The applicability of randomized controlled trials of psychosocial treatments for PTSD to a veteran population

Treating Veterans at Risk for Suicide: An Examination of the Safety, Tolerability, and Outcomes of Cognitive Processing Therapy

Individuals with posttraumatic stress disorder (PTSD) are at increased risk for suicidal thoughts and behaviors; however, clinicians often report apprehension about recommending trauma-focused therapy to patients with an increased risk of suicide. The present study aimed to evaluate the safety, tolerability, and response to cognitive processing therapy (CPT) among a sample of military veterans with PTSD and increased suicide risk. A secondary aim was to provide a clinically useful definition of high suicide risk. Chart review was used to classify the suicide risk level of 290 veterans who participated in CPT at a Veterans Affairs clinic. Treatment outcomes in veterans with different suicide risk levels were also gathered and compared. Over 50% (n = 155) of the sample demonstrated increased suicide risk, and 1.0% (n = 3) engaged in suicidal behavior after initiating treatment. To date, hospital records show no suicide deaths since 2016 among clinic patients who received CPT. Suicide risk level was not associated with CPT tolerability, and PTSD symptom change was equivalent across groups, ps = .085-.976. Veterans across groups reported clinically significant reductions in PTSD symptoms. The tested suicide risk categorization schemes performed similarly in differentiating the odds of CPT completion and PTSD symptom reduction. These results suggest that veterans with PTSD and an increased risk of suicide, including those with previous suicide attempts and current ideation, can tolerate and benefit from CPT. Additional variables must be considered to truly determine the acute and imminent suicide risk that would deem CPT to be contraindicated.

Trauma on duty: cognitive functioning in police officers with and without posttraumatic stress disorder (PTSD)

BACKGROUND

Neuropsychological alterations co-occur with Posttraumatic Stress Disorder (PTSD); yet, the nature and magnitude of such alterations in police officers remains unknown despite their high level of trauma exposure.

OBJECTIVE

The current research sought to examine (1) cognitive functioning among police officers with and without PTSD; (2) the clinical significance of their cognitive performance; and (3) the relationship between PTSD symptoms and cognition.

METHOD

Thirty-one police officers with PTSD were compared to thirty age- and sex-matched trauma-exposed officers without PTSD. Clinical assessment and self-report questionnaires established PTSD status. All participants underwent a neuropsychological evaluation.

RESULTS

Police officers with PTSD displayed lower cognitive performance across several domains, notably executive functioning, verbal learning and memory, and lexical access, compared to controls. The neuropsychological decrements in the PTSD group were mild compared to normative data, with average performances falling within normal limits. Among officers with PTSD, higher levels of intrusion symptoms were associated with reduced efficacy in executive functioning, as well as attention and working memory. Moreover, increased intrusion and avoidance symptoms were associated with slower information processing speed.

CONCLUSION

Considering that even mild subclinical cognitive difficulties may affect their social and occupational functioning, it appears important to integrate neuropsychological assessments in the clinical management of police officers diagnosed with PTSD.

Does timing matter? Examining the impact of session timing on outcome

OBJECTIVE

First-line treatments for posttraumatic stress disorder (PTSD) are often implemented twice per week in efficacy trials. However, there is considerable variability in the frequency of treatment sessions (e.g., once per week or twice per week) in clinical practice. Moreover, clients often cancel or reschedule treatment sessions, leading to even greater variability in treatment session timing. The goal of the current study is to investigate the impact of PTSD treatment session frequency on treatment outcome.

METHOD

One hundred thirty-six women (Mage = 32.16 [SD = 9.90]) with PTSD were randomized to receive cognitive processing therapy or prolonged exposure. PTSD symptom outcome was measured using the Clinician-Administered PTSD Scale, and session frequency and consistency were measured using dates of treatment session attendance. Session frequency was operationalized using average days between session, and consistency was defined by the standard deviation of the number of days between treatment sessions.

RESULTS

Piecewise growth curve modeling revealed that higher average days between sessions was associated with significantly smaller PTSD symptom reduction, with more frequent sessions yielding greater PTSD symptom reduction (p < .001, d = .82). Higher consistency was also associated with significantly greater PTSD symptom reduction (p < .01, d = .48). The substantially larger effect size for frequency suggests that average days between treatment sessions impacts treatment outcome more than consistency. Follow-up analyses revealed a longer time interval between Sessions 4 and 5 was associated with smaller reductions in PTSD treatment outcome.

CONCLUSIONS

More frequent scheduling of sessions may maximize PTSD treatment outcomes. (PsycINFO Database Record

Inclusion and exclusion criteria in randomized controlled trials of psychotherapy for PTSD

OBJECTIVE

Posttraumatic stress disorder (PTSD) is a prevalent and often disabling condition. Fortunately, effective psychological treatments for PTSD are available. However, research indicates that these treatments may be underutilized in clinical practice. One reason for this underutilization may be clinicians' unwarranted exclusion of patients from these treatments based on their understanding of exclusion criteria used in clinical trials of psychological treatments for PTSD. There is no comprehensive and up-to-date review of inclusion and exclusion criteria used in randomized clinical trials (RCTs) of psychological treatments for PTSD. Therefore, our objective was to better understand how patients were excluded from such RCTs in order to provide guidance to clinicians regarding clinical populations likely to benefit from these treatments.

METHODS

We conducted a comprehensive literature review of RCTs of psychological treatments for PTSD from January 1, 1980 through April 1, 2012. We categorized these clinical trials according to the types of psychotherapy discussed in the major guidelines for treatment of PTSD and reviewed all treatments that were studied in at least two RCTs (N=64 published studies with 75 intervention arms since some studies compared two or more interventions). We abstracted and tabulated information concerning exclusion criteria for each type of psychotherapy for PTSD.

RESULTS

We identified multiple RCTs of cognitive behavioral therapy (n=56), eye movement desensitization and reprocessing (n=11), and group psychotherapy (n=8) for PTSD. The most common exclusions were psychosis, substance abuse and dependence, bipolar disorder, and suicidal ideation. Clinical trials varied in how stringently these criteria were applied. It is important to note that no exclusion criterion was used in all studies and there was at least one study of each type of therapy that included patients from each of the commonly excluded groups. A paucity of evidence exists concerning the treatment of patients with PTSD and four comorbidities: alcohol and substance abuse or dependence with current use, current psychosis, current mania, and suicidal ideation with current intent.

CONCLUSIONS

Psychological treatments for PTSD have been studied in broad and representative clinical populations. It appears that more liberal use of these treatments regardless of comorbidities is warranted.

Multicomponent behavioral treatment for chronic combat-related posttraumatic stress disorder: a randomized controlled trial

This study examined the efficacy of a multicomponent cognitive-behavioral therapy, Trauma Management Therapy, which combines exposure therapy and social emotional rehabilitation, to exposure therapy only in a group of male combat veterans with chronic posttraumatic stress disorder (PTSD). Thirty-five male Vietnam veterans with PTSD were randomly assigned to receive either Trauma Management Therapy (TMT) or Exposure Therapy Only (EXP). Participants were assessed at pre-treatment, mid-treatment, and post-treatment. Primary clinical outcomes were reduction of PTSD symptoms and improved social emotional functioning. Results indicated that veterans in both conditions showed statistically significant and clinically meaningful reductions in PTSD symptoms from pre- to post-treatment, though consistent with a priori hypotheses there were no group differences on PTSD variables. However, compared to the EXP group, participants in the TMT group showed increased frequency in social activities and greater time spent in social activities. These changes occurred from mid-treatment (after completion of exposure therapy) to post-treatment (after completion of the social emotional rehabilitation component); supporting the hypothesis that TMT alone would result in improved social functioning. Although the TMT group also had a significant decrease in episodes of physical rage, that change occurred prior to introduction of the social emotional component of TMT. This study demonstrates efficacy of exposure therapy for treating the core symptoms of PTSD among combat veterans with a severe and chronic form of this disorder. Moreover, multi-component CBT shows promise for improving social functioning beyond that provided by exposure therapy alone, particularly by increasing social engagement/interpersonal functioning in a cohort of veterans with severe and chronic PTSD.

Dialectical behavior therapy as a precursor to PTSD treatment for suicidal and/or self-injuring women with borderline personality disorder

This study examined the efficacy of dialectical behavior therapy (DBT) in reducing behaviors commonly used as exclusion criteria for posttraumatic stress disorder (PTSD) treatment. The sample included 51 suicidal and/or self-injuring women with borderline personality disorder (BPD), 26 (51%) of whom met criteria for PTSD. BPD clients with and without PTSD were equally likely to eliminate the exclusionary behaviors during 1 year of DBT. By posttreatment, 50-68% of the BPD clients with PTSD would have been suitable candidates for PTSD treatment. Borderline personality disorder clients with PTSD who began treatment with a greater number of recent suicide attempts and more severe PTSD were significantly less likely to become eligible for PTSD treatment.