Technology-enhanced in vivo exposures in Prolonged Exposure for PTSD: A pilot randomized controlled trial

In vivo exposures (IVEs) are a key component of exposure-based treatments, during which patients approach fear-provoking, yet safe, situations in "real life." This pilot study assessed the use of a wearable technology (Bio Ware) during IVEs to enhance Prolonged Exposure (PE) therapy for PTSD. Bio Ware provides a clinician dashboard with real-time physiological and subjective data for clinicians to use for virtually guided IVEs. Participants (N = 40) were randomized to a Guided group that received standard PE and virtual, clinician-guided IVEs with the Bio Ware device, or a Non-Guided group that received standard PE and used the Bio Ware device on their own for IVEs. Multilevel linear models with bootstrapping were completed on the intent-to-treat (ITT; N = 39) and per-protocol samples (PP; n = 23), defined as completing at least eight sessions of PE and using the Bio Ware system during ≥ 1 IVEs. In the PP sample, there were significant effects of treatment condition (b = -14.55, SE = 1.47, 95% CI [-17.58, -11.78], p < .001) and time (b = -1.98, SE = 0.25, 95% CI [-2.47, -1.48], p < .001). While both groups showed reductions in PTSD symptoms, the Guided group evidenced significantly greater reductions than the Non-Guided group. These findings demonstrate the feasibility and safety of leveraging Bio Ware for virtual, clinician-guided IVEs during PE therapy for PTSD and suggest that virtual, clinician-guided exposures may enhance treatment outcomes. CLINICAL TRIAL REGISTRATION: NCT04471207.

Delivered as Described: A Successful Case of Cognitive Processing Therapy With an Older Woman Veteran With PTSD

Cognitive processing therapy (CPT) is a first-line, evidence-based treatment for posttraumatic stress disorder (PTSD). Little is known, however, about the use of CPT for older adults. As the United States population continues to grow and age, an understanding of the utility of CPT for older adults is vital. We present a case study describing the assessment and cognitive treatment of a 74-year-old woman veteran with PTSD secondary to military sexual trauma. CPT was associated with decreased PTSD symptoms as measured before and after treatment. Factors contributing to the veteran's response, as well as contextual and environmental factors, are discussed. The case demonstrates that CPT may be effective for older adults without major modification.

Exposure therapy for PTSD in military populations: A systematic review and meta-analysis of randomized clinical trials

Military populations are disproportionally affected by posttraumatic stress disorder (PTSD) and may experience less benefit from first line psychotherapies for PTSD relative to civilians. We examined the efficacy of exposure therapy among Veterans and active duty military personnel across various control conditions and tested potential treatment-related, demographic, and clinical moderators. Randomized controlled trials of exposure-based therapies for PTSD in military populations were identified from a recent meta-analysis and through PsycINFO and Medline. Nineteen studies met inclusion criteria and were included in the meta-analysis (total N = 2905). Exposure therapy had medium to large effects compared to waitlist and treatment as usual, a small effect compared to non-trauma-focused therapy, and no effect relative to other trauma-focused therapy. The overall effect was similar at post-treatment and follow up. The effect size for exposure was larger in studies with younger participants, more women, fewer participants with comorbid major depression, and fewer participants taking psychiatric medication. Effect sizes were not impacted by treatment length or type, participant race or ethnicity, comorbid substance use, Veteran versus active duty status, or study risk of bias. Findings document the variable efficacy of exposure therapy in military populations across comparator types and point to several potentially important moderators of outcome that should be examined in future research.

Enhancing Prolonged Exposure therapy for PTSD using physiological biomarker-driven technology

Prolonged Exposure (PE) therapy is one of the most efficacious, evidence-based treatments for posttraumatic stress disorder (PTSD). A key component of PE involves in vivo exposures (IVEs) during which patients approach situations or activities in "real life" that are safe but avoided because they elicit a fear response. Despite their critical role in treatment, little research has focused on IVEs. This gap in knowledge is primarily due to the fact that IVEs are typically conducted by patients in between therapy sessions, leaving clinicians reliant upon patient self-report. This approach has numerous shortcomings, which the current study addresses by leveraging technology to develop an innovative device that allows for physiological, biomarker-driven, therapist-guided IVEs. The new system enables clinicians to virtually accompany patients during IVEs and provides real-time physiological (heart rate, skin conductance) and self-report (subjective units of distress) data that clinicians can use to modify the exposure and optimize therapeutic value. This Small Business Innovation Research (SBIR) Phase I project aims to: (1) integrate physiological sensors and live audio/visual streaming into a system for clinicians to guide patients during IVEs; (2) determine feasibility and acceptability of the system; and (3) conduct a pilot randomized clinical trial among veterans with PTSD (N = 40) to evaluate the preliminary efficacy of the system in reducing PTSD symptoms during PE. This paper describes the rationale, design, and methodology of the Phase I project. The findings from this study have the potential to innovate clinical practice, advance the science of exposure therapy, and improve clinical outcomes.

How do gender and military sexual trauma impact PTSD symptoms in cognitive processing therapy and prolonged exposure?

OBJECTIVE

Effectiveness of evidence-based psychotherapy (EBP) for PTSD can vary based on gender and trauma type, with poorer outcomes for men and sexual traumas. Among veterans receiving EBPs for PTSD, the effects of the interaction between gender and military sexual trauma (MST) on treatment outcome are unclear. This study examined how gender and MST impact PTSD symptoms following cognitive processing therapy (CPT) and prolonged exposure (PE).

METHOD

We conducted a national, retrospective cohort study of all post 9/11 veterans who had a PTSD diagnosis from 10/2001-9/2017 at VHA facilities and >1 psychotherapy visit. Inclusion criteria included completion of ≥8 CPT/PE sessions and pre- and post-treatment PCL (N = 9711). Mixed-effects linear regression models were conducted, separately by treatment, to examine associations between changes in PTSD symptoms and gender, MST, and their interactions with time.

RESULTS

For both treatments, there were no significant differences in pre-treatment PCL by gender or MST, and PCL decreased significantly over time. In adjusted models, only the gender by time interaction on pre-to-post-CPT change was significant (p < .001); the decrease in women's PCL was 2.67 points greater, compared to men.

CONCLUSIONS

Women veterans demonstrated greater reductions in PTSD symptoms from CPT. There were no differences by gender for PE, suggesting men and women veterans benefit similarly. Results suggest outcomes may be impacted by gender socialization when utilizing certain cognitive behavioral techniques. MST, regardless of gender, did not impact PTSD outcomes for either treatment. Both CPT and PE may thus be effective for veterans irrespective of MST history.

Gender Difference in Substance Use and Psychiatric Outcomes Among Dually Diagnosed Veterans Treated in Specialized Intensive PTSD Programs

OBJECTIVES

Posttraumatic stress disorder (PTSD) is a problem of growing importance among female veterans, which is especially challenging when accompanied by comorbid substance use disorder (SUD). Since women are still a small minority of Veterans Health Administration (VHA) patients, there is concern that outcomes among dually diagnosed women may be worse than among men.

METHOD

National program evaluation data were collected at admission and 4 months after discharge from 7,074 dually diagnosed veterans including 203 women (2.9%) treated at 57 specialized intensive VHA PTSD treatment programs between 1993 and 2011. Multiple regression was used to compare clinical change in women and men adjusting for baseline differences.

RESULTS

Women showed no significant differences from men in measures of substance use or total PTSD symptoms at admission although they were more likely to have experienced sexual trauma and less likely to report combat exposure. With adjustment for these differences, there were no significant gender differences in length of stay, satisfaction with treatment, or measures of change in substance use or total PTSD symptoms 4 months after discharge. Reductions in an index of days of substance use was associated with reduction in total PTSD symptoms among both women (R = 0.33; p = .01) and men (R = 0.44, p < .0001) with no significant gender difference.

CONCLUSION

No significant gender differences were observed in substance use or PTSD outcomes, despite the extreme minority status of women in VHA programs. Highly vulnerable women can benefit as much as men, even when treatment is not formally tailored to address gender-specific needs.

Oestradiol, threat conditioning and extinction, post-traumatic stress disorder, and prolonged exposure therapy: A common link

The accumulating evidence regarding the impact of estradiol on learning and memory synergized studies to examine its influence on enhancing animal's ability to quell fear and anxiety. In this review, we first provide a foundational platform regarding the impact of oestradiol on cellular mechanisms of learning and memory and we review recent advances from rodent and human data showing that oestrogen enhances extinction learning across species. We then propose clinical application to these data. We discuss the potential role of oestradiol variance on the aetiology, maintenance and treatment for post-traumatic stress disorder. Specifically, we argue that the use of oestradiol as an adjunct to prolonged exposure (PE) therapy for PTSD may provide a new treatment approach for enhancing the efficacy of PE in women with PTSD. This could advance our understanding of the mechanisms of PTSD and help tailor sex-specific treatments for this disorder.

Comparing Outcomes of Women-Only and Mixed-Gender Intensive Posttraumatic Stress Disorder Treatment for Female Veterans

Although most female veterans treated in specialized intensive Veterans Health Administration (VHA) posttraumatic stress disorder (PTSD) programs receive services in settings in which over 95% of participants are men, two programs include only women. Whether outcomes for women with PTSD are superior in women-only programs has not been evaluated. National program evaluation data on 1,357 women veterans from 57 sites were collected at program entry and 4 months after discharge. With adjustment for differences in baseline characteristics, outcomes of women in two women-only programs (n = 469) were compared with those from 55 mixed-gender programs (n = 888), using mixed models with random effect for site. The primary outcome was total PTSD symptom level, with supplementary information on PTSD assessment subscales, substance use, and other outcomes. At program entry, female veterans in women-only programs had lower scores on measures of total PTSD symptoms, p = .013, d = -0.24, and on several subscales. Adjusting for these differences, there were no significant differences between program types in terms of PTSD total score or scores on secondary measures. In women-only programs, veterans had longer lengths of stay and were rated by their clinicians to have a higher level of commitment to therapy at discharge. Thus, women-only programs did not show superior outcomes; however, compared to participants in mixed-gender programs, those in women-only programs had longer lengths of stay, higher levels of commitment to therapy, and were more likely to participate in posttreatment outcome assessments following discharge.

Factors associated with completing evidence-based psychotherapy for PTSD among veterans in a national healthcare system

Little is known about predictors of initiation and completion of evidence-based psychotherapy (EBP) for posttraumatic stress disorder (PTSD), with most data coming from small cohort studies and post-hoc analyses of clinical trials. We examined patient and treatment factors associated with initiation and completion of EBP for PTSD in a large longitudinal cohort. We conducted a national, retrospective cohort study of all Iraq and Afghanistan War veterans who had a post-deployment PTSD diagnosis from 10/01-9/15 at a Veterans Health Administration facility and had at least one coded post-deployment psychotherapy visit. We examined utilization of PE and CPT (individual or group) during any 24-week period. We used ordered logistic, logistic, and Cox proportional hazards regressions to examine variables associated with EBP initiation, early termination, and completion, and time to completion. Over a 15-year period, of 265,566 veterans with PTSD, 22.8% initiated an EBP, and only 9.1% completed treatment. Completers did so about three years after their initial mental health visit. Factors positively associated with EBP completion included military sexual trauma, older age, race/ethnicity (i.e., African-American race for PE), combat, and multiple deployments. The VHA has become timelier in delivering EBP for PTSD, and several subgroups are more likely to complete EBP.

You can do that?!: Feasibility of virtual reality exposure therapy in the treatment of PTSD due to military sexual trauma

This initial feasibility study examined the use of virtual reality exposure therapy (VRE) in the treatment of MST-related PTSD, with newly developed content tailored to MST. Participants included 15 veterans (26% male) with MST-related PTSD. Assessment of PTSD, depression, and psychophysiological indicators of distress occurred at pre-treatment, post-treatment, and 3-month follow-up. Treatment included 6-12 VRE sessions. There were significant reductions in pre- to post-treatment PTSD (CAPS severity: t(10) = 3.69, p = .004; PCL-5: t(10) = 3.79, p = .004) and depressive symptoms, (PHQ-9: t(8) = 2.83, p = .022), which were maintained at follow-up. There also was a significant pre- to post-treatment reduction in heart rate response to a trauma cue. Cohen's d effect sizes were large (CAPS: d = 1.11; PCL-5: d = 1.14, PHQ-9: d = .94), and the percentage of participants meeting PTSD criteria continued to decline from post-treatment (53%) to follow-up (33%). Findings indicate VRE can be safely delivered and is a promising treatment for MST-related PTSD.

Computer-Guided Problem-Solving Treatment for Depression, PTSD, and Insomnia Symptoms in Student Veterans: A Pilot Randomized Controlled Trial

Depression is a highly prevalent psychological disorder experienced disproportionately by college student military veterans with many deleterious effects including risk for suicide. Treatment can help, but the debilitating nature of depression often makes seeking in-person treatment difficult and many are deterred by stigma, inconvenience, concerns about privacy, or a preference to manage problems themselves. The current study examines the efficacy of a computer-guided Problem-Solving Treatment (ePST^®) for reducing symptoms of depression, posttraumatic stress disorder (PTSD), and insomnia in student military veterans. Twenty-four student veterans (Mean_age = 32.7) with symptoms of depression were randomly assigned either to a treatment group receiving six weekly sessions of ePST or to a minimal contact control group (MCC). Participants completed the Patient Health Questionnaire-9 (PHQ-9) depression scale at baseline and then weekly through post-ePST or post-MCC. PTSD and insomnia questionnaires were also completed at baseline and posttreatment. A linear mixed model regression showed a statistically significant Group (ePST vs. MCC) × Time (pretreatment through posttreatment) interaction for depression, with the ePST showing substantial improvements in depressive symptoms over the 6-week period. Significant improvements were also seen in PTSD and insomnia symptoms. Results suggest that ePST can effectively treat depression, PTSD, and insomnia symptoms in student military veterans and may be a viable alternative for those who are not able to access live therapy. Future work should examine the durability of treatment effects and utility for more severe depression and suicide prevention.

PTSD in Court II: Risk factors, endophenotypes, and biological underpinnings in PTSD

The second article in the series of three for the journal on "PTSD in Court" especially concerns the biological bases that have been found to be associated with PTSD (posttraumatic stress disorder). The cohering concepts in this section relate to risk factors; candidate genes; polygenetics; "gene×environment" interactions; epigenetics; endophenotypes; biomarkers; and connective networks both structurally and functionally (in terms of intrinsic connectivity networks, ICNs, including the DMN, SN, and CEN; that is, default mode, salience, and central executive networks, respectively). Risk factors related to PTSD include pre-event, event- and post-event ones. Some of the genes related to PTSD include: FKBP5, 5-HTTLPR, and COMT (which are, respectively, FK506-binding protein 5 gene, serotonin-transporter linked polymorphic region, catechol-O-methyl-transferase). These genetic findings give an estimate of 30% for the genetic influence on PTSD. The typical brain regions involved in PTSD include the amygdala, hippocampus, and prefrontal cortex, along with the insula. Causal models of behavior are multifactorial and biopsychosocial, and these types of models apply to PTSD, as well. The paper presents a multilevel systems model of psychopathology, including PTSD, which involves three levels - a top-down psychological construct one, a bottom-up symptom connection one, and a middle one involving symptom appraisal. Legally, causality refers to the event at issue needing to meet the bar of being materially contributory to the outcome. Finally, this section of the article reviews empirically-supported therapies for PTSD and the dangers of not receiving treatment for it.

A non-inferiority trial of Prolonged Exposure for posttraumatic stress disorder: In person versus home-based telehealth

This is the first randomized controlled trial to evaluate non-inferiority of Prolonged Exposure (PE) delivered via home-based telehealth (HBT) compared to standard in-person (IP) PE. One-hundred thirty two Veterans recruited from a Southeastern Veterans Affairs Medical Center and affiliated University who met criteria for posttraumatic stress disorder (PTSD) were randomized to receive PE via HBT or PE via IP. Results indicated that PE-HBT was non-inferior to PE-IP in terms of reducing PTSD scores at post-treatment, 3 and 6 month follow-up. However, non-inferiority hypotheses for depression were only supported at 6 month follow-up. HBT has great potential to reduce patient burden associated with receiving treatment in terms of travel time, travel cost, lost work, and stigma without sacrificing efficacy. These findings indicate that telehealth treatment delivered directly into patients' homes may dramatically increase the reach of this evidence-based therapy for PTSD without diminishing effectiveness.