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Peterson AL, Blount TH, Foa EB, Brown LA, McLean CP, Mintz J, Schobitz RP, DeBeer BR, Mignogna J, Fina BA, Evans WR, Synett S, Hall-Clark BN, Rentz TO, Schrader C, Yarvis JS, Dondanville KA, Hansen H, Jacoby VM, Lara-Ruiz J, Straud CL, Hale WJ, Shah D, Koch LM, Gerwell KM, Young-McCaughan S, Litz BT, Meyer EC, Blankenship AE, Williamson DE, Roache JD, Javors MA, Sharrieff AFM, Niles BL, Keane TM. Massed vs Intensive Outpatient Prolonged Exposure for Combat-Related Posttraumatic Stress Disorder: A Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2249422. [PMID: 36602803 PMCID: PMC9856757 DOI: 10.1001/jamanetworkopen.2022.49422] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
IMPORTANCE Improved, efficient, and acceptable treatments are needed for combat-related posttraumatic stress disorder (PTSD). OBJECTIVE To determine the efficacy of 2 compressed prolonged exposure (PE) therapy outpatient treatments for combat-related PTSD. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial was conducted among military personnel and veterans at 4 sites in Texas from 2017 to 2019. Assessors were blinded to conditions. Data were analyzed from November 2020 to October 2022. INTERVENTIONS The interventions were massed-PE, which included 15 therapy sessions of 90 minutes each over 3 weeks, vs intensive outpatient program PE (IOP-PE), which included 15 full-day therapy sessions over 3 weeks with 8 treatment augmentations. The IOP-PE intervention was hypothesized to be superior to massed-PE. MAIN OUTCOMES AND MEASURES Coprimary outcomes included the Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) (CAPS-5) and the PTSD Checklist for DSM-5 (PCL-5) administered at baseline and posttreatment follow-ups. Measures ranged from 0 to 80, with higher scores indicating greater severity. Diagnostic remission and reliable change were secondary outcomes. RESULTS Among 319 military personnel and veterans screened, 234 were randomized (mean [SD] age, 39.20 [7.72] years; 182 [78%] male participants), with 117 participants randomized to IOP-PE and 117 participants randomized to massed-PE. A total of 61 participants (26%) were African American, 58 participants (25%) were Hispanic, and 102 participants (44%) were White; 151 participants (65%) were married. Linear mixed-effects models found that CAPS-5 scores decreased in both treatment groups at the 1-month follow-up (IOP-PE: mean difference, -13.85 [95% CI, -16.47 to -11.23]; P < .001; massed-PE: mean difference, -14.13 [95% CI, -16.63 to -11.62]; P < .001). CAPS-5 change scores differed from 1- to 6-month follow-ups (mean difference, 4.44 [95% CI, 0.89 to 8.01]; P = .02). PTSD symptoms increased in massed-PE participants during follow-up (mean difference, 3.21 [95% CI, 0.65 to 5.77]; P = .01), whereas IOP-PE participants maintained treatment gains (mean difference, 1.23 [95% CI, -3.72 to 1.27]; P = .33). PCL-5 scores decreased in both groups from baseline to 1-month follow-up (IOP-PE: mean difference, -21.81 [95% CI, -25.57 to -18.04]; P < .001; massed-PE: mean difference, -19.96 [95% CI, -23.56 to -16.35]; P < .001) and were maintained at 6 months (IOP-PE: mean change, -0.21 [95% CI, -3.47 to 3.06]; P = .90; massed-PE: mean change, 3.02 [95% CI, -0.36 to 6.40]; P = .08). Both groups had notable PTSD diagnostic remission at posttreatment (IOP-PE: 48% [95% CI, 36% to 61%] of participants; massed-PE: 62% [95% CI, 51% to 73%] of participants), which was maintained at 6 months (IOP-PE: 53% [95% CI, 40% to 66%] of participants; massed-PE: 52% [95% CI, 38% to 66%] of participants). Most participants demonstrated reliable change on the CAPS-5 (61% [95% CI, 52% to 69%] of participants) and the PCL-5 (74% [95% CI, 66% to 81%] of participants) at the 1-month follow-up. CONCLUSIONS AND RELEVANCE These findings suggest that PE can be adapted into compressed treatment formats that effectively reduce PTSD symptoms. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03529435.
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Affiliation(s)
- Alan L. Peterson
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio
- Research and Development Service, South Texas Veterans Health Care System, San Antonio
- Department of Psychology, University of Texas at San Antonio, San Antonio
| | - Tabatha H. Blount
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio
| | - Edna B. Foa
- Center for the Treatment and Study of Anxiety, Department of Psychiatry, University of Pennsylvania, Philadelphia
| | - Lily A. Brown
- Center for the Treatment and Study of Anxiety, Department of Psychiatry, University of Pennsylvania, Philadelphia
| | - Carmen P. McLean
- Dissemination and Training Division, National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, California
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California
| | - Jim Mintz
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio
- Research and Development Service, South Texas Veterans Health Care System, San Antonio
- Department of Population Health Sciences, University of Texas Health Science Center at San Antonio, San Antonio
| | - Richard P. Schobitz
- Department of Behavioral Health, Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas
| | - Bryann R. DeBeer
- VISN-17 Center of Excellence for Returning War Veterans, Central Texas Veterans Health Care System, Waco
- Rocky Mountain Mental Illness Research Education and Clinical Center for Suicide Prevention, Department of Veterans Affairs, Aurora, Colorado
| | - Joseph Mignogna
- VISN-17 Center of Excellence for Returning War Veterans, Central Texas Veterans Health Care System, Waco
- Rocky Mountain Mental Illness Research Education and Clinical Center for Suicide Prevention, Department of Veterans Affairs, Aurora, Colorado
| | - Brooke A. Fina
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio
| | - Wyatt R. Evans
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio
| | - Samantha Synett
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio
- VISN-17 Center of Excellence for Returning War Veterans, Central Texas Veterans Health Care System, Waco
- Rocky Mountain Mental Illness Research Education and Clinical Center for Suicide Prevention, Department of Veterans Affairs, Aurora, Colorado
| | - Brittany N. Hall-Clark
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio
| | - Timothy O. Rentz
- Research and Development Service, South Texas Veterans Health Care System, San Antonio
| | - Christian Schrader
- Department of Behavioral Health, Carl R. Darnall Army Medical Center, Fort Hood, Texas
| | - Jeffrey S. Yarvis
- Department of Behavioral Health, Carl R. Darnall Army Medical Center, Fort Hood, Texas
- School of Social Work, Tulane University, New Orleans, Louisiana
| | - Katherine A. Dondanville
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio
| | - Hunter Hansen
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio
| | - Vanessa M. Jacoby
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio
| | - Jose Lara-Ruiz
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio
- Department of Psychology, University of Texas at San Antonio, San Antonio
| | - Casey L. Straud
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio
- Research and Development Service, South Texas Veterans Health Care System, San Antonio
- Department of Psychology, University of Texas at San Antonio, San Antonio
| | - Willie J. Hale
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio
- Department of Psychology, University of Texas at San Antonio, San Antonio
| | - Dhiya Shah
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio
- Research and Development Service, South Texas Veterans Health Care System, San Antonio
| | - Lauren M. Koch
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio
| | - Kelsi M. Gerwell
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio
| | - Stacey Young-McCaughan
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio
- Research and Development Service, South Texas Veterans Health Care System, San Antonio
| | - Brett T. Litz
- Department of Psychiatry, School of Medicine, Boston University, Boston, Massachusetts
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston
- Department of Psychological and Brain Sciences, School of Arts and Sciences, Boston University, Boston, Massachusetts
| | - Eric C. Meyer
- VISN-17 Center of Excellence for Returning War Veterans, Central Texas Veterans Health Care System, Waco
- Department of Rehabilitation Science and Technology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Abby E. Blankenship
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio
| | - Douglas E. Williamson
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, North Carolina
- Durham VA Health Care System, Durham, North Carolina
| | - John D. Roache
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio
- Research and Development Service, South Texas Veterans Health Care System, San Antonio
| | - Martin A. Javors
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio
| | - Allah-Fard M. Sharrieff
- Department of Behavioral Health, Carl R. Darnall Army Medical Center, Fort Hood, Texas
- Department of Homeland Security, Miami, Florida
| | - Barbara L. Niles
- Department of Psychiatry, School of Medicine, Boston University, Boston, Massachusetts
- Behavioral Science Division, National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts
| | - Terence M. Keane
- Department of Psychiatry, School of Medicine, Boston University, Boston, Massachusetts
- Behavioral Science Division, National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts
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