Predictors of Consent to Treatment and Premature Termination of Treatment in a Sample of Veterans With Military-Related PTSD

Changes in comorbid depression following intensive trauma-focused treatment for PTSD and complex PTSD

BACKGROUND

The extent to which intensive trauma-focused treatment for individuals with post-traumatic stress disorder (PTSD) is also effective in treating comorbid major depressive disorder (MDD) remains unclear.

OBJECTIVE

The purpose of the present study was to test the hypothesis that brief intensive trauma-focused therapy for PTSD is associated with significant reductions in depressive symptoms and loss of diagnostic status of MDD.

METHODS

A total of 334 adult patients with PTSD (189 patients who were also diagnosed with MDD) underwent a brief intensive trauma-focused treatment programme consisting of EMDR therapy, prolonged exposure, physical activity, and psychoeducation. At pre-treatment, post-treatment and 6-month follow-up, severity and diagnostic status of PTSD and MDD were assessed. A linear mixed model was used to analyze changes in the severity of PTSD and depressive symptoms, whereas a generalized linear mixed model was used to determine changes in the MDD diagnostic status.

RESULTS

Treatment resulted in a significant and strong decrease of PTSD and MDD symptoms at post-treatment (d = 2.34 and 1.22, respectively), and at 6-month follow-up (d = 1.67 and 0.73, respectively). The proportion of patients fulfilling the diagnostic status of MDD changed from 57% at pre-treatment to 33% at the 6-month follow-up. Although the initial response to treatment did not differ between patients with and without comorbid MDD, for both groups a significant relapse in depressive symptoms was found after six months, which could be explained almost entirely by the presence of CPTSD at baseline.

CONCLUSIONS

The results support the notion that brief, intensive trauma-focused treatment is highly effective for individuals with PTSD and comorbid MDD. Because patients with CPTSD are vulnerable to relapse in depressive symptoms, this target group may require additional treatment.

Predictors of treatment completion in group psychotherapy for male veterans with posttraumatic stress disorder

Group therapy is a frequently used therapy format for posttraumatic stress disorder (PTSD). However, factors contributing to treatment completion remain understudied. The current study examined predictors of treatment completion, defined as having completed 10 out of 14 sessions within 16 weeks, in veterans with PTSD who engaged in a hybrid efficacy-effectiveness randomized controlled trial of group psychotherapy for PTSD. Veterans (N = 198) were randomly assigned to 14 sessions of either group cognitive behavioral treatment (GBCT; n = 98) or group present-centered treatment (GPCT; n = 100). Four primary domains of predictors were examined, encompassing sociodemographic factors, the severity of PTSD and comorbid conditions, modifiable predictors, and treatment condition. Multilevel binomial logistic regression models following the Fournier analysis approach were used to examine significant predictors within domains, which were then included in a final model. Overall, 70.7% of participants completed treatment (GCBT = 61.6%, GPCT = 79.8%). Participants in the GPCT condition were 2.389 times, 95% CI [1.394, 4.092], more likely to complete treatment than those in the GCBT condition. Older age, a higher income and level of educational attainment, more lifetime and current mental health diagnoses, and higher use of positive reappraisal ER skills predicted treatment completion. Higher levels of depressive symptoms, cumulative trauma burden, and use of positive refocusing ER skills predicted treatment noncompletion. These findings are discussed in the context of current clinical and research practices for examining treatment noncompletion, with attention to the inclusion of translational predictors.

Predictors of Attrition and Response in Cognitive Processing Therapy for Interpersonal Trauma Survivors with PTSD

With the establishment of empirically validated treatments for posttraumatic stress disorder (PTSD), concerns remain regarding the effectiveness of such treatments in real-world clinical settings. Specifically, premature termination and treatment response limit the effectiveness of these interventions. The current study investigated factors potentially related to premature termination and treatment response in Cognitive Processing Therapy with Account (CPT-A). Participants in this study included 42 women (Mage = 30.70 SDage = 9.40) with PTSD from exposure to interpersonal trauma. Demographic characteristics, pre-treatment symptoms of PTSD and depression, and transdiagnostic factors were examined as predictors of attrition and treatment response. Hierarchical regression and logistic regression models were analyzed to test the variance explained and predictive value of these factors. The present study revealed that age was a significant factor related to dropout from CPT-A whereas baseline PTSD symptom severity was significantly related to treatment response. Results of this study suggest the importance of the interrelationships among pre-treatment predictors as well as the consideration of attrition and treatment response as distinct metrics of treatment outcome. Further, these results inform the application of CPT-A for PTSD in survivors of interpersonal trauma, as consideration of the identified predictors of dropout and non-response at intake may contribute to treatment retention and response.

The Effect of Concurrent Depression on PTSD Outcomes in Trauma-Focused Psychotherapy: A Meta-Analysis of Randomized Controlled Trials

The co-occurrence of depression with posttraumatic stress disorder (PTSD) is common and associated with greater severity and impairment than PTSD alone, but the effects on PTSD treatment outcomes are unclear. This study investigated the impact of baseline depression on PTSD symptom change and dropout in a meta-analysis of 44 randomized controlled trials (N = 4,866) of trauma-focused psychotherapies for PTSD. Analyses included 107 active (k = 71) and control (k = 36) conditions. Baseline depression was indexed within samples as (a) continuous symptom severity (e.g., Beck Depression Inventory), standardized across depression measures and (b) proportion of patients with comorbid depressive disorder diagnosis. Among active conditions reporting continuous depression scores (k = 62), greater depression severity predicted smaller PTSD treatment effect sizes (ß = -.36, p = .002), but not dropout (ß = .25, p = .18). Categorical depressive diagnosis rates (k = 29)-reported less frequently-were not associated with treatment effects or dropout in active conditions. Greater depression severity may reflect a risk factor for attenuated response in PTSD psychotherapies, potentially demanding complementary strategies within trauma-focused interventions. Variability between trials in baseline depression symptoms may suggest the need to consider this sample characteristic when comparing treatment outcomes across studies.

Exploring Theta Burst Stimulation for Post-traumatic Stress Disorder in Australian Veterans—A Pilot Study

Introduction

Post-traumatic stress disorder (PTSD) is a severe and debilitating condition affecting a significant proportion of the veteran community. A substantial number of veterans with PTSD fail to benefit from trauma-focused psychological therapies or pharmacotherapy or are left with residual symptoms, and therefore, investigation of new and innovative treatment is required. Theta Burst Stimulation (TBS) is a novel form of Repetitive Transcranial Magnetic Stimulation, which has been shown to improve depression symptoms and associated cognitive deficits. The current pilot study aimed to explore the acceptability, safety, and tolerability of intermittent TBS (iTBS) as a treatment for PTSD in Australian veterans.

Materials and Methods

This study employed a case series, repeated-measures design. Eight Australian Defence Force veterans with PTSD received 20 bilateral iTBS treatments (1 session per day, 5 days per week over a 4-week period) and were assessed on a range of mental health and neuropsychological measures, including the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and Hamilton Depression Rating Scale (HAM-D), at pretreatment, post-treatment, and a 3-month follow-up.

Results

Treatment was generally welltolerated, with reported side-effects including mild to moderate site-specific cranial pain and headaches during stimulation, which were relieved with the use of low dose analgesics. No serious side effects or adverse events were reported. Participants exhibited reductions in both PTSD and depression symptom severity (the repeated-measures effect size [dRM] for the CAPS-5 was −1.78, and the HAM-D was −1.16 post-treatment), as well as improvements in working memory and processing speed. Although significance cannot be inferred, these preliminary estimates of effect size indicate change over time.

Conclusions

Bilateral iTBS appears to be welltolerated by Australian veterans. Within this repeated-measures case series, iTBS treatment shows promise in reducing both PTSD and mood symptoms, as well as improving cognitive difficulties associated with these disorders. Large-scale randomized controlled trials of this promising treatment are warranted.