When to Change the Treatment Plan: An Analysis of Diminishing Returns in VA Patients Undergoing Prolonged Exposure and Cognitive Processing Therapy.

Evidence-based treatments for posttraumatic stress disorder (PTSD) often produce significant symptom reduction within eight sessions. However, some patients take longer to respond and a better understanding of predictors of later response can help guide treatment. In the current study, the cohort consisted of all VA patients with a PTSD diagnosis who received at least eight sessions of documented evidence-based treatment within a 6-month period in FY16-FY17 and had at least two PTSD symptom assessments. We examined the proportion of patients who achieved meaningful change (defined as at least 50% reduction in self-reported PTSD symptoms), both within the first eight sessions and subsequently. Fourteen percent of patients achieved meaningful change within eight sessions and 10% subsequently. Symptom change within the first eight sessions was highly predictive of subsequent change. Those who experienced at least 20% symptom reduction by session eight were twice as likely to subsequently achieve meaningful change as compared with all patients who continued treatment. Patients receiving service-connected disability compensation were less likely and White patients more likely to achieve meaningful change. Without some degree of symptom reduction by session eight, patients are unlikely to achieve meaningful change if treatment is not enhanced or changed.

Extending prolonged exposure for veterans with posttraumatic stress disorder: When is enough really enough?

Program evaluation data from 451 veterans treated with at least four sessions of prolonged exposure (PE) within a U.S. Department of Veterans Affairs outpatient posttraumatic stress disorder program were examined to explore to what degree change by Session 8 predicted achieving meaningful change (MC; 50% reduction on the Posttraumatic Stress Disorder Symptom Scale-Self-Report [PSS-SR]) after Session 8. The overall MC rate was 33.4%. A survival analysis determined the number of sessions required to achieve MC on the PSS-SR had a modal number of nine sessions. Logistic regressions found that younger veterans and those from more recent wars were more likely to achieve MC than the rest of the sample. An analysis of a subset of 156 patients who had more than eight sessions, had not achieved MC by Session 8, and had a Session 8 PSS-SR available found that those who had a reduction of at least 10% on the PSS-SR by Session 8 (71 patients) had a 42.3% rate of MC, while only 7.1% of the 85 patients with a less than 10% reduction by Session 8 went on to achieve MC. Approximately 636 post-Session 8 clinician hours were spent treating these 85 patients with PE to have only 6 achieve MC. These outcomes suggest that patients without an at least 10% reduction on the PSS-SR by Session 8 are unlikely to achieve MC with additional PE sessions; therefore, alternate treatments or augmentation of PE should be considered. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Combining group-based exposure therapy with prolonged exposure to treat U.S. Vietnam veterans with PTSD: a case study.

Group-based exposure therapy (GBET) of 16-week duration was developed to treat combat-related posttraumatic stress disorder (PTSD) and decreased PTSD symptoms in 3 noncontrolled open trials with low attrition (0%-5%). Group-based exposure therapy has not produced as much PTSD symptom reduction as Prolonged Exposure (PE) within a U.S. Veterans Affairs PTSD treatment program, although PE had more dropouts (20%). This pilot study was of a model that combined key elements of GBET with components of PE in an effort to increase the effectiveness of a group-based treatment while reducing its length and maintaining low attrition. Twice per week, 8 Vietnam combat veterans with PTSD were treated for 12 weeks, with an intervention that included 2 within-group war trauma presentations per participant, 6 PE style individual imaginal exposure (IE) sessions per participant, daily listening to recorded IE sessions, and daily in vivo exposure exercises. All completed treatment and showed Significant reductions on all measures of PTSD with large effect sizes; 7 participants no longer met PTSD criteria on treating clinician administered interviews and a self-report measure at posttreatment. Significant reductions in depression with large effect sizes and moderate reductions in PTSD-related cognitions were also found. Most gains were maintained 6 months posttreatment.

A pilot study of a 12-week model of group-based exposure therapy for veterans with PTSD.

Group-based exposure therapy (GBET) is an intensive group treatment that targets posttraumatic stress disorder (PTSD) symptoms through repeated imaginal and in vivo exposure. The purpose of the present study was to assess the feasibility and acceptability of a modified 12-week course of GBET (modified from the standard 16 weeks) and to examine its effectiveness in reducing veterans' PTSD symptoms. Participants were 10 male Operation Iraqi Freedom and Vietnam-era veterans recruited from a PTSD specialty clinic at a large Veterans Affairs Medical Center. All participants were retained and demonstrated clinically significant reductions in PTSD symptoms (η(2) = .84-.87) comparable to the standard protocol. The findings from this small sample indicate that the abbreviated 12-week GBET protocol is a potentially effective treatment for PTSD.

Comparing virtual reality exposure therapy to present-centered therapy with 11 U.S. Vietnam veterans with PTSD.

Eleven Vietnam veterans with war-related posttraumatic stress disorder (PTSD) were randomly assigned to 10 sessions of either virtual reality exposure (VRE) therapy within a computer-generated virtual Vietnam environment or present-centered therapy (PCT) that avoided traumatic content and utilized a problem-solving approach. Participants were assessed at pretreatment, posttreatment, and 6 months posttreatment by an independent assessor blind to treatment condition. Nine participants completed treatment with one dropout per condition. No significant differences emerged between treatments, likely due to insufficient power. Although comparison of mean changes in PTSD symptoms for the VRE and PCT conditions yielded a moderate effect size (d = 0.56) in favor of VRE at 6 months posttreatment, changes in PTSD scores were more variable, and therefore less reliable, within the VRE condition. The utility of VRE with older veterans with PTSD is discussed.

A field test of group based exposure therapy with 102 veterans with war-related posttraumatic stress disorder.

Group-based exposure therapy (GBET) was field-tested with 102 veterans with war-related posttraumatic stress disorder (PTSD). Nine to 11 patients attended 3 hours of group therapy per day twice weekly for 16-18 weeks. Stress management and a minimum of 60 hours of exposure was included (3 hours of within-group war-trauma presentations per patient, 30 hours of listening to recordings of patient's own war-trauma presentations and 27 hours of hearing other patients' war-trauma presentations). Analysis of assessments conducted by treating clinicians pre-, post- and 6-month posttreatment suggests that GBET produced clinically significant and lasting reductions in PTSD symptoms for most patients on both clinician symptoms ratings (6-month posttreatment effect size delta = 1.22) and self-report measures with only three dropouts.

Veterans seeking treatment for posttraumatic stress disorder: what about comorbid chronic pain?

Our primary aim was to document the rate of comorbidity of physician-diagnosed chronic pain conditions in veterans who were seeking treatment for posttraumatic stress disorder (PTSD). Chronic pain diagnoses (e.g., chronic low-back pain and osteoarthritis) were examined with retrospective chart review. Of the patients with PTSD, 66% had chronic pain diagnoses at pretreatment. These findings are consistent with previous studies that documented the high comorbidity of chronic pain and PTSD using samples of pain patients. Our secondary aim was to examine pain ratings before, during, and after PTSD treatment. Using data that were a part of clinical practice, we found that patients with more pain before treatment reported reductions in pain over the course of PTSD treatment and in the 4 months following treatment. While our results must be interpreted cautiously because of multiple confounding factors and the absence of experimental manipulation, they highlight the importance of PTSD and pain comorbidity.