Dropout in a clinical trial for comorbid PTSD and MDD among US service members: Are pretreatment characteristics predictive?

OBJECTIVE: Despite effective treatment options for posttraumatic stress disorder (PTSD), many patients do not complete therapy. This includes U.S. active duty service members, yet factors linked to attendance in this population remain understudied and dropout remains difficult to predict. Additionally, most studies have not examined samples with PTSD and co-occurring major depressive disorder (MDD) despite high rates of comorbidity. METHOD: The current study explored predictors of dropout among service members with comorbid PTSD and MDD (N = 94) randomized to cognitive processing therapy enhanced with behavioral activation (BA + CPT) or CPT as part of a clinical trial. RESULTS: Using the Fournier approach, only two predictors were associated with lower dropout risk among over 20 examined: shorter duration between pretreatment assessment and Session 1 (p = .041) and past 3-month PTSD treatment engagement (p = .036). CONCLUSION: Results suggest the possible utility of early momentum in starting therapy and leveraging recent treatment to improve attendance. However, this study also highlights the possible limitations of commonly assessed pretreatment factors in predicting attendance and current challenges in measuring dropout risk. Strategies to improve prediction, such as shifting focus to assess modifiable factors and processes more proximal to dropout during treatment, may be needed.Trial registration: ClinicalTrials.gov identifier: NCT02874131.

A randomized controlled trial of surf and hike therapy for U.S. active duty service members with major depressive disorder.

BACKGROUND: Major depressive disorder (MDD) is the most prevalent mental health disorder worldwide, including among U.S. service members. In addition to evidence-based treatments, activity-based approaches have been shown to effectively treat depressive symptoms, particularly when they occur in the natural environment. METHODS: This study compared two activity-based interventions, Surf Therapy and Hike Therapy, on depression outcomes among 96 active duty service members with MDD. Participants were randomized to 6 weeks of Surf or Hike Therapy. Clinician-administered and self-report measures were completed at preprogram, postprogram, and 3-month follow-up. A brief depression/anxiety measure was completed before and after each activity session. RESULTS: Multilevel modeling results showed that continuous depression outcomes changed significantly over time (ps < .001). Although service members in Hike Therapy reported higher average depression scores than those in Surf Therapy, the trajectory of symptom improvement did not significantly differ between groups. Regarding MDD diagnostic status, there were no significant differences between the groups at postprogram (p = .401), but Surf Therapy participants were more likely to remit from MDD than were those in Hike Therapy at the 3-month follow-up (p = .015). LIMITATIONS: The sample consisted of service members, so results may not generalize to other populations. Most participants received concurrent psychotherapy or pharmacotherapy, and, although statistically accounted for, results should be interpreted in this context. CONCLUSIONS: Both Surf and Hike Therapies appear to be effective adjunctive interventions for service members with MDD. Research is needed to examine the effectiveness of these therapies as standalone interventions. TRIAL REGISTRATION: Clinical trials registration number NCT03302611; First registered on 05/10/2017.

Investigating the effects of suicide exposure among a clinical sample of active duty service members.

Suicide exposure warrants further investigation as a risk factor for suicide among military service members. This study aimed to examine associations among suicide exposure, suicidal ideation (SI), and psychological symptoms in a clinical sample of service members (N = 1,565, 64.4% suicide-exposed) and identify how one's relationship with the deceased impacts suicidality and psychological health in exposed individuals. A secondary analysis of cross-sectional survey data was conducted. Generalized linear regression analyses were used to identify associations between suicide exposure and both current SI and psychological symptoms among all participants; the associations between suicide exposure characteristics and psychological symptoms were only examined among exposed individuals. Exposure was not significantly associated with higher SI, ß = .007, SE = .16, p = .965, but was associated with PTSD, ß = 1.60, SE = 0.49, p = .001; anxiety, ß = .68, SE = .31, p = .031; and insomnia symptoms, ß = .98, SE = .25, p < .001. Among participants who had been exposed, high/long impact of exposure was positively associated with SI, ß = 0.94, SE = .26, p < .001, and psychological symptoms, PTSD: ß = 2.32, SE = .77, p = .002; anxiety: ß = 1.39, SE = .50, p = .005; insomnia: ß = .96, SE = .39, p = .015. Results illustrate the significant issue of suicide exposure within the military and show consideration of suicide exposure as a potential risk factor for adverse psychological outcomes is warranted.

Psychological comorbidity: Predictors of residential treatment response among U.S. service members with posttraumatic stress disorder.

Residential posttraumatic stress disorder (PTSD) research in military samples generally shows that in aggregate, PTSD symptoms significantly improve over the course of treatment but can remain at elevated levels following treatment. Identifying individuals who respond to residential treatment versus those who do not, including those who worsen, is critical given the extensive resources required for such programs. This study examined predictors of treatment response among 282 male service members who received treatment in a U.S. Department of Defense residential PTSD program. Using established criteria, service members were classified as improved, indeterminate (referent), or worsened in terms of self-reported PTSD symptoms. Multinomial logistic regression results showed that for PTSD symptoms, higher levels of pretreatment PTSD symptom severity were associated with significantly lower odds of being in the improved group, adjusted odds ratio (aOR) = 0.955, p = .018. In addition, service members who completed treatment were significantly more likely to be in the improved group, aOR = 2.488, p = .048. Longer average pretreatment nightly sleep duration, aOR = 1.157, p = .035, and more severe pretreatment depressive symptoms, aOR = 1.109, p = .014, were associated with significantly higher odds of being in the improved group. These findings reveal clinical characteristics better suited for residential PTSD treatment and highlight implications for comorbid conditions.

Gender differences in disorders comorbid with posttraumatic stress disorder among U.S. Sailors and Marines.

Psychological comorbidity, the co-occurrence of mental health disorders, is more often the rule than the exception among individuals with posttraumatic stress disorder (PTSD). Research shows that prevalence estimates for specific psychological disorders differ by gender; however, little is known about whether these patterns persist in the presence of a comorbid PTSD diagnosis. This study examined gender differences in prevalence estimates for conditions comorbid with PTSD using medical records for 523,626 active duty U.S. Sailors and Marines who entered the military over an 8-year period. Using chi-square tests of independence, we detected statistically significant gender differences for specific comorbid conditions in the subsample of 9,447 service members with a PTSD diagnosis. Women were more likely than men to have PTSD with comorbid adjustment, OR = 1.35; depressive, OR = 1.71; and generalized anxiety or other anxiety disorders, OR = 1.16, with the largest effects for eating, OR = 12.60, and personality disorders, OR = 2.97. In contrast, women were less likely than men to have a diagnosis of PTSD with comorbid alcohol use, OR = 0.69, and drug use disorders, OR = 0.72, with the largest effects for insomnia, OR = 0.42, and traumatic brain injury, OR = 0.17. No significant gender differences emerged for comorbid bipolar, obsessive-compulsive, panic/phobic, psychotic, or somatoform/dissociative disorders, ps = .029-.314. The results show gender differences in conditions comorbid with PTSD generally align with internalizing and externalizing dimensions. Differences in comorbidities with PTSD between women and men could have implications for treatment development and delivery.

Overcoming Adversity and Stress Injury Support (OASIS): Evaluation of Residential Treatment Outcomes for U.S. Service Members with Posttraumatic Stress Disorder.

Research on residential posttraumatic stress disorder (PTSD) treatment has predominantly focused on the U.S. veteran population, whereas limited research exists regarding active duty service members. The present study evaluated outcomes among service members who received treatment in the Department of Defense's only residential PTSD program, Overcoming Adversity and Stress Injury Support (OASIS). Over a 5-year period, 289 male service members with combat-related PTSD received treatment in the program. Service members completed an initial assessment and weekly PTSD and depression self-report measures during the 10-week program. Multilevel modeling results demonstrated statistically significant reductions in PTSD. On average, participants reported a 0.76-point reduction on the PTSD Checklist, B = -0.76, p < .001, for each additional week of treatment. Pretreatment symptom scores and fitness-for-duty status predicted PTSD symptoms across time. Weekly changes in depression symptoms were not statistically significant; however, a significant Time × Pretreatment Depression Severity interaction emerged. Service members with higher baseline levels of depression severity showed larger reductions in depression symptom severity than those with lower levels, B = -0.02, p = .020, although a sizeable minority continued to retain symptoms at diagnostic levels. Depression symptom change was not related to any other treatment- or service-related variables. Differing trajectories were found between service members whose symptoms improved over the course of residential treatment and those who did not. The results indicate that there were larger improvements in PTSD than depression symptoms and highlight the need to optimize care provision for service members with severe PTSD or comorbid symptoms.

Posttraumatic Stress Disorder Symptom Clusters in Service Members Predict New-Onset Depression Among Military Spouses.

Military operations in Iraq and Afghanistan have brought increased attention to posttraumatic stress disorder (PTSD) among service members and, more recently, its impact on spouses. Existing research has demonstrated that PTSD among service members is associated with depression among military spouses. In the current study, we extended these findings by using data from service member-spouse dyads enrolled in the Millennium Cohort Family Study for which the service member had evidence of PTSD (n = 563). Prospective analyses identified the association between PTSD symptom clusters reported by the service member and new-onset depression among military spouses. Over the 3-year study period, 14.4% of these military spouses met the criteria for new-onset depression. In adjusted models, service member ratings of symptoms in the effortful avoidance cluster, odds ratio (OR) = 1.61, 95% CI [1.03, 2.50], predicted an increased risk of new-onset depression among military spouses, whereas reexperiencing symptoms, adjusted OR = 0.57; 95% CI [0.32, 1.01], were marginally protective. These findings suggest that PTSD symptom clusters in service members differentially predict new-onset depression in military spouses, which has implications for treatment provision.

The Impact of Depression Severity on Treatment Outcomes Among Older Male Combat Veterans with Posttraumatic Stress Disorder.

Posttraumatic stress disorder (PTSD) and depression are highly comorbid within the veteran population. Research studies have yielded divergent findings regarding the effect of depression on PTSD treatment outcomes. The present study investigated the influence of pretreatment depression severity on PTSD and depression symptom trajectories among 85 older (i.e., ≥ 60 years) male veterans with military-related PTSD who received either prolonged exposure or relaxation training as part of a randomized controlled trial. Participants were categorized as having no/mild depression (n = 23) or moderate/severe depression (n = 62). The PTSD Checklist (PCL-S) and Patient Health Questionnaire (PHQ-9) were completed at pretreatment, each of 12 therapy sessions, posttreatment, and 6-month follow-up, for a total of up to 15 data points per participant. Multilevel modeling (MLM) was used to evaluate the impact of pretreatment depression severity on piecewise symptom trajectories (i.e., active treatment and follow-up periods) over time and to determine whether treatment condition moderated the trajectories. The final MLM results showed significant main effects of depression severity on PCL-S scores, B = 10.84, p = .043 and PHQ-9 scores, B = 7.09, p = .001, over time. No significant interactions emerged for either the PCL-S or PHQ-9, indicating that although older veterans with more severe depression endorsed higher PTSD and depression scores across time, the symptom trajectories were not moderated by depression severity, treatment condition, or their interaction.

Longitudinal trajectories of comorbid PTSD and depression symptoms among U.S. service members and veterans.

BACKGROUND: Posttraumatic stress disorder (PTSD) often co-occurs with other psychiatric disorders, particularly major depressive disorder (MDD). The current study examined longitudinal trajectories of PTSD and MDD symptoms among service members and veterans with comorbid PTSD/MDD. METHODS: Eligible participants (n = 1704) for the Millennium Cohort Study included those who screened positive at baseline for both PTSD (PTSD Checklist-Civilian Version) and MDD (Patient Health Questionnaire). Between 2001 and 2016, participants completed a baseline assessment and up to 4 follow-up assessments approximately every 3 years. Mixture modeling simultaneously determined trajectories of comorbid PTSD and MDD symptoms. Multinomial regression determined factors associated with latent class membership. RESULTS: Four distinct classes (chronic, relapse, gradual recovery, and rapid recovery) described symptom trajectories of PTSD/MDD. Membership in the chronic class was associated with older age, service branch, deployment with combat, anxiety, physical assault, disabling injury/illness, bodily pain, high levels of somatic symptoms, and less social support. CONCLUSIONS: Comorbid PTSD/MDD symptoms tend to move in tandem, and, although the largest class remitted symptoms, almost 25% of participants reported chronic comorbid symptoms across all time points. Results highlight the need to assess comorbid conditions in the context of PTSD. Future research should further evaluate the chronicity of comorbid symptoms over time.

Depression among military spouses: Demographic, military, and service member psychological health risk factors.

BACKGROUND: More than a decade of war has strained service members and their families and the psychological health of military spouses is a concern. This study uses data from the largest study of military families in the United States to examine the demographic, military-specific, and service member mental health correlates of probable diagnosis of major depressive disorder (MDD) among military spouses. METHODS: Data were from service member-spouse dyads from all branches of the U.S. military. Demographic and military-specific factors were assessed using administrative personnel records and survey data. RESULTS: Of the 9,038 spouses, 4.9% had a probable diagnosis of MDD. In unadjusted models, spouses of service members who deployed and experiencecd combat-related events, were enlisted, had a probable posttraumatic stress disorder (PTSD) diagnosis, or screened positive for alcohol misuse were more likely to screen positive for MDD. In adjusted models, only spouses married to enlisted service members or those with PTSD had increased risk for MDD. Other demographic and military-related factors associated with MDD in spouses included less educational attainment, unemployment, having four or more children, and having prior military service (although not currently serving in the military) in the adjusted models. CONCLUSIONS: Findings characterize demographic, military, and service member psychological health factors that are associated with depression among military spouses. These findings imply that deployment alone may not negatively affect military spouses, but rather it may be the mental health impact on the service member, especially PTSD that increases the odds for MDD among military spouses.

Prevalence of Posttraumatic Stress Disorder and Psychological Comorbidities Among U.S. Active Duty Service Members, 2006-2013.

Among active duty service members, posttraumatic stress disorder (PTSD) diagnoses have increased dramatically since 2000. Because psychiatric comorbidity is more common for PTSD than for other mental health disorders, we examined the prevalence estimates of disorders comorbid or trimorbid with PTSD in this study. The medical records of 523,626 female and male active duty Sailors and Marines who entered the U.S. military between 2006 and 2013 were examined for diagnoses of PTSD and 14 potentially comorbid disorders. Results showed that 1.8% of military members had a PTSD diagnosis; among those with PTSD, 83.3% had a comorbid mental health disorder, and 62.2% had a third (i.e., trimorbid) disorder. Most frequently, PTSD co-occurred with depressive disorder (49.0%), adjustment disorder (37.0%), generalized anxiety disorder (36.1%), and alcohol use disorder (26.9%). All disorders we examined were significantly more likely to be diagnosed in service members with PTSD than in those without PTSD, odds ratios = 1.52-29.63. For service members with PTSD, comorbid mental health disorders are the rule rather than the exception. Consequently, it is important that clinicians also assess for other disorders and select treatment options that address both PTSD and comorbid conditions.

Effectiveness of Cognitive Processing Therapy for Male and Female U.S. Veterans With and Without Military Sexual Trauma.

Military sexual trauma (MST) affects approximately 2% and 36% of male and female veterans, respectively, (e.g., Allard, Gregory, Klest, & Platt, 2011). Although the deleterious consequences of MST have been clearly established, few studies have explored treatment effectiveness for this population. Using archival data from a residential treatment program, the current study explored the effectiveness of cognitive processing therapy (CPT) in treating full or subthreshold posttraumatic stress disorder (PTSD) to compare U.S. veterans reporting an MST index trauma (MST-IT) to those without MST-IT. Of the 481 participants, 40.7% endorsed MST-IT. Multiway frequency analyses were utilized to compare men and women with and without MST on baseline demographic variables. Hierarchical linear models were constructed to investigate treatment outcome by MST status and sex. Results showed that 44.8%, 23.8%, and 19.6% of the variation in clinician- and self-reported PTSD and depression symptoms were explained by three models. Scores on all outcome measures significantly decreased over time for both groups. Additionally, women demonstrated a sharper decrease in PTSD symptoms over time than men. Lastly, men who reported MST-IT had higher PTSD symptoms than men without MST-IT on average. With no control group or random assignment, preliminary findings suggest residential treatment including CPT may be effective for MST-IT regardless of sex.

Mindful attention increases and mediates psychological outcomes following mantram repetition practice in veterans with posttraumatic stress disorder.

BACKGROUND: Several evidence-based treatments are available to veterans diagnosed with posttraumatic stress disorder (PTSD). However, not all veterans benefit from these treatments or prefer to engage in them. OBJECTIVES: The current study explored whether (1) a mantram repetition program (MRP) increased mindful attention among veterans with PTSD, (2) mindful attention mediated reduced PTSD symptom severity and enhanced psychological well-being, and (3) improvement in mindful attention was due to the frequency of mantram repetition practice. RESEARCH DESIGN: Data from a randomized controlled trial comparing MRP plus treatment as usual (MRP+TAU) or TAU were analyzed using hierarchical linear models. SUBJECTS: A total of 146 veterans with PTSD from military-related trauma were recruited from a Veterans Affairs outpatient PTSD clinic (71 MRP+TAU; 75 TAU). MEASURES: The Clinician Administered PTSD Scale (CAPS), PTSD Checklist (PCL), the Brief Symptom Inventory-18 depression subscale, Health Survey SF-12v2, and Mindfulness Attention Awareness Scale (MAAS) were used. Frequency of mantram repetition practice was measured using wrist-worn counters and daily logs. RESULTS: Intent-to-treat analyses indicated greater increases in mindful attention, as measured by the MAAS, for MRP+TAU as compared with TAU participants (P<0.01). Mindful attention gains mediated previously reported treatment effects on reduced PTSD symptoms (using both CAPS and PCL), reduced depression, and improved psychological well-being. Frequency of mantram repetition practice in turn mediated increased mindful attention. CONCLUSIONS: The MRP intervention and specifically, mantram practice, improved mindful attention in veterans with PTSD, yielding improved overall psychological well-being. MRP may be a beneficial adjunct to usual care in veterans with PTSD.

Comparing effectiveness of CPT to CPT-C among U.S. Veterans in an interdisciplinary residential PTSD/TBI treatment program.

Cognitive processing therapy (CPT) is a leading cognitive-behavioral treatment for posttraumatic stress disorder (PTSD) and a front-line intervention according to the U.S. Department of Veterans Affairs treatment guidelines. The original CPT protocol entails the creation of a written trauma account and use of cognitive therapy. Cognitive processing therapy-cognitive therapy only (CPT-C) does not involve a written account and in a previous study resulted in faster symptom improvement and fewer dropouts than standard CPT. This study sought to replicate these findings by comparing the effectiveness of CPT to CPT-C in a sample of 86 U.S. male veterans receiving treatment in a PTSD residential program for individuals with a history of traumatic brain injury. CPT and CPT-C were delivered in a combined individual and group format as part of a comprehensive, interdisciplinary treatment program. Outcomes were self- and clinician-reported PTSD and self-reported depression symptoms. Multilevel analysis revealed no significant difference for PTSD symptoms, but did show a greater decrease in depression at posttreatment (d = 0.63) for those receiving CPT. When an experiment-wise α correction was applied, this effect did not remain significant.

Interdisciplinary residential treatment of posttraumatic stress disorder and traumatic brain injury: effects on symptom severity and occupational performance and satisfaction.

OBJECTIVE. This study examined outcomes of an 8-wk residential treatment program for veterans with posttraumatic stress disorder (PTSD) and a history of traumatic brain injury (TBI). METHOD. Twenty-six veterans completed the Canadian Occupational Performance Measure, Clinician-Administered PTSD Scale, Beck Depression Inventory-2nd Edition, and PTSD Checklist before and after treatment. RESULTS. Veterans demonstrated significant improvements in occupational performance and satisfaction with their performance, as well as in PTSD and depression symptom severity after residential PTSD/TBI treatment. Additionally, improvements in occupational performance and satisfaction were associated with decreases in depression symptom severity. CONCLUSION. Although preliminary, results suggest that veterans with PTSD and a history of TBI experienced significant decreases in PTSD and depression symptom severity and improvement in self-perception of performance and satisfaction in problematic occupational areas. Changes in occupational areas and depression symptom severity were related, highlighting the importance of interdisciplinary treatment.

Residual posttraumatic stress disorder and depression symptoms following a residential posttraumatic stress disorder treatment program for U.S. active duty service members.

OBJECTIVE: Even after the most effective posttraumatic stress disorder (PTSD) treatments, symptoms often persist. Understanding residual symptoms is particularly relevant in military populations, who may be less responsive to PTSD interventions. METHOD: The sample consisted of 282 male service members who engaged in a residential PTSD treatment program at a military treatment facility that provided evidence-based PTSD psychotherapies and adjunctive interventions. PTSD and depression symptoms were assessed before and after treatment and weekly during treatment via the PTSD Checklist-Military Version and Patient Health Questionnaire-8. Logistic regression with Hochberg's step-up procedure compared the likelihood of individual residual symptoms between service members who did (n = 92, 32.6%) and did not (n = 190, 67.4%) experience clinically significant PTSD change (≥ 10-point PTSD Checklist-Military Version reduction). RESULTS: Not achieving clinically significant PTSD change was associated with greater odds of nearly all residual symptoms (OR = 2.03-6.18), excluding two Patient Health Questionnaire-8 items (appetite and psychomotor changes). Among service members experiencing clinically significant PTSD change, concentration difficulties (73.3%), physical reactions to reminders (71.1%), and intrusions (70.8%) were PTSD symptoms most likely to persist. Poor sleep (56.2%), low energy (50.0%), and concentration difficulties (48.3%) were the most common for depression. CONCLUSIONS: To our knowledge, this study is the first to examine residual PTSD and depression symptoms following residential PTSD treatment for active duty service members. Given the low rates of clinically significant PTSD change and the high frequency of residual symptoms, strategies may be needed to improve residential PTSD treatment outcomes in the military. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Gender Differences in Psychological Outcomes Following Surf versus Hike Therapy among U.S. Service Members.

BACKGROUND: Surf and hike therapies have demonstrated effectiveness as adjunct interventions for service members with major depressive disorder (MDD). This study explores gender differences in intervention outcomes following a pragmatic, randomized controlled trial of Surf and Hike Therapy for service members with MDD (N = 96; men, n = 46; women, n = 50). METHODS: Clinician-administered and self-report measures (depression, anxiety, positive affect, negative affect, resilience, and pain) were completed at preprogram, postprogram, and 3-month follow-up; brief measures (depression/anxiety and positive affect) were completed before and after each session. RESULTS: Multilevel modeling results showed that anxiety decreased from pre- to postprogram and significantly differed by gender (B = -2.26, p = 0.029), with women reporting greater reductions. The remaining outcomes from pre- to postprogram demonstrated significant improvements that did not differ by gender (ps = 0.218-0.733). There were no gender differences through follow-up (ps = 0.119-0.780). However, within sessions, women reported greater improvements in depression/anxiety (B = -0.93, p = 0.005) and positive affect (B = 3.73, p = 0.001). The change in positive affect scores within sessions was greater for women in Hike Therapy compared to men (p = 0.016). CONCLUSIONS: Overall, results demonstrate that both genders benefit from adjunctive Surf and Hike Therapies, but women exhibit a better response in terms of longer-term anxiety and immediate psychological outcomes.

PTSD, depression, and treatment outcomes: A latent profile analysis among active duty personnel in a residential PTSD program.

Depression frequently co-occurs with posttraumatic stress disorder (PTSD), including among active duty service members. However, symptom heterogeneity of this comorbidity is complex and its association with treatment outcomes is poorly understood, particularly among active duty service members in residential treatment. This study used latent profile analysis (LPA) to identify symptom-based subgroups of PTSD and depression among 282 male service members in a 10-week, residential PTSD treatment program with evidence-based PTSD psychotherapies and adjunctive interventions. The PTSD Checklist-Military Version and Patient Health Questionnaire-8 were completed by service members at pre- and posttreatment and weekly during treatment. Multilevel models compared subgroups on PTSD and depression symptom change across treatment. LPA indicated four subgroups provided optimal fit: Depressive (high depression severity, low PTSD avoidance; n = 33, 11.7%), Avoidant (high PTSD avoidance, moderate depression severity; n = 89, 31.6%), Moderate (moderate PTSD and depression severity; n = 27, 9.6%), and Distressed (high PTSD and depression severity; n = 133, 47.2%). Treatment response differed across classes for both PTSD and depression outcomes (time × LPA class interaction ps < 0.001). In PTSD models, post-hoc comparisons indicated the Moderate class was associated with less PTSD symptom improvement relative to the other classes (ps < 0.006). In depression models, symptom reduction was greatest for the Distressed and Depressive subgroups relative to the other two classes (ps < 0.009). Study results provide an initial model for two prevalent, impairing disorders among service members and show how these symptom-based subgroups may differentially respond to residential PTSD treatment.

Comparing response to cognitive processing therapy in military veterans with subthreshold and threshold posttraumatic stress disorder.

Research suggests that subthreshold posttraumatic stress disorder (PTSD) symptomatology is associated with increased risk for psychological and functional impairment, including increased risk for suicidal ideation. However, it does not appear that any studies to date have investigated whether subthreshold PTSD can effectively be treated with evidence-based, trauma-focused treatment. Accordingly, we tested response to cognitive processing therapy (CPT) in 2 groups of military veterans receiving care at a VA outpatient specialty clinic, 1 with subthreshold PTSD at pretreatment (n = 51) and the other with full, diagnostic PTSD (n = 483). Multilevel analysis revealed that both groups experienced a significant decrease in PTSD symptoms over the course of therapy (the full and subthreshold PTSD groups experienced an average decrease of 1.79 and 1.52 points, respectively, on the PTSD Checklist with each increment of time, which was coded from 0 at pretreatment to 13 at posttreatment). After controlling for pretreatment symptom severity, a between-groups difference was not found. These results suggest that CPT is an effective form of treatment among military veterans, and that its effectiveness does not differ between subthreshold and threshold groups.

The effectiveness of the National Veterans Summer Sports Clinic for veterans with probable posttraumatic stress disorder.

Introduction: Recreational and adaptive sports programs may be beneficial therapeutic interventions for improving psychological outcomes among veterans and service members with posttraumatic stress disorder (PTSD) because they provide opportunities for exercise, socialization, respite, and time outdoors. Although there are an increasing number of sports programs for veterans and service members with PTSD, data evaluating the outcomes of such programs are limited. Materials and methods: The sample included 74 U.S. veterans who participated in the National Veterans Summer Sports Clinic (NVSSC), an annual, week-long adaptive sports program in San Diego, California. Participants were categorized into two subgroups: those who met criteria for probable PTSD using the PTSD Checklist for DSM-5 (n = 20) and those who did not (n = 54). Participants completed self-report assessments before and after each daily activity, before and after the program, and 3 months following program completion. Results: Over the course of NVSSC program participation, the diagnostic subgroups (probable PTSD vs. no PTSD) did not significantly differ on changes in depression, positive affect, negative affect, or insomnia. Compared to those without PTSD, veterans with PTSD experienced greater reduction in generalized anxiety during the program (MD = -3.07, p = 0.034). Veterans with PTSD also experienced significant improvements in PTSD symptoms at postprogram (MD = -23.76, p < 0.001). For both groups, significant benefits were shown during the program but rebounded by the 3-month follow-up. Over the course of each daily activity, positive affect (MD = 2.71, p < 0.001) and depression/anxiety scores significantly decreased (MD = -0.75, p < 0.001), with no differences between PTSD diagnostic groups across time (ps = 0.714 and 0.961, respectively). Conclusion: Veterans with and without PTSD benefited from participation in the NVSSC. Participants with probable PTSD experienced greater improvements in generalized anxiety at postprogram only; there were no other significant differences between the two groups at postprogram or at 3-month follow-up. In line with prior research, benefits for those with PTSD were lost by 3-month follow-up, suggesting that regular engagement in recreational and adaptive sports may be necessary to sustain psychological health improvements.