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.