Prolonged exposure therapy for combat-related posttraumatic stress disorder: comparing outcomes for veterans of different wars

Serving Vietnam Veterans Hospitalized Outside the VA System: A Scoping Review of Presumptive Service-Related Illnesses and Presentations

BACKGROUND

Recent legislation, the MISSION Act and the PACT Act, expanded access to and utilization of non-Department of Veterans Affairs (VA) health care; more Veterans now receive care from non-VA healthcare providers. Hospitalists outside the VA may be less familiar with Veterans' service-related exposures and presumptive service-related conditions. We aimed to summarize research findings on service-related exposures and conditions among Vietnam War Veterans.

METHODS

Using Arksey and O'Malley's methodological framework for scoping reviews, we searched PubMed, EMBASE, and Web of Science databases in June 2023. References were imported into EndNote and screened using Covidence collaborative review software. Two reviewers assessed eligibility, with disagreements resolved by a third, then one extracted data. We included papers published in 1998 or later focused on US Vietnam Veterans, excluding genetic/modeling studies, study protocols, case reports/series, clinical trials, and papers without relevance to hospital medicine.

RESULTS

We identified 1185 papers; 251 were duplicates, 450 were excluded through title/abstract review, and 335 were excluded after full-text review. A total of 149 studies were included. The exposures mentioned most frequently were Agent Orange/unspecified herbicides (n = 55), violence/combat (n = 14), and infectious disease (n = 9). The most common conditions were PTSD (n = 39), neuropsychiatric conditions (n = 35), cancer (n = 19), metabolic/endocrine disease (n = 11), and neurological dysfunction (n = 11). Overall mortality was addressed in 13 studies.

CONCLUSIONS

The current literature highlights numerous service-related exposures and conditions recognized by the VA, which may assist hospitalists caring for Vietnam Veterans outside the VA.

Design and methods of a randomized controlled trial evaluating the effects of the PE Coach mobile application on prolonged exposure among veterans with PTSD

BACKGROUND

Little is known about the impact of mobile applications (apps) designed to support patients progressing through an evidence-based psychotherapy. Prolonged exposure (PE) is an efficacious treatment for posttraumatic stress disorder (PTSD) and PE Coach is a treatment companion app that may increase patient engagement with the active components of PE, thereby supporting recovery.

METHODS

This paper describes a randomized clinical trial that will evaluate PE delivered with and without PE Coach at post-treatment, and 1-month and 4-months post-treatment. Veterans with PTSD (N = 124) will be randomized (1:1) to conditions and complete up to 15 treatment sessions based on a priori defined termination criteria. We hypothesize that compared to PE without PE Coach, PE with the app will result in greater improvements in PTSD-related social and occupational functioning (primary outcome is the PTSD-Related Functioning Inventory), quality of life, and greater reductions in functional impairment, neurobehavioral symptoms, depression, and suicidal ideation (Aim 1). We also hypothesize that including PE Coach will reduce assessor-masked PTSD symptom severity, relative to PE without the app, as assessed by the revised Clinician-Administered PTSD Scale for DSM-5 (Aim 2). We hypothesize that PE Coach will facilitate increased treatment adherence, as measured by completion of PE homework (Aim 3). We will explore the impact of PE Coach on treatment engagement, as measured by reduced treatment dropout.

CONCLUSION

Data on the outcomes of PE Coach can inform dissemination efforts and help evaluate the return on investment to guide future mental health app development.

CLINICAL TRIAL REGISTRATION NUMBER

ClinicalTrials.govNCT04959695.

The Influence of Service Era: Comparing Personality Assessment Inventory (PAI) Scale Scores Within a Posttraumatic Stress Disorder Treatment Clinic (PCT)

Research is mixed on the role of service era in symptom endorsement among Veterans, with differences emerging depending on the instrument evaluated. This study compares Personality Assessment Inventory (PAI) scale scores of VA test-takers who served during the Vietnam, Desert Storm, or Post-9/11 service eras. The sample was collected at a VA Posttraumatic Stress Disorder Clinical Team. Associations between gender and combat exposure were also examined as covariates. Results suggest that Veterans' self-report on the PAI is influenced by service era, even after accounting for gender and combat exposure during deployment. The largest differences were between Vietnam or Post-9/11 Veterans and those from the Gulf War era. Symptom differences typically varied across scales commonly associated with symptoms of trauma exposure/posttraumatic stress disorder. Implications for the clinical use of, and research with, the PAI and other broadband personality assessments within the VA healthcare system and trauma treatment settings are discussed.

A comparison of prolonged exposure therapy, pharmacotherapy, and their combination for PTSD: What works best and for whom; study protocol for a randomized trial

BACKGROUND

Several efficacious psychological and pharmacological treatments for posttraumatic stress disorder (PTSD) are available; however, the comparative effectiveness of these treatments represents a major gap in the literature. The proposed study will compare the effectiveness of two leading PTSD treatments - Prolonged Exposure (PE) therapy and pharmacotherapy with paroxetine or venlafaxine extended release - as well as the combination of PE and medication.

METHODS

In a randomized clinical trial, veterans with PTSD (N = 450) recruited across six Veterans Affairs Medical Centers will complete assessments at baseline, mid-treatment (Week 7), post-treatment (Week 14), and follow-up (Weeks 27 and 40). The primary outcome will be change in (both clinician-rated and self-reported) PTSD severity. Depression symptoms, quality of life, and functioning will also be measured and examined as secondary outcomes. Baseline demographic and clinical data will be used to develop "personalized advantage indices" (PAIs), with the goal of identifying who is most likely to benefit from which treatment.

CONCLUSIONS

This planned trial will yield findings to directly inform clinical practice guidelines for PTSD, by providing comparative effectiveness data to support recommendations about what can be considered the "first-line" treatment option(s) for PTSD. Further, findings from this trial have the potential to guide treatment planning for individual patients, through implementation of PAIs developed from study data, in service of "personalized medicine."

TRIAL REGISTRATION

https://clinicaltrials.gov/ct2/show/NCT04961190.

Mental Health Needs of Aging Veterans: Recent Evidence and Clinical Recommendations

Objectives: Large numbers of older Americans have a history of military service, which may be positively or negatively associated with mental health in late life. We reviewed literature with the aim of better understanding the mental health needs of older Veterans.Methods: Articles included those published in 2009-2018 and focused on prevalence/risk for mental illness and suicide among older Veterans; utilization of mental health services; effectiveness of evidence-based behavioral treatments; and pertinent care delivery models.Results: Older Veterans are generally resilient. A significant minority experience mental health concerns that are associated with poor outcomes including a substantial number of suicides. Most published research is based on the approximately one third of Veterans who use the Veterans Health Administration (VHA) for care. Older Veterans with mental health diagnoses are less likely to utilize mental health services compared to younger Veterans, but as likely to benefit once engaged. Integrated care models in primary and geriatric care settings are promising.Conclusions: Aging Veterans are a large subset of Americans whose mental health needs are complex and deserve attention.Clinical Implications: Clinicians should ask about history of military service (i.e., Veteran status) and utilize available resources when providing care for older Veterans.

Enhanced Mental Health with Virtual Reality Mental Hygiene by a Veteran Suffering from PTSD

This paper describes the application and feasibility of the use of Virtual Reality Mental Hygiene (VRMH) as a mean to reduce anxiety and stress in a Danish veteran suffering from posttraumatic stress disorder (PTSD) and enduring personality change after a catastrophic experience. The results from this case study provide preliminary evidence that VRMH can be used as a mean to reduce arousal in patients with severe PTSD.

Comparing MMPI-2-Restructured Form Scores by Service Era for Veterans Assessed Within the Veteran Affairs Healthcare System

This study compares profiles of Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) scale scores from 1492 VA test-takers who served during the Vietnam or Gulf War service eras. The sample includes all such cases collected at any VA posttraumatic stress disorder Clinical Teams across the United States between January 1, 2008 and May 31, 2015 using the MMPI-2 or MMPI-2-RF (via the VA Mental Health Assistant suite). Associations between gender and score differences were also examined. In contrast to past research using the MMPI-2, results of this study suggest that veterans are generally homogeneous in their MMPI-2-RF profiles across different periods of service. Specifically, the magnitudes of mean differences are small and not clinically significant. Thus, responses on the MMPI-2-RF do not appear influenced by service era. Implications for the clinical use of, and research with, the MMPI-2-RF are discussed within the VA healthcare system.

The efficacy of written exposure therapy versus imaginal exposure delivered online for posttraumatic stress disorder: Design of a randomized controlled trial in Veterans

Adapting evidence-based treatments for online delivery has potential to significantly increase the reach of effective care to Veterans with posttraumatic stress disorder (PTSD). This paper describes the rationale for and methods of a randomized controlled trial comparing the efficacy and efficiency of written exposure therapy versus imaginal exposure for PTSD delivered in a novel online and variable length format. Participants will be 300 Veterans seeking treatment for clinically significant symptoms of PTSD. Participants will be randomly assigned to either written exposure or imaginal exposure via verbal recounting and will complete between 4 and 8 online therapy sessions facilitated by trained peer support specialists. Treatment is terminated before session 8 if the PTSD symptom improvement criterion is met. Assessments will be conducted at baseline, post-treatment, and at 3-month follow-up. The primary hypotheses are that written exposure therapy will be noninferior to imaginal exposure with respect to treatment efficacy and efficiency. Secondary hypotheses relate to identifying and comparing potential mediators of PTSD treatment outcome, including trauma-related cognitions and emotion regulation.

Comorbid mood and anxiety disorders and severity of posttraumatic stress disorder symptoms in treatment-seeking veterans

OBJECTIVE

Comorbidity is the rule and not the exception among veterans with posttraumatic stress disorder (PTSD). Examining comorbidities in a veteran population allows us to better understand veterans' symptoms and recognize when mental health treatment may need to be tailored to other co-occurring issues. This article evaluates comorbid mood and anxiety disorders and PTSD symptom severity in a large sample of veterans from multiple eras of service, including the recent wars in Iraq and Afghanistan.

METHOD

The current study used data from veterans who sought treatment for PTSD at a VA PTSD Clinical Team from 2005 to 2013. Veterans were assessed for PTSD, mood, and anxiety disorders using a structured clinical interview and completed self-report symptom measures as part of the PTSD clinic intake procedure. A total of 2,460 veterans were evaluated, and 867 met diagnostic criteria for PTSD.

RESULTS

Veterans with PTSD were significantly more likely than those without PTSD to be diagnosed with social anxiety disorder and obsessive-compulsive disorder, but significantly less likely to be diagnosed with depression. In addition, veterans who had at least one comorbid diagnosis in addition to PTSD reported significantly higher PTSD symptom severity than veterans with PTSD alone. PTSD symptom severity also varied by era of service.

CONCLUSION

These results suggest that among veterans seeking treatment for PTSD, comorbid mood and anxiety disorders may be associated with greater severity of PTSD symptoms. Future work is needed to determine the impact of specific comorbidities on trauma-focused treatment outcomes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Does Traumatic Brain Injury Attenuate the Exposure Therapy Process?

Research indicates that exposure therapy is efficacious for combat-related posttraumatic stress disorder (PTSD) comorbid with traumatic brain injury (TBI) as is shown by reduced PTSD treatment outcome scores. What is unknown, however, is whether the process of fear extinction is attenuated in veterans with TBI history. Increased PTSD symptomatology and possible cognitive deficits associated with TBI sequelae may indicate additional or longer exposure sessions to achieve habituation and extinction comparable to individuals without TBI history. As such, a more extensive course of treatment may be necessary to achieve comparable PTSD treatment outcome scores for individuals with TBI history. Using a sample of veterans with combat-related PTSD, some of whom were comorbid for TBI, this study compared process variables considered relevant to successful treatment outcome in exposure therapy. Individuals with and without TBI demonstrated similar rates of fear activation, length and number of exposure sessions, within-session habituation, between-session habituation, and extinction rate; results remained consistent when controlling for differential PTSD symptomatology. Furthermore, results indicated that self-perception of executive dysfunction did not impact the exposure process. Results suggest that individuals with PTSD and TBI history engage successfully and no differently in the exposure therapy process as compared to individuals with PTSD alone. Findings further support exposure therapy as a first-line treatment for combat-related PTSD regardless of TBI history.

Posttraumatic stress disorder, depression, and suicidal ideation in veterans: Results from the mind your heart study

Veterans with PTSD or depression are at increased risk for suicidal ideation. However, few studies have examined that risk in those with comorbid PTSD and depression, instead focusing on these disorders individually. This study investigates the association of suicidal ideation with comorbid PTSD and depression and examines the role of military and psychosocial covariates. We evaluated 746 veterans using the CAPS to assess PTSD and the PHQ-9 to measure depression and suicidal ideation. Covariates were assessed via validated self-report measures. 49% of veterans with comorbid PTSD and depression endorsed suicidal ideation, making them more likely to do so than those with depression alone (34%), PTSD alone (11%), or neither (2%). In multivariate logistic regression models, this association remained significant after controlling for demographics and symptom severity. Anger, hostility, anxiety, alcohol use, optimism and social support did not explain the elevated risk of suicidal ideation in the comorbid group in fully adjusted models. As suicidal ideation is a known risk factor for suicide attempts and completions, veterans with comorbid PTSD and depression represent a vulnerable group who may need more intensive monitoring and treatment to reduce risk of suicide.

Description and Preliminary Outcomes of an In Vivo Exposure Group Treatment for Posttraumatic Stress Disorder

Prolonged exposure (PE) therapy is traditionally delivered individually to patients. To engage more veterans in care, an in vivo exposure group treatment was developed in an urban VA medical center. This treatment represented a modification of the in vivo exposure portion of PE, with the addition of in-session, therapist-assisted in vivo exposures. Here, we describe this 12-week treatment and present preliminary outcome data. Demographics and pre- and posttreatment scores on the PTSD Checklist-Specific (PCL-S) and Beck Depression Inventory-II (BDI-II) were extracted from a program evaluation database. The sample included veterans with a diagnosis of posttraumatic stress disorder (PTSD) who participated in the in vivo exposure group between October 2010 and March 2014 and had available treatment outcome data (N = 43). The majority of participants in the sample were male (n = 41, 95.3%) and Black (n = 34, 79.1%). Participation in the in vivo group was associated with a significant decrease in PCL-S scores, with a medium-large effect size, t(42) = 5.35, p < .001, d = 0.73, and a significant decrease in BDI-II scores, with a small effect size, t(38) = 2.55, p = .015, d = 0.23. Previous participation in an evidenced-based treatment (EBT) was not associated with symptom change following the in vivo group. Findings suggest that in vivo exposure group therapy constitutes a promising intervention for individuals who decline EBTs or remain symptomatic after completing an EBT for PTSD. Further study of this treatment using a randomized controlled trial design is warranted.

An intensive outpatient treatment program for combat-related PTSD: Trauma Management Therapy

An estimated 18.5% of veterans returning from Operation Iraqi Freedom, Operation Enduring Freedom, and Operation New Dawn are suffering from posttraumatic stress or posttraumatic stress disorder (PTSD). The number of veterans and service duty personnel requesting VA health care services is increasing, and the VA's ability to handle requests is dwindling. Thus, both the content of interventions and the format by which these services are delivered need to be reconceptualized. The authors present a multicomponent intervention program known as Trauma Management Therapy (TMT), a comprehensive, empirically supported treatment that can be delivered in an intensive, 3-week outpatient format. TMT combines individual exposure therapy with group social and emotional rehabilitation skills training to address specific aspects of the combat-related PTSD syndrome. The authors present the format of this novel intensive outpatient program, describe the components, and address implementation factors such as treatment compliance, dropout rates, and administrative considerations.

Beyond Pathologizing Harm: Understanding PTSD in the Context of War Experience

An alternative to objectifying approaches to understanding Post-traumatic Stress Disorder (PTSD) grounded in hermeneutic phenomenology is presented. Nurses who provided care for soldiers injured in the Iraq and Afghanistan wars, and sixty-seven wounded male servicemen in the rehabilitation phase of their recovery were interviewed. PTSD is the one major psychiatric diagnosis where social causation is established, yet PTSD is predominantly viewed in terms of the usual neuro-physiological causal models with traumatic social events viewed as pathogens with dose related effects. Biologic models of causation are applied reductively to both predisposing personal vulnerabilities and strengths that prevent PTSD, such as resiliency. However, framing PTSD as an objective disease state separates it from narrative historical details of the trauma. Personal stories and cultural meanings of the traumatic events are seen as epiphenomenal, unrelated to the understanding of, and ultimately, the therapeutic treatment of PTSD. Most wounded service members described classic symptoms of PTSD: flashbacks, insomnia, anxiety etc. All experienced disturbance in their sense of time and place. Rather than see the occurrence of these symptoms as decontextualized mechanistic reverberations of war, we consider how these symptoms meaningfully reflect actual war experiences and sense of displacement experienced by service members.

Effectiveness of Cognitive Processing Therapy and Prolonged Exposure in the Department of Veterans Affairs

Objective

This study evaluated the effectiveness of cognitive processing therapy and prolonged exposure in conditions reflective of current clinical practice within the Veterans Health Administration.

Method

This study involved a retrospective review of 2030 charts. A total of 750 veterans from 10 U.S. states who received cognitive processing therapy or prolonged exposure in individual psychotherapy were included in the study (participants in cognitive processing therapy, N = 376; participants in prolonged exposure, N = 374). The main dependent variable was self-reported posttraumatic stress disorder symptoms as measured by total scores on the Posttraumatic Stress Disorder Checklist. The study used multilevel modeling to evaluate the absolute and relative effectiveness of both treatments and determine the relationship between patient-level variables and total Posttraumatic Stress Disorder Checklist scores during treatment.

Results

Cognitive processing therapy and prolonged exposure were equally effective at reducing total Posttraumatic Stress Disorder Checklist scores. Veterans who completed therapy reported significantly larger reductions in the Posttraumatic Stress Disorder Checklist than patients who did not complete therapy. There were no significant differences in the improvement of posttraumatic stress disorder symptoms with respect to age and three racial/ethnic groups (Caucasian, African American, and Hispanic).

Conclusions

Cognitive processing therapy and prolonged exposure were shown to be effective in conditions highly reflective of clinical practice and with a highly diverse sample of veterans. Challenges related to dropout from trauma focused therapy should continue to be researched.

High rates of PTSD treatment dropout: A possible red herring?

Few studies have examined symptom change among dropouts from posttraumatic stress disorder (PTSD) treatment. However, dropout is widely considered a negative event needing to be addressed. The present study investigated PTSD and depression symptom change in patients with PTSD who discontinued psychotherapy. Female civilians (n=321) diagnosed with PTSD participated in two randomized clinical trials examining PTSD treatment outcomes. Of those, 53 were identified as dropouts and included in this study. Symptom change was assessed by clinically significant change (CSC) criteria and symptom end-state criteria. Results demonstrated that considerable proportions of participants (35.85-55.56%) displayed significant improvement and/or met good end-state criteria for PTSD and depression. Results also revealed that participants who displayed symptom improvement were younger, attended more treatment sessions, were married or partnered, and had higher annual household income. Although preliminary, these findings contradict belief that treatment dropouts do not display symptom improvement.

Integrated Treatment of PTSD and Substance Use Disorders: Examination of Imaginal Exposure Length

Efforts to improve the efficiency of prolonged exposure (PE) therapy for posttraumatic stress disorder (PTSD) have demonstrated that reducing the length of imaginal exposures does not negatively affect treatment outcome. A recent adaptation of PE, called Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure [COPE], integrates substance use disorder treatment with PE in the same timeframe (twelve 90-minute sessions, 8 of which include imaginal exposure). The current study, which represents a subanalysis of a larger randomized controlled trial, examined how the length of imaginal exposures (nonrandomized and measured continually) related to PTSD, substance use, and depression in a sample of military veterans (N = 31) who completed the COPE treatment. Participants completed an average of 11.5 of the 12 therapy sessions and 7.2 of the 8 imaginal exposures during treatment. Results of 3 linear mixed models indicate that PTSD, substance use, and depressive symptoms all improved over the course of treatment (ps < .001; η² ranged between .17 and .40), and that the length of imaginal exposures did not significantly interact with any outcome. Although preliminary, the findings suggest that it may be feasible to shorten imaginal exposures without mitigating treatment gains. Implications for treatment are discussed.

Concurrent Dialectical Behavior Therapy and Prolonged Exposure Reduces Symptoms and Improves Overall Quality of Life for a Veteran With Posttraumatic Stress Disorder and Borderline Personality Disorder

This article presents a case study illustration of integrated, concurrent dialectical behavior therapy (DBT) and prolonged exposure (PE), conducted within a Veterans Affairs health care system. Treatment in this case effectively reduced symptoms and improved overall quality of life. Based on clinical complexities encountered (e.g., substance use, nonsuicidal self-harm, treatment setting constraints), recommendations are provided for concurrent treatment of posttraumatic stress disorder and borderline personality disorder in veterans. Recommendations include consideration of flexibility in duration of pre-PE stabilization, modification of DBT phone coaching protocol, management of structural barriers to treatment access, full use of consultation, and coordination of clinician roles.

A non-inferiority trial of Prolonged Exposure for posttraumatic stress disorder: In person versus home-based telehealth

This is the first randomized controlled trial to evaluate non-inferiority of Prolonged Exposure (PE) delivered via home-based telehealth (HBT) compared to standard in-person (IP) PE. One-hundred thirty two Veterans recruited from a Southeastern Veterans Affairs Medical Center and affiliated University who met criteria for posttraumatic stress disorder (PTSD) were randomized to receive PE via HBT or PE via IP. Results indicated that PE-HBT was non-inferior to PE-IP in terms of reducing PTSD scores at post-treatment, 3 and 6 month follow-up. However, non-inferiority hypotheses for depression were only supported at 6 month follow-up. HBT has great potential to reduce patient burden associated with receiving treatment in terms of travel time, travel cost, lost work, and stigma without sacrificing efficacy. These findings indicate that telehealth treatment delivered directly into patients' homes may dramatically increase the reach of this evidence-based therapy for PTSD without diminishing effectiveness.

Open trial of exposure therapy for PTSD among patients with severe and persistent mental illness

OBJECTIVE

There are few empirical data regarding effective treatment of trauma-related symptoms among individuals with severe mental illness (SMI; e.g., bipolar disorder, schizophrenia). This under-examined clinical issue is significant because rates of trauma and PTSD are higher among individuals with SMI relative to the general population, and there are sufficient data to suggest that PTSD symptoms exacerbate the overall course and prognosis of SMI.

METHOD

34 veterans with SMI received prolonged exposure (PE) for PTSD using an open trial study design.

RESULTS

Data suggest that PE is feasible to implement, well-tolerated, and results in clinically significant decreases in PTSD severity in patients with SMI. Mean CAPS scores improved 27.2 points from baseline to immediate post [95% CI for mean change: -44.3, - 10.1; p = 0.002, paired t-test, and treatment gains were maintained at 6 months [mean change from baseline to 6-months, -16.1; 95% CI: -31.0, -1.2; p = 0.034, paired t-test].

CONCLUSIONS

The current data support the use of exposure-based interventions for PTSD among individuals with SMI and highlight the need for rigorous randomized efficacy trials investigating frontline PTSD interventions in this patient population.

Cognitive-behavioral therapy for late-life anxiety: Similarities and differences between Veteran and community participants

Cognitive-behavioral therapy (CBT) is an evidence-based treatment for anxiety; however, a growing body of research suggests that CBT effect sizes are smaller in Veteran samples. The aim of this study was to perform secondary data analyses of a randomized controlled trial of CBT for late-life generalized anxiety disorder compared with treatment as usual (TAU) in a Veteran (n = 101) and community-based (n = 122) sample. Veterans had lower income and less education than community participants, greater severity on baseline measures of anxiety and depression, poorer physical health, and higher rates of psychiatric comorbidity. Treatment effects were statistically significant in the community sample (all ps < 0.01), but not in Veterans (all ps > 0.05). Further analyses in Veterans revealed that poorer perceived social support significantly predicted poorer outcomes (all ps < 0.05). Our results underscore the complexity of treating Veterans with anxiety, and suggest that additional work is needed to improve the efficacy of CBT for Veterans, with particular attention to social support.

Early treatment withdrawal from evidence-based psychotherapy for PTSD: telemedicine and in-person parameters

OBJECTIVE

To determine differences in reported barriers to treatment completion associated with telemedicine vs. in-person delivery of evidence-based treatment for PTSD in combat veterans.

METHOD

The present study was derived from two ongoing randomized controlled trials (RCTs) comparing in-person vs. telemedicine delivery of exposure therapy for PTSD. A one-time telephone assessment of participants who dropped out from the treatment phase of these two studies was conducted, with measures focusing on reported reasons for dropout, and perceived comfort and efficacy of the treatment modality. Dichotomous data were analyzed via chi-square and logistic regression; continuous data via ANOVA.

RESULTS

Forty-seven of 69 total dropouts participated. There was no difference in rate of dropout between modalities. A greater proportion of participants receiving in-person exposure therapy reported difficulties with logistical aspects of care (e.g., parking), whereas a greater proportion of participants receiving telemedicine therapy reported difficulty tolerating certain stressful aspects of treatment; however, those receiving telemedicine delivered treatment completed more sessions before dropping out. Participants in both conditions reported that they liked and were confident in their therapist Conclusions: Dropout reasons varied according to type of treatment delivery. Recommendations for future research are given in terms of modification of treatment protocol according to delivery modality.

The US framework for understanding, preventing, and caring for the mental health needs of service members who served in combat in Afghanistan and Iraq: a brief review of the issues and the research

This paper reviews the psychological health research conducted in the United States in support of combat veterans from Iraq and Afghanistan, using the Military Psychological Health Research Continuum, which includes foundational science, epidemiology, etiology, prevention and screening, treatment, follow-up care, and services research. The review is limited to those studies involving combat veterans and military families. This review discusses perplexing issues regarding the impact of combat on the mental health of service members such as risk and resilience factors of mental health, biomarkers of posttraumatic stress syndrome (PTSD), mental health training, psychological screening, psychological debriefing, third location decompression, combat and suicide, the usefulness of psychotherapy and drug therapy for treating PTSD, role of advanced technology, telemedicine and virtual reality, methods to reduce stigma and barriers to care, and best approaches to the dissemination of evidence-based interventions. The mental health research of special populations such as women, National Guardsmen and reservists, and military families is also presented. The review concludes by identifying future areas of research.

A comparison of Narrative Exposure Therapy and Prolonged Exposure therapy for PTSD

The purpose of this review was to compare and contrast Prolonged Exposure (PE) and Narrative Exposure Therapy (NET). We examined the treatment manuals to describe the theoretical foundation, treatment components, and procedures, including the type, manner, and focus of exposure techniques and recording methods used. We examined extant clinical trials to investigate the range of treatment formats reported, populations studied, and clinical outcome data. Our search resulted in 32 studies on PE and 15 studies on NET. Consistent with prior reviews of PTSD treatment, it is evident that PE has a solid evidence base and its current status as a first line treatment for the populations studied to this date is warranted. We argue that NET may have advantages in treating complex traumatization seen in asylum seekers and refugees, and for this population NET should be considered a recommended treatment. NET and PE have several commonalities, and it is recommended that studies of these treatments include a broader range of populations and trauma types to expand the current knowledge on the treatment of PTSD.

Characteristics of U.S. veterans who begin and complete prolonged exposure and cognitive processing therapy for PTSD

This retrospective chart-review study examined patient-level correlates of initiation and completion of evidence-based psychotherapy (EBP) for posttraumatic stress disorder (PTSD) among treatment-seeking U.S. veterans. We identified all patients (N = 796) in a large Veterans Affairs PTSD and anxiety clinic who attended at least 1 individual psychotherapy appointment with 1 of 8 providers trained in EBP. Within this group, 91 patients (11.4%) began EBP (either Cognitive Processing Therapy or Prolonged Exposure) and 59 patients (7.9%) completed EBP. The medical records of all EBP patients (n = 91) and a provider-matched sample of patients who received another form of individual psychotherapy (n = 66) were reviewed by 4 independent raters. Logistic regression analyses revealed that Iraq and Afghanistan veterans were less likely to begin EBP than veterans from other service eras, OR = 0.48, 95% CI = [0.24, 0.94], and veterans who were service connected for PTSD were more likely than veterans without service connection to begin EBP, OR = 2.33, 95% CI = [1.09, 5.03]. Among those who began EBP, Iraq and Afghanistan veteran status, OR = 0.09, 95% CI = [0.03, 0.30], and a history of psychiatric inpatient hospitalization, OR = 0.13, 95% CI = [0.03, 0.54], were associated with decreased likelihood of EBP completion.

PTSD symptoms and family versus stranger violence in Iraq and Afghanistan veterans

As a diagnosis, posttraumatic stress disorder (PTSD) has been associated with violence committed by veterans in many studies; however, a potential link to specific PTSD symptoms has received relatively less attention. This paper examines the relationship between PTSD symptoms and different types of violent behavior in Iraq and Afghanistan veterans. Participants were randomly sampled from a roster of all separated U.S. military service members or national guard/reservists who served after September 11, 2001. Data were collected at baseline and 1-year follow-up from a national sample of N = 1,090 veterans, from 50 states and all military branches. Of these veterans, 13% reported aggression toward a family member and 9% toward a stranger during the 1-year study period. Anger symptoms at baseline predicted higher odds of family violence at follow-up, both severe (OR = 1.30, CI [1.13, 1.48], p < .0001) and any (OR = 1.28, CI [1.19, 1.37], p < .0001). PTSD flashback symptoms at baseline predicted higher odds of stranger violence at follow-up, both severe (OR = 1.26, CI [1.11, 1.42], p < .0001) and any (OR = 1.16, CI [1.05, 1.28], p = .0029). Analyses revealed that males were more likely to engage in stranger violence, whereas females were more likely to endorse aggression in the family context. The results provide limited support to the hypothesis that PTSD "flashbacks" in veterans are linked to violence. The differing multivariate models illustrate distinct veteran characteristics associated with specific types of violence.

PTSD in active combat soldiers: to treat or not to treat

In this paper, we consider ethical issues related to the treatment of posttraumatic stress disorder (PTSD) in combat zones, via exposure therapy. Exposure-oriented interventions are the most well-researched behavioral treatments for PTSD, and rigorous studies across contexts, populations, and research groups provide robust evidence that exposure therapy for PTSD is effective and can be widely disseminated. Clinical procedures for Prolonged Exposure therapy, a manualized exposure-oriented protocol for PTSD, are reviewed, and we illustrate the potential benefits, as well as the potential difficulties, associated with providing this treatment in combat zones. Several ethical considerations are identified: (1) Assuming successful treatment, is it ethical to send individuals with a known risk of developing PTSD back into combat? (2) If treatment is unsuccessful in theater (perhaps due to the confounding factor of ongoing danger), could that impact treatment effectiveness for soldiers who attempt therapy again post-deployment? (3) If the military finds combat-zone treatment effective and useful in maintaining an efficient work force, will treatment become mandatory for those diagnosed with PTSD? (4) What unintended consequences might be associated with large-scale dissemination of exposure therapy in or near combat, outside of mental health care infrastructures? (5) How would genetic variations known to be associated with PTSD risk influence decisions regarding who receives treatment or returns to combat? We conclude with a review of the personal and societal costs associated with not providing evidence-based PTSD treatments wherever possible.

Evaluating treatment of posttraumatic stress disorder with cognitive processing therapy and prolonged exposure therapy in a VHA specialty clinic

This retrospective chart review evaluates the effectiveness of manualized cognitive processing therapy (CPT) protocols (individual CPT, CPT group only, and CPT group and individual combined) and manualized prolonged exposure (PE) therapy on veterans' posttraumatic stress disorder (PTSD) symptoms in one Veterans Health Administration (VHA) specialty clinic. A total of 517 charts were reviewed, and analyses included 178 charts for CPT and 85 charts for PE. Results demonstrated CPT and PE to significantly reduce PTSD Checklist (PCL) scores. However, PE was significantly more effective than CPT after controlling for variables of age, service era, and ethnicity. Additional findings included different outcomes among CPT formats, decreased treatment dropouts for older veterans, and no significant differences in outcome between Hispanic and White veterans. Study limitations and future research directions are discussed.

Predictors of length of stay among OEF/OIF/OND veteran inpatient PTSD treatment noncompleters

High rates of attrition occur in outpatient and inpatient evidence-based treatments (EBTs) targeting newly returning veterans from Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF) and Operation New Dawn (OND) with posttraumatic stress disorder (PTSD). Traditionally, research has examined attrition as a dichotomous variable (i.e., noncompleters vs. completers) and focused almost exclusively on outpatient EBTs for PTSD. These studies have provided little information to inpatient psychiatric providers about timing-related predictors of treatment discontinuation. The present study attempted to mend these gaps by examining attrition as a continuous variable and investigated predictors of length of stay (LOS) among 282 OEF/OIF/OND male veterans, 69 of which did not complete the full 25-day intensive, multimodal inpatient PTSD EBT program. At admission, participants completed a series of clinician-rated, biological, and self-report assessments. Linear regression analyses were used to identify predictors of shorter LOS. The results demonstrated that less improvement in symptom reduction, overall functioning, and greater number of drugs used at admission were significant and unique predictors of shorter LOS. Overall, these findings reveal clinically relevant, timing-related predictors of attrition and provide generalizable clinical information to inpatient psychiatric providers.

Nature adventure rehabilitation for combat-related posttraumatic chronic stress disorder: a randomized control trial

Chronic combat-related posttraumatic stress disorder (CR-PTSD) is a condition with many treatment barriers. Nature Adventure Rehabilitation (NAR) as a second line or as a supplemental intervention has the potential to overcome some of these barriers and incorporate aspects of successful treatment modalities for PTSD within an experiential learning paradigm. In a pre-post controlled trial, CR-PTSD veterans (n=22) underwent a 1-year NAR intervention compared to a waiting list (WL) control group (n=20). Posttraumatic symptoms (PTS), depression, functional problems, quality of life, perceived control over illness (PCI) and hope were measured by self report measures. PTS, emotional and social quality of life, PCI, hope and functioning improved significantly. Change in PTS was contingent upon change in PCI. The current study is the first to present NAR as a promising supplemental intervention for chronic CR-PTSD. NAR seems to work through a process of behavioral activation, desensitization, gradual exposure to anxiety evoking situations and gaining control over symptomatology.

Effectiveness of prolonged exposure for PTSD in older veterans

Exposure-based therapy is an effective treatment for PTSD, including combat-related PTSD. However, questions remain within PTSD treatment literature and among front-line clinicians about the appropriateness of exposure-based therapies for older adults. The current study examined the effectiveness of Prolonged Exposure (PE) in reducing PTSD and depression symptoms in a sample of 65 Veterans age 60 and older who were diagnosed with PTSD via structured clinical interview. In addition to within-subject repeated measure analyses, the entire intent to treat sample was compared to treatment completers. Within group d-type effect sizes across both groups were large (1.13-1.90) and the retention rate was high (85%). Importantly, no adverse medical or psychiatric events were reported over the course of the study. Results are discussed and limitations, along with future directions, are presented.

Enhancing exposure therapy for PTSD with yohimbine HCL: protocol for a double-blind, randomized controlled study implementing subjective and objective measures of treatment outcome

Prolonged exposure (PE) therapy is considered a gold standard protocol for the treatment of PTSD, and it is associated with large treatment effect sizes in combat veteran samples. However, considering high rates of PTSD in the present veteran population, ongoing research work is important toward improving treatment efficiency by decreasing time to symptom amelioration and increasing the amount of symptom amelioration. The proposed research aims to enhance exposure therapy outcomes for veterans with PTSD via combination treatment with PE and yohimbine hydrochloride (HCL), an alpha-2 adrenergic receptor antagonist. The proposed investigation entails a randomized, placebo-controlled trial investigating the effect of a single administration of yohimbine HCL (paired with the first session of imaginal exposure) on outcome of PE in 40 veterans with PTSD. An additional goal is to establish a pragmatic method of tracking psychophysiological measures over the course of therapy for incorporation into future clinical psychotherapy trials. Thus, in addition to traditional self- and clinician-reported psychological outcomes, heart rate and skin conductance reactivity will be measured during a standard trauma-specific imagery task before, during, and after PE treatment. We will further investigate whether changes in psychophysiological measures predict changes in patient- and clinician-reported outcome measures.

Behavioral activation and therapeutic exposure: an investigation of relative symptom changes in PTSD and depression during the course of integrated behavioral activation, situational exposure, and imaginal exposure techniques

Effectiveness of exposure therapy for posttraumatic stress disorder (PTSD) may be adversely influenced by comorbid disorders. The present study investigated behavioral activation and therapeutic exposure (BA-TE), a new integrated treatment designed specifically for comorbid symptoms of PTSD and depression. Combat veterans with PTSD (N = 117) completed eight sessions of BA-TE that included two phases of treatment: (a) behavioral activation (BA) in which some activities involved situational exposures and (b) BA and situational exposures with imaginal exposures. Findings supported improvements in symptoms of PTSD, and overlapping symptoms of PTSD and depression, but not in nonoverlapping symptoms of depression. The findings also demonstrated a relatively consistent rate of change in PTSD and depression symptoms during BA-TE, despite the addition of imaginal exposures midway through the treatment. Together, these findings provide preliminary support for BA-TE as a treatment for PTSD and depression, and highlight the utility of transdiagnostic treatments in addressing comorbidity and symptom overlap.