Effectiveness of prolonged exposure for PTSD in older veterans

Factors Associated with Engaging in Evidence-Based Psychotherapy During the First Year of Posttraumatic Stress Disorder Treatment Between 2017 and 2019

To address the burden of posttraumatic stress disorder (PTSD), the Veterans Health Administration (VHA) implemented evidence-based psychotherapies (EBPs) for PTSD at all VHA medical centers. Prior investigations show EBP utilization has increased following the initial nationwide implementation. However, most patients still do not engage in EBPs and those who do often have substantial delays between diagnosis and treatment which is associated with poorer treatment outcomes. The goal of the current study is to identify patient and clinical factors associated with initiating EBP and completing a minimally adequate dose of treatment within the first year of a new PTSD diagnosis. Overall, 263,018 patients started PTSD treatment between 2017 and 2019 and 11.6% (n = 30,462) initiated EBP during their first year of treatment. Of those who initiated EBP, 32.9% (n = 10,030) received a minimally adequate dose. Older patients were less likely to initiate EBP, but more likely to receive an adequate dose when they did initiate. Black, Hispanic/Latino/a, and Pacific Islander patients' likelihood of initiating EBP was not significantly different than White patients, but these patients were less likely to receive an adequate dose. Patients with comorbid depressive disorders, bipolar disorder, psychotic disorders, or substance use disorders were less likely to initiate EBP, while patients reporting MST were more likely to initiate EBP. This study identifies several patient-level disparities that could be prioritized to increase EBP utilization. In our evaluation, most patients did not engage in EBP during their first year of PTSD treatment, which is consistent with previous evaluations of EBP utilization. Future research should focus on understanding the flow of patients from PTSD diagnosis to treatment to support effective PTSD care delivery.

The Association Between Service Connection and Treatment Outcome in Veterans Undergoing Residential PTSD Treatment

The Department of Veterans Affairs has invested significant time and resources into the treatment of posttraumatic stress disorder (PTSD). Despite concerted efforts, a significant portion of patients do not respond optimally to trauma-focused treatment. One of the factors that has been hypothesized to be associated with treatment response is participation in the Veterans Benefits Administration service-connected disability process. This factor may be particularly relevant in the residential treatment setting, where most participants are engaged in the compensation seeking process. We conducted a retrospective chart review of 105 veterans who completed Cognitive Processing Therapy (CPT) in a residential rehabilitation program. ANCOVAs that adjusted for baseline PTSD severity compared symptom change between those who were and were non-compensation seeking at the time of treatment. Compensation seeking status was associated with significantly less symptom improvement over the course of CPT after adjusting for baseline PTSD severity (F(1, 102) = 4.29, p < .001, η² = .03). Sensitivity analyses did not detect a similar effect during a prior coping skills phase of treatment. During CPT, clinically significant change was met by 66.7% of non-compensation seeking veterans (M = -15, SD = 14.56) and by 40.1% of the compensation seeking group (M = -7.1, SD = 12.24). Compensation-seeking may be associated with reduced response to trauma-focused treatment in certain settings. Future research is needed to better understand the mechanisms underlying this effect.

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.

A Review of PTSD Augmentation Strategies for Older Adults and Case of rTMS-Augmented Prolonged Exposure

Evidence-based psychotherapies such as prolonged exposure therapy (PE) are recommended by clinical practice guidelines as first-line treatments for post-traumatic stress disorder (PTSD) and are safe and acceptable for use with older adults. One third to one half of all patients do not achieve a clinically meaningful response to standard outpatient PE and recent research suggests that older adults in particular may experience barriers to full engagement and response. Standard treatment may be challenging in older adults due to cognitive, medical, and psychosocial barriers. This article reviews the current state of the evidence on adjunctive and second-tier interventions that show promise for increasing response and/or engagement in evidence-based psychotherapy for PTSD, including medications such as d-cycloserine and 3,4-methylenedioxy-methamphetamine, neuromodulation techniques such as repetitive transcranial magnetic stimulation, and augmentations to the structure and content of psychotherapy, such as intensive outpatient formats. A case illustration of successful application of multiple augmentations to PE with an initially nonresponsive older adult patient is presented. A creative interdisciplinary approach based in available research may be beneficial for older adults who do not respond to first-line treatments.

A randomized controlled trial of prolonged exposure therapy versus relaxation training for older veterans with military-related PTSD

OBJECTIVE

Although prolonged exposure (PE) has strong support for treating posttraumatic stress disorder (PTSD), there is little research on PE for older adults. Likewise, Relaxation Training (RT) has shown some benefit for PTSD, but has not been adequately tested in this population.

METHOD

This study represents the first randomized controlled trial of two active psychotherapies for PTSD among older adults. Male combat veterans (N = 87; mean age = 65 years) were randomly assigned to 12 sessions of PE (n = 41) or RT (n = 46). Clinician-administered and self-report assessments were conducted at pre-treatment, post-treatment, and six-month follow-up; self-reported symptoms were also measured at each treatment session.

RESULTS

Multi-level modeling indicated that Clinician-Administered PTSD Scale scores significantly decreased from pre-treatment to follow-up, but the time by treatment condition interaction was not significant. Pre- to post-treatment change was large in PE and moderate in RT, but many gains were lost at follow-up. For self-reported PTSD symptoms, a significant time by treatment condition interaction emerged, suggesting that participants who received PE had both greater decreases in symptoms and a greater rebound in self-reported PTSD symptoms than those who received RT. Unlike PTSD symptoms, depression symptoms neither changed nor were moderated by treatment condition from pre-treatment to follow-up. For self-reported PTSD and depression symptoms assessed at each session, time significantly predicted symptom reductions across psychotherapy sessions.

CONCLUSIONS

PE and RT are well-tolerated, feasible, and effective for older adults, though treatment gains were not maintained at follow-up.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00539279.

Factors associated with the receipt of documented evidence-based psychotherapy for PTSD in VA

OBJECTIVES

The VA has mandated that evidence-based psychotherapies (EBPs) be offered to patients with PTSD, but only a small minority of the psychotherapy delivered to VA patients with PTSD is a documented EBP. It is unknown what factors are associated with receiving a documented EBP.

METHOD

Patients who received an EBP in FY2015 that was documented using a templated progress note (N = 21,808) were compared with patients who received psychotherapy for PTSD that was not documented using a template (N = 251,886).

RESULTS

Among psychotherapy recipients, VA patients with markers of clinical complexity such as service connection for PTSD, comorbid bipolar or psychotic disorder, longer duration of PTSD diagnosis, and a benzodiazepine prescription for PTSD had lower odds of receiving a documented EBP.

CONCLUSIONS

Recipients of documented EBPs differed from those who did not receive documented EBPs on several sociodemographic characteristics and indicators of treatment need. A limitation of our study is that some individuals in the group without EBP documentation may still have received an EBP, but did not receive EBP documentation in the electronic health record. Nevertheless, our results suggest that high-need or complex VA patients with PTSD may be less likely to receive documented EBPs.

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.

[Psychotherapy for posttraumatic stress disorder in older adults]

BACKGROUND

In contrast to the high demographic relevance of the older population, relatively little is known about prevalence rates, the typologies/symptom profiles and effective therapeutic approaches for posttraumatic stress disorder (PTSD) in older adults.

AIM

The aim of the present article is to provide an overview of prevalence rates, typologies of PTSD and effective treatment approaches for PTSD in the elderly.

RESULTS

Compared to younger cohorts, the group of older people has a markedly lower PTSD prevalence in the vast majority of epidemiological studies. There is a comparable structure over all age classes (i. e. classes with low, moderate and high symptoms) with respect to the symptom profile of PTSD. There are currently only a few controlled treatment studies for the cohort of older adults. The published controlled or randomized controlled interventional studies suggest that trauma-focused and narrative approaches seem to be effective in the treatment of PTSD in the elderly.

CONCLUSION

Future research should take account of the results so far in order to verify the existing preliminary results and to deal with current limitations. Randomized controlled trials are required, which should include a heterogeneous sample of elderly people and examine different therapeutic approaches in their effectiveness and feasibility in this cohort.

Systematic Review of the Clinical Application of Exposure Techniques to Community-Dwelling Older Adults with Anxiety

OBJECTIVES

Although exposure techniques are a first-line intervention for anxiety, clear evidence is lacking for their efficacy in treating the prevalent and debilitating condition of late life anxiety. This study sought to review the current literature on use of exposure with community-dwelling older patients.

METHODS

Searches of electronic databases were conducted to identify articles published through December 7, 2016. Inclusion criteria were: 1) sample age > 55, 2) therapy that included exposure, 3) anxiety as a target of the treatment. Exclusion criteria were: 1) not available in English, 2) no quantitative data, 3) inpatient setting. Methodological data and findings were extracted from the articles chosen for review.

RESULTS

The 54 eligible articles presented a total of 16 case studies, 9 uncontrolled trials, 24 controlled trials, and 6 secondary studies. A majority of the studies were conducted in the U.S.A with participants who received individual treatment. In vivo and imaginal exposure were the most frequently delivered techniques, and most treatments were multicomponent. Most studies found a reduction in anxiety symptoms.

CONCLUSIONS

Important research gaps need to be addressed.

CLINICAL IMPLICATIONS

The surveyed research provides a modest foundation of evidence for mental health practitioners who wish to incorporate exposure into treatment plans.

Mental Health Treatment for Older Veterans Newly Diagnosed with PTSD: A National Investigation

OBJECTIVE

Older veterans are the largest cohort served by the U.S. Department of Veterans Affairs (VA). The aim of this study was to examine mental health service utilization among older veterans recently diagnosed with posttraumatic stress disorder (PTSD), with an interest in sociodemographic and clinical characteristics related to receipt and type of mental health treatment.

DESIGN

VA National administrative data set and pharmacy records.

SETTING

VA Healthcare System.

PARTICIPANTS

The sample comprised 96,249 veterans aged 50+ years who received a new diagnosis of PTSD between fiscal years 2008-2011.

MEASUREMENTS

Demographic/clinical characteristics and treatment variables (receipt of mental health treatment; number of days before first appointment; receipt of psychotherapy, medication, or combination treatment; type of medication; number of psychotherapy visits) were assessed and relations were examined using logistic, negative binomial, and Cox regressions.

RESULTS

The majority of older veterans with newly diagnosed PTSD received at least one follow-up mental health visit. Increasing age was associated with decreased odds of receipt of any type of mental health treatment, and psychiatric comorbidities and greater number of medical appointments were associated with increased odds of treatment. Among veterans who received treatment, increased age was associated with decreased odds of receiving both psychotherapy and pharmacotherapy, decreased number of psychotherapy visits, and increased waiting times.

CONCLUSION

Among older veterans recently diagnosed with PTSD in the VA healthcare system, older individuals, particularly those over 80 years old, are at risk of not receiving timely and appropriate mental health treatment, indicating targeted outreach to this population could be helpful in improving care.

Post-traumatic stress disorder in older adults: a systematic review of the psychotherapy treatment literature

OBJECTIVES

Older adults represent the fastest growing segment of the US and industrialized populations. However, older adults have generally not been included in randomized clinical trials of psychotherapy for post-traumatic stress disorder (PTSD). This review examined reports of psychological treatment for trauma-related problems, primarily PTSD, in studies with samples of at least 50% adults aged 55 and older using standardized measures.

METHODS

A systematic review of the literature was conducted on psychotherapy for PTSD with older adults using PubMed, Medline, PsychInfo, CINAHL, PILOTS, and Google Scholar.

RESULTS

A total of 42 studies were retrieved for full review; 22 were excluded because they did not provide at least one outcome measure or results were not reported by age in the case of mixed-age samples. Of the 20 studies that met review criteria, there were: 13 case studies or series, three uncontrolled pilot studies, two randomized clinical trials, one non-randomized concurrent control study and one post hoc effectiveness study. Significant methodological limitations in the current older adult PTSD treatment outcome literature were found reducing its internal validity and generalizability, including non-randomized research designs, lack of comparison conditions and small sample sizes.

CONCLUSION

Select evidence-based interventions validated in younger and middle-aged populations appear acceptable and efficacious with older adults. There are few treatment studies on subsets of the older adult population including cultural and ethnic minorities, women, the oldest old (over 85), and those who are cognitively impaired. Implications for clinical practice and future research directions are discussed.

Efficacy of Psychosocial Interventions in Men Over 55

Whether psychosocial treatments work equally well for late middle-aged and older men and women is unknown. For this critical review, sixteen studies were identified that examined psychosocial treatments for psychopathology in men age 55 and older. The preponderance of evidence showed that treatments worked at least as well in men as in women. Six studies reported statistically significant treatment effects in exclusively male participants. Methodological problems include weak research designs, small sample size, and absence of indication of clinical significance. There continues to be a paucity of research addressing the efficacy of psychosocial interventions for late middle-aged and older men. Researchers are encouraged to include racially and ethnically diverse older men in carefully controlled studies that examine clinically significant change.

Treatment of complicated grief in elderly persons: a randomized clinical trial

IMPORTANCE

Complicated grief (CG) is a debilitating condition, most prevalent in elderly persons. However, to our knowledge, no full-scale randomized clinical trial has studied CG in this population.

OBJECTIVE

To determine whether complicated grief treatment (CGT) produces greater improvement in CG and depressive symptoms than grief-focused interpersonal psychotherapy (IPT).

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial enrolling 151 individuals 50 years or older (mean [SD] age, 66.1 [8.9] years) scoring at least 30 on the Inventory of Complicated Grief (ICG). Participants were recruited from the New York metropolitan area from August 20, 2008, through January 7, 2013, and randomized to receive CGT or IPT. The main outcome was assessed at 20 weeks after baseline, with interim measures collected at 8, 12, and 16 weeks after baseline.

INTERVENTIONS

Sixteen sessions of CGT (n = 74) or IPT (n = 77) delivered approximately weekly.

MAIN OUTCOMES AND MEASURES

Rate of treatment response, defined as a rating from an independent evaluator of much or very much improved on the Improvement subscale of the Clinical Global Impression Scale.

RESULTS

Both treatments produced improvement in CG symptoms. Response rate for CGT (52 individuals [70.5%]) was more than twice that for IPT (24 [32.0%]) (relative risk, 2.20 [95% CI, 1.51-3.22]; P < .001), with the number needed to treat at 2.56. Secondary analyses of CG severity and CG symptom and impairment questionnaire measures confirmed that CGT conferred a significantly greater change in illness severity (22 individuals [35.2%] in the CGT group vs 41 [64.1%] in the IPT group were still at least moderately ill [P = .001]), rate of CG symptom reduction (1.05 ICG points per week for CGT vs 0.75 points per week for IPT [t633 = 3.85; P < .001]), and the rate of improvement in CG impairment (0.63 work and Social Adjustment Scale points per week with CGT and 0.39 points per week with IPT [t503 = 2.87; P = .004]). Results were not moderated by participant age.

CONCLUSIONS AND RELEVANCE

Complicated grief treatment produced clinically and statistically significantly greater response rates for CG symptoms than a proven efficacious treatment for depression (IPT). Results strongly support the need for physicians and other health care providers to distinguish CG from depression. Given the growing elderly population, the high prevalence of bereavement in aging individuals, and the marked physical and psychological impact of CG, clinicians need to know how to treat CG in older adults.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01244295.

Exposure-Based CBT for Older Adults After Fall Injury: Description of a Manualized, Time-Limited Intervention for Anxiety

Fall accidents among older adults can be devastating events that, in addition to their physical consequences, lead to disabling anxiety warranting the attention of mental health practitioners. This article presents "Back on My Feet," an exposure-based cognitive-behavioral therapy (CBT) protocol that is designed for older adults with posttraumatic stress disorder (PTSD), subthreshold PTSD, or fear of falling resulting from a traumatic fall. The protocol can be integrated into care once patients have been discharged from hospital or rehabilitation settings back to the community. Following a brief description of its development, the article presents a detailed account of the protocol, including patient evaluation and the components of the eight home-based sessions. The protocol addresses core symptoms of avoidance, physiological arousal/anxiety, and maladaptive thought patterns. Because older patients face different coping challenges from younger patients (for whom the majority of evidence-based CBT interventions have been developed), the discussion ends with limitations and special considerations for working with older, injured patients. The article offers a blueprint for mental health practitioners to address the needs of patients who may present with fall-related anxiety in primary care and other medical settings. Readers who wish to develop their expertise further can consult the online appendices, which include a clinician manual and patient workbook, as well as guidance on additional resources.

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.