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

State of the Science of Cognitive Processing Therapy

This state of the science review provides an overview of the history and findings of cognitive processing therapy (CPT), one of the most recommended treatments for posttraumatic stress disorder, acute stress disorder, and comorbid conditions. After an introduction to CPT and the randomized controlled trials that have been conducted, the effects of CPT on comorbid conditions are reviewed, as well as new combination treatments. Cognitive mediators of change are described. Different formats for CPT that have been developed are described, as well as patient, therapy, and therapist factors in outcome; applicability across diverse populations; efforts to disseminate CPT; and ongoing studies into the future.

Veterans' 12-month PTSD and depression outcomes following 2- and 3-week intensive cognitive processing therapy-based treatment

Background: Growing evidence indicates that daily delivery of evidence-based PTSD treatments (e.g. Cognitive Processing Therapy (CPT)), as part of intensive PTSD treatment programmes (ITPs), is feasible and effective. Research has demonstrated that a 2-week CPT-based ITP can produce equivalent outcomes to a 3-week ITP, suggesting shorter treatment can also be highly effective. However, the extent to which ITP length and composition impact longer-term outcomes needs further study.Objective: We examined whether PTSD and depression symptoms 3-, 6-, and 12-months following completion of a 2-week ITP could be considered non-inferior, or equivalent, to those of a 3-week ITP.Method: Data from 638 veterans who participated in a 2-week CPT-based ITP were evaluated against 496 veterans who participated in a 3-week CPT-based ITP. A Bayes factor approach was used to examine whether PTSD and depression severity outcomes of the 2-week ITP could be considered equivalent to the 3-week ITP.Results: Participants across both ITPs reported large PTSD (d = 0.98) and moderate to large depression symptom reductions (d = 0.69) from baseline to 12-month follow-up. The PTSD and depression symptom reductions seen in the 2-week ITP were determined to be equivalent to those of the 3-week ITP.Conclusions: Low follow-up completion was a limitation. Future research might replicate the present findings using samples with greater follow-up rates and explore whether adjunctive services impact other relevant constructs, such as quality of life and functioning.

Brain derived neurotrophic factor and treatment outcomes among veterans attending an intensive treatment program for posttraumatic stress disorder

Brain derived neurotrophic factor (BDNF) may play an important role in the success of treatment for posttraumatic stress disorder (PTSD). Pre- and post-treatment blood samples were analyzed for 40 veterans who completed a 3-week intensive outpatient treatment for PTSD. The treatment included Cognitive Processing Therapy, mindfulness, and yoga as core treatment components. PTSD symptoms were assessed at pre-treatment, post-treatment, and 3-month follow-up. Participants reported large decreases in PTSD symptoms from pre-to post-treatment (d = 1.46, p < 0.001) and pre-treatment to 3-month follow-up (d = 0.91, p < 0.001). Unexpectedly, participants demonstrated a decrease in BDNF from pre-to post-treatment (d = 0.64, p < 0.001). Changes in BDNF from pre-to post-treatment were not significantly associated with PTSD symptom improvement. However, higher levels of post-treatment BDNF were significantly associated with lower PTSD symptoms at 3-month follow-up (n = 27, r = -0.57, p = 0.002) and greater improvements in PTSD symptoms from pre-treatment to 3-month follow-up (n = 27, r = 0.50, p = 0.008). Higher levels of post-treatment BDNF may facilitate the long-term success of intensive PTSD treatment. Further research with larger samples is needed to evaluate the processes by which BDNF may affect consolidation of improvements after completion of PTSD treatment.

12-month follow-up of intensive outpatient treatment for PTSD combining prolonged exposure therapy, EMDR and physical activity

BACKGROUND

Preliminary evidence shows promising treatment outcomes at short-term follow-up for intensive posttraumatic stress disorder (PTSD) treatment, but long-term follow-up studies are sparse. This study is a sequel to a previous pilot study and open trial, set out to investigate treatment outcomes at 12-month follow-up for outpatients completing an 8-day intensive treatment for PTSD.

METHODS

All patients were diagnosed with PTSD and had multiple previous psychotherapy attempts (M = 3.1). Patients were assessed at pre-treatment, post-treatment, 3- and 12-month follow-up. Of 35 treated patients, 32 (91.4%) attended the long-term follow-up assessment. The treatment programme combined prolonged exposure therapy, eye movement desensitization and reprocessing, and physical activity.

RESULTS

The effect sizes indicated large reductions in symptoms of PTSD, depression, anxiety, interpersonal problems, and well-being. Changes in functioning showed a small-medium effect. Results were stable across the follow-up period. The treatment response rates showed that 46-60% of patients achieved recovery with respect to PTSD symptoms, and that 44-48% no longer met diagnostic criteria for PTSD.

CONCLUSIONS

Time-limited and concentrated outpatient treatment for PTSD can yield large and enduring positive outcomes. Controlled trials are needed to establish relative efficacy.

TRIAL REGISTRATION

The study was registered in Current Research Information System In Norway (Cristin). Cristin-project-ID: 654,790. Date of registration: 18.03.2019.

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.

Massed v. standard prolonged exposure therapy for PTSD in military personnel and veterans: 12-month follow-up of a non-inferiority randomised controlled trial

BACKGROUND

The utilisation of massed therapy for treating posttraumatic stress disorder (PTSD) is gaining strength, especially prolonged exposure. However, it is unknown whether massed prolonged exposure (MPE) is non-inferior to standard prolonged exposure (SPE) protocols in the long term. The current study aimed to assess whether MPE was non-inferior to SPE at 12 months post-treatment, and to ascertain changes in secondary measure outcomes.

METHODS

A multi-site non-inferiority randomised controlled trial (RCT) compared SPE with MPE in 12 clinics. The primary outcome was PTSD symptom severity (CAPS-5) at 12 months post-treatment commencement. Secondary outcome measures included symptoms of depression, anxiety, anger, disability, and quality of life at 12 weeks and 12 months post-treatment commencement. Outcome assessors were blinded to treatment allocation. The intention-to-treat sample included 138 Australian military members and veterans and data were analysed for 134 participants (SPE = 71, MPE = 63).

RESULTS

Reductions in PTSD severity were maintained at 12 months and MPE remained non-inferior to SPE. Both treatment groups experienced a reduction in depression, anxiety, anger, and improvements in quality of life at 12 weeks and 12 months post-treatment commencement. Treatment effects for self-reported disability in the SPE group at 12 weeks were not maintained, with neither group registering significant effects at 12 months.

CONCLUSIONS

The emergence of massed protocols for PTSD is an important advancement. The current study provides RCT evidence for the longevity of MPE treatment gains at 12 months post-treatment commencement and demonstrated non-inferiority to SPE. Promisingly, both treatments also significantly reduced the severity of comorbid symptoms commonly occurring alongside PTSD.

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.

Examining trauma cognition change trajectories among initial PTSD treatment non-optimal responders: a potential avenue to guide subsequent treatment selection

BACKGROUND

Despite their general effectiveness, 14-50% of individuals do not fully respond to evidence-based treatments for posttraumatic stress disorder (PTSD). Although changes in negative posttrauma cognitions (NPCs) are considered a likely PTSD treatment mechanism, less is known about how NPCs change among individuals who continue to be symptomatic following treatment (non-optimal responders).

OBJECTIVE

The objective of this study was to examine NPC change trajectories among individuals who were determined to be non-optimally responsive to intensive PTSD treatment.

METHOD

Using a 3-week Cognitive Processing Therapy-based intensive PTSD treatment sample (ITP; N = 243), the present study examined the number of distinct NPC change trajectories among non-optimal responders via Group Based Trajectory Modeling and assessed predictors of non-optimal responders' NPC change trajectory membership. Analyses were replicated in a separate 2-week ITP sample (N = 215).

RESULTS

In both non-optimal responder samples, two trajectories emerged; a no NPC change group which represented those with an overall lack of NPC change throughout treatment and an NPC change group which represented those with an overall reduction of NPCs occurring primarily later in treatment. Changes in PTSD symptom severity during treatment was the only consistent predictor of NPC change trajectory group membership among treatment non-optimal responders across ITPs.

CONCLUSIONS

Findings suggest NPC change among non-optimal responders is nuanced and may inform subsequent intervention selection, resulting in testable hypotheses for future research.

More is not always better: 2 weeks of intensive cognitive processing therapy-based treatment are noninferior to 3 weeks

OBJECTIVE

Although there is mounting evidence that massed treatment for PTSD is both feasible and effective, many questions remain about the optimal length of intensive treatment programs (ITPs), as well as the role of adjunctive services, such as psychoeducation, mindfulness, and yoga. Our setting recently transitioned from a three-week ITP to a two-week program. Adjunctive services were reduced, but the amount of individual CPT between programs remained similar. The present study examined the effectiveness of a two-week ITP based on twice daily individual CPT sessions and evaluated the program's noninferiority to an established three-week ITP using a Bayesian analytical approach.

METHOD

Bayesian linear mixed regression models were used to explore PTSD and depression changes over time, as well as predictors of change. Noninferiority of the two-week ITP to a three-week ITP was also established using a Bayes factor approach.

RESULTS

Results indicate that program participants change meaningfully in both PTSD and depression severity over the course of treatment, and that changes in posttraumatic cognitions predict subsequent changes in these outcomes. Further, the two-week ITP can be considered noninferior to the three-week ITP in both clinical outcomes and overall satisfaction.

CONCLUSIONS

In the context of intensive PTSD treatment, the content of the ITP appears to matter more than its overall length. Shorter programs have the potential to increase access and treatment capacity. Our findings demonstrate the importance of continuous and rigorous program evaluation. Limitations as well as future directions for research, such as identifying the most effective treatment components, are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Evaluating changes in negative posttrauma cognition as a mechanism of PTSD severity changes in two separate intensive treatment programs for veterans

BACKGROUND

A wealth of evidence has illustrated that reductions in negative posttrauma cognitions (NPCs) predict improvement in posttraumatic stress disorder (PTSD) symptoms during treatment. Yet, the specific temporal arrangement of changes in these constructs is less well understood. This study examined the temporal association between NPC changes and PTSD symptom changes in two distinct intensive PTSD treatment samples.

METHODS

Data from 502 veterans who completed a 3-week CPT-based intensive PTSD treatment program was used to test the extent to which lagged NPC measurement predicted the next occurring PTSD severity measurement using linear mixed effects regression models. PTSD severity was assessed every other day during treatment. NPCs were assessed at three treatment timepoints. A second sample of 229 veterans who completed a 2-week CPT-based intensive PTSD treatment program was used to replicate these findings.

RESULTS

Across both intensive PTSD treatment programs, NPCs generally increased from intake the end of the first treatment week, which was followed by gradual decreases in NPCs throughout the rest of both programs. Change in NPCs during both the 3-week (b = .21, p < .001, R2 = .38) and the 2-week programs (b = 0.20, p < .001, R2 = .24) were significant predictors of change in PTSD symptom severity. However, the reverse was true as well, with change in PTSD severity predicting latter change in NPCs during both the 3-week (b = 1.51, p < .001, R2 = .37) and 2-week (b = 1.37, p < .001, R2 = .33) programs, further raising questions about temporality of the association between NPCs and PTSD symptom severity during treatment.

CONCLUSIONS

The present study demonstrated that changes in NPCs may not temporally precede changes in PTSD symptom severity in PTSD treatment samples. Instead, we observed earlier PTSD symptom changes and a bidirectional association between the two constructs across both samples. Clinically, the study supports the continued focus on NPCs as an important treatment target as they are an important indicator of successful PTSD treatment, even if they may not be a direct mechanism of treatment-based changes in PTSD severity. Future research should attempt to identify alternative mechanisms of change in CPT.

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.

Long-term effectiveness of a prolonged exposure-based intensive outpatient program for veterans with posttraumatic stress disorder

Empirically-supported psychotherapies for posttraumatic stress disorder (PTSD) are highly effective and recommended as first-line treatments, yet dropout rates from standard outpatient therapy are high. Intensive outpatient programs (IOPs) that provide these therapies in condensed format with complementary interventions show promise, as they have demonstrated similar efficacy and higher retention rates. The current study examined initial and long-term outcomes up to 12-months following a 2-week PTSD IOP involving daily prolonged exposure therapy (PE) and adjunctive interventions for veterans and military service members. Participants (N = 376) demonstrated high retention (91%) and large effect size reductions in self-reported PTSD and depression symptoms after two weeks. Small increases in symptoms occurred after 3 months but these stabilized and large reductions compared to baseline were maintained up to 12 months. Piecewise multilevel modeling indicated that demographic variables did not predict PTSD or depression symptom trajectories. Higher PTSD and depression severity at intake predicted higher symptomatology across timepoints and larger relative gains during treatment. Greater alcohol use prior to treatment was associated with higher PTSD symptomatology but did not affect the magnitude of gains. A history of childhood sexual abuse was associated with greater reduction in depression symptoms over treatment, although this effect faded over follow-up. Together these findings underscore the long-term effectiveness of a PE-based IOP across a diverse range of veterans and service members.

Treating posttraumatic stress disorder at home in a single week using 1-week virtual massed cognitive processing therapy

Posttraumatic stress disorder (PTSD) treatments are increasingly delivered in massed formats and have shown comparable results to standard, weekly treatment. To date, massed cognitive processing therapy (CPT), delivered daily, has been delivered primarily in combination with adjunctive services and among veteran populations, but it has not been rigorously evaluated as a standalone intervention. The present study evaluated 1-week massed CPT delivered virtually (i.e., via telehealth) to a community sample of trauma-exposed individuals (N = 24). Using a single-arm open-label design, participants received CPT twice per day for 5 days. The results indicated that most participants completed treatment (n = 23, 95.8%), and no adverse events were reported. Participants exhibited large reductions in clinician-rated, d = 2.01, and self-reported PTSD symptoms, d = 2.55, as well as self-reported depressive symptoms, d = 1.46. On average, participants reported a 5-point PTSD symptom reduction and 1-point reduction in depressive symptoms for each treatment day. Reductions in PTSD and depressive symptoms were maintained at 3-month follow-up. Overall, 1-week massed CPT delivered virtually was shown to be feasible and to result in rapid symptom reductions that were sustained over time. Virtual massed CPT has the potential to increase access to effective treatments and help trauma survivors restore aspects of their lives in short amounts of time.

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.

Improving mental, physical, and social functioning through participation in a 3-week cognitive processing therapy-based intensive PTSD treatment

Research has supported the utility of brief intensive treatment programs (ITPs) which utilize interventions, such as Cognitive Processing Therapy (CPT), for reducing severity of symptoms among veterans with posttraumatic stress disorder (PTSD). These treatments have produced large overall reductions in PTSD severity and demonstrated the persistence of these gains following treatment. However, the potential effects of ITPs on mental, physical, and social functioning following treatment completion has been largely unexplored. We utilized data from 204 veterans and 5 service members who completed a 3-week CPT-based ITP and 3-month follow-up assessments. We used a two-stage mixed effects location-scale model approach to initially model each participant's amount of PTSD change over time and used these estimates to predict mental, physical, and social functioning three months following treatment. Veterans reported moderate improvements in mental, physical, and social functioning from pre-treatment to 3-month follow-up (ds = 0.52,.42,.55, and.47, respectively). Results indicated that reductions in PTSD severity during treatment, rather than fluctuation in symptom reporting from one assessment to the next, significantly predicted improved mental, physical, and social functioning at follow-up. This study supports the ability of ITPs to enact meaningful improvement in functioning among veterans with PTSD in a short timeframe.

The role of depression in the maintenance of gains after a prolonged exposure intensive outpatient program for posttraumatic stress disorder

BACKGROUND

Intensive outpatient programs (IOPs) for trauma-focused therapy, such as prolonged exposure (PE), have the potential to deliver highly effective treatment, quickly and with minimal dropout. Identifying factors that predict maintenance of gains after treatment can help triage individuals who may need additional services.

METHODS

Growth mixture modeling (GMM) was used to identify classes of posttraumatic stress disorder (PTSD) and depression symptom trajectories across the year following a 2-week IOP, delivering daily PE for PTSD for post-9/11 Veterans. Predictors of trajectories were examined.

RESULTS

Three classes of trajectories best-fit the data for PTSD and depression symptoms. Two classes made up the majority of the sample (85%) and both maintained significantly reduced PTSD symptoms across the year following therapy. For a minority of the sample (14.6%), PTSD symptoms rebounded after treatment. These individuals were highly likely to be categorized in the persistent depression class.

CONCLUSIONS

IOP-delivered PE is effective, and gains are largely maintained. The minority of patients who do not maintain their gains as robustly are likely to report persistent depressive symptoms in treatment and higher PTSD symptoms on a self-report measure.

“Putting Down and Letting Go”: An Exploration of a Community-Based Trauma-Oriented Retreat Program for Military Personnel, Veterans, and RCMP

(1) Background: Current military members, veterans, and Royal Canadian Mounted Police (RCMP) experience higher rates of posttraumatic stress disorder (PTSD) and moral injury (MI). Trauma-oriented retreats have been offered as a means of addressing these concerns. This article aims to explore the impact of a non-evidence-based trauma-oriented retreat for the above populations experiencing PTSD or MI; (2) Methods: This qualitative study, nested within the larger mixed-methods pre/post longitudinal follow-up study, examined the experiences of 124 military members, veterans, and RCMP who participated in the retreat. Data were collected from semi-structured interviews and first-hand observations of the organization. Analysis was conducted using thematic analysis while being informed by realist evaluation principles; (3) Results: The results showed that important contextual elements were related to participants being ready, having multiple comorbidities and using the program as a first or last resort. Effectual mechanisms included a home-like setting; immersion; credibility of facilitators; experiential learning; an holistic approach; letting go, and reconnecting to self. Outcomes included: re-finding self, symptom management, social connection, and hope for a meaningful life. The gendered analysis suggested less favorable results; (4) Conclusions: Care is warranted as the evidence-base and effectiveness of trauma-oriented retreats yet needs to be established prior to broad use.

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.

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.