Brief Cognitive Behavioral Treatment of Deployment-Related PTSD in Primary Care Settings: A Randomized Controlled Trial

Mar 18, 2015

Just as the nature of their jobs makes active-duty military personnel more likely to experience trauma and associated posttraumatic stress, it also can make them less likely to seek the help they need to cope with that stress and heal from its effects. Fearing a stigma associated with seeking mental health treatment, members of the military may face concerns that they will be viewed negatively by their peers or that their supervisors will consider them unfit for continued duty or for a desired promotion. They might also be unable to set aside the amount of time required for the treatment programs currently available through mental health clinics.

The two evidence-based therapies with the most empirical support for their efficacy in treating PTSD – Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) – were both developed for use in specialty mental health clinics, and both are typically delivered in weekly 90-minute individual sessions over a 10- to 12-week period. This model of care may not be feasible for an active-duty member of the military who is working long hours in a job that provides limited opportunity to commit extended time to medical appointments; it also might be a deterrent to someone who wishes to be discreet about seeking mental health treatment. Thus, time-intensive psychotherapy delivered in a traditional mental health setting might not reach a significant portion of military members in need of assistance.

Increasing accessibility to PTSD treatment

In an effort to overcome the barriers faced by military personnel who need mental health care for PTSD, Lt Col Jeffrey Cigrang, PhD, at Wright-Patterson Air Force Base, Ohio, has developed a novel study for STRONG STAR. This study is testing the feasibility, safety and efficacy of providing psychotherapy treatment within the primary care setting, which may prove to be a more favorable environment both in terms of acceptability and reach to military members for a variety of reasons.

For one, the military services have already developed and implemented post-deployment health surveys that screen for PTSD using the primary care clinic. Also, in recent years, behavioral health consultants (BHCs) have been integrated into primary care clinics both in military and civilian settings. These developments increase opportunities to identify PTSD early on and to intervene before symptoms or conditions become chronic. Dr. Cigrang believes that early interventions with less symptomatic patients may allow for evidence-based treatments for PTSD to be adapted to fit within the time constraints of primary care clinics and still obtain clinically significant effects. In addition, he believes this type of care will be better utilized by men and women in uniform, because anecdotal evidence indicates that military personnel feel less stigmatized when accessing mental health services in primary care.

For this study, Dr. Cigrang has developed and is evaluating a brief cognitive-behavioral therapy (CBT) protocol for treating PTSD that can be implemented by mental health providers working in an integrated primary care setting. The protocol includes intervention methods from both Prolonged Exposure and Cognitive Processing Therapy that have proven effective in the mental health setting, but these methods have been adapted for use in the time-constrained environment of primary care. For example, rather than being treated in 60- or 90-minute sessions, patients are scheduled for 30-minute appointments.

Pilot Study

The study investigators initiated a pilot study to examine feasibility of the experimental CBT protocol and initial effectiveness with OIF/OEF veterans. The pilot study measured within subject changes in a series of clinical cases which allowed the investigators to evaluate the general effectiveness of this treatment approach when used in clinical practice in military primary care settings.

Pilot study findings showed that the primary care treatment reduced symptoms of PTSD and depression, and overall mental health functioning improved. Cigrang et.al. 2011

Study aims

This investigation will be used to determine:

whether Operation Iraqi Freedom/Operation Enduring Freedom/Operation New Dawn veterans with PTSD will accept an offer of CBT treatment in the primary care setting;
if this type of brief CBT protocol will significantly reduce patients’ PTSD symptoms in comparison to a minimal contact condition, and if the degree of improvement compares favorably with that seen by patients who receive care in specialty mental health settings; and
whether there are characteristics of patients at pretreatment that predict how well they will respond to PTSD treatment in primary care.

Ultimately, the investigators hope to deliver another very effective means of fighting the battle against PTSD being waged by a significant portion of active-duty and veteran military personnel.

Brief Cognitive-Behavioral Intervention for Managing Suicidal Behaviors in Military Settings

Apr 21, 2011

Military service has traditionally been seen as a protective factor against suicide, with rates of suicides and suicide attempts historically lower among service members than the general population. However, repeated combat tours with Operation Iraqi Freedom and Operation Enduring Freedom seem to be taking their toll, and for the first time in known history, suicide risk among active-duty U.S. military personnel and veterans is now greater than comparable males in the general population.

The Defense Department wants to help its service members and reverse this startling trend. To do so, it has enlisted the help of an expert research team led by M. David Rudd, PhD, of the University of Memphis. A former Army psychologist, Dr. Rudd is one of the leading suicide researchers in the nation. Together with investigators from The University of Texas Health Science Center at San Antonio and STRONG STAR, he has developed a program based at Fort Carson, Colorado, to deliver the leading civilian treatment for suicide risk to an active-duty military population, to evaluate the treatment’s success, and to determine how best to tailor it to our men and women in uniform.

Dr. Rudd’s study is nearly a first of its kind. Research on the treatment of suicidality is sparse, particularly with military populations. In fact, the only published study of a randomized clinical trial targeting suicidality with a military sample was by Dr. Rudd in the 1990s.

Effective treatment

Civilian research does point to one form of psychotherapy, or talk therapy, as the clear leader, with the most scientific support that it effectively reduces suicide attempts. That therapy is called Cognitive Behavior Therapy (CBT), and it embodies several key elements that are known to enhance treatment success:

Its theoretical model is easily explained to patients (specifically, it teaches them about the relationship between thoughts, emotions, and behaviors).
A manual-driven treatment approach with fidelity checks ensures consistency among providers.
Providers using this therapy focus on treatment compliance, and they teach patients specific skills as well as how to assume personal responsibility.

Military questions

But military research with this therapy is still needed. Will it be as effective, and how might it need to be tailored to meet the needs of a unique population that faces death on a regular basis; that has a higher tolerance for pain and suffering; and that must have access to weapons to carry out its job?

These are questions being asked by Dr. Rudd and his colleagues in a research program funded by the DoD’s Military Operational Medicine Research Program. The project delivers a Brief Cognitive-Behavior Therapy (B-CBT) that includes all the empirically supported treatment components of CBT in a modified, 12-session program.

Study participants, who are referred by providers at Fort Carson clinical facilities (e.g., outpatient clinic, emergency room, or inpatient facility), are randomly assigned to receive either B-CBT or the existing outpatient treatment currently available at Fort Carson; study evaluations at various points over the course of 24 months are used to follow patients’ progress.

Expected outcomes

It is hoped that the study will reduce suicide attempts and self-harm behavior among military in the short term by offering an evidence-based therapy to at-risk individuals at Fort Carson, and in the long term by providing the DoD and VA with an effective treatment program that can be disseminated among their own providers.

In addition, Dr. Rudd and his colleagues will conduct a prospective investigation of suicide risk factors and warning signs, and they will develop a centralized software assessment/management tracking system for high-risk suicidal individuals. Outcomes of both efforts could prove to be highly valuable to all of the health professionals working to save the lives of psychologically wounded men and women who have served and continue to serve our country with great honor.

Outcomes of Prolonged Exposure and Cognitive Processing Therapy used in the Treatment of Combat Operational Stress Reactions in Deployed Settings

Aug 18, 2010

Posttraumatic stress disorder is one of the most frequent and significant mental health consequences of exposure to violence and trauma, making this potentially devastating disorder a growing concern for the U.S. military as more and more troops are deployed in the war on terror. In fact, three recent studies have found substantial PTSD symptoms in 5% to 24% of Army Soldiers and Marines who have returned from a deployment to Iraq or Afghanistan.

Considering the consequences borne by affected individuals and the military at large if symptoms become chronic, the best course of action is to intervene with mental health assistance as early as possible and stop the development of PTSD before it becomes debilitating. For active-duty military personnel, the earliest opportunity for that intervention is immediately after combat-trauma exposure in the deployed setting. That is why, for several decades, the overall military concept of operations for mental health treatment during combat deployments has been that brief treatment should be provided near the battlefield and as soon as possible to increase the likelihood that there is a good outcome and that service members can return to duty in the deployed setting.

Investigators explore uncharted territory

However, little data has been collected on the efficacy of any type of mental health treatment delivered in theater. The two most commonly used evidence-based treatments in Iraq are Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT), because these PTSD therapies have the largest empirical body of support. In fact, the Institute of Medicine reported in 2007 that exposure therapies such as PE and CPT are the only treatments with sufficient scientific evidence to support their efficacy in treating PTSD. Several studies of civilians with non-combat-related PTSD have indicated that a large portion of patients can be treated to the point of recovery, remission or the loss of diagnosis when PE and CPT are used as early interventions. But due to a lack of studies on these therapies when used with active-duty military personnel in a deployed setting, many questions remain regarding the impact of this unique environment upon treatment delivery and outcomes.

STRONG STAR hopes to find answers to these questions through a pilot study headed by STRONG STAR Consortium Director Lt Col Alan Peterson, PhD, ABPP, (USAF, Ret.) of The University of Texas Health Science Center at San Antonio. Dr. Peterson and his colleagues are following up on a recently completed small pilot investigation to evaluate PE for the treatment of three active-duty military members deployed to Iraq who had combat-related PTSD symptoms. The results of this case series were similar to those found in randomized clinical trials with civilians with non-combat-related PTSD. All three patients had significant reductions in PTSD symptoms and were able to remain in the deployed setting, fully qualified to perform their military duties.

Assessing treatment outcomes: Does in-theater treatment work as expected?

Dr. Peterson’s research team is now expanding the initial investigation by collecting and evaluating outcome measures of 40 deployed service members who show symptoms of combat operational stress reactions, including acute stress disorder and PTSD, and who voluntarily seek and receive treatment from providers at military mental health clinics in Iraq and Afghanistan. Providers will have previously been trained in either PE or CPT and will offer patients the form of treatment in which the provider specializes. Treatment will not be provided by STRONG STAR investigators, but as part of the military’s routine clinical care, with treatment sessions scheduled and conducted flexibly to allow for adaptations needed to meet the work demands of troops serving in a deployed location. Patients who meet study criteria will be offered the opportunity to participate voluntarily.

Following the completion of patients’ clinical care, STRONG STAR researchers will collect information on treatment outcomes and assess study participants’ reductions in symptoms at the end of therapy, as well as how treatment gains are maintained at 3- and 6-month follow-up periods. They hopefully expect to see a significant and lasting reduction in symptoms among study participants as they gather valuable pilot data for a future, more scientifically rigorous, randomized clinical trial. Their findings are expected to provide much-needed insight on the effectiveness of the leading non-pharmacological treatments as early-intervention approaches for the prevention and treatment of combat operational stress disorder, combat-related PTSD, and acute stress disorder.

Treatment of Chronic Stress Reaction and Chronic Pain after Traumatic Orthopedic Injury

Aug 18, 2010

Chronic pain after a traumatic orthopedic injury and posttraumatic stress disorder (PTSD) are each major concerns for the U.S. military in their own right. Both conditions have a direct impact on military readiness and are leading causes of medical discharges from active duty, as well as long-term VA disability, according to a 2006 report by the U.S. Department of Defense and the U.S. Department of Veterans Affairs. When these conditions become chronic, they can lead to a lifetime of pain and suffering for veterans and potentially contribute to an array of socioeconomic difficulties. In financial terms, the costs associated with the treatment of these conditions exceed hundreds of billions of dollars annually.

As different as these two conditions are, they are not necessarily separate problems that can be addressed in isolation from each other, because they frequently come together in one “unwanted package,” and each adversely affects the other. An increasing body of evidence from civilian studies suggests that individuals who experience physical trauma are likely to experience symptoms of significant psychosocial distress as well. In fact, one specific study published by A.J. Starr and colleagues in 2004 identified over half of a civilian sample of orthopedic trauma patients who met criteria for PTSD after their injury. To date, these studies have not been replicated in a military population, but it is suspected that the rates of comorbid orthopedic trauma and PTSD would be similar to those found in civilians, if not higher. The problem is not just that physical trauma can lead to the development of PTSD. Studies have also shown that PTSD affects patients’ reports of physical complaints, and PTSD is among the variables that are most predictive of functional outcome following injury.

Making matters worse, recent research by M.J. Bosse and colleagues suggests that individuals experiencing comorbid chronic pain and traumatic stress may respond poorly to treatment targeting only one diagnosis, contributing to the chronicity and severity of both PTSD and pain. On the positive side, data from other studies suggest that early interventions for orthopedic trauma pain and related traumatic stress can be effective in preventing chronic pain or PTSD syndromes.

The potential of cognitive therapy in treating both PTSD and pain: A STRONG STAR investigation

Robert Gatchel, PhD, of The University of Texas at Arlington hopes to build on these positive findings through a novel study he has designed for STRONG STAR to examine the effects of combining preventive pain and PTSD treatments for trauma patients. As part of their investigation, Dr. Gatchel and his co-investigators will identify the comorbidity of orthopedic trauma and traumatic stress in an active-duty military population, and they will evaluate a preventive behavioral health treatment strategy aimed at helping to retard or halt the development of PTSD and/or chronic pain syndromes. The study will examine the efficacy of multiple treatment options, utilizing a four-group randomized experimental design to measure the effects of cognitive behavioral therapies targeting pain treatment only, PTSD treatment only, and the treatment of both pain and PTSD compared to treatment as usual.

Evaluations of these four groups will be conducted at pretreatment, immediately at posttreatment, and at 6- and 12-month follow-up periods in order to determine differential outcomes on numerous variables. The investigators hypothesize that treating individuals with chronic pain and PTSD symptoms (e.g., lasting 12 weeks or more) through a proven psychosocial model will help to improve psychological, socioeconomic and physical symptoms of these chronic clinical syndromes. They further aim to demonstrate the efficacy of these early treatments in facilitating the return to active duty of military personnel living with pain and traumatic stress. Finally, they also expect to have a positive impact on other psychosocial and socioeconomic outcomes, such as work retention, additional health-care utilization, depression symptoms, health-related quality of life, and perceived disability.

The benefits of success

If Dr. Gatchel and his colleagues successfully demonstrate that integrating pain and PTSD treatments leads to improved outcomes for wounded warriors, the payoff will be substantial: affected military personnel could potentially enjoy a greatly improved quality of life; the U.S. Department of Defense could save billions of dollars in elevated treatment costs attributable to comorbid pain and PTSD; and thousands of civilian trauma patients could benefit from this improved treatment method.

Cognitive Processing Therapy for Combat-Related PTSD

Aug 18, 2010

Do therapists need to give up efficiency for efficacy when it comes to treating posttraumatic stress disorder, or can the two go hand in hand? That is a key question asked by Patricia Resick, PhD, of the National Center for PTSD in Boston in a randomized clinical trial she is leading for STRONG STAR.

Dr. Resick developed Cognitive Processing Therapy (CPT), one of the two treatments with the most empirical support for efficacy in treating PTSD. It has proven to be highly successful with civilian PTSD patients. Now, in an effort to find treatment-delivery methods that best meet the needs of military patients, she has developed a STRONG STAR study to evaluate the efficacy of CPT in individual versus group settings.

Group therapy for PTSD is currently being used in both military and VA settings. If effective, this is an efficient way to treat the disorder. But the question remains: Is group therapy for PTSD effective?

Group vs. individual therapy

In 2007, the Institute of Medicine’s (IOM) Committee on the Treatment of Posttraumatic Stress Disorder published a report stating that there is insufficient evidence to support or refute the efficacy of group therapy for the treatment of PTSD because of a lack of well-designed studies comparing group and individual treatment formats. However, in examining individual treatment for PTSD, the IOM committee did find sufficient evidence on the efficacy of exposure therapies such as CPT.

It is interesting to note that CPT – which includes psychoeducation, cognitive therapy, and exposure in the form of rereading written accounts of trauma – was first developed as a group treatment. However, in the large randomized clinical trial to compare CPT with Prolonged Exposure therapy, it was necessary to test CPT with an individual therapy format. Later trials with CPT followed suit and examined the therapy either as an individual treatment or as a treatment that combined individual and group therapy. In a recent clinical trial to dismantle the components of CPT (Resick et al., 2008), Dr. Resick and her colleagues found that a cognitive-only version of CPT, called CPT-C, was equally effective to the full version of CPT and perhaps more efficient. CPT-C does not include the portion of CPT in which patients record and reread their account of their traumatic experience.

Currently, CPT is being rolled out nationally in a large dissemination project by the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DoD) as one of the gold standard treatments for PTSD. In 2007, nearly 900 VA and DoD clinicians were trained in CPT. Given that CPT can be administered as either a group or individual treatment, it is important to determine whether the two are equivalent or whether one type of format is sufficiently superior to warrant recommendation either for or against group administration. This is the goal of STRONG STAR in the first-ever PTSD study to compare group versus individual therapy. Given that there are now multiple versions of group CPT being used in VA and military settings, Dr. Resick will use the CPT-C version of the therapy in this STRONG STAR clinical trial, which has several goals:

To compare the efficacy of CPT-C in a group versus an individual setting.
To compare group-administered CPT to another type of supportive group therapy.
To test the efficacy of CPT for the first time with active-duty military personnel.
To examine predictors of treatment outcome, such as gender, race/ethnicity, and comorbid conditions, along with the effect of multiple deployments and traumatic brain injury.

Potential impact

The significance of the study will be large no matter what the outcome because of the public health implications. If both individual and group CPT treatments are equivalent, then group treatment would be a much more efficient therapy modality in most cases. On the other hand, if there are large differences between the two modalities, the DoD and the VA may need to invest greater resources in individual therapy.

Prolonged Exposure for PTSD among OIF/OEF/OND Personnel: Massed vs. Spaced Trials

Aug 18, 2010

Posttraumatic stress disorder is an often chronic and debilitating condition that is associated with many comorbid medical and psychiatric disorders. So as our nation’s war on terror rages on and the prevalence of PTSD among our men and women in the military increases—epidemiological studies indicate that 10% to 20% of military personnel returning from Iraq and Afghanistan show symptoms of PTSD—so does the need for increasingly efficient ways of effectively treating the disorder.

There is currently a large body of knowledge on how to treat PTSD effectively and efficiently using cognitive behavioral therapy (CBT), particularly Prolonged Exposure (PE). In fact, PE is one of two treatments with the most empirical support for efficacy in treating PTSD in civilian trauma survivors.

Now the developer of PE therapy, Edna Foa, PhD, of the Center for the Treatment & Study of Anxiety at the University of Pennsylvania, is heading a STRONG STAR clinical trial with two key objectives:

evaluate the efficacy of Prolonged Exposure in treating combat-related PTSD in a military population; and
see if this evidence-based therapy can be delivered even more efficiently so as to better serve the needs of service members.

What is PE therapy, and how effective is it?

PE is designed to help PTSD patients emotionally process traumatic events by providing education about PTSD, repeated and prolonged imaginal exposure to trauma memories, and repeated in vivo confrontation with trauma-related situations the patient may be avoiding. In treatment centers around the world, the therapy has proven efficacious in reducing PTSD and related psychopathology with various types of trauma. In addition to greatly reducing PTSD symptom severity, studies have shown that PE also reduces depression and general anxiety, guilt, anger, and anxiety sensitivity, and that it improves social functioning. Importantly, results of follow-up assessments consistently indicate that most people maintain their treatment gains over time.

What questions is STRONG STAR trying to answer?

Treatment studies with civilians have repeatedly found that PE yields clinically meaningful improvement following 8 to 12 sessions administered once or twice weekly over the course of 5 to 12 weeks. Although this is an efficient treatment regimen that can work well for civilians, it may still seem too lengthy for an active-duty service member awaiting a new assignment or deployment.

Therefore, Dr. Foa has designed a study to evaluate the efficacy and feasibility of delivering PE to an active-duty military population, both in its traditional format and in a treatment regimen that has been condensed to accommodate the time constraints of military life. Specifically, she will compare

a standard PE outpatient treatment approach for PTSD consisting of 10 treatment sessions spaced over 8 weeks;
the same amount of treatment delivered in a massed format (PE-M) consisting of 10 sessions of daily treatment over a 2-week period;
treatment with another evidence-based form of psychotherapy, Present-Centered Therapy;
study participants who have minimal contact with a mental health provider until delayed entry into a treatment program.

This study will deliver one of the premier psychotherapies for PTSD to a military population and demonstrate its efficacy in treating combat-related PTSD. And if the regimen of massed treatment delivered in a 2-week period is shown to be as effective as the standard 8-week treatment approach, it will offer a valuable new treatment option for military personnel.

Individual PE vs. Couples’ Cognitive-Behavioral Therapy for Combat-Related PTSD

Aug 18, 2010

The military family plays a much more complex role in a soldier’s life than simply “keeping the home fires burning.” In fact, family members play a significant role in how service members adjust in the aftermath of their combat experiences. Studies of veterans from previous wars have found that the presence of adequate social support following combat is one of the strongest predictors of successful adjustment, and the absence of such support is associated with the persistence of posttraumatic stress disorder (PTSD). Families often represent the chief source of support, so developing programs to assist military families in adjusting to deployment and providing support to the returning combatant is vital.

Unfortunately, the individuals most in need of family support may be least able to obtain it. Symptoms of PTSD, such as emotional numbing, irritability, and anhedonia, or the inability to experience pleasure in normally pleasurable acts, can push loved ones away and cause relationships to deteriorate. Studies reveal that both veterans and their partners report significant marital and family problems associated with veterans’ PTSD symptoms, including lower relationship satisfaction, less cohesive relationships, less emotional expression and intimacy in their relationships, and more conflict in the relationships. Studies also have found elevated levels of anger, hostility, conflict, and violence in the families of veterans with PTSD.

The interdependence of individual and family adjustment can lead to a negatively spiraling process. As individual distress and PTSD symptoms worsen, family difficulties are likely to increase, and as family difficulties increase, so does stress upon the individual. But this process does not have to be only negative; it also can work in a positive direction. When families are able to provide a safe, stable environment for the returning service members, they can help to promote a more positive adjustment process, and when service members are able to reach out and reconnect with family members, it can strengthen the family structure.

Getting the family to help with treatment, and treatment to help the family

Several treatments have been proposed or developed to address the needs of families following trauma. Some focus on relieving family distress rather than focusing on a particular individual’s PTSD symptoms. Alternatively, other programs focus on the role of the partner and family members in helping the trauma survivor to recover from the symptoms arising from the trauma. These approaches are not mutually exclusive, and one recently developed program, Cognitive-Behavioral Couples Therapy (CBCT) for PTSD, includes techniques designed both to treat PTSD and to reduce relationship distress. This program has shown promising results in small, uncontrolled studies of combat veterans with chronic PTSD.

Now, under the direction of Candice Monson, PhD, of Canada’s Ryerson University, the STRONG STAR Consortium has designed a study to examine the efficacy of this treatment in a sample of active-duty military personnel who have recently returned from combat deployments. This randomized clinical trial compares traditional Prolonged Exposure therapy, which involves only the individual service member, to CBCT, which includes the service member’s partner. It also includes behavioral communication skills training in addition to psychoeducation and cognitive interventions based on Cognitive Processing Therapy. Because the CBCT protocol addresses both individual and couple-level distress, Dr. Monson expects to see greater improvement in couple functioning with this treatment as she explores the role that military spouses can play in PTSD treatment and recovery.