Clinical Effectiveness Trial of In-Home Cognitive Processing Therapy for Combat-Related PTSD

Apr 19, 2016

Will more military service members and veterans participate in effective treatment programs for posttraumatic stress disorder (PTSD)–and perhaps even receive a higher level of care–if that treatment is delivered in their own home? Is such a treatment format even feasible? Those are questions posed by Dr. Alan Peterson of The University of Texas Health Science Center at San Antonio and co-investigator Dr. Patricia Resick of Duke University Medical Center in a STRONG STAR-affiliated study on the effectiveness of in-home Cognitive Processing Therapy (CPT) for combat-related PTSD.

Study rationale and objectives

Even as evidence-based therapies for PTSD are becoming more readily available within the Departments of Defense (DoD) and Veterans Affairs (VA), a recent report by the RAND Corporation shows that the majority of military members and veterans are not receiving adequate care for the psychological wounds they received from tours in Iraq and Afghanistan. Reasons likely vary and are believed to include the following:

concerns about the stigma of seeking mental health care;
job and scheduling conflicts;
an inability to access traditional care in mental health clinics because of limited mobility and transportation issues, particularly among those who are seriously injured or living in rural areas.

This study will evaluate the feasibility and efficacy of a treatment delivery method that could help overcome these barriers to care, potentially making effective PTSD treatment more accessible to underserved military personnel and veterans. It will evaluate one of the leading treatments for PTSD, a form of counseling known as Cognitive Processing Therapy (CPT), when delivered in service members’ and veterans’ homes, either through in-person therapist visits or via video teleconference (similar to Skype), as compared to standard, face-to-face treatment in a therapist’s office.

Why in-home therapy might be better

Traditional CPT already has been shown to yield recovery rates as high as 80% with civilian PTSD patients, and to a lesser degree with veterans with combat-related PTSD. Researchers hypothesize that in-home delivery may further improve CPT’s efficacy in treating both PTSD and related problems, such as depression, alcohol dependence, and family strain. Reasons include the decreased likelihood of patients to miss appointments as well as therapists’ enhanced ability to see and address patients’ personal barriers to successful treatment.

Who will benefit if home-based CPT delivery is shown to be as or more effective than in-office care?

The VA and DoD: Both would have valuable new methods for delivering evidence-based treatment to currently underserved active duty and veteran populations.

Military and veteran PTSD patients: They could see improved access to high-quality care that could give them a greater chance at full recovery, enabling them to resume happy, productive lives in continued military service or as civilians.

Military and VA mental health providers: They would have an opportunity to tailor and enhance individual patient care to potentially improve treatment outcomes. Providers could capitalize on insights gained in the home to (1) help patients translate therapy lessons to daily life; (2) recognize and address environmental and lifestyle factors, as well as co-occurring social and mental health problems, that impede recovery from PTSD; and (3) better manage high-risk and suicidal patients by gaining a clearer sense of overall risk and a direct path to effective risk-management interventions.

Brief Treatment for PTSD: Enhancing Treatment Engagement and Retention

Feb 19, 2016

Although we have treatments for posttraumatic stress disorder (PTSD) that are known to be effective, too many military personnel avoid therapy or drop out prematurely, often citing a lack of time. Many also avoid talking about their trauma experience with others, yet this mental re-exposure to their trauma is a key component of effective treatments called “exposure therapies.”

One approach that could help many people overcome barriers to treatment is a form of narrative therapy called Written Exposure Therapy (WET). Patients in WET simply write about their trauma, gaining the benefit of exposure therapies. WET may be easier for patients to complete because it is short in duration, with no out-of-office homework assignments. Although some studies have found narrative therapy comparable to more standard therapies in reducing PTSD symptoms in civilians and veterans, it has not yet been studied with active duty military.

Comparing WET to a leading talk therapy

In this STRONG STAR-affiliated study, a team of investigators led by Denise Sloan, PhD, of the Department of Veterans Affairs’ National Center for PTSD and the Boston University School of Medicine, will measure the effectiveness of WET with active-duty service members in San Antonio and Killeen, Texas. The research team will examine whether WET is as effective at reducing PTSD symptoms as a gold-standard talk therapy for PTSD called Cognitive Processing Therapy, Cognitive-only version (CPT-C).

The study also will examine patient dropout rates. Researchers believe that WET, with its valuable exposure-based writing component, will be as effective as CPT-C in alleviating symptoms and helping patients recover from PTSD. They also believe that the shorter course of treatment and fewer time demands will lead to greater patient retention and overall treatment satisfaction. WET is delivered in five weekly sessions, with the first session lasting an hour and the remaining four lasting 40 minutes. CPT-C requires 12 one-hour sessions delivered twice weekly over six weeks.

Potential benefits

If proven effective, WET could provide an evidence-based form of PTSD treatment that is appealing and accessible to many service members who have avoided or discontinued other treatments. It requires a shorter treatment period and can be administered by peer counselors as well as psychotherapists, with less direct provider supervision required compared to more traditional therapies. These features of the treatment would help increase the number of patients who could be served in the busy military mental health care system as it strives to improve the emotional, mental, and physical health of thousands of service members suffering silently with PTSD.

In addition, the general public would benefit through improved force readiness and potentially reduced military costs of PTSD-related lost-work time and veteran disability benefits. Civilians with PTSD also may benefit from yet another effective treatment option.

Randomized Clinical Trial of Cognitive-Behavioral Therapy for Posttraumatic Headache

Dec 10, 2015

More than 100,000 military service members and veterans suffer from chronic headaches resulting from a traumatic brain injury (TBI) sustained during deployment. Although that population has seen a sharp increase in these posttraumatic headaches (PTHA), the condition is extraordinarily difficult to treat. There is very little evidence guiding its management.

Complicating things is the fact that those who have suffered a traumatic injury during deployment often have co-occurring symptoms of posttraumatic stress, which may worsen their headaches or make them more difficult to treat.

To better inform our understanding of how to help our suffering war veterans, principal investigator Donald McGeary of the University of Texas Health Science Center at San Antonio and co-principal investigator Donald Penzien of Wake Forest University have developed a study for the Consortium to Alleviate PTSD (CAP) addressing posttraumatic headache in war veterans with co-occurring symptoms of posttraumatic stress.

A key aim of the study will be to evaluate whether a leading psychological therapy for migraine headaches is effective with posttraumatic headaches. Investigators also seek to determine if treatment for PTHA likewise improves problems with PTSD, and whether treatment for PTSD simultaneously alleviates headaches.

To accomplish these aims, the study will have three arms, with participants placed randomly into one of three treatment conditions:

Treatment as usual, receiving standard care for PTHA through the South Texas Veterans Health Care System’s Polytrauma Rehabilitation Center in San Antonio;
A gold standard, manualized cognitive-behavioral intervention for headache; or
A gold-standard treatment for PTSD, called Cognitive Processing Therapy.

Expected benefit

Because posttraumatic headache is the most common and debilitating chronic symptom of deployment-related traumatic brain injury, this study, if successful, could lead to improved treatment for the more than 100,000 active military and veterans with chronic PTHA. That would mean relief for a variety of problems, including poor general health, missed work days, increased frequency of medical visits, and other physical and mental health symptoms. Cognitive behavioral therapy also costs considerably less to provide than other TBI treatments.

If the proposed study is successful and its hypotheses hold true, it will provide the first scientific evidence supporting the efficacy of any therapy—pharmacological or psychological—in directly treating posttraumatic headache. Consequently, it would offer clinicians and the service members and veterans they treat a safe, effective, medication-free intervention that specifically targets posttraumatic headache symptoms without risk of negative side effects. Cognitive-behavioral treatment could relieve wounded warriors’ suffering from a chronic and often debilitating condition in as little as 6 weeks, facilitating their rapid return to home and work activities and greatly enhancing their quality of life.

For the Defense Department, the dissemination of CBT for posttraumatic headache could potentially save millions of dollars in lost work time while ensuring its primary goals: the rapid care of affected service members and the continued strength of the military’s mission. The therapy’s relatively short duration and its lack of negative side effects enable its use in theater.

Using Emotion Regulation to Decrease Aggression in Veterans with PTSD

Nov 20, 2015

Aggression is common among veterans with posttraumatic stress disorder (PTSD), one of the signature wounds affecting those who deployed post-9/11. Aggressive behavior can lead to devastating interpersonal and societal consequences, such as family violence and incarceration, and it can disrupt social support and other factors that can enhance therapy. The fear of an inability to control emotions may also prevent many veterans from ever seeking treatment for PTSD.

Veterans with PTSD primarily engage in impulsive aggression, which is emotional, reactive, and uncontrolled. An inability to manage one’s emotions, known as emotion dysregulation, is an underlying cause of impulsive aggression.

In this pilot study for the Consortium to Alleviate PTSD, Shannon Miles, PhD, of the James A. Haley Veterans’ Hospital in Tampa, Florida, and her study team will work with post-9/11 combat veterans with PTSD and impulsive aggression. The veterans will be identified as having impulsive aggression if they report having engaged in at least three episodes of aggression within the past month. The investigators will provide training in emotion regulation via an innovative three-session training called Managing Emotions to Reduce Aggression, or MERA.

The goal of the pilot study is to test the feasibility of MERA in reducing impulsive aggression. A secondary goal is to prepare veterans for psychotherapy for PTSD. One reason that too few veterans seek PTSD treatment may be that they fear that they will not be able to control their emotional responses when they begin treatment. The investigators for this study believe that equipping veterans with emotion regulation skills and knowledge about PTSD treatments may help them initiate, complete, and benefit from evidence-based psychotherapies.

MERA is provided in a three-session, condensed time frame to make it accessible to veterans whose careers, school, and families compete with treatment time. The training is delivered in a group format and incorporates emotion education, cognitive-behavioral and acceptance-based skills training, and information about what emotional experiences to expect from PTSD treatments. Study participants will undergo weekly assessments for emotion regulation and aggression. Following the MERA training, study participants will be followed by CAP investigators to monitor whether they seek out, receive, and complete evidence-based psychotherapies for PTSD.

Success of the program and the feasibility of later conducting a large-scale, randomized clinical trial will be evaluated by veterans’ judgments of MERA and if reductions are seen in impulsive aggression and/or emotion dysregulation. Investigators will also monitor the number of veterans who initiate PTSD psychotherapy, attend at least two sessions, and remain in treatment until the therapist indicates that they have improved sufficiently.

The researchers predict that those who complete MERA will:

Have reductions in impulsive aggression and emotion dysregulation, and
Initiate, engage in, and complete evidence-based PTSD psychotherapies at a greater rate than those who do not complete MERA.

Expected benefits

If successful, this study will demonstrate that teaching emotion regulation skills to veterans with impulsive aggression may be a feasible method to reduce aggression. This would help the large number of veterans suffering from posttraumatic stress to maintain productive careers and healthy relationships. It also would benefit their families and society overall by reducing interpersonal violence, injury, and incarceration. The study may have the added benefit of equipping veterans to initiate PTSD treatment. Successful outcomes would support the feasibility of larger studies examining emotion regulation training in reducing aggression among veterans with PTSD.

Treatment of Comorbid Sleep Disorders and PTSD

Nov 10, 2015

Approximately 10% to 18% of post-9/11 service members and veterans have developed posttraumatic stress disorder (PTSD). The vast majority of these individuals – 68% to 93% – also suffer from insomnia and nightmares.

While sleep disturbances typically are seen as secondary symptoms of PTSD, research indicates that they likely are independent conditions that hinder recovery from PTSD and can make it worse.

One reason may be that insomnia and nightmares significantly disrupt both rapid eye movement (REM) sleep and slow wave sleep (SWS). REM and SWS are thought to be particularly important to the normal consolidation of memory and emotional experiences into long-term memory. That consolidation of memory and emotion is crucial for recovery from posttraumatic stress.

Unfortunately, therapists have no scientific data available on how best to treat individuals suffering from all three disorders. Cognitive behavioral therapies of PTSD, insomnia and nightmares are the first-line treatments for these conditions, but PTSD treatments do not typically address insomnia or nightmares, and insomnia and nightmare treatments do not typically address PTSD.

Daniel Taylor, PhD, of the University of North Texas leads a research team conducting a study for the Consortium to Alleviate PTSD that aims to improve treatment for people with co-occurring PTSD, insomnia, and nightmares. The study at the Carl R. Darnall Army Medical Center at Fort Hood, Texas, will include 222 active duty and recently discharged veterans suffering from a combination of PTSD, insomnia, and nightmares.

Study aims

The double-blind study involves two forms of cognitive-behavioral therapy in treating people suffering from PTSD and comorbid insomnia and nightmares, as well as variations in treatment delivery. From this, investigators aim to determine which variation of the treatment leads to the greatest improvements in both PTSD and related sleep problems.

As part of the study, investigators also seek to identify biomarkers — measurable factors, such as genes, sleep stages and levels of certain biological substances associated with inflammation in the body — to assess whether any biomarkers can help clinicians identify co-occurring PTSD and sleep disturbances, predict how well an individual will respond to treatment, and/or assess how well a therapy is working.

Expected benefits

If successful, the proposed study will significantly advance treatment strategies for co-occurring PTSD, insomnia, and nightmares. It also could identify biomarkers that will aid in diagnosis, prognosis and measurement of the efficacy of treatment. No study has targeted the treatment of insomnia/nightmares before or after evidence based treatment of PTSD as a way to improve long-term outcomes of PTSD therapy.

Variable-Length Cognitive Processing Therapy for Combat-Related PTSD

Aug 20, 2015

People are different. Traumatic experiences are different. So it’s understandable that different people with different life experiences and personality traits, and who live through a trauma unique to them, might respond differently to the same form of treatment for posttraumatic stress disorder, or PTSD.

In an age when doctors see more and more the benefits of individualized medicine, investigators affiliated with the STRONG STAR Consortium see the need to personalize PTSD care. Recent research supports that idea.

Civilian studies with Cognitive Processing Therapy (CPT), delivered in its standard format for 12 sessions, have shown that it is successful in treating 80% of PTSD patients to the point of remission. But one study showed that more than half (58%) of CPT patients did not need the full course of treatment; they recovered in fewer than 12 sessions. However, 27% still met diagnostic criteria for PTSD after 12 sessions but improved with additional treatment. Three months after treatment, only 2 of the 50 participants (4%) still had a PTSD diagnosis.

Now Dr. Patricia Resick of Duke University Medical Center, the developer of CPT and CPT-C, wants to see if similar results can be achieved with an active duty military population affected by combat-related PTSD. She and STRONG STAR colleagues Dr. Jennifer Wachen, PhD and Dr. Alan Peterson have designed a study with CPT-C that allows clinicians to adjust the length of treatment to meet individual patient needs, with a limit of 24 treatment sessions.

Study aims

By doing away with a “one-size-fits-all” approach to PTSD care and tailoring treatment to the individual, these researchers hope to achieve several goals:

Improve the overall efficacy of CPT-C for combat-related PTSD.
Identify predictors of who will benefit from shorter or longer courses of treatment, helping guide therapists in the treatment of future patients.
Evaluate the effect of variable-length CPT-C on co-occurring psychological problems (e.g., depression), health risk factors (e.g., substance abuse), and psychosocial functioning (e.g., return to work, family functioning).

Expected benefits for the military, mental health providers, and patients

Because this research is being conducted in a military setting, study findings should be directly applicable to military mental health providers. They will be better enabled to tailor CPT-C to meet the needs of individual patients, both by adjusting the length of treatment and more directly targeting individual factors that influence treatment outcomes.

For patients, the greatest expected benefit is an overall improvement in the quality of their care, and with that, a greater chance at defeating PTSD. The variable format may improve patient satisfaction with CPT and encourage them to complete treatment. Those who are able to shorten the required treatment time will be able to resume their daily responsibilities more quickly. On the other hand, those who respond to treatment more slowly will be able to extend their care and increase their chance of full recovery.

Comparing Internet and In-Person Brief Cognitive Behavioral Therapy of Insomnia

Jul 08, 2015

The Defense Department is seeking a better way to address the most common complaint of military personnel following deployment to a war zone: insomnia. Daniel Taylor, PhD, of the University of North Texas is working in collaboration with STRONG STAR to try to address it.

Current treatment options

Currently, medications are the most commonly used treatment for insomnia in military populations, and although they can be helpful in the short term, sleep medications also can create problems of their own. Potential side effects such as grogginess, slowed cognitive processing, and slowed reaction time can negatively impact service members’ job performance and even endanger their safety in the war zone, when they may need to awaken quickly or respond immediately to an ambush, mortar or rocket attack, or other emergency situation.

A promising alternative

Dr. Taylor wants to examine the efficacy and feasibility of delivering a form of talk therapy called Cognitive Behavior Therapy for Insomnia (CBTi) to a military population. CBTi is the most effective treatment for insomnia among civilians, with considerably better long-term outcomes than medication — and few if any side effects. New studies show that a more accessible form of this therapy, delivered over the Internet, is also effective with civilians.

Treatment effects may be different in the military, however. On one hand, there are extra treatment challenges, such as erratic military work schedules and the fact that war veterans may associate sleep with combat events, such as nighttime attacks. On the other hand, service members might actually do better with Internet-based treatment than civilians due to the military’s higher literacy rates and the fact that deployed service members have greater access to computers than to behavioral health providers.

The Department of Defense awarded a research grant to Dr. Taylor to investigate these promising therapies, and he has teamed up with the STRONG STAR Multidisciplinary PTSD Research Consortium to achieve his objectives. For his study, he will recruit post-deployment active-duty service members at Fort Hood with chronic insomnia. Participants will receive in-person or Internet-based CBTi during six sessions spread out over six weeks (some will receive treatment at a delayed start date as part of research control measures).

Expected outcomes

Dr. Taylor will evaluate participants’ progress and compare the benefits of these interventions on improvement in sleep as well as on commonly related conditions such as depression, substance abuse, and PTSD symptoms. Ultimately, he aims to provide the military with an evidence-based intervention for deployment-related insomnia with the potential to improve psychological and physical health, decrease accidents, and improve overall war-fighter fitness.

The Role of Exercise in the Treatment of PTSD Symptoms

Apr 13, 2015

Whether you’re reviewing the scientific literature, reading a health magazine, or simply watching the news, it’s hard not to hear something just about every day about the benefits of exercise, both on our physical and psychological health. Is it possible, then, that exercise could even make PTSD treatment more effective, particularly in a military population that places high value on physical fitness?

That is the question being explored by COL (Ret) Stacey Young-McCaughan, RN, PhD, of the University of Texas Health Science Center at San Antonio, who is leading a STRONG STAR-affiliated study on the role of exercise in the treatment of posttraumatic stress disorder.

The study combines components of one of the leading talk therapies for PTSD, called Prolonged Exposure (PE) therapy, with a supervised exercise program to see if participants do better with therapy alone, exercise alone, a combination of PE therapy and exercise, or self-care.

The treatment program

Prolonged Exposure has already been shown to be highly effective with civilians who have noncombat-related PTSD; the majority of those treated have recovered and not seen their symptoms return.

One component of PE is called “imaginal exposure,” in which individuals actively visualize images of their trauma with the assistance of their mental health care provider until the images no longer cause significant physical, behavioral, or emotional reactions. These imaginal exposure exercises are usually considered the most difficult part of the PE treatment program, because the individual has to “tough it out” and experience these significant reactions until they subside. The reactions are thought to be similar to the “fight-or-flight” alarm reactions that occur when adrenaline is released into the body when individuals are exposed to actual dangerous situations. However, in this case, it is actually a false alarm, because these reactions are triggered not by exposure to true danger, but exposure to the individual’s memory of the traumatic event.

The current study hypothesizes that allowing an individual to exercise during exposure to the traumatic memory will decrease the distress of the imaginal exposure procedure by allowing the individual to channel the fight-or-flight stress reaction into the physical exercise.

Research questions and expected outcomes

With a research grant from the Tri-Service Nursing Research Program and the collaboration of the STRONG STAR PTSD Research Consortium, Dr. Young-McCaughan designed a clinical trial to test this hypothesis. Participants who enroll will be randomly assigned to a course of treatment that includes exposure therapy only, aerobic exercise only, exposure therapy augmented with aerobic exercise, or self care.

Dr. Young-McCaughan and her team will then conduct an evaluation to answer the following questions:

Are PTSD symptoms reduced by imaginal exposure alone?
Are PTSD symptoms reduced by exercise alone?
Are PTSD symptoms reduced by a combination of imaginal exposure and exercise?
Does the combination of exercise and imaginal exposure produce a better outcome than either treatment alone?

It is hoped that study outcomes can be used in the development of an effective, evidence-based nursing intervention in which military personnel with PTSD symptoms can engage as part of their routine health promotion activities.

A Study of Dog Adoption in Veterans with Posttraumatic Stress Disorder

Apr 13, 2015

Could man’s best friend help war Veterans who are living with PTSD? This is a question being investigated by Stephen L. Stern, MD, of the South Texas Veterans Health Care System in collaboration with co-investigator and STRONG STAR Consortium Director Alan L. Peterson, PhD, of The University of Texas Health Science Center at San Antonio.

Numerous research studies have shown that social support is key both to PTSD prevention and recovery. Now, with funding support from the Department of Veterans Affairs Office of Research and Development, Rehabilitation, and the close collaboration of the San Antonio Humane Society, Dr. Stern and colleagues are looking at the value of social support from “man’s best friend.” Specifically, Dr. Stern’s team has developed a randomized clinical trial to examine how a dog’s companionship might help reduce psychological distress and improve overall quality of life for Veterans with PTSD.

Prompted by many personal stories from Veterans about how much they had been helped by having a dog, Dr. Stern and his colleagues — supported by the Disabled American Veterans (DAV) Charitable Service Trust — previously recruited Veterans with PTSD to participate in a pilot study of shelter dog adoption from the San Antonio Humane Society.

The positive results from their pilot study led Dr. Stern and his colleagues to undertake the present, larger study. It will look in more detail at the benefits of dog adoption and what might be the mechanisms at work. For example, in addition to the companionship that a sociable pet like a dog provides, having a dog could encourage Veterans to get outside and exercise with their dog through interactive play or a walk. This may additionally lead to more social interaction with people. The satisfaction of giving a happy home to a homeless animal might also contribute to the benefits of dog adoption.

How the study works

After an evaluation with study staff, participants will be randomly assigned either to adopt a dog right away or to go onto a waiting list for three months and then adopt their pet. With the assistance of the San Antonio Humane Society veterinarian and adoption counselors, participants will be able to choose their new life-long companion from the many animals available at the shelter. The adoption fee will be waived, and free training classes and veterinary care for the duration of the study will be provided. Veterans will be responsible for the other costs of caring for their pet. Study investigators will follow study participants closely over the course of six months to evaluate potential benefits related to PTSD, depression, and health-related quality of life.

Potential impact

If the results of this study are positive, investigators hope it will lead to shelter dog adoptions becoming a widely available option for enhancing the care of Veterans with PTSD and helping to heal the psychological wounds of war.

SSRI Treatment of Dual Diagnosis PTSD and Alcohol Dependence: A Test of the Serotonergic Hypothesis

Apr 06, 2015

Both PTSD and alcohol dependence are devastating disorders capable of destroying lives and disabling veterans and their families. Unfortunately, many veterans battle both problems at the same time. PTSD can spur the development of alcohol dependence, while heavy alcohol drinking can contribute to the development or worsening of PTSD symptoms. And when the two conditions come together, each is more difficult to overcome. Veterans who are diagnosed with both PTSD and alcohol use disorder have a worse prognosis than individuals just having a single diagnosis, highlighting the need to better understand the impact of one condition upon the other and to address both when designing treatment plans.

Regrettably, combined treatments are complicated and generally unavailable, but the STRONG STAR Consortium is examining how alcohol use disorder impacts the effectiveness of the only FDA-approved medication for the long-term treatment of PTSD: selective serotonin reuptake inhibitors (SSRIs). Under the direction of John Roache, PhD, of The University of Texas Health Science Center at San Antonio, the study’s ultimate goal is to identify baseline predictors of response to SSRI treatment, providing clinicians with a valuable tool to assess individuals who would benefit from such therapy and those who would be neutrally or even negatively affected by it. This would allow treating physicians to tailor patient therapy accordingly, without risking unnecessary or ineffective medication.

According to the VA/DoD Clinical Practice Guidelines for the Management Interventions Module Summary of Post Traumatic Stress published in 2007, SSRIs are the first-line medication treatment for PTSD and are a strongly recommended standard of care. However, a 2007 report by the Institute of Medicine concluded that the evidence for SSRI effectiveness is not certain. Given these mixed messages and uncertain evidence of benefit, it is important to know exactly for whom SSRI medication may be beneficial and for whom these medications are ineffective or cause unanticipated risk.

An explanation for the confusion over of the benefits of drug therapy

The central hypothesis of Dr. Roache’s STRONG STAR study suggests a possible explanation for the limited effectiveness of SSRIs: There are subgroups of patients who respond differently to SSRIs, such that some show benefits and others show either no effect or actual adverse responses. Furthermore, those subgroups relate to subtypes of alcoholism.

Research already has demonstrated that SSRIs show reduced effectiveness in the presence of co-occurring alcohol use disorder. There also is good evidence that individuals with different subtypes of alcohol use disorder respond differently to SSRI treatment, such that individuals with Type B or early onset alcoholism do worse on SSRI treatment than with placebo, while those with Type A or late onset alcoholism may benefit from SSRI treatment. A few key dimensions seem to predict Type B membership:

onset of problem drinking at an early age;
a family history of alcoholism (FH+); and
co-occurring anxiety or depression.

Experiment

Dr. Roache and his research team have devised an experiment to reveal the impact of alcohol use disorder on the effectiveness of SSRI treatment in patients with PTSD. The experiment aims to provide treatment for veterans who experienced traumatic events during military service and who have been dually diagnosed with PTSD and alcohol use disorder. Treatment involves randomized assignment to receive sertraline or placebo and while patients receive manualized Cognitive Behavioral-based Therapy (CBT) for both PTSD and alcohol use disorder. Working with these patients, Dr. Roache seeks to determine whether multidimensional baseline measures are useful in classifying individuals with the comorbidities of PTSD and alcohol use disorder according to Type A and Type B subtypes of alcoholism. From here, he will examine whether the efficacy of the SSRI sertraline differs between subjects who fall under the Type A or Type B subtype classification.

Potential benefit for doctors and patients

Eventually, Dr. Roache and his STRONG STAR colleagues aim to provide clinicians with a set of baseline predictors of SSRI treatment response that can be used to design the best course of treatment for PTSD patients. With the necessary tools for classifying patients by appropriate subtypes, clinicians could offer SSRI treatment to those for whom it would be beneficial and forgo the drug therapy with individuals for whom it would be ineffective or contra-therapeutic.