Feasibility of a 3-week intensive treatment program for service members and veterans with PTSD

Factor analysis of the neurobehavioral symptom inventory in veterans with PTSD and no history of mild TBI

It is well established that long-term postconcussive symptoms following a mild traumatic brain injury (mTBI) are associated with underlying physical, emotional, and behavioral conditions. The Neurobehavioral Symptom Inventory (NSI) is a measure used to assess neurobehavioral symptoms that can occur following a mTBI and has demonstrated a 3- or 4-factor structure in veterans. The present study aimed to investigate the factor structure of veterans with PTSD without a history of mTBI. A confirmatory factor analysis (CFA) was conducted on a sample of 221 treatment-seeking veterans and service members with PTSD and without a history of mTBI. Results supported a 4-factor structure comprised of vestibular, somatic, cognitive, and affective domains in veterans with PTSD. Subsequent, correlational analyses between the four NSI factors and the four subscales of the Posttraumatic Stress Disorder Checklist - Fifth Edition (PCL-5) revealed high correspondence between the cognitive and affective factors of the NSI and the negative alterations in mood and cognitions and hyperarousal symptom subscales of PTSD. Collectively, findings demonstrated that the NSI functions similarly in veterans with PTSD with or without a history of mTBI. Findings suggest that neurobehavioral symptoms assessed by the NSI appear to be nonspecific and not explicitly associated with mTBI.

Treating a common comorbidity: Pain outcomes following a 3-week cognitive processing therapy-based intensive treatment for posttraumatic stress disorder address

Posttraumatic stress disorder (PTSD) commonly co-occurs with pain and has been implicated in the maintenance of chronic pain. However, limited research has examined whether intervening for PTSD can hinder or optimize treatment outcomes for co-occurring pain and PTSD. In the present study, we examined changes in pain, PTSD, and depressive symptoms among 125 veterans completing a 3-week cognitive processing therapy (CPT)-based intensive treatment program (ITP) for PTSD. We also explored whether pretreatment pain interference predicted changes in PTSD and depressive symptom severity and whether larger changes in pain interference over the course of treatment were associated with larger changes in PTSD and depressive symptom severity. Linear mixed models revealed that participants' pain interference decreased throughout treatment, d = 0.15, p = .039. Higher levels of pretreatment pain interference were associated with higher PTSD, p = .001, and depressive symptom severity, p = .014, over time. Larger reductions in pain interference corresponded to more improvement in PTSD symptoms, β = -.03; p < .001, but not depressive symptoms. These findings indicate that ITPs for PTSD can reduce pain interferences, albeit to a small degree, and that reductions in pain interference can contribute to reductions in PTSD symptom severity. Future studies should examine which treatment components contribute to larger changes in symptom severity for veterans with co-occurring pain and PTSD.

A pilot study of trauma-sensitive yoga and Breathe2Relax among service members in an intensive outpatient program

Emerging research indicates that yoga is a promising adjunct to psychological trauma treatment. The current pilot study examined the associations between psychophysiological stress, diaphragmatic breathing (DB), and a trauma-sensitive yoga (TSY) regimen developed specifically for trauma-exposed service members in alignment with recent calls for precision in reporting therapeutic yoga protocols. Participants were 31 service members enrolled in a trauma-focused intensive outpatient program (IOP). Service members participated in a brief diaphragmatic breathing (DB) session using the Breathe2Relax (B2R) app followed by the TSY session. Heart rate (HR) and perceived stress were measured at baseline and after both the DB practice and the TSY session. We assessed Yoga and DB expectancies at baseline and post TSY. Participants also rated the acceptability and usability of the B2R app. Results of linear mixed effects regression models showed decreases in HR and perceived stress, compared to baseline, following DB (HR, b = -8.68, CI 95% = -13.34, -4.02; perceived stress, b = -1.77, CI 95% = -2.35, -1.18) and TSY (HR, b = -12.44, CI 95% = -17.15, -7.73; perceived stress b = -3.69, CI 95% = -4.29, -3.08). Higher levels of expectancies, compared to lower levels, related to stronger decreases in HR and perceived stress, particularly after TSY. Overall, participants rated the B2R usability as high; virtually all participants reported that "most would learn to use the app quickly," and 76.6% reported that they would use it frequently.

Moving toward precision PTSD treatment: predicting veterans' intensive PTSD treatment response using continuously updating machine learning models

BACKGROUND

Considerable heterogeneity exists in treatment response to first-line posttraumatic stress disorder (PTSD) treatments, such as Cognitive Processing Therapy (CPT). Relatively little is known about the timing of when during a course of care the treatment response becomes apparent. Novel machine learning methods, especially continuously updating prediction models, have the potential to address these gaps in our understanding of response and optimize PTSD treatment.

METHODS

Using data from a 3-week (n = 362) CPT-based intensive PTSD treatment program (ITP), we explored three methods for generating continuously updating prediction models to predict endpoint PTSD severity. These included Mixed Effects Bayesian Additive Regression Trees (MixedBART), Mixed Effects Random Forest (MERF) machine learning models, and Linear Mixed Effects models (LMM). Models used baseline and self-reported PTSD symptom severity data collected every other day during treatment. We then validated our findings by examining model performances in a separate, equally established, 2-week CPT-based ITP (n = 108).

RESULTS

Results across approaches were very similar and indicated modest prediction accuracy at baseline (R2 ~ 0.18), with increasing accuracy of predictions of final PTSD severity across program timepoints (e.g. mid-program R2 ~ 0.62). Similar findings were obtained when the models were applied to the 2-week ITP. Neither the MERF nor the MixedBART machine learning approach outperformed LMM prediction, though benefits of each may differ based on the application.

CONCLUSIONS

Utilizing continuously updating models in PTSD treatments may be beneficial for clinicians in determining whether an individual is responding, and when this determination can be made.

The role of time since trauma on treatment outcomes of veterans in two intensive posttraumatic stress disorder treatment programs

Research on the impact of time since trauma (TST) on posttraumatic stress disorder (PTSD) treatment outcomes lacks consensus and has not been examined in cognitive processing therapy (CPT)-based intensive PTSD treatment programs (ITPs). Furthermore, little is known about how TST impacts other trauma-related outcomes, such as depressive symptoms and negative posttrauma cognitions. We examined whether TST predicted severity and changes in PTSD and depressive symptoms and negative posttrauma cognitions, controlling for trauma type (combat or military sexual trauma), age, sex, and race, in two separate samples of veterans with PTSD who completed 2-week (n = 132) or 3-week (n = 407) CPT-based ITPs. In the 3-week sample, PTSD symptom reduction differed based on TST; however, these differences lacked clinical significance, TST x Time R² _b = .002, and were not replicated in the 2-week sample, R² _b < .001. TST did not significantly predict depressive symptoms, R² _b = .005, or negative posttrauma cognition severity or changes, R² _b = .002, in the 3-week sample. In the 2-week sample, linear mixed-effects models indicated that TST also did not significantly predict PTSD or depressive symptoms, R² _b s < .001, or negative posttrauma cognition severity or changes, R² _b s = .002. These findings suggest that TST is not a clinically relevant predictor of PTSD symptoms, depressive symptoms, or negative posttrauma cognitions among individuals engaged in CPT-based ITPs. Future research should investigate the association between TST and trauma-related outcomes in more trauma type- and age-diverse samples within different intensive treatment settings.

Building strong therapeutic relationships quickly: The effect of the perceived working alliance on veterans' intensive PTSD treatment outcomes

Intensive treatment programs (ITPs) are successful at reducing posttraumatic stress disorder (PTSD) and depression symptoms in veterans. However, the role of the working alliance in the context of ITPs is largely unexplored. The purpose of this study was to examine veteran-rated working alliance with their individual cognitive processing therapy (CPT) provider as a predictor of changes in PTSD and depression symptoms as well as negative posttrauma cognitions in two unique ITP formats. Data were collected from 128 veterans who completed a 2-week ITP, involving 2 × individual CPT/day, as well as 73 veterans who completed a 3-week ITP, involving 1 × group CPT/day and 1 × individual CPT/day. Both ITPs included adjunctive wellness, skills, and psychoeducation services in addition to CPT. Linear mixed-effects models were used to determine whether changes in working alliance predicted changes in PTSD and depression symptoms. Stronger veteran-reported working alliance with their individual CPT therapist, most notably agreement on tasks, predicted significant reductions in both the 2-week and 3-week programs in PTSD (ps = .012 and .002, respectively) and depression symptoms (ps = .009 and .007, respectively) and negative posttrauma cognitions (ps = .009 and .016, respectively). These results highlight the importance of veterans' perceived working alliance with their individual treatment therapists in ITPs. Results suggest that a strong working alliance that is meaningful for treatment outcomes can be developed quickly despite the brevity of this intensive treatment format. Future research should examine ways to facilitate the development of a strong working alliance prior to or as early as possible in ITPs. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Changes in guilt cognitions in intensive PTSD treatment among veterans who experienced military sexual trauma or combat trauma

Unresolved trauma-related guilt has been identified as a factor that can intensify posttraumatic stress disorder PTSD symptomology and is associated with many negative mental health outcomes. Evidence-based treatments, such as Cognitive Processing Therapy (CPT), have been shown to successfully reduce trauma-related guilt. However, less is known about how trauma-related guilt cognitions change over the course of PTSD treatment and, more specifically, intensive PTSD treatments. The current study examined whether guilt cognitions (i.e., hindsight bias/responsibility, insufficient justification, wrongdoing) changed over the course of a 3-week CPT-based intensive treatment program (ITP), whether guilt cognition changes predicted PTSD and depression symptom reductions over time, and whether guilt cognition changes and their association with PTSD and depression symptom changes differed based on whether they worked on combat trauma or military sexual trauma. Data were collected from 360 veterans enrolled in a 3-week ITP. Results from linear mixed effects models suggested that trauma-related guilt cognitions reduced significantly over the course of treatment (ps < .001), changes in wrongdoing (p = .032) and hindsight bias/responsibility (p = .003) were significant predictors of PTSD symptom reductions and hindsight bias/responsibility (p = .032) was the only significant predictor of depression symptom reduction. Overall differences in guilt cognitions over time based on cohort type were only significant for insufficient justification (p = .001). These findings suggest that changes in hindsight bias/responsibility demonstrated the largest effect size (d = 0.1.14), implying that hindsight bias/responsibility may be one of the most important guilt cognitions to target. This study also highlights the importance of the relationship between trauma-related guilt and PTSD and depression symptoms. Future research should examine whether changes in guilt cognitions precede changes in PTSD and depression symptoms, and if addressing certain types of guilt cognitions is more important to achieving PTSD and depression symptom reductions.

Abnormal intestinal milieu in posttraumatic stress disorder is not impacted by treatment that improves symptoms

Posttraumatic stress disorder (PTSD) is a psychiatric disorder, resulting from exposure to traumatic events. Current recommended first-line interventions for the treatment of PTSD include evidence-based psychotherapies, such as cognitive processing therapy (CPT). Psychotherapies are effective for reducing PTSD symptoms, but approximately two-thirds of veterans continue to meet diagnostic criteria for PTSD after treatment, suggesting there is an incomplete understanding of what factors sustain PTSD. The intestine can influence the brain and this study evaluated intestinal readouts in subjects with PTSD. Serum samples from controls without PTSD (n = 40) from the Duke INTRuST Program were compared with serum samples from veterans with PTSD (n = 40) recruited from the Road Home Program at Rush University Medical Center. Assessments included microbial metabolites, intestinal barrier, and intestinal epithelial cell function. In addition, intestinal readouts were assessed in subjects with PTSD before and after a 3-wk CPT-based intensive treatment program (ITP) to understand if treatment impacts the intestine. Compared with controls, veterans with PTSD had a proinflammatory intestinal environment including lower levels of microbiota-derived metabolites, such as acetic, lactic, and succinic acid, intestinal barrier dysfunction [lipopolysaccharide (LPS) and LPS-binding protein], an increase in HMGB1, and a concurrent increase in the number of intestinal epithelial cell-derived extracellular vesicles. The ITP improved PTSD symptoms but no changes in intestinal outcomes were noted. This study confirms the intestine is abnormal in subjects with PTSD and suggests that effective treatment of PTSD does not alter intestinal readouts. Targeting beneficial changes in the intestine may be an approach to enhance existing PTSD treatments.NEW & NOTEWORTHY This study confirms an abnormal intestinal environment is present in subjects with PTSD. This study adds to what is already known by examining the intestinal barrier and evaluating the relationship between intestinal readouts and PTSD symptoms and is the first to report the impact of PTSD treatment (which improves symptoms) on intestinal readouts. This study suggests that targeting the intestine as an adjunct approach could improve the treatment of PTSD.

Who will respond to intensive PTSD treatment? A machine learning approach to predicting response prior to starting treatment

Despite the established effectiveness of evidence-based PTSD treatments, not everyone responds the same. Specifically, some individuals respond early while others respond minimally throughout treatment. Our ability to predict these trajectories at baseline has been limited. Predicting which individuals will respond to a certain type of treatment can significantly reduce short- and long-term costs and increase the ability to preemptively match individuals with treatments to which they are most likely to respond. In the present study, we examined whether veterans' responses to a 3-week Cognitive Processing Therapy-based intensive PTSD treatment program could be accurately predicted prior to the first session. Using a sample of 432 veterans, and a wide range of demographic and clinical data collected during intake, we assessed six machine learning and statistical methods and their ability to predict fast and minimal responders prior to treatment initiation. For fast response classification, gradient boosted models (GBM) had the highest AUC-PR (0.466). For minimal response classification, elastic net (EN) had the highest mean CV AUC-PR (0.628). Using the best performing classifiers, we were able to predict both fast and minimal responders prior to starting treatment with relatively high AUC-ROC of 0.765 (GBM) and 0.826 (EN), respectively. These results may inform treatment modifications, although the accuracy may not be sufficient for clinicians to base inclusion/exclusion decisions entirely on the classifiers. Future research should evaluate whether these classifiers can be expanded to predict to which treatment type(s) an individual is most likely to respond based on various clinical, circumstantial, and biological features.

Impact of Treatment Setting and Format on Symptom Severity Following Cognitive Processing Therapy for Posttraumatic Stress Disorder

Preliminary data suggest cognitive processing therapy (CPT) significantly reduces posttraumatic stress disorder (PTSD) symptom severity among military personnel and veterans when delivered over 12 days and combined with daily recreational activities (Bryan et al., 2018). The present study aimed to examine how therapy pace (i.e., daily vs. weekly sessions) and setting (i.e., clinic vs. recreational) impacts change in PTSD symptom severity. Forty-five military personnel and veterans diagnosed with PTSD chose to receive CPT (a) daily at a recreational facility with recreational programming, (b) daily on a university campus without recreational programming, and (c) weekly on a university campus without recreational programming. PTSD symptom severity was assessed with the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) and the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5). Reductions in CAPS-5 and PCL-5 scores were large and statistically significant across all three settings (Cohen's ds > 2.1). As compared to reductions in CAPS-5 and PCL-5 scores in daily therapy at a recreational facility (CAPS-5: d = 1.63-2.40; PCL-5: d = 1.99-2.17), reductions in CAPS-5 and PCL-5 scores were significantly larger in daily therapy on campus, CAPS-5: t(80) = -2.9, p = .005, d = 2.23-2.69; PCL-5: t(78) = 2.6, p = .010, d = 2.54-4.43, but not weekly therapy on campus, CAPS-5: t(80) = 0.2, p = .883, d = 1.04-2.47; PCL-5: t(78) = 1.0, p = .310, d = 1.77-3.44. Participants receiving daily therapy on campus and weekly therapy on campus also had higher rates of clinically significant improvement and good end-state functioning. Results support the effectiveness of CPT across multiple treatment settings and formats and suggest that daily CPT may be less effective when delivered in combination with recreational activities.

Divergent experiences of U.S. veterans who did and did not complete trauma-focused therapies for PTSD: A national qualitative study of treatment dropout

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.

Associations between residual hyperarousal and insomnia symptoms in veterans following a 2-week intensive outpatient program for posttraumatic stress disorder

Many returning military service members and veterans who were deployed following the September 11, 2001, terrorist attacks (9/11) suffer from posttraumatic stress disorder (PTSD) and insomnia. Although intensive treatment programs for PTSD have shown promise in the treatment of PTSD symptoms, recent research has demonstrated that sleep disturbance shows little improvement following intensive trauma-focused treatment. The aim of the present study was to evaluate changes in self-reported insomnia symptoms among veterans and service members following participation in a 2-week intensive program for PTSD. We further aimed to investigate if residual PTSD symptoms, specifically hyperarousal, were associated with residual insomnia symptoms. Participants (N = 326) completed self-report assessments of insomnia, PTSD symptoms, and depressive symptoms at pre- and posttreatment. At pretreatment, 73.9% of participants (n = 241) met the criteria for moderate or severe insomnia, whereas at posttreatment 67.7% of participants (n = 203) met the criteria. Results of paired t tests demonstrated statistically significant differences between pre- and posttreatment Insomnia Severity Index scores; however, the effect size was small, d = 0.34. Analyses revealed that posttreatment hyperarousal symptoms were associated with posttreatment insomnia. These findings suggest that although an intensive program for service members and veterans with PTSD may significantly reduce insomnia symptoms, clinically meaningful residual insomnia symptoms remain. Further research is warranted to elucidate the association between residual hyperarousal and insomnia symptoms following intensive trauma-focused treatment.

Examining the Impact of Sexual Revictimization in a Sample of Veterans Undergoing Intensive PTSD Treatment

Sexual revictimization refers to exposure to more than one incident of rape and is a known risk factor for poor mental health among civilians. This construct has been understudied among veterans. In addition, although individuals who have experienced revictimization generally have greater symptom severity than those who have experienced one rape, it is unclear whether these differences persist following treatment. This study examined differences between veterans who reported histories of revictimization (n =111) or a single rape (n = 45), over the course of a 3-week intensive cognitive processing therapy (CPT)-based treatment program for veterans with posttraumatic stress disorder (PTSD). The sample consisted of predominately female (70.5%) post-9/11 veterans (82.7%). Self-reported PTSD and depression symptom severity were assessed regularly throughout the course of treatment. Controlling for non-interpersonal trauma exposure and whether veterans were seeking treatment for combat or military sexual trauma, sexual revictimization was generally associated with greater pretreatment distress and impairment. However, sexual revictimization did not impact rates of PTSD or depression symptom change over the course of intensive treatment, or overall improvement in these symptoms posttreatment. Our findings suggest that the rates of sexual revictimization are high among treatment-seeking veterans with PTSD. Although veteran survivors of sexual revictimization tend to enter treatment with higher levels of distress and impairment than their singly victimized peers, they are equally as likely to benefit from treatment.

Impact of intensive treatment programs for posttraumatic stress disorder on suicidal ideation in veterans and service members

Intensive treatment programs (ITPs) are treating veterans with posttraumatic stress disorder (PTSD) and suicidal ideation (SI). The reduction of SI is a target to the abatement of suicide risk. This study examined whether ITPs utilizing PTSD treatments reduce SI and whether SI reduction is associated with PTSD symptom improvement. Veterans (N = 684) enrolled in a 2-week Prolonged Exposure (PE)-ITP or a 3-week Cognitive Processing Therapy (CPT)-ITP. Study data were drawn from self-report measures [PTSD Checklist for DSM-5 (PCL-5); item 9 of the Patient Health Questionnaire-9 (PHQ-9)] administered at intake and throughout treatment. The ITPs produced large treatment effects for PTSD. SI scores also decreased over time. Lower PTSD symptom severity was associated with less severe SI in both the PE-ITP and CPT-ITP. In conclusion, both PE- and CPT-ITPs effectively treat PTSD and reduce SI among veterans in as little as 2 weeks of intensive PTSD treatment. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Delivering Intensive PTSD Treatment Virtually: The Development of a 2-Week Intensive Cognitive Processing Therapy-Based Program in Response to COVID-19

Of the many vulnerable groups affected by the spread of COVID-19, veterans have been especially impacted by the pandemic. Beginning in March 2020, nationwide shelter-in-place orders rapidly led to widespread job loss and economic upheaval; disruption and breakdown of multiple support systems; and increases in family stress, all of which may exacerbate underlying PTSD symptoms. Although telehealth has proven an effective means of delivering evidence-based psychotherapies for PTSD, little is known about the delivery of these treatments in an intensive, daily format over telehealth. There is growing need for intensive treatment options to reduce treatment-interfering barriers such as high dropout rates. In order to address this gap in the literature, this paper details several design considerations as well as patient selection procedures for a 2-week virtual intensive treatment program (vITP) for veterans with posttraumatic stress disorder (PTSD), consisting of daily individual Cognitive Processing Therapy (CPT) and other adjunctive interventions. We also describe two cases of veterans who successfully completed the vITP including their clinical outcomes, therapist reflections on the process, feedback regarding the program, as well as challenges patients encountered with the telehealth platform. Intensive evidence-based psychotherapy for PTSD delivered through a virtual format seems to show promise, but more systemic research is needed.

Treatment response trajectories in a three-week CPT-Based intensive treatment for veterans with PTSD

Response to weekly evidence-based PTSD treatments varies. Little is known about response trajectories and predictors in intensive PTSD treatments. This study sought to identify different trajectories of symptom change among veterans who completed a 3-week CPT-based intensive PTSD treatment program and examined potential predictors of trajectory group membership. Four hundred fifty-two veterans completed the program. Demographics, PTSD and depression severity, negative posttrauma cognitions, and alcohol use were assessed at intake and evaluated as possible predictors of group membership. Group based trajectory modeling was used to determine distinct groups based on PTSD symptom trajectory over the course of treatment, as well as predictors of group membership. Four distinct treatment trajectories were identified: Fast responders (15.3%), steady responders (32.0%), partial responders (38.4%), and minimal responders (14.4%). Fast and steady responders reported substantial symptom reductions and dropped below the "probable PTSD" threshold, with fast responders achieving improvements after just one week of treatment. Partial responders experienced clinically significant reductions but remained above the "probable PTSD" threshold. Minimal responders reported the highest baseline PTSD symptoms and changed the least throughout treatment. Negative posttrauma cognitions as well as self-reported and clinician-rated PTSD symptom severity assessed at intake successfully predicted trajectory membership. The identified trajectories closely resemble findings in the limited existing literature on intensive PTSD treatment trajectories. Results suggest that some individuals may improve with even shorter interventions and others might benefit from additional treatment sessions. Overall, findings support the importance of evaluating individual- and group-level treatment responses.

Impact of hazardous alcohol use on intensive PTSD treatment outcomes among veterans

Background: Intensive treatment programmes (ITPs) for posttraumatic stress disorder (PTSD) produce large symptom reductions and have generally higher completion rates compared to traditional weekly care. Although ITPs do not appear to increase substance use, it has yet to be determined whether their effectiveness differs for veterans with and without hazardous alcohol use (HAU). Objective: This study examined the effectiveness of a 3-week Cognitive Processing Therapy-based ITP for 538 veterans with PTSD (66.0% male; mean age = 41.22 years) and with (n = 193) or without HAU (n = 343) for reducing PTSD and depression symptoms. Method: Veterans' PTSD (PCL-5) and depression (PHQ-9) symptoms were assessed at pre-treatment, during treatment, and at post-treatment. HAU (AUDIT-C total score ≥4 for males; ≥3 for females) was measured at intake. Results: Treatment completion rates were high for both individuals who endorsed HAU (92.68%) and those who did not (93.37%), likely due to veterans being housed near the treatment facility. Mixed effects regression models revealed a significant time by alcohol use interaction when predicting both PCL-5 (p < .001) and PHQ-9 (p = .003), suggesting time-trends over the course of the ITP differed based on alcohol use. Veterans who endorsed HAU improved to a statistically significantly lesser extent. However, endpoint differences between groups for both outcomes were small (Cohen's ds between 0.15 and 0.20). Conclusions: Veterans with and without HAU reported significant reductions in PTSD and depression symptoms and completed the ITP at comparably high rates. Findings support the effectiveness of intensive PTSD treatment programmes for individuals with PTSD and HAU. Future studies should utilize controlled designs to evaluate whether intensive PTSD treatment can reduce HAU.

Disability Status Attenuates Treatment Effects in an Intensive Outpatient Program for PTSD

INTRODUCTION

The utilization of intensive outpatient programs for the treatment of military-related post-traumatic stress disorder (PTSD) has increased through initiatives both inside and outside the military health care system. However, research in veteran populations suggest that patients concurrently undergoing disability evaluation may not respond well to such interventions. This study evaluates the relationship between disability separation and endorsement of PTSD symptoms during treatment at an intensive outpatient program.

METHODS

Patients in this retrospective study were 81 service members enrolled in a half-day, 6-week intensive outpatient program for PTSD. Sixty-seven percent (n = 54) were concurrently enrolled in the integrated disability evaluation system and were pending medical separation. Fifty-two percent (n = 42) also received a 4-week skills training intervention before beginning PTSD treatment. Patients completed the PTSD Checklist before, during, and after the treatment program as an index of PTSD symptoms.

RESULTS

A significant interaction effect was observed in which PTSD symptoms throughout program enrollment differed as a function of enrollment in the integrated disability evaluation system. Patients undergoing disability evaluations did not show significant changes in endorsed PTSD symptoms during program enrollment, whereas significant decreases in PTSD symptoms were observed in patients not undergoing disability evaluations. These effects controlled for lost treatment days as a result of training or other appointments.

CONCLUSIONS

These results provide preliminary data indicating that participation in disability separation may attenuate the effect of PTSD treatment and endorsement of PTSD symptoms in an intensive outpatient setting.

Do morally injurious experiences and index events negatively impact intensive PTSD treatment outcomes among combat veterans?

Background: It has been suggested that current frontline posttraumatic stress disorder (PTSD) treatments are not effective for the treatment of moral injury and that individuals who have experienced morally injurious events may respond differently to treatment than those who have not. However, these claims have yet to be empirically tested. Objective: This study evaluated the rates of morally injurious event exposure and morally injurious index trauma and their impact on PTSD (PCL-5) and depression symptom (PHQ-9) reductions during intensive PTSD treatment. Method: Data from 161 USA military combat service members and veterans (91.3% male; mean age = 39.94 years) who participated in a 3-week Cognitive Processing Therapy (CPT)-based intensive PTSD treatment programme (ITP) was utilized. Morally injurious event exposure was established via the Moral Injury Event Scale (MIES). Index traumas were also coded by the treating clinician. Linear mixed effects regression analyses were conducted to examine if differences in average effects or trends over the course of treatment existed between veterans with morally injurious event exposure or index trauma and those without. Results: Rates of morally injurious event exposure in this treatment sample were high (59.0%-75.2%). Morally injurious event exposure and the type of index trauma did not predict changes in symptom outcomes from the ITP and veterans reported large reductions in PTSD (d = 1.35-1.96) and depression symptoms (d = 0.95-1.24) from pre- to post-treatment. Non-inferiority analyses also demonstrated equivalence across those with and without morally injurious event exposure and index events. There were no significant gender differences. Conclusions: The present study suggests that PTSD and depression in military veterans with morally injurious event exposure histories may be successfully treated via a 3-week CPT-based ITP.

Maintenance of treatment gains up to 12-months following a three-week cognitive processing therapy-based intensive PTSD treatment programme for veterans

BACKGROUND

Intensive treatment programmes (ITPs) have shown promise for reducing PTSD and depression symptoms. It is still unknown whether treatment gains are maintained following completion.

OBJECTIVE

This study examined whether veterans were able to maintain treatment gains for up to 12 months after an ITP for PTSD and whether reductions in negative posttrauma cognitions predicted treatment gain maintenance.

METHODS

209 veterans (62.7% male, mean age = 40.86 years) completed a 3-week, CPT-based ITP for PTSD. Participants' PTSD (PCL-5) and depression (PHQ-9) symptoms were assessed at pre-treatment, post-treatment, and at 3-, 6-, and 12-month follow-up timepoints.

RESULTS

Despite small symptom increases from post-treatment to 3-month follow-up, significant and clinically meaningful reductions in PTSD and depression symptoms were reported from intake to 12 months follow-up (averaging >18 points on the PCL-5 and >6 points on the PHQ-9; d = 1.28, and d = 1.18, respectively). Greater reductions in negative posttrauma cognitions during treatment were associated with lower PTSD (p <.001) and depression (p =.005) severity at follow-up. Most veterans who completed the aftercare survey followed treatment recommendations and reported seeing a mental health provider at 3-, 6-, and 12-months post-treatment. Aftercare treatment did not significantly predict whether veterans maintained treatment gains at follow-up.

CONCLUSIONS

Overall maintenance of treatment gains long-term suggests veterans may be able to apply skills acquired during the ITP following treatment. These findings further support the feasibility and effectiveness of intensive, trauma-focused, evidence-based therapy delivery.