurosciences, Veterans Affairs Portland Health Care System, Portland, Oregon
- Department of Psychiatry, Oregon Health & Science University, Portland
| | - Melinda Higgins
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | | | - Meghna Patel
- Mental Health Service Line, Joseph Maxwell Cleland Atlanta VA Medical Center, Atlanta, Georgia
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - David Emerson
- The Center for Trauma and Embodiment at Justice Resource Institute, Needham, Massachusetts
| | - Kimberly Hubbard
- Research and Development Service, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - Jennifer M. Loftis
- Research and Development Service, Veterans Affairs Portland Health Care System, Portland, Oregon
- Department of Psychiatry, Oregon Health & Science University, Portland
- Department of Behavioral Neuroscience, Oregon Health & Science University, Portland
| | - Ursula A. Kelly
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
- Nursing and Patient Care Services, Joseph Maxwell Cleland Atlanta VA Medical Center, Atlanta, Georgia
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Lau W, Chisholm K, Gallagher M, Felmingham K, Murray K, Pearce A, Doyle N, Alexander S, O'Brien H, Putica A, Khatri J, Bockelmann P, Hosseiny F, Librado A, Notarianni M, O'Donnell M. Comparing the unified protocol for transdiagnostic treatment of emotional disorders to prolonged exposure for the treatment of PTSD: Design of a non-inferiority randomized controlled trial. Contemp Clin Trials Commun 2023; 33:101134. [PMID: 37228903 PMCID: PMC10205430 DOI: 10.1016/j.conctc.2023.101134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 03/21/2023] [Accepted: 04/10/2023] [Indexed: 05/27/2023] Open
Abstract
Background Prolonged Exposure (PE), a trauma-focused therapy, is one of the most efficacious treatments available for PTSD. However, many people with PTSD do not lose their diagnosis following delivery of PE. The Unified Protocol (UP) for Transdiagnostic Treatment of Emotional Disorders is a non-trauma focused treatment that may offer an alternative treatment for PTSD. Methods This paper describes the study protocol for IMPACT, an assessor-blinded randomized controlled trial that examines the non-inferiority of UP relative to PE for participants who meet DSM-5 criteria for current PTSD. One hundred and twenty adult participants with PTSD will be randomized to receive either 10 × 90-min sessions of UP or PE with a trained provider. The primary outcome is severity of PTSD symptoms assessed by the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) at post-treatment. Discussion While evidence-based treatments are available for PTSD, high levels of treatment dropout and non-response require new approaches to be tested. The UP is based on emotion regulation theory and is effective in treating anxiety and depressive disorders, however, there has been limited application to PTSD. This is the first rigorous study comparing UP to PE in a non-inferiority randomized controlled trial and may help improve clinical outcomes for those with PTSD. Trial registration This trial was prospectively registered with the Australian New Zealand Clinical Trials Registry, Trial ID (ACTRN12619000543189).
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Affiliation(s)
- W. Lau
- Phoenix Australia – Centre for Posttraumatic Mental Health, Department of Psychiatry, The University of Melbourne, Victoria, Australia
| | - K. Chisholm
- Phoenix Australia – Centre for Posttraumatic Mental Health, Department of Psychiatry, The University of Melbourne, Victoria, Australia
| | - M.W. Gallagher
- Department of Psychology, The University of Houston, TX, USA
| | - K. Felmingham
- Melbourne School of Psychological Sciences, The University of Melbourne, Victoria, Australia
| | - K. Murray
- Phoenix Australia – Centre for Posttraumatic Mental Health, Department of Psychiatry, The University of Melbourne, Victoria, Australia
| | - A. Pearce
- Phoenix Australia – Centre for Posttraumatic Mental Health, Department of Psychiatry, The University of Melbourne, Victoria, Australia
| | - N. Doyle
- Phoenix Australia – Centre for Posttraumatic Mental Health, Department of Psychiatry, The University of Melbourne, Victoria, Australia
| | - S. Alexander
- Phoenix Australia – Centre for Posttraumatic Mental Health, Department of Psychiatry, The University of Melbourne, Victoria, Australia
| | - H. O'Brien
- Phoenix Australia – Centre for Posttraumatic Mental Health, Department of Psychiatry, The University of Melbourne, Victoria, Australia
| | - A. Putica
- Phoenix Australia – Centre for Posttraumatic Mental Health, Department of Psychiatry, The University of Melbourne, Victoria, Australia
| | - J. Khatri
- Canberra Health Services, Australian Capital Territory Government, Canberra, Australia
| | - P. Bockelmann
- Phoenix Australia – Centre for Posttraumatic Mental Health, Department of Psychiatry, The University of Melbourne, Victoria, Australia
| | - F. Hosseiny
- Atlas Institute for Veterans and Families, Ottawa, Canada
- University of Ottawa Institute of Mental Health Research at The Royal, Canada
| | - A. Librado
- Atlas Institute for Veterans and Families, Ottawa, Canada
| | - M. Notarianni
- Atlas Institute for Veterans and Families, Ottawa, Canada
- University of Ottawa Institute of Mental Health Research at The Royal, Canada
| | - M.L. O'Donnell
- Phoenix Australia – Centre for Posttraumatic Mental Health, Department of Psychiatry, The University of Melbourne, Victoria, Australia
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Stoycos SA, Berzenski SR, Beck JG, Unger W, Cappellano JM, Spofford CM, Sloan DM. Predictors of treatment completion in group psychotherapy for male veterans with posttraumatic stress disorder. J Trauma Stress 2023; 36:346-358. [PMID: 36782378 PMCID: PMC10101887 DOI: 10.1002/jts.22915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 12/13/2022] [Accepted: 12/13/2022] [Indexed: 02/15/2023]
Abstract
Group therapy is a frequently used therapy format for posttraumatic stress disorder (PTSD). However, factors contributing to treatment completion remain understudied. The current study examined predictors of treatment completion, defined as having completed 10 out of 14 sessions within 16 weeks, in veterans with PTSD who engaged in a hybrid efficacy-effectiveness randomized controlled trial of group psychotherapy for PTSD. Veterans (N = 198) were randomly assigned to 14 sessions of either group cognitive behavioral treatment (GBCT; n = 98) or group present-centered treatment (GPCT; n = 100). Four primary domains of predictors were examined, encompassing sociodemographic factors, the severity of PTSD and comorbid conditions, modifiable predictors, and treatment condition. Multilevel binomial logistic regression models following the Fournier analysis approach were used to examine significant predictors within domains, which were then included in a final model. Overall, 70.7% of participants completed treatment (GCBT = 61.6%, GPCT = 79.8%). Participants in the GPCT condition were 2.389 times, 95% CI [1.394, 4.092], more likely to complete treatment than those in the GCBT condition. Older age, a higher income and level of educational attainment, more lifetime and current mental health diagnoses, and higher use of positive reappraisal ER skills predicted treatment completion. Higher levels of depressive symptoms, cumulative trauma burden, and use of positive refocusing ER skills predicted treatment noncompletion. These findings are discussed in the context of current clinical and research practices for examining treatment noncompletion, with attention to the inclusion of translational predictors.
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Affiliation(s)
- Sarah A Stoycos
- Behavioral Science Division, National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Sara R Berzenski
- Department of Psychology, California State University Northridge, Northridge, California, USA
| | - J Gayle Beck
- Department of Psychology, University of Memphis, Memphis, Tennessee, USA
| | - William Unger
- VA Providence Medical Center, Providence, Rhode Island, USA
| | | | - Christopher M Spofford
- Department of Psychiatry, Dartmouth Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Denise M Sloan
- Behavioral Science Division, National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
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Alpert E, Carpenter JK, Smith BN, Woolley MG, Raterman C, Farmer CC, Kehle-Forbes SM, Galovski TE. Leveraging observational data to identify in-session patient and therapist predictors of cognitive processing therapy response and completion. J Trauma Stress 2023; 36:397-408. [PMID: 36987703 PMCID: PMC10228524 DOI: 10.1002/jts.22924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 01/04/2023] [Accepted: 01/06/2023] [Indexed: 03/30/2023]
Abstract
Cognitive processing therapy (CPT) is an evidence-based treatment for posttraumatic stress disorder (PTSD), but little is known about in-session process variables that predict symptom reduction and treatment completion during CPT. Examining potentially malleable factors that may promote or impede recovery can inform care delivery and enhance outcomes. The current study used observational ratings of CPT session recordings to examine in-session patient and therapist factors in cognitive, affective, and interpersonal domains to identify their relative contributions to predicting symptom outcomes and treatment completion. Participants were 70 adult survivors of interpersonal violence who received CPT. Predictors of better posttreatment PTSD outcomes included less patient fear, β = .32, and less patient avoidance of engaging with the therapist, β = .35. When using the last available PTSD score, less fear, β = .23, and avoidance, β = .28, continued to predict better outcomes, and more patient cognitive flexibility emerged as a stronger predictor of outcome, β = -.33. Predictors of a higher likelihood of treatment completion included more therapist use of Socratic dialogue, OR = 6.75, and less therapist encouragement of patient affect, OR = 0.11. Patient sadness and anger and therapist expression of empathy did not predict symptom outcomes or treatment completion versus dropout. The results highlight the importance of patients' cognitions, emotions, and engagement with their therapist in CPT as well as the role of therapist behaviors in patient completion of treatment.
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Affiliation(s)
- Elizabeth Alpert
- National Center for PTSD Women's Health Sciences Division at VA Boston Healthcare System, Boston, Massachusetts, USA
- Boston University Chobanian & Avedisian School of Medicine Department of Psychiatry, Boston, Massachusetts, USA
| | - Joseph K. Carpenter
- National Center for PTSD Women's Health Sciences Division at VA Boston Healthcare System, Boston, Massachusetts, USA
- Boston University Chobanian & Avedisian School of Medicine Department of Psychiatry, Boston, Massachusetts, USA
| | - Brian N. Smith
- National Center for PTSD Women's Health Sciences Division at VA Boston Healthcare System, Boston, Massachusetts, USA
- Boston University Chobanian & Avedisian School of Medicine Department of Psychiatry, Boston, Massachusetts, USA
| | - Mercedes G. Woolley
- National Center for PTSD Women's Health Sciences Division at VA Boston Healthcare System, Boston, Massachusetts, USA
| | | | | | - Shannon M. Kehle-Forbes
- National Center for PTSD Women's Health Sciences Division at VA Boston Healthcare System, Boston, Massachusetts, USA
- Center for Care Delivery & Outcomes Research at Minneapolis VA Healthcare System, Minneapolis, Minnesota, USA
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Tara E. Galovski
- National Center for PTSD Women's Health Sciences Division at VA Boston Healthcare System, Boston, Massachusetts, USA
- Boston University Chobanian & Avedisian School of Medicine Department of Psychiatry, Boston, Massachusetts, USA
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Sciarrino NA, Myers US. If it's offered, will they come? Practical considerations when offering intensive PTSD treatment in an outpatient Veterans Affairs PTSD clinic. Bull Menninger Clin 2023; 87:46-62. [PMID: 36856477 DOI: 10.1521/bumc.2023.87.1.46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
Evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD) are efficacious; however, treatment dropout remains high. The delivery of intensive EBPs for PTSD (i.e., sessions three times per week or more) and telemental health may address barriers impacting dropout. Current evidence for intensive EBPs comes primarily from programs specifically designed for this level of care. Therefore, the feasibility of delivering intensive EBPs for PTSD in traditional outpatient clinics remains unclear. The aim of this pilot study was to identify veteran level of interest in intensive treatment and explore the feasibility of delivering intensive treatment via telemental health in an outpatient PTSD clinic at a Veterans Affairs (VA) hospital. One provider offered intensive treatment to 14 veterans. Three of the veterans initiated intensive treatment and completed with benefit. Veteranand system-level barriers, as well as veteran preferences for initiating intensive therapy and suggestions for implementing intensive EBPs in a routine outpatient clinic, are discussed.
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Affiliation(s)
- Nicole A Sciarrino
- The Ralph H. Johnson VA Medical Center, and in the Department of Psychiatry and Behavioral Sciences, Military Sciences Division, Medical University of South Carolina, Charleston, South Carolina. Dr
| | - Ursula S Myers
- The Ralph H. Johnson VA Medical Center, and in the Department of Psychiatry and Behavioral Sciences, Military Sciences Division, Medical University of South Carolina, Charleston, South Carolina. Dr.,The Charleston Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson VA Medical Center, Charleston, South Carolina
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10
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Takagishi Y, Ito M, Kanie A, Morita N, Makino M, Katayanagi A, Sato T, Imamura F, Nakajima S, Oe Y, Kashimura M, Kikuchi A, Narisawa T, Horikoshi M. Feasibility, acceptability, and preliminary efficacy of cognitive processing therapy in Japanese patients with posttraumatic stress disorder. J Trauma Stress 2023; 36:205-217. [PMID: 36514902 DOI: 10.1002/jts.22901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 10/21/2022] [Accepted: 10/23/2022] [Indexed: 12/15/2022]
Abstract
Cognitive processing therapy (CPT) is one of the most widely tested evidence-based treatments for posttraumatic stress disorder (PTSD). However, most studies on CPT have been conducted in Western cultural settings. This open-label, single-arm trial investigated the feasibility, acceptability, and preliminary efficacy of CPT for treating Japanese patients with PTSD. A total of 25 outpatients underwent 12 CPT sessions. The primary outcome was the assessment of PTSD symptoms using the Clinician-Administered PTSD Scale for DSM-IV (CAPS-IV); secondary outcomes included the assessment of subjective PTSD severity, depressive and anxiety symptoms, trauma-related cognitions, and subjective quality of life. All outcomes were evaluated at pretreatment (i.e., baseline), posttreatment, and 6- and 12-month follow-ups. On average, participants attended 13 sessions of CPT (SD = 1.38), with a completion rate of 96.0%. One serious adverse event (hospitalization) occurred. Significant within-subjects standardized mean differences in CAPS-IV scores were found from baseline to treatment completion, g = -2.28, 95% CI [-3.00, -1.56]; 6-month follow-up, g = -2.95, 95% CI [-3.79, -2.12]; and 12-month follow-up, g = -2.15, 95% CI [-2.89, -1.41]. Moderate-to-large effects, gs = -0.77 to -2.45, were found on secondary outcomes. These findings support the feasibility, acceptability, and preliminary efficacy of CPT in a Japanese clinical setting.
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Affiliation(s)
- Yuriko Takagishi
- National Center for Cognitive-Behavior Therapy and Research, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Masaya Ito
- National Center for Cognitive-Behavior Therapy and Research, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Ayako Kanie
- National Center for Cognitive-Behavior Therapy and Research, National Center of Neurology and Psychiatry, Tokyo, Japan.,Department of Child Psychiatry, The University of Tokyo Hospital, Tokyo, Japan
| | - Nobuaki Morita
- Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Miyuki Makino
- National Center for Cognitive-Behavior Therapy and Research, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Akiko Katayanagi
- National Center for Cognitive-Behavior Therapy and Research, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Tamae Sato
- National Center for Cognitive-Behavior Therapy and Research, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Fumi Imamura
- Department of Clinical Psychology, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Satomi Nakajima
- Faculty of Human Sciences, Musashino University, Tokyo, Japan
| | - Yuki Oe
- National Center for Cognitive-Behavior Therapy and Research, National Center of Neurology and Psychiatry, Tokyo, Japan.,Department of Neuropsychiatry, Kyorin University School of Medicine, Tokyo, Japan
| | | | - Akiko Kikuchi
- Faculty of Human Sciences, Musashino University, Tokyo, Japan
| | - Tomomi Narisawa
- Faculty of Human Sciences, Musashino University, Tokyo, Japan
| | - Masaru Horikoshi
- National Center for Cognitive-Behavior Therapy and Research, National Center of Neurology and Psychiatry, Tokyo, Japan
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11
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Killeen TK, Wen CC, Neelon B, Baker N. Predictors of Treatment Completion among Women Receiving Integrated Treatment for Comorbid Posttraumatic Stress and Substance Use Disorders. Subst Use Misuse 2023; 58:500-511. [PMID: 36705433 DOI: 10.1080/10826084.2023.2170183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Background: Retention in treatment for individuals with comorbid posttraumatic stress disorder (PTSD) and substance use disorders (SUD) is an area of concern in treatment outcome studies. The current study explores key variables related to retention in a group of women with comorbid PTSD and SUD enrolled in community SUD treatment randomized to eight weekly sessions of a trauma adapted mindfulness-based relapse prevention (TA-MBRP) or an integrated coping skills (ICS) group intervention. Methods: Two unadjusted and adjusted logistic discrete failure time (DFT) models were fit to examine associations between participants and the time (in weeks) to treatment completion status. Key covariates of interest, including time-varying PTSD Symptom Scale-Self Report (PSS) total score, time-varying Five Factors Mindfulness Questionnaire (FFMQ) total score, group assignment, baseline endorsements of substance use and demographics such as age, race and employment status were fit into the model. Results: In the adjusted PSS model, increased levels of PTSD symptom severity (PSS) scores at week 5 and 7 (PSS OR: 1:06: OR 1.13, respectively) were associated with higher odds of non-completion. In the FFMQ model, increased levels of FFMQ scores at week 6 (OR: 0:92) were associated with lower odds of non-completion. In both models, assignment to the ICS control group and unemployment were associated with lower odds of completion and baseline use of cocaine and sedatives were associated with higher odds of completion. Conclusion: Monitoring PTSD symptom severity and measures of mindfulness can inform providers on strategies to enhance retention early in treatment for individuals with comorbid PTSD/SUD.ClinicalTrials.gov # NCT02755103.
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Affiliation(s)
- Therese K Killeen
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Chun-Che Wen
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Brian Neelon
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Nathanial Baker
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
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12
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van der Velden PG, Contino C, Das M, Wittmann L. To what extent do post-traumatic mental health and other problems reflect pre-existing problems? Findings from the prospective comparative population-based VICTIMS-study. Int J Soc Psychiatry 2022:207640221140287. [PMID: 36464851 DOI: 10.1177/00207640221140287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
BACKGROUND Findings from prospective studies question the assumption that mental health problems observed in traumatized adults mainly reflect the effects of potentially traumatic events. AIMS Aim of the present comparative prospective study is to clarify the extent to which victims of potentially traumatic events with mental health, social, financial, and/or legal problems, already suffered from such problems before these events. METHOD Data was extracted from three surveys of the prospective VICTIMS-study (T1 = 2018, T2 = 2019, T3 = 2020), conducted with the population-based longitudinal LISS-panel. Differences between victims (n = 340, victimized by violence, accidents, and serious threats in the 12 months before T3) and nonvictims (n = 3,872, not victimized by such events in this period), were examined using multivariate logistic regression analyses. RESULTS The large majority of victims with current (at T3) anxiety and depression symptomatology (74%), general mental health problems (71%), partner/family (67%), financial (76%), and legal problems (58%), and lack of support (79%), already had these problems (at T1 and/or at T2). A similar pattern was observed among nonvictims. Of the victims with current probable PTSD (at T3), 87% already had any mental health problem. At T3, among both groups, the incidence of problems was substantially lower than their prevalence. The large majority of victims with post-event mental health, social, financial, and legal problems already suffered from these problems in the past. CONCLUSIONS When victims seek help for their problems, professional care providers should be aware that in most cases, as among nonvictims, these problems are chronic/re-current rather than new problems.
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Affiliation(s)
- Peter G van der Velden
- Centerdata, Tilburg, The Netherlands.,TRANZO, Tilburg School of Social and Behavioral Sciences, Tilburg University, Tilburg, The Netherlands
| | | | - Marcel Das
- Centerdata, Tilburg, The Netherlands.,Tilburg School of Economics and Management, Tilburg University, Tilburg, The Netherlands
| | - Lutz Wittmann
- International Psychoanalytic University Berlin, Berlin, Germany
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13
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Grau PP, Bohnert KM, Ganoczy D, Sripada RK. Who improves in trauma-focused treatment: A cluster analysis of treatment response in VA patients undergoing PE and CPT. J Affect Disord 2022; 318:159-166. [PMID: 36070830 DOI: 10.1016/j.jad.2022.08.126] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 05/20/2022] [Accepted: 08/28/2022] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Peter P Grau
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), 2800 Plymouth Road, Bldg 16, Ann Arbor, MI 48109, United States; VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, United States; Department of Psychiatry, University of Michigan Medical School, United States.
| | - Kipling M Bohnert
- Department of Epidemiology and Biostatistics, Michigan State University, United States
| | - Dara Ganoczy
- Veterans Affairs Center for Clinical Management Research, Health Services Research and Development, Ann Arbor, MI, United States
| | - Rebecca K Sripada
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, United States; Department of Psychiatry, University of Michigan Medical School, United States; Veterans Affairs Center for Clinical Management Research, Health Services Research and Development, Ann Arbor, MI, United States
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14
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Social Factors Predict Treatment Engagement in Veterans with PTSD or SUD. J Behav Health Serv Res 2022; 50:286-300. [PMID: 36456866 DOI: 10.1007/s11414-022-09823-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2022] [Indexed: 12/03/2022]
Abstract
Veterans with PTSD and SUDs often fail to initiate, or prematurely discontinue, mental health treatment in Veteran Affairs Medical Centers (VAMC). While much is known about clinical characteristics and demographic factors impacting treatment engagement in this population, less is known about the role of social factors. This retrospective study examines primary care-based screening assessment and specialty mental healthcare appointment data in a VAMC, to test whether social factors predict treatment initiation and appointment attendance. Findings reveal veterans were more likely to initiate treatment when (a) those with SUDs (n = 235) reported more frequent negative exchanges with others and (b) those with PTSD (n = 2107) reported more perceived support or being partnered. Those with PTSD who were partnered had higher appointment attendance rates. Findings suggest social factors are relevant to treatment initiation among veterans with PTSD and SUDs and that close others may be helpful in facilitating referrals.
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15
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Zaccari B, Sherman ADF, Febres-Cordero S, Higgins M, Kelly U. Findings from a pilot study of Trauma Center Trauma-Sensitive Yoga versus cognitive processing therapy for PTSD related to military sexual trauma among women Veterans. Complement Ther Med 2022; 70:102850. [PMID: 35820575 PMCID: PMC9704511 DOI: 10.1016/j.ctim.2022.102850] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 07/03/2022] [Accepted: 07/07/2022] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The study objective was to explore the preliminary efficacy of trauma-sensitive yoga compared to cognitive processing therapy (CPT) for women Veterans with posttraumatic stress disorder (PTSD) related to military sexual trauma (MST) in a pilot randomized control trial (RCT). We then compared these results to published interim results for the subsequent full-scale RCT. METHOD The analytic sample included women Veterans (N = 41) with PTSD related to MST accessing healthcare in a southeastern Veterans Affairs Health Care System. The majority were African American, non-Hispanic (80.5 %). The protocol-driven group interventions, Trauma Center Trauma-Sensitive Yoga (TCTSY; n = 17) and the evidence-based control condition, CPT (n = 24), were delivered weekly for 10 and 12 sessions, respectively. Multilevel linear models (MLM) were used to compare changes over time between the two groups. RESULTS The primary outcomes presented here are PTSD symptom severity and diagnosis, assessed using the Clinician Administered PTSD Scale (CAPS) and the PTSD Symptom Checklist (PCL) total scores. PTSD symptom severity on both clinician-administered (CAPS) and self-reported (PCL) measures, improved significantly (p < .005) over time, with large within group effect sizes (0.90-0.99) consistent with the subsequent RCT. Participants in the TCTSY group showed clinically meaningful improvements earlier than the CPT group participants from baseline on the CAPS and PCL Total scores. CONCLUSIONS Results support published findings of the effectiveness of TCTSY in the treatment for PTSD related to MST among women Veterans, particularly African American women. TCTSY warrants consideration as an adjunctive, precursor, or concurrent treatment to evidence-based psychotherapies. Future research should include patient preference, men with sexual trauma, and civilian populations.
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Affiliation(s)
- Belle Zaccari
- Veterans Affairs Portland Health Care System, 3710 SW US Veterans Hospital Rd, Portland, OR 97239, USA; Department of Psychiatry, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA.
| | - Athena D F Sherman
- Nell Hodgson Woodruff School of Nursing, Emory University, 1520 Clifton Rd, Atlanta, GA, USA.
| | - Sarah Febres-Cordero
- Nell Hodgson Woodruff School of Nursing, Emory University, 1520 Clifton Rd, Atlanta, GA, USA.
| | - Melinda Higgins
- Nell Hodgson Woodruff School of Nursing, Emory University, 1520 Clifton Rd, Atlanta, GA, USA.
| | - Ursula Kelly
- Nell Hodgson Woodruff School of Nursing, Emory University, 1520 Clifton Rd, Atlanta, GA, USA; Atlanta VA Health Care System, Decatur, GA, USA.
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16
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Kehle-Forbes SM, Nelson D, Norman SB, Schnurr PP, Shea MT, Ackland PE, Meis L, Possemato K, Polusny MA, Oslin D, Hamblen JL, Galovski T, Kenny M, Babajide N, Hagedorn H. Comparative effectiveness of trauma-focused and non-trauma-focused psychotherapy for PTSD among veterans with comorbid substance use disorders: Protocol & rationale for a randomized clinical trial. Contemp Clin Trials 2022; 120:106876. [PMID: 35987487 DOI: 10.1016/j.cct.2022.106876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 07/28/2022] [Accepted: 08/04/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Co-occurrence of posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) is common and concurrent treatment is recommended. Relatively little is known about which evidence-based psychotherapies for PTSD are most effective for patients with varying substance use profiles. We aim to examine the comparative effectiveness of trauma-focused therapy (TFT) and non-trauma-focused therapy (NTFT) among Veterans with PTSD and SUD. TFT has been found to be effective among those with PTSD/SUD, though effects are smaller and rates of treatment non-completion are higher than in those without SUD. NTFTs suggested for the treatment of PTSD, such as Present Centered Therapy, (PCT) have not been examined among those with co-occurring SUD, despite lower rates of treatment dropout. We will also examine the comparative effectiveness of TFT and NTFT for patients with varying SUD severity, type of substances used, and patient treatment preference. METHOD 420 Veterans with PTSD and SUD will be randomized in a prospective, pragmatic comparative effectiveness trial at 14 Veterans Health Administration facilities. Participants will receive either TFT (Prolonged Exposure or Cognitive Processing Therapy) or NTFT (PCT) after enrolling in concurrent SUD treatment-as-usual. Assessments will occur at baseline, posttreatment, 3- and 6 -months posttreatment. Main outcomes are PTSD symptom severity and PTSD treatment dropout. Clinician, patient, and leadership stakeholder panels advise study activities, and a process evaluation will identify strategies to enhance the implementation of evidence-based PTSD treatments in SUD care settings. CONCLUSIONS Results will provide critical information to guide clinicians when recommending PTSD treatments to patients with comorbid SUD. CLINICALTRIALS gov Identifier: NCT04581434.
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Affiliation(s)
- Shannon M Kehle-Forbes
- Center for Care Delivery & Outcomes Research, Minneapolis VA Healthcare System, One Veterans Drive, Minneapolis, MN 55417, United States of America; Women's Health Sciences Division at VA Boston, National Center for PTSD, 150 S. Huntington Ave, Boston, MA 02130, United States of America; Department of Medicine, University of Minnesota, 420 Delaware St SE, Minneapolis, MN 55455, United States of America.
| | - David Nelson
- Center for Care Delivery & Outcomes Research, Minneapolis VA Healthcare System, One Veterans Drive, Minneapolis, MN 55417, United States of America; Department of Medicine, University of Minnesota, 420 Delaware St SE, Minneapolis, MN 55455, United States of America
| | - Sonya B Norman
- National Center for PTSD, 215 North Main Street, White River Junction, VT 05009, United States of America; Department of Psychiatry, University of California San Diego, 3350 La Jolla Village Drive, La Jolla, CA 92161, United States of America
| | - Paula P Schnurr
- National Center for PTSD, 215 North Main Street, White River Junction, VT 05009, United States of America; Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, NH 03577, United States of America
| | - M Tracie Shea
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI 02906, United States of America
| | - Princess E Ackland
- Center for Care Delivery & Outcomes Research, Minneapolis VA Healthcare System, One Veterans Drive, Minneapolis, MN 55417, United States of America; Department of Medicine, University of Minnesota, 420 Delaware St SE, Minneapolis, MN 55455, United States of America
| | - Laura Meis
- Center for Care Delivery & Outcomes Research, Minneapolis VA Healthcare System, One Veterans Drive, Minneapolis, MN 55417, United States of America; Department of Medicine, University of Minnesota, 420 Delaware St SE, Minneapolis, MN 55455, United States of America
| | - Kyle Possemato
- VA Center for Integrated Healthcare, 800 Irving Avenue, Syracuse, NY 13204, United States of America
| | - Melissa A Polusny
- Center for Care Delivery & Outcomes Research, Minneapolis VA Healthcare System, One Veterans Drive, Minneapolis, MN 55417, United States of America; Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN 55417, United States of America; Department of Psychiatry & Behavioral Sciences, University of Minnesota Medical School, 2312 South 6(th) Street, Minneapolis, MN 55454, United States of America
| | - David Oslin
- VISN 4 MIRECC, Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA 19104, United States of America; Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 1 191049, United States of America
| | - Jessica L Hamblen
- National Center for PTSD, 215 North Main Street, White River Junction, VT 05009, United States of America; Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, NH 03577, United States of America
| | - Tara Galovski
- Women's Health Sciences Division at VA Boston, National Center for PTSD, 150 S. Huntington Ave, Boston, MA 02130, United States of America; Department of Psychiatry, Boston University, Boston, MA 02118, United States of America
| | - Marie Kenny
- Center for Care Delivery & Outcomes Research, Minneapolis VA Healthcare System, One Veterans Drive, Minneapolis, MN 55417, United States of America
| | - Nofisat Babajide
- Center for Care Delivery & Outcomes Research, Minneapolis VA Healthcare System, One Veterans Drive, Minneapolis, MN 55417, United States of America
| | - Hildi Hagedorn
- Center for Care Delivery & Outcomes Research, Minneapolis VA Healthcare System, One Veterans Drive, Minneapolis, MN 55417, United States of America; Department of Psychiatry & Behavioral Sciences, University of Minnesota Medical School, 2312 South 6(th) Street, Minneapolis, MN 55454, United States of America
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17
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Levinson DB, Halverson TF, Wilson SM, Fu R. Less dropout from prolonged exposure sessions prescribed at least twice weekly: A meta-analysis and systematic review of randomized controlled trials. J Trauma Stress 2022; 35:1047-1059. [PMID: 35278229 DOI: 10.1002/jts.22822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 11/29/2021] [Accepted: 12/01/2021] [Indexed: 11/06/2022]
Abstract
Trauma-focused psychotherapies, such as prolonged exposure (PE), are strongly recommended to treat posttraumatic stress disorder due to their effects in reducing symptoms. However, such therapies may also suffer from high dropout rates. To investigate how clients might benefit from trauma-focused therapy while minimizing dropout, we conducted a meta-analysis of 1,508 adults from 35 randomized controlled trials (RCTs) of outpatient PE programs to evaluate treatment frequency as a predictor of dropout. When an RCT prescribed PE sessions at least twice weekly compared to less frequently, the dropout rate was significantly lower at 21.0%, 95% CI [13.9%, 30.4%], compared to 34.0%, 95% CI [28.9%, 39.4%], OR = 0.52, 95% CI [0.30, 0.89], p = .018. It was not possible to draw causal conclusions, as only one RCT compared two PE treatment frequencies head-to-head. Nonetheless, the findings remained significant after controlling for study characteristics. These data invite reconsideration of the common practice of weekly psychotherapy in favor of twice-weekly sessions in standard outpatient treatment.
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Affiliation(s)
| | - Tate F Halverson
- Durham VA Health Care System, Durham, North Carolina, USA
- VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, North Carolina, USA
| | - Sarah M Wilson
- Durham VA Health Care System, Durham, North Carolina, USA
- Division of Behavioral Medicine and Neurosciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Rongwei Fu
- School of Public Health, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon, USA
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18
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Kehle-Forbes SM, Ackland PE, Spoont MR, Meis LA, Orazem RJ, Lyon A, Valenstein-Mah HR, Schnurr PP, Zickmund SL, Foa EB, Chard KM, Alpert E, Polusny MA. Divergent experiences of U.S. veterans who did and did not complete trauma-focused therapies for PTSD: A national qualitative study of treatment dropout. Behav Res Ther 2022; 154:104123. [PMID: 35644083 PMCID: PMC9873271 DOI: 10.1016/j.brat.2022.104123] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 05/04/2022] [Accepted: 05/13/2022] [Indexed: 01/26/2023]
Abstract
Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) are first-line treatments for posttraumatic stress disorder (PTSD) and have been disseminated throughout the U.S. Veterans Health Administration. Treatment non-completion is common and lessens clinical effectiveness; however, prior work has failed to identify factors consistently associated with non-completion. Semi-structured interviews were conducted with a national sample of veterans who recently completed (n = 60) or did not complete (n = 66) PE or CPT. Non-completer interviews focused on factors that contributed to veterans' decisions to drop out and efforts undertaken to complete PE/CPT. Completer interviews focused on challenges faced in completing treatment and facilitators of completion. Transcripts were coded using a mixed deductive/inductive approach; constant comparison was used to identify differences between completers and non-completers. Completers and non-completers differed in the extent of treatment-specific therapist support received, therapists' flexibility in treatment delivery, the type of encouragement offered by the care team and social supports, their interpretation of symptom worsening, the perceived impact of treatment on functioning, and the impact of stressors on their treatment engagement. Treatment-specific therapist support, more patient-centered and flexible treatment delivery, leveraging the full care team, and addressing functional concerns are potential targets for PE and CPT engagement interventions.
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Affiliation(s)
- Shannon M. Kehle-Forbes
- Center for Care Delivery & Outcomes Research, Minneapolis VA Healthcare System, One Veterans Drive, Minneapolis, MN, 55417, USA,Women’s Health Sciences Division at VA Boston, National Center for PTSD, 150 S Huntington Ave, Boston, MA, 02130, USA,University of Minnesota, Department of Medicine, 420 Delaware St SE, Minneapolis, MN, 55455, USA,Corresponding author. Center for Care Delivery & Outcomes Research, Minneapolis VA Healthcare System, One Veterans Drive, Minneapolis, MN, 55417, USA. (S.M. Kehle-Forbes)
| | - Princess E. Ackland
- Center for Care Delivery & Outcomes Research, Minneapolis VA Healthcare System, One Veterans Drive, Minneapolis, MN, 55417, USA,University of Minnesota, Department of Medicine, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Michele R. Spoont
- Center for Care Delivery & Outcomes Research, Minneapolis VA Healthcare System, One Veterans Drive, Minneapolis, MN, 55417, USA,University of Minnesota, Department of Medicine, 420 Delaware St SE, Minneapolis, MN, 55455, USA,National Center for PTSD, Pacific Islands Division, 459 Patterson Rd, Honolulu, HI, 96819, USA
| | - Laura A. Meis
- Center for Care Delivery & Outcomes Research, Minneapolis VA Healthcare System, One Veterans Drive, Minneapolis, MN, 55417, USA,University of Minnesota, Department of Medicine, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Robert J. Orazem
- Center for Care Delivery & Outcomes Research, Minneapolis VA Healthcare System, One Veterans Drive, Minneapolis, MN, 55417, USA
| | - Alexandra Lyon
- Center for Care Delivery & Outcomes Research, Minneapolis VA Healthcare System, One Veterans Drive, Minneapolis, MN, 55417, USA
| | - Helen R. Valenstein-Mah
- Center for Care Delivery & Outcomes Research, Minneapolis VA Healthcare System, One Veterans Drive, Minneapolis, MN, 55417, USA
| | - Paula P. Schnurr
- National Center for PTSD, Department of Veterans Affairs, 163 Veterans Dr, White River Junction, VT, 05009, USA,Geisel School of Medicine, Dartmouth College, 1 Rope Ferry Rd, Hanover, NH, 03755, USA
| | - Susan L. Zickmund
- Informatics, Decision-Enhancement & Analytic Sciences Center, Salt Lake City VA, 500 S Foothill Blvd, Salt Lake City, UT, 84108, USA
| | - Edna B. Foa
- Department of Psychiatry, University of Pennsylvania, 6th Gateway, 3535 Market St, Philadelphia, PA, 19104, USA
| | - Kathleen M. Chard
- Cincinnati VA Medical Center, 3200 Vine St, Cincinnati, OH, 45220, USA
| | - Elizabeth Alpert
- Women’s Health Sciences Division at VA Boston, National Center for PTSD, 150 S Huntington Ave, Boston, MA, 02130, USA
| | - Melissa A. Polusny
- Center for Care Delivery & Outcomes Research, Minneapolis VA Healthcare System, One Veterans Drive, Minneapolis, MN, 55417, USA,University of Minnesota, Department of Psychiatry, 420 Delaware St SE, Minneapolis, MN, 55455, USA
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19
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McGeary DD, Resick PA, Penzien DB, McGeary CA, Houle TT, Eapen BC, Jaramillo CA, Nabity PS, Reed DE, Moring JC, Bira LM, Hansen HR, Young-McCaughan S, Cobos BA, Mintz J, Keane TM, Peterson AL. Cognitive Behavioral Therapy for Veterans With Comorbid Posttraumatic Headache and Posttraumatic Stress Disorder Symptoms: A Randomized Clinical Trial. JAMA Neurol 2022; 79:746-757. [PMID: 35759281 PMCID: PMC9237802 DOI: 10.1001/jamaneurol.2022.1567] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Question Do cognitive behavioral therapies for posttraumatic headache and posttraumatic stress disorder (PTSD) symptoms improve headache-related disability in veterans compared with treatment per usual? Findings A randomized clinical trial of 193 post-9/11 combat veterans with posttraumatic headache and PTSD symptoms found headache disability was significantly improved with cognitive behavioral therapy for headaches compared with treatment per usual. Though participants randomly assigned to cognitive processing therapy reported significantly greater improvement in PTSD symptom severity compared with treatment per usual, there was no significant effect of cognitive processing therapy on headache disability. Meaning Cognitive behavioral therapies are efficacious treatments for veterans with comorbid posttraumatic headache and PTSD symptoms. Importance Posttraumatic headache is the most disabling complication of mild traumatic brain injury. Posttraumatic stress disorder (PTSD) symptoms are often comorbid with posttraumatic headache, and there are no established treatments for this comorbidity. Objective To compare cognitive behavioral therapies (CBTs) for headache and PTSD with treatment per usual (TPU) for posttraumatic headache attributable to mild traumatic brain injury. Design, Setting, and Participants This was a single-site, 3–parallel group, randomized clinical trial with outcomes at posttreatment, 3-month follow-up, and 6-month follow-up. Participants were enrolled from May 1, 2015, through May 30, 2019; data collection ended on October 10, 2019. Post-9/11 US combat veterans from multiple trauma centers were included in the study. Veterans had comorbid posttraumatic headache and PTSD symptoms. Data were analyzed from January 20, 2020, to February 2, 2022. Interventions Patients were randomly assigned to 8 sessions of CBT for headache, 12 sessions of cognitive processing therapy for PTSD, or treatment per usual for headache. Main Outcomes and Measures Co–primary outcomes were headache-related disability on the 6-Item Headache Impact Test (HIT-6) and PTSD symptom severity on the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (PCL-5) assessed from treatment completion to 6 months posttreatment. Results A total of 193 post-9/11 combat veterans (mean [SD] age, 39.7 [8.4] years; 167 male veterans [87%]) were included in the study and reported severe baseline headache-related disability (mean [SD] HIT-6 score, 65.8 [5.6] points) and severe PTSD symptoms (mean [SD] PCL-5 score, 48.4 [14.2] points). For the HIT-6, compared with usual care, patients receiving CBT for headache reported −3.4 (95% CI, −5.4 to −1.4; P < .01) points lower, and patients receiving cognitive processing therapy reported −1.4 (95% CI, −3.7 to 0.8; P = .21) points lower across aggregated posttreatment measurements. For the PCL-5, compared with usual care, patients receiving CBT for headache reported −6.5 (95% CI, −12.7 to −0.3; P = .04) points lower, and patients receiving cognitive processing therapy reported −8.9 (95% CI, −15.9 to −1.9; P = .01) points lower across aggregated posttreatment measurements. Adverse events were minimal and similar across treatment groups. Conclusions and Relevance This randomized clinical trial demonstrated that CBT for headache was efficacious for disability associated with posttraumatic headache in veterans and provided clinically significant improvement in PTSD symptom severity. Cognitive processing therapy was efficacious for PTSD symptoms but not for headache disability. Trial Registration ClinicalTrials.gov Identifier: NCT02419131
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Affiliation(s)
- Donald D McGeary
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center San Antonio, San Antonio.,Department of Rehabilitation Medicine, The University of Texas Health Science Center at San Antonio, San Antonio.,South Texas Veterans Health Care System, San Antonio.,Department of Psychology, The University of Texas at San Antonio, San Antonio
| | - Patricia A Resick
- Department of Psychiatry and Behavioral Sciences, Duke Health, Durham, North Carolina
| | - Donald B Penzien
- Departments of Psychiatry and Behavioral Medicine & Neurology, Wake Forest University, Winston-Salem, North Carolina
| | - Cindy A McGeary
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center San Antonio, San Antonio.,South Texas Veterans Health Care System, San Antonio
| | - Timothy T Houle
- Department of Anesthesia, Massachusetts General Hospital, Boston
| | - Blessen C Eapen
- Greater Los Angeles Veterans Health Care System, Los Angeles, California.,Department of Physical Medicine and Rehabilitation, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles
| | - Carlos A Jaramillo
- Department of Rehabilitation Medicine, The University of Texas Health Science Center at San Antonio, San Antonio.,South Texas Veterans Health Care System, San Antonio
| | - Paul S Nabity
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center San Antonio, San Antonio.,South Texas Veterans Health Care System, San Antonio
| | - David E Reed
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center San Antonio, San Antonio
| | - John C Moring
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center San Antonio, San Antonio.,South Texas Veterans Health Care System, San Antonio
| | - Lindsay M Bira
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center San Antonio, San Antonio
| | - Hunter R Hansen
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center San Antonio, San Antonio
| | - Stacey Young-McCaughan
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center San Antonio, San Antonio.,South Texas Veterans Health Care System, San Antonio
| | - Briana A Cobos
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center San Antonio, San Antonio.,Department of Psychology, The University of Texas at San Antonio, San Antonio
| | - Jim Mintz
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center San Antonio, San Antonio.,South Texas Veterans Health Care System, San Antonio
| | - Terence M Keane
- Behavioral Science Division, National Center for PTSD, Boston, Massachusetts.,VA Boston Healthcare System, Boston, Massachusetts.,Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts
| | - Alan L Peterson
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center San Antonio, San Antonio.,South Texas Veterans Health Care System, San Antonio.,Department of Psychology, The University of Texas at San Antonio, San Antonio
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20
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Scharff FB, Lau ME, Gondan M, Folke S, Arendt IMTP, Moeller SB. Evaluation of a standardized posttraumatic stress disorder treatment framework in routine mental health care: Effectiveness and predictors of treatment outcome in a consecutive sample. J Trauma Stress 2022; 35:827-838. [PMID: 35338519 DOI: 10.1002/jts.22790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 10/22/2021] [Accepted: 10/24/2021] [Indexed: 11/07/2022]
Abstract
The primary aim of the present study was to evaluate the effectiveness of standardized care package (CP) treatment for posttraumatic stress disorder (PTSD) in a Danish sample of adult psychiatric outpatients (N = 948). Secondary aims were to identify baseline predictors of treatment outcomes and investigate between-group differences in outcomes with regard to sex and treatment modality (i.e., group vs. individual therapy). The naturalistic, nonrandomized study followed a pre-post design. Patient data from five psychiatric outpatient clinics were collected between March 2011 and November 2017. Data were drawn from self-report questionnaires (i.e., SCL-90-R, WHO-5, BHS) and therapist-reported measures (i.e., GAF-S, GAF-F) administered at baseline and posttreatment. Between-group effects for sex and therapy modality (group vs. individual) were analyzed using analyses of variance, and possible predictors of outcomes were selected through LASSO regression and analyzed via hierarchical regression. Pre-post effects were small to moderate, ds = 0.39-0.69. No differences emerged regarding treatment modality, but women had significantly better outcomes than men. Aside from sex, only baseline symptom severity predicted outcomes. The effectiveness of the CP treatment was generally limited, indicating the need to implement improved therapeutic practices, such as the use of evidence-based treatments, and to provide better training to mental health clinicians. The findings underscore the need for further comparisons of group and individual treatment modalities using evidence-based therapies as well as the need to investigate factors that may affect treatment outcome.
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Affiliation(s)
- Frederik B Scharff
- Stolpegaard Psychotherapy Centre, Mental Health Services, Capital Region of Denmark, Copenhagen, Denmark
| | - Marianne E Lau
- Stolpegaard Psychotherapy Centre, Mental Health Services, Capital Region of Denmark, Copenhagen, Denmark
| | - Matthias Gondan
- Department of Psychology, University of Innsbruck, Innsbruck, Austria
| | - Sofie Folke
- Danish Veterans Centre, Danish Ministry of Defense, Ringsted, Denmark
| | - Ida-Marie T P Arendt
- Clinic for Affective Disorders, Mental Health Services, Capital Region of Denmark, Copenhagen, Denmark
| | - Stine B Moeller
- Stolpegaard Psychotherapy Centre, Mental Health Services, Capital Region of Denmark, Copenhagen, Denmark.,Department of Psychology, University of Southern Denmark, Odense, Denmark
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21
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Henner RL, Keshavan MS, Hill KP. Review of potential psychedelic treatments for PTSD. J Neurol Sci 2022; 439:120302. [DOI: 10.1016/j.jns.2022.120302] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 04/27/2022] [Accepted: 05/24/2022] [Indexed: 12/20/2022]
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22
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Macdonald A, Fredman SJ, Taylor DJ, Pruiksma KE, Blount TH, Hall-Clark BN, Fina BA, Dondanville KA, Mintz J, Litz BT, Young-McCaughan S, Le Y, Jenkins AIC, Monson CM, Yarvis JS, Keane TM, Peterson AL. Secondary individual outcomes following multicouple group therapy for posttraumatic stress disorder: An uncontrolled pilot study with military dyads. J Trauma Stress 2022; 35:321-329. [PMID: 34800060 DOI: 10.1002/jts.22729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 04/04/2021] [Accepted: 05/02/2021] [Indexed: 11/11/2022]
Abstract
Cognitive-behavioral conjoint therapy (CBCT) for posttraumatic stress disorder (PTSD) has demonstrated efficacy for improving PTSD and comorbid symptoms and relationship adjustment. To enhance treatment efficiency and scalability, we developed a 2-day, abbreviated, intensive, multicouple group version of CBCT for PTSD (AIM-CBCT for PTSD). Prior work demonstrated that AIM-CBCT for PTSD wasassociated with reductions in PTSD and comorbid symptoms in a sample of 24 post-9/11 active duty military or veteran couples who received the treatment in a retreat format over a single weekend. The current study investigated secondary outcomes regarding trauma-related cognitions, psychosocial impairment, and insomnia. For trauma-related cognitions, reductions were nonsignificant and small at 1-month follow-up, ds = -0.14 to -0.32. However, by 3-month follow-up, there were significant, medium effect size reductions in total trauma-related cognitions, d = -0.68, and negative views of self and others, ds = -0.64 and -0.57, respectively, relative to baseline. There was also a nonsignificant, small-to-medium effect-size reduction in self-blame, d = -0.43, p = .053, by 3-month follow-up. For psychosocial impairment, there were significant and medium-to-large and large effect size reductions by 1- and 3-month follow-ups, ds = -0.73 and -0.81, respectively. There were nonsignificant, small effect size reductions in insomnia at both 1- and 3-month follow-ups relative to baseline, ds = -0.30 and -0.34, respectively. These findings suggest that AIM-CBCT for PTSD is associated with reductions in maladaptive posttraumatic cognitions and psychosocial impairment but that adjunctive interventions may be needed to address insomnia.
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Affiliation(s)
- Alexandra Macdonald
- Department of Psychology, The Citadel, Military College of South Carolina, Charleston, South Carolina, USA
| | - Steffany J Fredman
- Department of Human Development and Family Studies, The Pennsylvania State University, University Park, Pennsylvania, USA
| | - Daniel J Taylor
- Department of Psychology, University of Arizona, Tucson, Arizona, USA
| | - Kristi E Pruiksma
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Tabatha H Blount
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Brittany N Hall-Clark
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Brooke A Fina
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Katherine A Dondanville
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Jim Mintz
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Brett T Litz
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Stacey Young-McCaughan
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Yunying Le
- Department of Human Development and Family Studies, The Pennsylvania State University, University Park, Pennsylvania, USA.,Department of Psychology, University of Miami, Coral Gables, Florida, USA
| | - August I C Jenkins
- Department of Human Development and Family Studies, The Pennsylvania State University, University Park, Pennsylvania, USA
| | | | - Jeffrey S Yarvis
- Department of Behavioral Health, Carl R. Darnall Army Medical Center, Fort Hood, Texas, USA.,Jeffrey S. Yarvis is now at Department of Social Work, Texas A&M University - Central Texas, Killeen, Texas, USA
| | - Terence M Keane
- Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA.,Behavioral Science Division, National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Alan L Peterson
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.,Research and Development Service, South Texas Veterans Health Care System, San Antonio, Texas, USA.,Department of Psychology, The University of Texas at San Antonio, San Antonio, Texas, USA
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23
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Peterson AL, Mintz J, Moring JC, Straud CL, Young-McCaughan S, McGeary CA, McGeary DD, Litz BT, Velligan DI, Macdonald A, Mata-Galan E, Holliday SL, Dillon KH, Roache JD, Bira LM, Nabity PS, Medellin EM, Hale WJ, Resick PA. In-office, in-home, and telehealth cognitive processing therapy for posttraumatic stress disorder in veterans: a randomized clinical trial. BMC Psychiatry 2022; 22:41. [PMID: 35038985 PMCID: PMC8763446 DOI: 10.1186/s12888-022-03699-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 01/04/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Trauma-focused psychotherapies for combat-related posttraumatic stress disorder (PTSD) in military veterans are efficacious, but there are many barriers to receiving treatment. The objective of this study was to determine if cognitive processing therapy (CPT) for PTSD among active duty military personnel and veterans would result in increased acceptability, fewer dropouts, and better outcomes when delivered In-Home or by Telehealth as compared to In-Office treatment. METHODS The trial used an equipoise-stratified randomization design in which participants (N = 120) could decline none or any 1 arm of the study and were then randomized equally to 1 of the remaining arms. Therapists delivered CPT in 12 sessions lasting 60-min each. Self-reported PTSD symptoms on the PTSD Checklist for DSM-5 (PCL-5) served as the primary outcome. RESULTS Over half of the participants (57%) declined 1 treatment arm. Telehealth was the most acceptable and least often refused delivery format (17%), followed by In-Office (29%), and In-Home (54%); these differences were significant (p = 0.0008). Significant reductions in PTSD symptoms occurred with all treatment formats (p < .0001). Improvement on the PCL-5 was about twice as large in the In-Home (d = 2.1) and Telehealth (d = 2.0) formats than In-Office (d = 1.3); those differences were statistically large and significant (d = 0.8, 0.7 and p = 0.009, 0.014, respectively). There were no significant differences between In-Home and Telehealth outcomes (p = 0.77, d = -.08). Dropout from treatment was numerically lowest when therapy was delivered In-Home (25%) compared to Telehealth (34%) and In-Office (43%), but these differences were not statistically significant. CONCLUSIONS CPT delivered by telehealth is an efficient and effective treatment modality for PTSD, especially considering in-person restrictions resulting from COVID-19. TRIAL REGISTRATION ClinicalTrials.gov ID NCT02290847 (Registered 13/08/2014; First Posted Date 14/11/2014).
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Affiliation(s)
- Alan L. Peterson
- grid.267309.90000 0001 0629 5880Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229 USA ,grid.280682.60000 0004 0420 5695South Texas Veterans Health Care System, San Antonio, TX USA ,grid.215352.20000000121845633Department of Psychology, University of Texas at San Antonio, San Antonio, TX USA
| | - Jim Mintz
- grid.267309.90000 0001 0629 5880Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229 USA ,grid.280682.60000 0004 0420 5695South Texas Veterans Health Care System, San Antonio, TX USA
| | - John C. Moring
- grid.267309.90000 0001 0629 5880Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229 USA ,grid.280682.60000 0004 0420 5695South Texas Veterans Health Care System, San Antonio, TX USA
| | - Casey L. Straud
- grid.267309.90000 0001 0629 5880Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229 USA ,grid.280682.60000 0004 0420 5695South Texas Veterans Health Care System, San Antonio, TX USA
| | - Stacey Young-McCaughan
- grid.267309.90000 0001 0629 5880Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229 USA ,grid.280682.60000 0004 0420 5695South Texas Veterans Health Care System, San Antonio, TX USA
| | - Cindy A. McGeary
- grid.267309.90000 0001 0629 5880Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229 USA ,grid.280682.60000 0004 0420 5695South Texas Veterans Health Care System, San Antonio, TX USA
| | - Donald D. McGeary
- grid.267309.90000 0001 0629 5880Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229 USA ,grid.280682.60000 0004 0420 5695South Texas Veterans Health Care System, San Antonio, TX USA ,grid.267309.90000 0001 0629 5880Department of Rehabilitation Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX USA
| | - Brett T. Litz
- grid.189504.10000 0004 1936 7558Department of Psychiatry, Boston University School of Medicine, Boston, MA USA ,grid.410370.10000 0004 4657 1992Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System, Boston, MA USA ,grid.189504.10000 0004 1936 7558Department of Psychological and Brain Sciences, Boston University, Boston, MA USA
| | - Dawn I. Velligan
- grid.267309.90000 0001 0629 5880Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229 USA
| | - Alexandra Macdonald
- grid.421223.40000 0001 2153 4843The Citadel, Military College of South Carolina, Charleston, SC USA
| | - Emma Mata-Galan
- grid.267309.90000 0001 0629 5880Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229 USA ,grid.280682.60000 0004 0420 5695South Texas Veterans Health Care System, San Antonio, TX USA
| | - Stephen L. Holliday
- grid.267309.90000 0001 0629 5880Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229 USA ,grid.280682.60000 0004 0420 5695South Texas Veterans Health Care System, San Antonio, TX USA
| | - Kirsten H. Dillon
- grid.512153.1Durham VA Health Care System, Durham, North Carolina USA
| | - John D. Roache
- grid.267309.90000 0001 0629 5880Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229 USA ,grid.280682.60000 0004 0420 5695South Texas Veterans Health Care System, San Antonio, TX USA
| | - Lindsay M. Bira
- grid.267309.90000 0001 0629 5880Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229 USA
| | - Paul S. Nabity
- grid.267309.90000 0001 0629 5880Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229 USA
| | - Elisa M. Medellin
- grid.267309.90000 0001 0629 5880Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229 USA
| | - Willie J. Hale
- grid.267309.90000 0001 0629 5880Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229 USA ,grid.215352.20000000121845633Department of Psychology, University of Texas at San Antonio, San Antonio, TX USA
| | - Patricia A. Resick
- grid.412100.60000 0001 0667 3730Department of Psychiatry and Behavioral Sciences, Duke Health, Durham, North Carolina USA
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24
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Examining attendance patterns across integrated therapies for posttraumatic stress disorder and alcohol use disorder. J Anxiety Disord 2022; 85:102498. [PMID: 34823044 DOI: 10.1016/j.janxdis.2021.102498] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 09/06/2021] [Accepted: 11/02/2021] [Indexed: 11/23/2022]
Abstract
A substantial body of evidence supports the use of integrated treatments for posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD). Integrated trauma-focused exposure therapies reduce PTSD symptoms more than comparison treatments, including integrated coping skills therapies, but demonstrate lower attendance, raising questions regarding the relationships between attendance, outcomes, and treatment type. We aimed to examine these relationships in a RCT comparing integrated prolonged exposure (Concurrent Treatment for PTSD and Substance Use Disorders Using Prolonged Exposure, COPE; n = 58), to integrated coping skills therapy (Seeking Safety, SS; n = 52) offered in 12 sessions, with an option to extend up to four additional sessions. Participants were categorized based on number of sessions attended (0-4; 5-8; 9-12; 13-16). Multilevel modeling revealed that only when examining therapy attendance segments individually, clinical outcomes were comparable across treatments except in the 9-12 group, with COPE resulting in greater reductions in PTSD symptoms (p < 0.001), but not in alcohol use. Extending past 12 sessions was not associated with additional clinically meaningful symptom improvement for either treatment. These results suggest that attending a complete or near complete course of exposure therapy may enhance PTSD outcomes relative to non-trauma-focused therapies.
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25
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McLean CP, Levy HC, Miller ML, Tolin DF. Exposure therapy for PTSD: A meta-analysis. Clin Psychol Rev 2021; 91:102115. [PMID: 34954460 DOI: 10.1016/j.cpr.2021.102115] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 10/26/2021] [Accepted: 12/16/2021] [Indexed: 11/03/2022]
Abstract
Posttraumatic stress disorder (PTSD) is associated with high morbidity and functional impairment in the absence of effective treatment. Exposure therapy for PTSD is a trauma-focused treatment that typically includes in vivo and/or imaginal exposure. The goal of this meta-analysis was to examine the overall efficacy of exposure therapy for PTSD compared to various control conditions. We also assessed the efficacy of individual exposure-based treatments and the potentially moderating impact of various demographic, clinical, and treatment-related factors. PsycINFO and Medline were searched for randomized controlled trials of exposure-based therapies for adult PTSD. A total of 934 abstracts were screened for initial eligibility; of these, 65 articles met inclusion criteria and were included in the meta-analysis (total N = 4929 patients). Exposure therapy showed large effects relative to waitlist and treatment-as-usual, a small effect relative to non-trauma-focused comparators and a negligible effect relative to other trauma-focused treatments or medication. At follow-up most effects sizes were stable, except for a medium effect favoring exposure over medication. The individual exposure-based therapies examined were similarly effective. Moderator analyses revealed larger effect sizes in studies with fewer sessions, younger samples, fewer participants diagnosed with substance use disorder, and fewer participants on psychiatric medication. Effect sizes were also larger in studies of refugees and civilians compared to military samples, studies of PTSD related to natural disasters and transportation accidents vs. other traumatic events, and studies of individual vs. group therapy. Findings support the overall efficacy of exposure therapy and highlight that there are a number of efficacious exposure-based therapies available.
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Affiliation(s)
- Carmen P McLean
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA 94025, USA; Department of Psychiatry and Behavioral Sciences, Stanford University, 401 Quarry Road, Stanford, CA 94305-5717, USA.
| | - Hannah C Levy
- Anxiety Disorders Center, The Institute of Living/Hartford Hospital, 200 Retreat Avenue, Hartford, CT 06106, USA
| | - Madeleine L Miller
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA 94025, USA
| | - David F Tolin
- Anxiety Disorders Center, The Institute of Living/Hartford Hospital, 200 Retreat Avenue, Hartford, CT 06106, USA; Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510, USA
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26
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Anger and predictors of drop-out from PTSD treatment of veterans and first responders. Behav Cogn Psychother 2021; 50:237-251. [PMID: 34569465 DOI: 10.1017/s1352465821000382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Drop-out is an important barrier in treating post-traumatic stress disorder (PTSD) with consequences that negatively impact clients, clinicians and mental health services as a whole. Anger is a common experience in people with PTSD and is more prevalent in military veterans. To date, no research has examined if anger may predict drop-out in military veterans or first responders. AIMS The present study aimed to determine the variables that predict drop-out among individuals receiving residential treatment for PTSD. METHOD Ninety-five military veterans and first responders completed pre-treatment measures of PTSD symptom severity, depression, anxiety, anger, and demographic variables. Logistic regression analyses were used to determine if these variables predicted drop-out from treatment or patterns of attendance. RESULTS Female gender was predictive of drop-out. However, when analysed by occupation female gender was predictive of drop-out among first responders and younger age was predictive of drop-out in military participants. Anger, depression, anxiety and PTSD symptom severity were not predictive of drop-out in any of the analyses. No variables were found to predict attendance patterns (consistent or inconsistent) or early versus late drop-out from the programme. CONCLUSION These results suggest that although anger is a relevant issue for treating PTSD, other factors may be more pertinent to drop-out, particularly in this sample. In contrast with other findings, female gender was predictive of drop-out in this study. This may indicate that in this sample, there are unique characteristics and possible interacting variables that warrant exploration in future research.
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27
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Tyler H, Fina BA, Marx BP, Young-McCaughan S, Sloan DM, Kaplan AM, Green VR, Blankenship A, Bryan CJ, Peterson AL. Written Exposure Therapy for Suicide in a Psychiatric Inpatient Unit: A Case Series. COGNITIVE AND BEHAVIORAL PRACTICE 2021. [DOI: 10.1016/j.cbpra.2021.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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28
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Edwards-Stewart A, Smolenski DJ, Bush NE, Cyr BA, Beech EH, Skopp NA, Belsher BE. Posttraumatic Stress Disorder Treatment Dropout Among Military and Veteran Populations: A Systematic Review and Meta-Analysis. J Trauma Stress 2021; 34:808-818. [PMID: 33524199 DOI: 10.1002/jts.22653] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 11/17/2020] [Accepted: 01/06/2021] [Indexed: 11/06/2022]
Abstract
High treatment dropout rates reported in recent literature have brought into question the effectiveness of trauma-focused posttraumatic stress disorder (PTSD) treatments among military populations. The aim of the current systematic review was to evaluate PTSD treatment dropout rates among military populations by treatment type and other study-level variables. We searched four databases as well as gray literature for randomized controlled trials that evaluated evidence-based PTSD treatments in samples of active duty personnel and/or veterans. In total, 26 studies were included in this review, with a total of 2,984 participants. We analyzed dropout rates across treatment types using multivariate meta-analysis. Across all forms of treatment, the aggregated dropout rate was 24.2%. Dropout percentages based on treatment type were 27.1% for trauma-focused treatments, 16.1% for non-trauma-focused treatments, and 6.8% for waitlist groups. We found substantial heterogeneity between studies that was not explained by military status or other study-level covariates. Summary risk ratios (RRs) comparing relative dropout between treatment groups indicated that trauma-focused treatment groups had a higher risk of dropout compared to non-trauma-focused treatments, RR = 1.60. The statistical heterogeneity of within-treatment dropout risk ratios was negligible. Dropout rates among military patients receiving trauma-focused therapies were only slightly higher than those reported in the literature among civilian populations and were not explained by study-level covariates.
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Affiliation(s)
- Amanda Edwards-Stewart
- Department of Health Affairs, Psychological Health Center of Excellence, Research Branch, Tacoma, Washington, USA
| | - Derek J Smolenski
- Department of Health Affairs, Psychological Health Center of Excellence, Performance & Analytics Branch, Tacoma, Washington, USA
| | - Nigel E Bush
- Department of Health Affairs, Psychological Health Center of Excellence, Research Branch, Tacoma, Washington, USA
| | - Betty-Ann Cyr
- Alliant International University, the California School of Professional Psychology, Clinical Psychology, San Francisco, California, USA
| | - Erin H Beech
- Department of Health Affairs, Psychological Health Center of Excellence, Research Branch, Tacoma, Washington, USA
| | - Nancy A Skopp
- Department of Health Affairs, Psychological Health Center of Excellence, Research Branch, Tacoma, Washington, USA
| | - Bradley E Belsher
- Department of Health Affairs, Psychological Health Center of Excellence, Research Branch, Tacoma, Washington, USA
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29
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Sijercic I, Liebman RE, Stirman SW, Monson CM. The Effect of Therapeutic Alliance on Dropout in Cognitive Processing Therapy for Posttraumatic Stress Disorder. J Trauma Stress 2021; 34:819-828. [PMID: 33772892 DOI: 10.1002/jts.22676] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 01/23/2021] [Accepted: 02/21/2021] [Indexed: 01/10/2023]
Abstract
A substantial number of individuals who undergo cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) drop out before receiving a full course of treatment. Therapeutic alliance, defined as the working relationship between the therapist and client, is a dynamic process within therapy that may change over time. Research suggests that therapeutic alliance is associated with dropout in various treatments. However, no studies have yet examined the association between therapeutic alliance and dropout in CPT, and few studies have examined therapeutic alliance longitudinally over the course of treatment. Examining alliance in CPT through different methods may increase clinicians' understanding of how to tailor interventions to prevent treatment dropout. The present study examined the association between therapeutic alliance and treatment dropout among 169 participants in a randomized implementation effectiveness trial. In total, 33.1% of clients dropped out over the course of CPT, and nearly half of these individuals dropped out during the first six sessions. Continuous-time survival analysis results indicated that mean ratings of alliance significantly predicted treatment dropout, Wald χ2 (1, N = 167) = 4.08, Exp(β) = .64, p = .043, whereas initial alliance, late alliance, and change in alliance over treatment did not. These findings suggest that overall therapeutic alliance is an important predictor of dropout from CPT.
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Affiliation(s)
- Iris Sijercic
- Department of Psychology, Ryerson University, Toronto, Canada
| | - Rachel E Liebman
- Department of Psychology, Ryerson University, Toronto, Canada.,Faculty of Health, York University, Toronto, Canada
| | - Shannon Wiltsey Stirman
- National Center for PTSD, Menlo Park, California, USA.,Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California, USA
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Gray JC, Larson MJ, Moresco N, Ritter GA, Dufour S, Milliken CS, Adams RS. The association of engagement in substance use treatment with negative separation from the military among soldiers with post-deployment alcohol use disorder. Drug Alcohol Depend 2021; 221:108647. [PMID: 33647586 PMCID: PMC8136466 DOI: 10.1016/j.drugalcdep.2021.108647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 02/09/2021] [Accepted: 02/14/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Alcohol use disorder (AUD) reduces the health of soldiers and the readiness of the Armed Forces. It remains unknown if engagement in substance use treatment in the Military Health System improves retention in the military. METHODS The sample consisted of active duty soldiers returning from an Afghanistan/Iraq deployment in fiscal years 2008-2010 who received an AUD diagnosis within 150 days of completing a post-deployment health re-assessment survey (n = 4,726). A Heckman probit procedure was used to examine predictors of substance use treatment initiation and engagement in accordance with Healthcare Effectiveness Data and Information Set (HEDIS) criteria. Cox proportional hazard modeling was used to examine the association between treatment engagement and retention, defined as a negative separation for a non-routine cause (e.g., separation due to misconduct, poor performance, disability) from the military in the two years following the index AUD diagnosis. RESULTS 40 % of soldiers meeting HEDIS AUD criteria initiated and 24 % engaged in substance use treatment. Among soldiers diagnosed with AUD, meeting criteria for treatment engagement was associated with a significantly higher hazard of having a negative separation compared to soldiers who did not engage in treatment. CONCLUSIONS Rates of initiation and engagement in substance use treatment for post-deployment AUD were relatively low. Soldiers with AUD who engaged in substance use treatment were more likely to have a negative separation from the military than soldiers with AUD who did not engage. Our findings imply that in the study cohort, treatment did not mitigate negative career consequences of AUD.
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Affiliation(s)
- Joshua C Gray
- Department of Medical and Clinical Psychology, Uniformed Services University, 4301 Jones Bridge Rd, Bethesda, MD, 20814, USA.
| | - Mary Jo Larson
- Heller School, Institute for Behavioral Health, Brandeis University, 415 South Street MS 035, Waltham, MA, 02453, USA
| | - Natalie Moresco
- Heller School, Institute for Behavioral Health, Brandeis University, 415 South Street MS 035, Waltham, MA, 02453, USA
| | - Grant A Ritter
- Heller School, Institute for Behavioral Health, Brandeis University, 415 South Street MS 035, Waltham, MA, 02453, USA
| | - Steven Dufour
- Department of Medical and Clinical Psychology, Uniformed Services University, 4301 Jones Bridge Rd, Bethesda, MD, 20814, USA
| | - Charles S Milliken
- Army's Substance Use Disorder Clinical Care, Office of the Army Surgeon General, Defense Health Headquarters, 7700 Arlington Blvd, Falls Church, VA, 22042, USA
| | - Rachel Sayko Adams
- Heller School, Institute for Behavioral Health, Brandeis University, 415 South Street MS 035, Waltham, MA, 02453, USA; Rocky Mountain Mental Illness Research Education and Clinical Center, Veterans Health Administration, 1700 N. Wheeling Street, Aurora, CO, 80045, USA
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Litz BT, Rusowicz-Orazem L, Doros G, Grunthal B, Gray M, Nash W, Lang AJ. Adaptive disclosure, a combat-specific PTSD treatment, versus cognitive-processing therapy, in deployed marines and sailors: A randomized controlled non-inferiority trial. Psychiatry Res 2021; 297:113761. [PMID: 33540206 DOI: 10.1016/j.psychres.2021.113761] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 01/23/2021] [Indexed: 11/18/2022]
Abstract
Adaptive Disclosure (AD) is a new emotion-focused psychotherapy for combat-related PTSD. As a second step in the evaluation process, we conducted a non-inferiority (NI) trial of AD, relative to Cognitive Processing Therapy - Cognitive Therapy version (CPT-C), an established first-line psychotherapy. Participants were 122 U.S. Marines and Sailors. The primary endpoint was PTSD symptom severity change from pre- to posttreatment, using the Clinician Administered PTSD Scale for DSM-IV. Secondary endpoints were depression (Patient Health Questionnaire-9; PHQ-9) and functioning (Veterans Rand Health Survey-12; VR-12). For cases with complete data, the mean difference in CAPS-IV change scores was 0.33 and the confidence interval (CI) did not include the predefined NI margin (95% CI =-10.10, 9.44). The mean difference in PHQ-9 change scores was -1.01 and the CI did not include the predefined margin (95% CI = -3.31, 1.28), as was the case for the VR-12 Physical Component and VR-12 Mental Component subscale scores (0.27; 95% CI = -4.50, 3.95, and -2.10; 95% CI = -7.03, 2.83, respectively). A series of intent-to-treat sensitivity analyses confirmed these results. The differential effect size for CAPS-IV was d = 0.01 (nonsignificant). As predicted, Adaptive Disclosure was found to be no less effective than a first-line psychotherapy.
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Affiliation(s)
- Brett T Litz
- Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System, Boston, MA, United States; Department of Psychiatry, Boston University School of Medicine, Boston, MA, United States.
| | - Luke Rusowicz-Orazem
- Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System, Boston, MA, United States; Department of Biostatistics, Boston University School of Public Health, Boston, MA, United States
| | - Gheorghe Doros
- Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System, Boston, MA, United States; Department of Biostatistics, Boston University School of Public Health, Boston, MA, United States
| | - Breanna Grunthal
- Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System, Boston, MA, United States
| | - Matthew Gray
- Department of Psychology, University of Wyoming College of Arts and Sciences, Laramie, WY, United States
| | - William Nash
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Ariel J Lang
- Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, San Diego, CA, United States; Department of Psychiatry, University of California San Diego, San Diego, CA, United States
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Cannabis use and posttraumatic stress disorder comorbidity: Epidemiology, biology and the potential for novel treatment approaches. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2021; 157:143-193. [PMID: 33648669 DOI: 10.1016/bs.irn.2020.09.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Cannabis use is increasing among some demographics in the United States and is tightly linked to anxiety, trauma, and stress reactivity at the epidemiological and biological level. Stress-coping motives are highly cited reasons for cannabis use. However, with increased cannabis use comes the increased susceptibility for cannabis use disorder (CUD). Indeed, CUD is highly comorbid with posttraumatic stress disorder (PTSD). Importantly, endogenous cannabinoid signaling systems play a key role in the regulation of stress reactivity and anxiety regulation, and preclinical data suggest deficiencies in this signaling system could contribute to the development of stress-related psychopathology. Furthermore, endocannabinoid deficiency states, either pre-existing or induced by trauma exposure, could provide explanatory insights into the high rates of comorbid cannabis use in patients with PTSD. Here we review clinical and preclinical literature related to the cannabis use-PTSD comorbidity, the role of endocannabinoids in the regulation of stress reactivity, and potential therapeutic implications of recent work in this area.
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Substance use predictors of attendance among veterans in integrated PTSD and alcohol use disorder treatment. J Subst Abuse Treat 2021; 124:108278. [PMID: 33771279 DOI: 10.1016/j.jsat.2021.108278] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 11/12/2020] [Accepted: 01/03/2021] [Indexed: 10/22/2022]
Abstract
Comorbid post-traumatic stress disorder (PTSD) and alcohol use disorder (AUD) is common, defined by greater severity and impairment than either disorder alone, and associated with poor treatment attendance. Exposure therapies are effective in treating PTSD+AUD, yet substance use is still cited as a potential contraindication for exposure. This study examined substance use-related predictors of session attendance among veterans (N = 119) randomized to receive integrated exposure therapy (Concurrent Treatment of PTSD and Substance Use Disorders using Prolonged Exposure [COPE]; Back et al., 2015) or integrated coping skills therapy (Seeking Safety [SS]; Najavits, 2002) in a clinical trial for comorbid PTSD+AUD (Norman et al., 2019). At baseline, greater percentage of heavy drinking days (β = -0.23, p = .011) and greater AUD severity per structured clinical interview for DSM-IV-TR (β = -0.21, p = .019) predicted fewer sessions across both treatments. Treatment type did not moderate the relationship between predictors and attendance, except for a trend for craving (p = .057), where greater craving predicted fewer sessions in SS (β = -0.31, p = .02) but not COPE (β = 0.14, p = .28). Percentage of abstinence days, AUD duration, and living in a controlled environment (e.g., recovery home) at the start of therapy were not associated with attendance in either treatment condition. Only a subset of substance use characteristics predicted attendance. Findings did not support the notion that alcohol use leads to lower attendance in exposure therapy compared to nonexposure therapy.
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Persistence targeted smoking cessation for smokers with schizophrenia or schizoaffective disorder: a feasibility study. J Smok Cessat 2020. [DOI: 10.1017/jsc.2020.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
AbstractIntroductionIndividuals with schizophrenia are more likely to smoke and less likely to quit smoking than those without schizophrenia. Because task persistence is lower in smokers with than without schizophrenia, it is possible that lower levels of task persistence may contribute to greater difficulties in quitting smoking observed among smokers with schizophrenia.AimsTo develop a feasible and acceptable intervention for smokers with schizophrenia.MethodsParticipants (N = 24) attended eight weekly individual cognitive behavioral therapy sessions for tobacco use disorder with a focus on increasing task persistence and received 10 weeks of nicotine patch.ResultsIn total, 93.8% of participants rated the intervention as at least a 6 out of 7 regarding how ‘easy to understand’ it was and 81.3% rated the treatment as at least a 6 out of 7 regarding how helpful it was to them. A total of 62.5% attended at least six of the eight sessions and session attendance was positively related to nicotine dependence and age and negatively related to self-efficacy for quitting.DiscussionThis intervention was feasible and acceptable to smokers with schizophrenia. Future research will examine questions appropriate for later stages of therapy development such as initial efficacy of the intervention and task persistence as a mediator of treatment outcome.
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Fredman SJ, Macdonald A, Monson CM, Dondanville KA, Blount TH, Hall-Clark BN, Fina BA, Mintz J, Litz BT, Young-McCaughan S, Hancock AK, Rhoades GK, Yarvis JS, Resick PA, Roache JD, Le Y, Wachen JS, Niles BL, McGeary CA, Keane TM, Peterson AL. Intensive, Multi-Couple Group Therapy for PTSD: A Nonrandomized Pilot Study With Military and Veteran Dyads. Behav Ther 2020; 51:700-714. [PMID: 32800299 PMCID: PMC10760800 DOI: 10.1016/j.beth.2019.10.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 10/09/2019] [Accepted: 10/13/2019] [Indexed: 11/25/2022]
Abstract
Cognitive-behavioral conjoint therapy for posttraumatic stress disorder (CBCT for PTSD; Monson & Fredman, 2012) is efficacious in improving PTSD symptoms and relationship adjustment among couples with PTSD. However, there is a need for more efficient delivery formats to maximize engagement and retention and to achieve faster outcomes in multiple domains. This nonrandomized trial was designed to pilot an abbreviated, intensive, multi-couple group version of CBCT for PTSD (AIM-CBCT for PTSD) delivered over a single weekend for 24 couples that included an active-duty service member or veteran with PTSD who had deployed in support of combat operations following September 11, 2001. All couples completed treatment. Assessments conducted by clinical evaluators 1 and 3 months after the intervention revealed significant reductions in clinician-rated PTSD symptoms (ds = -0.77 and -0.98, respectively) and in patients' self-reported symptoms of PTSD (ds = -0.73 and -1.17, respectively), depression (ds = -0.60 and -0.75, respectively), anxiety (ds = -0.63 and -0.73, respectively), and anger (ds = -0.45 and -0.60, respectively), relative to baseline. By 3-month follow-up, partners reported significant reductions in patients' PTSD symptoms (d = -0.56), as well as significant improvements in their own depressive symptoms (d = -0.47), anxiety (d = -0.60), and relationship satisfaction (d = 0.53), relative to baseline. Delivering CBCT for PTSD through an abbreviated, intensive multi-couple group format may be an efficient strategy for improving patient, partner, and relational well-being in military and veteran couples with PTSD.
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Affiliation(s)
| | | | | | | | | | | | - Brooke A Fina
- The University of Texas Health Science Center at San Antonio
| | - Jim Mintz
- The University of Texas Health Science Center at San Antonio
| | - Brett T Litz
- VA Boston Healthcare System; Boston University School of Medicine
| | | | | | | | | | | | - John D Roache
- The University of Texas Health Science Center at San Antonio
| | | | - Jennifer S Wachen
- National Center for PTSD; VA Boston Healthcare System; Boston University School of Medicine
| | - Barbara L Niles
- National Center for PTSD; VA Boston Healthcare System; Boston University School of Medicine
| | - Cindy A McGeary
- The University of Texas Health Science Center at San Antonio
| | - Terence M Keane
- National Center for PTSD; VA Boston Healthcare System; Boston University School of Medicine
| | - Alan L Peterson
- The University of Texas Health Science Center at San Antonio; South Texas Veterans Health Care System; The University of Texas at San Antonio
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Sciarrino NA, Warnecke AJ, Teng EJ. A Systematic Review of Intensive Empirically Supported Treatments for Posttraumatic Stress Disorder. J Trauma Stress 2020; 33:443-454. [PMID: 32598561 DOI: 10.1002/jts.22556] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 03/23/2020] [Accepted: 04/12/2020] [Indexed: 01/03/2023]
Abstract
Various clinical practice guidelines for the treatment of posttraumatic stress disorder (PTSD) have consistently identified two frontline evidence-based psychotherapies (EBPs)-prolonged exposure (PE) and cognitive processing therapy (CPT)-as well as other empirically supported treatments (EST), such as eye movement desensitization and reprocessing (EMDR) and cognitive therapy for PTSD (CT for PTSD). However, researchers and clinicians continue to be concerned with rates of symptom improvement and patient dropout within these treatments. Recent attempts to address these issues have resulted in intensive, or "massed," treatments for PTSD. Due to variability among intensive treatments, including treatment delivery format, fidelity to the EST, and the population studied, we conducted a systematic review to summarize and integrate the literature on the impact of intensive treatments on PTSD symptoms. A review of four major databases, with no restrictions regarding publication date, yielded 11 studies that met all inclusion criteria. The individual study findings denoted a large impact of treatment on reduction of PTSD symptoms, ds = 1.15-2.93, and random-effects modeling revealed a large weighted mean effect of treatment, d = 1.57, 95% CI [1.24, 1.91]. Results from intensive treatments also noted high rates of treatment completion (i.e., 0%-13.6% dropout; 5.51% pooled dropout rate across studies). The findings suggest that intensive delivery of these treatments can be an effective alternative to standard delivery and contribute to improved treatment response and reduced treatment dropout.
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Affiliation(s)
| | | | - Ellen J Teng
- Michael E. DeBakey VA Medical Center, Houston, Texas, USA.,Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine, Houston, Texas, USA.,South Central Mental Illness Research, Education, and Clinical Center, Houston, Texas, USA
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