Refining Trauma-Focused Treatments for Servicemembers and Veterans With Posttraumatic Stress Disorder: Progress and Ongoing Challenges

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.

Virtually-delivered Sudarshan Kriya Yoga (SKY) for Canadian veterans with PTSD: A study protocol for a nation-wide effectiveness and implementation evaluation

BACKGROUND

Post-traumatic stress disorder (PTSD) remains a significant treatment challenge among Canadian veterans. Currently accessible pharmacological and non-pharmacological interventions for PTSD often do not lead to resolution of PTSD as a categorical diagnosis and have significant non-response rates. Sudarshan Kriya Yoga (SKY), a complementary and integrative health (CIH) intervention, can improve symptoms of PTSD. In response to the COVID-19 pandemic, this intervention has pivoted to virtual delivery and may be reaching new sets of participants who face multiple barriers to care.

OBJECTIVE

To evaluate the implementation and effectiveness of virtually delivered Sudarshan Kriya Yoga (SKY) on decreasing PTSD symptom severity, symptoms of depression, anxiety, and pain, and improving quality of life in Canadian veterans affected by PTSD.

METHODS AND ANALYSIS

Using a mixed-methods approach guided by the RE-AIM framework, we will conduct a hybrid type II effectiveness and implementation study of virtually delivered Sudarshan Kriya Yoga (SKY) for Canadian veterans. Effectiveness will be evaluated by comparing virtually delivered SKY to a waitlist control in a single-blinded (investigator and data analyst) randomized controlled trial (RCT). Change in PTSD symptoms (PCL-5) is the primary outcome and quality of life (SF-36), symptoms of depression (PHQ-9), anxiety (GAD-7), and pain (BPI) are secondary outcomes. The SKY intervention will be conducted over a 6-week period with assessments at baseline, 6-weeks, 12-weeks, and 30 weeks. The reach, effectiveness, adoption, implementation, and maintenance of the intervention will be evaluated through one-on-one semi-structured interviews with RCT participants, SKY instructors, health professionals, and administrators that work with veterans.

DISCUSSION

This is the first investigation of the virtual delivery of SKY for PTSD in veterans and aims to determine if the intervention is effective and implementable at scale.

Stages of Psychotherapy for Trauma and Stress-related Disorders

Psychotherapy technique should change as the stages of treatment for stress response syndromes progress. A formulation helps clinicians determine what to do at each stage. This progression should allow for integration of modalities of therapy. Configurational analysis provides 4 categories for organizing clinical inferences. It begins with an assessment of key symptoms and then the states of mind in which the symptoms vary because of degrees of emotional regulation. Unresolved emotional topics that lead to symptoms are then addressed in stages of exploring the meaning of memories. Finally, the self and relational schemas that lead to maladaptive patterns are inferred and lead toward integrative techniques for re-narrations and re-schematizations.

Barriers to Accessing Mental Health Care After a Sexual Assault Medical Forensic Examination

BACKGROUND

Research indicates low rates of accessing mental health care following sexual assault; however, barriers associated with accessing care are not well understood.

DESIGN

Participants (N = 37) were recruited from a local hospital following a sexual assault medical forensic examination (SAMFE). Hierarchical linear regressions models examined the effects of age, racial identity, student status, insurance status, relationship to perpetrator, time since assault, problematic drinking, and posttraumatic stress symptoms on (a) barriers to accessing care and (b) the likelihood of seeking mental health treatment at no charge.

RESULTS

Lack of insurance was associated with more barriers to accessing mental health care and a higher likelihood of seeking post-SAMFE care at no charge. Posttraumatic stress symptoms were associated with more barriers to accessing care (p = 0.038). Identifying as a student (p = 0.026) and engaging in problematic drinking (p = 0.047) were associated with a lower likelihood of seeking post-SAMFE care, whereas increased symptoms of posttraumatic stress were associated with a greater likelihood of seeking post-SAMFE care (p = 0.007).

CONCLUSIONS

Providing post-SAMFE care, irrespective of insurance, may be a needed first step in addressing the mental health needs of individuals with recent sexual assault. Secondary prevention programs targeted toward alcohol misuse may also be warranted.

The probability of change versus dropout in veterans receiving Cognitive Processing Therapy for posttraumatic stress disorder

OBJECTIVE

We sought to elucidate the timing of symptom change and treatment dropout in a leading evidence-based psychotherapy for posttraumatic stress disorder, Cognitive Processing Therapy (CPT). Despite its efficacy across numerous populations, treatment nonresponse and premature dropout are common in CPT and other trauma-focused interventions, particularly among military veterans. Advancements are therefore needed to reduce dropout and increase retention.

METHOD

Survival analysis was used to identify the temporal probability of symptom amelioration at each session of CPT (with written trauma account; CPT-A) and compare this with the cumulative, session-by-session probability of dropout. Data were obtained from 194 veterans seeking outpatient treatment at a Veterans Affairs specialty clinic.

RESULTS

Overall, 49-61% of veterans reported meaningful symptom reduction in the course of CPT-A and 40% dropped out prematurely. The cumulative probability of dropout exceeded the probability of symptom change beginning after session six of therapy. Secondary analyses indicated that this six session rule generalized well across subgroups.

CONCLUSIONS

When symptom amelioration is not observed by the midway point in CPT-A, a change in therapeutic approach appears warranted for preempting dropout among veterans and boosting treatment retention.

A Tale of Two Compulsions - Two Case Studies Using Accelerated Resolution Therapy (ART) for Obsessive Compulsive Disorder (OCD)

Although research for accelerated resolution therapy (ART) has been predominately for post-traumatic stress disorder, ART has shown promise as a treatment for other behavioral health conditions as well. ART is a brief, trauma-focused, eye movement-based therapy that has been successfully utilized to treat a wide array of behavioral health disorders, including obsessive compulsive disorder. This article will present an overview of the theory behind the reconsolidation concept used in ART and two cases of obsessive compulsive disorder treatment using ART with outcome measures visual trend analysis.

Trauma management therapy with virtual-reality augmented exposure therapy for combat-related PTSD: A randomized controlled trial

Virtual reality exposure therapy (VRET) realistically incorporates traumatic cues into exposure therapy and holds promise in the treatment of combat-related posttraumatic stress disorder (PTSD). In a randomized controlled trial of 92 Iraq and Afghanistan veterans and active duty military personnel with combat-related PTSD, we compared the efficacy of Trauma Management Therapy (TMT; VRET plus a group treatment for anger, depression, and social isolation) to VRET plus a psychoeducation control condition. Efficacy was evaluated at mid- and post-treatment, and at 3- and 6-month follow-up. Consistent with our hypothesis, VRET resulted in significant decreases on the Clinician Administered PTSD Scale and the PTSD Checklist-Military version for both groups. Also consistent with our hypothesis, significant decreases in social isolation occurred only for those participants who received the TMT group component. There were significant decreases for depression and anger for both groups, although these occurred after VRET and before group treatment. All treatment gains were maintained six-months later. Although not part of the original hypotheses, sleep was not improved by either intervention and remained problematic. The results support the use of VRET as an efficacious treatment for combat-related PTSD, but suggest that VRET alone does not result in optimal treatment outcomes across domains associated with PTSD.

A Randomized Controlled Trial of Group Cognitive Behavioral Treatment for Veterans Diagnosed With Chronic Posttraumatic Stress Disorder

Relative to advances in the literature that have examined individual treatment approaches for posttraumatic stress disorder (PTSD), scientific knowledge about group treatment approaches has lagged, resulting in no currently available group treatment for PTSD despite the frequency with which this format is used. Our goal was to build upon the existing literature by examining the efficacy of a group cognitive-behavioral treatment (GCBT) for PTSD relative to group present-centered treatment (GPCT). The sample consisted of 198 male veterans with PTSD who were recruited at two Department of Veteran Affairs medical centers and randomly assigned to either GCBT (n = 98) or GPCT (n = 100); both treatments were 14 sessions. Assessments occurred at baseline, midtreatment, posttreatment, and 3-, 6-, and 12-month follow-ups. Findings indicated significant reductions in PTSD severity and PTSD diagnostic status following treatment for both GCBT, d = 0.97, and GPCT, d = 0.61. In addition, we observed significant reductions for depression symptoms, anxiety symptoms, and functional impairment for both group treatments as well as a reduction in the percentage of veteran participants who met diagnostic status for co-occurring major depression disorder and generalized anxiety disorder. Notably, these treatment gains were maintained at 12-month follow-up. Contrary to expectations, there were no significant differences between treatment conditions. Veterans diagnosed with PTSD were successfully treated using a group approach. Consistent with a growing body of evidence, the findings also suggest GPCT is as equally efficacious as group trauma-focused treatment. The trial was registered at clinicaltrials.gov (NCT01544088).

The efficacy of Trauma Management Therapy: A controlled pilot investigation of a three-week intensive outpatient program for combat-related PTSD

Despite the 8-18.5% of returning Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF) and Operation New Dawn (OND) veterans who are suffering from posttraumatic stress disorder (PTSD), few receive empirically supported treatments. Among those that do, the dropout rate is high and more than 50% retain their diagnosis after treatment. This study evaluated the efficacy of Trauma Management Therapy (TMT), delivered in a 3-week intensive outpatient (IOP) format. TMT combines virtual-reality augmented individual exposure therapy with a group intervention to address social isolation, anger, and depression. One hundred twelve (112) OIF/OEF/OND veterans and active duty personnel participated. Assessment included measures of PTSD, sleep, depression, anger, guilt, and social isolation, administered at post-treatment, 3-month, and 6-month follow-up. The effect size for TMT delivered in an IOP format was 2.06, with 65.9% no longer meeting diagnostic criteria for PTSD. There were similar positive effects in other domains and treatment gains were maintained at 6-month follow-up. The results are discussed regarding the need for efficacious, multi-component interventions that can be delivered safely and rapidly, and the potential of this approach towards that end.