Decreasing Suicide Risk among Service Members with Posttraumatic Stress Using Written Exposure Therapy


Mar 01, 2022

Military service members and veterans have high rates of posttraumatic stress disorder (PTSD) and suicidal behavior. And PTSD more than doubles the likelihood that they will attempt suicide, researchers have reported.
Although evidence-based treatments for PTSD have been shown to reduce suicidal thinking, it is challenging to provide these therapies to high-risk patients hospitalized for acute care in military facilities. That is because the treatments require more time and resources than are typically afforded during inpatient stays.

Evaluating a therapy delivered in five sessions

A new STRONG STAR-affiliated study will test a therapy that the study team believes will reduce severity of posttraumatic stress symptoms and decrease suicide risk with only five sessions. They will evaluate an intervention called Written Exposure Therapy for Suicide (WET-S), which involves the patient writing about the same trauma experience during multiple sessions.

Brian P. Marx, PhD, deputy director of the Behavioral Science Division of the National Center for PTSD at the VA Boston Healthcare System, will lead the study at the Carl R. Darnall Army Medical Center at Fort Hood, Texas. His research team will work with consenting patients who are hospitalized for suicidal thoughts, suicide plan, or suicide attempt, who also have PTSD or symptoms of posttraumatic stress. A total of 124 patients will be randomly assigned either to “treatment as usual (TAU)” or WET-S plus TAU.

TAU consists of daily contact and patient-centered care by an acute psychiatric inpatient unit provider team that includes psychiatrists, therapists, case managers, and behavioral health technicians. TAU also involves initial psychiatric stabilization, nurse case management, medication management, psychoeducation groups, and discharge planning.

Writing about the “index trauma”

WET-S consists of five private treatment sessions, each lasting approximately one hour. During the first session, the therapist educates the patient about common reactions to trauma and the rationale for
WET-S as a treatment for PTSD. Then the patient receives instructions for completing the written trauma narratives and completes the first narrative writing session. For each of the five sessions, the patient writes about the “index trauma” – the traumatic event that is deemed to be the worst by the patient and an independent assessor. Patients will receive at least one session per day.

Benefits of the therapy and future impact

Previous research found Written Exposure Therapy (WET) for PTSD to be comparable to other evidence-based treatments, with data also indicating that it helped to reduce suicidal thinking. WET-S is a reformulation of WET that adds a suicide prevention strategy called Crisis Response Planning (CRS). WET-S addresses trauma-related symptoms that are both targets for PTSD treatment and warning signs for suicidal thoughts and behaviors.
The therapy is brief and easy to administer. It also requires fewer resources and less training for the mental health provider than treatments currently used with at-risk patients in military settings. If found to be effective, WET-S could be scaled up and disseminated easily across the Department of Defense to reduce suicidal behavior among service members and veterans.

Multi-Couple Group Intervention for PTSD


Feb 10, 2022

Posttraumatic stress disorder (PTSD) is a life-disrupting, frequently chronic condition that can cause devastating relationship problems. Intimate relationship difficulties can also interfere with recovery from PTSD. Numerous studies have documented an association between PTSD symptoms and impaired intimate relationship functioning in military and veteran couples, including relationship distress, physical and psychological aggression, and partner psychological distress.

Previous research has demonstrated that cognitive-behavioral conjoint therapy for PTSD (CBCT for PTSD), a couple-based therapy designed specifically for PTSD, is efficacious in simultaneously treating PTSD and co-occurring symptoms and improving intimate relationship functioning. However, the standard format of fifteen 75-minute sessions over 15 weeks presents challenges for large-scale dissemination of the treatment for active duty service members and veterans.

In this pilot study conducted through the Consortium to Alleviate PTSD, principal investigator Steffany J. Fredman, PhD, of the Pennsylvania State University and her research team will deliver a version of CBCT for PTSD in which session content is taught in an accelerated, multi-couple group format over a weekend.

Participants in the pilot study will be recruited at and around the U.S. Army’s Fort Hood in Killeen, Texas, and must include an active-duty service member or veteran diagnosed with PTSD and in a committed, partnered relationship. Both members of the couple must be available to participate in intensive treatment delivered over one weekend.

How the study works

Twenty-four couples will attend 12-hour, retreat-style workshops over the course of a weekend at a hotel about an hour away from Fort Hood in Austin, Texas. There will be seven weekend retreats, and six couples will be treated at each retreat.

Therapists with extensive experience working with active duty service members and veterans with PTSD in the context of the STRONG STAR Consortium will lead the workshops. They will provide couples with an understanding of how PTSD and intimate relationships affect one another and guide the couples in ways to think, feel, and behave differently in order to improve the service member’s or veteran’s PTSD symptoms, the couples’ relationship health, and the partners’ psychological well-being.

If the pilot study proves successful, the research team hopes to conduct a randomized controlled trial of accelerated CBCT for PTSD through a larger study funded by the U.S. Department of Defense or Department of Veterans Affairs.

Expected benefits

The investigators believe that accelerated delivery of cognitive behavioral conjoint therapy has the potential for rapid dissemination and implementation, while capturing the majority of the benefits of the original therapy format. It is also expected that providing the therapy in a non-military, non-VA setting will reduce the stigma of seeking mental health care. An added expected benefit is that participating in a program with other couples will provide social support for couples coping with the effects of 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.

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.

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.

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.