State of the Science: Prolonged exposure therapy for the treatment of posttraumatic stress disorder.

Prolonged exposure therapy (PE) is a well-established first-line treatment for posttraumatic stress disorder (PTSD) that is based on emotional processing theory. PE has been rigorously evaluated and tested in a large number of clinical trials in many countries covering a wide range of trauma populations. In this review, we summarize the evidence base supporting the efficacy of PE across populations, including adults with sexual assault-related PTSD and mixed trauma-related PTSD, military populations, and adolescents. We highlight important strengths and gaps in the research on PE with individuals from marginalized communities. We discuss the efficacy of PE on associated psychopathology and in the presence of the most commonly comorbid conditions, either alone or integrated with other treatments. In addition, we provide an overview of research examining strategies to augment PE. Much of this work remains preliminary, but numerous trials have tested PE in combination with other psychological or pharmacological approaches, interventions to facilitate extinction learning, and behavioral approaches, in the hopes of further increasing the efficiency and efficacy of PE. There are now several trials testing PE in novel formats that may have advantages over standard in-person PE, such as lower dropout and increased scalability. We examine this recent work on new models of delivering PE, including massed treatment, telehealth, and brief adaptations for primary care, all of which have the potential to increase access to PE. Finally, we highlight several promising areas for future research.

A dynamical systems analysis of change in PTSD symptoms, depression symptoms, and suicidal ideation among military personnel during treatment for PTSD.

OBJECTIVE: The connections among posttraumatic stress disorder (PTSD), depression, and suicidal ideation are elusive because of an overreliance on cross-sectional studies. In this secondary analysis of pooled data from three clinical trials of 742 military personnel, we examined the dynamic relationships among PTSD, depression, and suicidal ideation severity assessed repeatedly during and after outpatient treatment for PTSD. METHODS: We conducted dynamical systems analyses to explore the potential for coordinated change over time in psychotherapy for PTSD. RESULTS: Over the course of psychotherapy, PTSD, depression, and suicidal ideation severity changed in coordinated ways, consistent with an interdependent network. Results of eigenvalue decomposition analysis indicated the dominant change dynamic involved high stability and resistance to change but indicators of cycling were also observed, indicating participants "switched" between states that resisted change and states that promoted change. Depression (B = 0.48, SE = 0.11) and suicidal desire (B = 0.15, SE = 0.01) at a given assessment were associated with greater change in PTSD symptom severity at the next assessment. Suicidal desire (B = 0.001, SE < 0.001) at a given assessment was associated with greater change in depression symptom severity at the next assessment. Neither PTSD (B = -0.004, SE = 0.007) nor depression symptom severity (B = 0.000, SE = 0.001) was associated with subsequent change in suicidal ideation severity. CONCLUSIONS: In a sample of treatment-seeking military personnel with PTSD, change in suicidal ideation and depression may precede change in PTSD symptoms but change in suicidal ideation was not preceded by change in PTSD or depression symptoms.

Predictors of clinical worsening during a discontinuation trial of serotonin reuptake inhibitors for obsessive compulsive disorder.

OBJECTIVE: To explore predictors and moderators of clinical worsening during a double-blind trial in which patients with obsessive-compulsive disorder (OCD) were randomized to either continue or discontinue their Serotonin Reuptake Inhibitor (SRI) medication after achieving wellness from the addition of exposure and response prevention (EX/RP) therapy. METHOD: The data came from a double-blind discontinuation trial that included N = 101 participants, 35 of whom were removed from the study due to clinical worsening. We first used LASSO logistic regression to identify which of the 34 potential baseline variables of interest (including demographics, diagnoses, other relevant clinical constructs, and specific genotypes), might moderate or predict this clinical worsening. Then logistic regression was used to examine which of these identified variables were significantly related to later clinical worsening. We verified the validity of our final prediction model using k-fold cross-validation. RESULTS: There was one significant predictor of clinical worsening: In both groups, those with more past diagnoses had a greater likelihood of clinical worsening (p = .015). There were several moderators. Rates of clinical worsening were higher in the Discontinuation group compared to the Continuation group for participants who were taking a shorter half-life SRI (p = .044), were female (p = .022), had higher baseline levels of maladaptive metacognitions (p < .001), had fewer sleep problems at baseline (p = .001), and/or had more years of education (p < .001). CONCLUSIONS: Our results identified several factors that may predict the development of clinical worsening in OCD patients discontinuing SRI medication following successful EX/RP treatment.

Efficacy and moderators of efficacy of cognitive behavioural therapies with a trauma focus in children and adolescents: an individual participant data meta-analysis of randomised trials.

BACKGROUND: Existing clinical trials of cognitive behavioural therapies with a trauma focus (CBTs-TF) are underpowered to examine key variables that might moderate treatment effects. We aimed to determine the efficacy of CBTs-TF for young people, relative to passive and active control conditions, and elucidate putative individual-level and treatment-level moderators. METHODS: This was an individual participant data meta-analysis of published and unpublished randomised studies in young people aged 6-18 years exposed to trauma. We included studies identified by the latest UK National Institute of Health and Care Excellence guidelines (completed on Jan 29, 2018) and updated their search. The search strategy included database searches restricted to publications between Jan 1, 2018, and Nov 12, 2019; grey literature search of trial registries ClinicalTrials.gov and ISRCTN; preprint archives PsyArXiv and bioRxiv; and use of social media and emails to key authors to identify any unpublished datasets. The primary outcome was post-traumatic stress symptoms after treatment (<1 month after the final session). Predominantly, one-stage random-effects models were fitted. This study is registered with PROSPERO, CRD42019151954. FINDINGS: We identified 38 studies; 25 studies provided individual participant data, comprising 1686 young people (mean age 13·65 years [SD 3·01]), with 802 receiving CBTs-TF and 884 a control condition. The risk-of-bias assessment indicated five studies as low risk and 20 studies with some concerns. Participants who received CBTs-TF had lower mean post-traumatic stress symptoms after treatment than those who received the control conditions, after adjusting for post-traumatic stress symptoms before treatment (b=-13·17, 95% CI -17·84 to -8·50, p<0·001, τ2=103·72). Moderation analysis indicated that this effect of CBTs-TF on post-traumatic stress symptoms post-treatment increased by 0·15 units (b=-0·15, 95% CI -0·29 to -0·01, p=0·041, τ2=0·03) for each unit increase in pre-treatment post-traumatic stress symptoms. INTERPRETATION: This is the first individual participant data meta-analysis of young people exposed to trauma. Our findings support CBTs-TF as the first-line treatment, irrespective of age, gender, trauma characteristics, or carer involvement in treatment, with particular benefits for those with higher initial distress. FUNDING: Swiss National Science Foundation.

Predictors of EX/RP alone versus EX/RP with medication for adults with OCD: does medication status moderate outcomes?

Exposure and response prevention (EX/RP) can be delivered as monotherapy or to augment serotonin reuptake inhibitors (SRIs). While both options are considered effective OCD treatments, responses are heterogenous. Substantial work has investigated EX/RP predictors to account for this variability in responses, with mixed findings. Little research has studied whether EX/RP predictors may differ in medicated versus non-medicated samples (i.e., medication status as a moderator). We pooled data from two clinical trials conducted concurrently in the same specialty OCD clinic. One enrolled patients who were on stable SRI doses (EX/RP as SRI augmentation, n=58) while the other enrolled non-medicated patients (EX/RP monotherapy, n=38). Both trials used the same manualized EX/RP protocol and blinded independent evaluators. LASSO regression derived predictors and moderators of outcome. Improvement did not significantly differ between the EX/RP alone group and the SRI+EX/RP group. In both groups, higher baseline OCD severity and worse quality of life predicted poorer outcome. OCPD traits moderated results: Patients with more severe OCPD traits had better outcomes from EX/RP monotherapy than those receiving EX/RP with SRIs. Patient adherence to EX/RP homework mediated the associations between the baseline variables and outcome. The effect of OCPD traits on outcome warrants future study to improve care.

Exposure Therapy and Its Mechanisms.

Exposure therapy is the gold-standard treatment approach for pathological anxiety. This therapeutic approach builds on principles of extinction training from traditional fear conditioning and extinction protocols. In this chapter, we discuss principles of exposure therapy in the clinic and the laboratory experimental results that guide our decisions in the therapy. We discuss emotional processing theory and inhibitory learning principles, with a focus on expectation violation. We conclude with future research directions needed to improve exposure therapy outcomes among patients with anxiety-related disorders.

DSM-5 criterion-a-based trauma types in service members and veterans seeking treatment for posttraumatic stress disorder.

OBJECTIVE: In posttraumatic stress disorder (PTSD), the assumption of the equipotentiality of traumas ignores potentially unique contexts and consequences of different traumas. Accordingly, Stein et al. (2012) developed a reliable typing scheme in which assessors categorized descriptions of traumatic events into six "types": life threat to self (LTS), life threat to other, aftermath of violence (AV), traumatic loss, moral injury by self (MIS), and moral injury by other (MIO). We extended this research by validating the typing scheme using participant endorsements of type, rather than assesor-based types. We examined the concordance of participant and assesor types, frequency, and validity of participant-based trauma types by examining associations with baseline mental and behavioral health problems. METHOD: Interviewers enrolled military personnel and veterans (N = 1,443) in clinical trials of PTSD and helped them select the most currently distressing Criterion-A trauma. Participants and, archivally, assessors typed the distressing aspect(s) of this experience. RESULTS: AV was the most frequently participant-endorsed type, but LTS was the most frequently rated worst part of an event. Although participants endorsed MIS and MIO the least frequently, these were associated with worse mental and behavioral health problems. The agreement between participants and assessors regarding the worst part of the event was poor. CONCLUSION: Because of discrepancies between participant and assessor typologies, clinical researchers should use participants' ratings, and these should trump assessor judgment. Differences in pretreatment behavioral and mental health problems across some participant-endorsed trauma types partially support the validity of the participant ratings. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Examining emotional processing theory and predictors of outcome in prolonged exposure for PTSD.

Prolonged exposure (PE) is an empirically supported treatment for posttraumatic stress disorder (PTSD). The current study examined multiple facilitators and indicators of emotional processing to identify key predictors of outcome in PE using observational coding methods. Participants were 42 adults with PTSD who received PE. Video recordings of sessions were coded to capture negative emotion activation, negative and positive trauma-related cognitions, and cognitive rigidity. Two variables emerged as predictors of PTSD symptom improvement assessed via self-report, but not clinical interview: a greater decrease in negative trauma-related cognitions and lower average cognitive rigidity. Peak emotion activation, reductions in negative emotions, and increases in positive cognitions did not predict PTSD improvement (self-report or clinical interview). Findings contribute to growing evidence highlighting the importance of cognitive change as part of emotional processing and as a key ingredient of PE, beyond activation and reduction in negative emotions. Implications for evaluating emotional processing theory and for clinical practice are discussed.

A multistep mediation model examining how consultation in prolonged exposure therapy affects PTSD treatment outcomes.

Prolonged exposure therapy (PE) is an evidence-based psychotherapy (EBP) for posttraumatic stress disorder (PTSD) that is underutilized in the military health system. Previous research suggests that postworkshop consultation is important for successful implementation. However, little is known about how consultation may relate to EBP adoption or patient outcomes. The present study addressed these gaps by examining associations between consultation, provider self-efficacy, use of PE, and patient outcomes using a multistep mediation model. This study used data from Foa et al. (2020), a two-armed randomized implementation trial comparing two PE training models: standard training (workshop only) and extended training (workshop + 6-8 months of postworkshop expert consultation) at three U.S. Army sites. Participants were patients with PTSD (N = 242) receiving care from the participating providers (N = 103). Providers who received extended training reported greater PE self-efficacy compared to standard training providers, but self-efficacy was unrelated to their use of PE components or to patient outcomes. Extended training providers used more PE components and had superior patient outcomes than standard training providers, and patient outcomes were mediated by the use of PE components. To our knowledge, this is the first study to demonstrate that EBP consultation leads to improved clinical outcomes for patients through increased use of the EBP. PE adoption (i.e., use of PE components in therapy) was not explained by increases in self-efficacy among providers who received extended training. Therefore, future research should assess how other factors may influence provider behavior in implementing EBPs. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Identifying trajectories of symptom change in adults with obsessive compulsive disorder receiving exposure and response prevention therapy.

Exposure and response prevention (EX/RP) is a recommended psychotherapy for obsessive-compulsive disorder (OCD). Yet, not all patients benefit equally from EX/RP. Prior studies have examined EX/RP predictors by predicting endpoint symptoms and/or pre-post symptom change, rather than accounting for trajectories of symptom change across treatment. We pooled data from four NIMH-funded clinical trials, yielding a large sample (N = 334) of adults who received a standard course of manualized EX/RP. Independent evaluators rated OCD severity using the Yale-Brown Obsessive-Compulsive Scale (YBOCS). Data were analyzed using growth mixture modeling (GMM) to detect subgroups of participants with similar trajectories of symptom change followed by multinomial logistic regression to identify baseline variables capable of predicting class membership. GMM revealed three distinct trajectory classes: 22.5% of the sample showed dramatic improvement (dramatic progress class), 52.1% showed moderate improvement (moderate progress class), and 25.4% showed little change (little to no progress class). Membership in the little to no progress class was predicted by baseline avoidance and transdiagnostic internalizing factor levels. These findings suggest that OCD symptom improvement with outpatient EX/RP occurs via distinct trajectories. These findings have implication regarding identifying treatment non-responders and personalizing treatment depending one's baseline characteristics in order to optimize treatment effectiveness.

Psychometric Properties of the Self-Injurious Thoughts and Behaviors Interview-Short Form Among U.S. Active Duty Military Service Members and Veterans.

We assessed the interrater reliability, convergent validity, and discriminant validity of the Self-Injurious Thoughts and Behaviors Interview-Short Form (SITBI-SF) in a sample of 1,944 active duty service members and veterans seeking services for posttraumatic stress disorder (PTSD) and related conditions. The SITBI-SF demonstrated high interrater reliability and good convergent and discriminant validity. The measurement properties of the SITBI-SF were comparable across service members and veterans. Approximately 8% of participants who denied a history of suicidal ideation on the SITBI-SF reported suicidal ideation on a separate self-report questionnaire (i.e., discordant responders). Discordant responders reported significantly higher levels of PTSD symptoms than those who denied suicidal ideation on both response formats. Findings suggest that the SITBI-SF is a reliable and valid interview-based measure of suicide-related thoughts and behaviors for use with military service members and veterans. Suicide risk assessment might be optimized if the SITBI-SF interview is combined with a self-report measure of related constructs.

Massed vs Intensive Outpatient Prolonged Exposure for Combat-Related Posttraumatic Stress Disorder: A Randomized Clinical Trial.

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.

Prevalence of Fibromyalgia Syndrome in Active-Duty Military Personnel.

OBJECTIVE: Previous research with civilian populations has found strong associations between fibromyalgia (FM) and posttraumatic stress disorder (PTSD). We undertook this study to investigate the prevalence of FM in military service members with and without PTSD. METHODS: Participants were active duty military personnel recruited into either an epidemiologic cohort study of service members before a military deployment or 1 of 3 PTSD treatment trials. Instruments used to document FM and PTSD included the PTSD Checklist-Stressor-Specific Version, the PTSD Symptom Scale-Interview, and the 2012 American College of Rheumatology FM questionnaire. RESULTS: Across the 4 studies, 4,376 subjects completed surveys. The prevalence of FM was 2.9% in the predeployment cohort, and the prevalence was significantly higher in individuals with PTSD (10.8%) compared with those without PTSD (0.8%). In the treatment trials, all of the participants met criteria for PTSD before starting treatment, and the prevalence of FM was 39.7%. CONCLUSION: The prevalence of FM in active duty service members preparing to deploy is similar to that reported for the general population of the US but is higher than expected for a predominantly male cohort. Furthermore, the prevalence of FM was significantly higher in service members with comorbid PTSD and was highest among those seeking treatment for PTSD. Further investigation is needed to determine the factors linking PTSD and FM.

Psychometric Properties of Malay Obsessive-compulsive Inventory-child Version (OCI-CV) in Malaysian Perspectives.

Background: This study aimed to examine the psychometric properties of reliability and validity of OCI-CV in a non-clinical sample of Malaysian children and adolescents. Method: Participants of school-age and adolescent students from Klang Valley School completed the 21-item Malay OCI-CV using Google Form. OCI-CV English version was translated backward and forward to the Malay language. Face validity was conducted first before distributing the questionnaire to the participants. Exploratory Factor analysis (EFA) and Confirmatory Factor Analysis (CFA) was conducted to evaluate the psychometric properties of OCI-CV. Results: A total of 102 school-age children and adolescents with a mean age of 15.96 years (male: 41.2%, female: 58.8%) participated in the study. The Malay OCI-CV showed high internal consistency, with Cronbach Alpha values of 0.90 for the whole scale. EFA showed multifactorial components. Five factors were labelled as "Washing / Ordering, Doubting, Obsessions, Checking, and Hoarding,". In the CFA, the five-factor model indicates adequate fit indices of (χ2/df = 1.51, RMSEA = .071, GFI = .824, AGFI = .769, NFI = .724, CFI = .880). Conclusion: The Malay OCI-CV has good psychometric properties and is suitable for use in the Malaysian context. Further validation studies should be conducted among a clinical population to enhance the generalization of this finding.

Divergent experiences of U.S. veterans who did and did not complete trauma-focused therapies for PTSD: A national qualitative study of treatment dropout.

Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) are first-line treatments for posttraumatic stress disorder (PTSD) and have been disseminated throughout the U.S. Veterans Health Administration. Treatment non-completion is common and lessens clinical effectiveness; however, prior work has failed to identify factors consistently associated with non-completion. Semi-structured interviews were conducted with a national sample of veterans who recently completed (n = 60) or did not complete (n = 66) PE or CPT. Non-completer interviews focused on factors that contributed to veterans' decisions to drop out and efforts undertaken to complete PE/CPT. Completer interviews focused on challenges faced in completing treatment and facilitators of completion. Transcripts were coded using a mixed deductive/inductive approach; constant comparison was used to identify differences between completers and non-completers. Completers and non-completers differed in the extent of treatment-specific therapist support received, therapists' flexibility in treatment delivery, the type of encouragement offered by the care team and social supports, their interpretation of symptom worsening, the perceived impact of treatment on functioning, and the impact of stressors on their treatment engagement. Treatment-specific therapist support, more patient-centered and flexible treatment delivery, leveraging the full care team, and addressing functional concerns are potential targets for PE and CPT engagement interventions.

The efficacy of 90-min versus 60-min sessions of prolonged exposure for PTSD: A randomized controlled trial in active-duty military personnel.

OBJECTIVE: Prolonged exposure (PE) therapy is a first-line posttraumatic stress disorder (PTSD) treatment, but the manualized 90-min session format constitutes a barrier to adopting PE in most settings because they use 60-min sessions for scheduling and billing. We examined whether 60-min PE sessions were as effective and efficient as 90-min PE sessions. METHOD: In total, 160 active-duty military personnel with PTSD were randomized to 8-15 sessions of 60- or 90-min PE sessions and assessed pre- and posttreatment, and 3- and 6-month posttreatment, using the Clinician Administered PTSD Scale for Diagnostic and Statistical Manual for Mental Disorders, 5th edition [DSM-5] (CAPS-5). Participants were also assessed weekly during treatment using the PTSD Checklist for DSM-5 (PCL-5). A 60-min PE was hypothesized to be noninferior to 90-min PE based on preliminary studies. RESULTS: Using intent-to-treat analyses, the 95% CI for the difference between 60- and 90-min PE was less than the noninferiority margin (4.69 for the CAPS-5 and 7.38 for the PCL-5) at all three endpoints, suggesting that the efficacy of 60-min PE was noninferior to that of 90-min PE. Similarly, the rate of improvement per session for 60-min PE was noninferior to the rate for 90-min sessions for the PCL-5. Sensitivity analyses and Bayes factors were consistent with these results. CONCLUSIONS: 60-min sessions of PE are noninferior to 90-min sessions with regard to both efficacy and efficiency. Thus, PE can be effectively delivered in shorter sessions, making it easier for behavioral health providers to implement within the military health system and in other mental health systems that use 60-min session appointments. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

"The effects of web-prolonged exposure among military personnel and veterans with posttraumatic stress disorder": Correction.

Reports an error in "The effects of web-prolonged exposure among military personnel and veterans with posttraumatic stress disorder" by Carmen P. McLean, Edna B. Foa, Katherine A. Dondanville, Christopher K. Haddock, Madeleine L. Miller, Sheila A. M. Rauch, Jeffery S. Yarvis, Edward C. Wright, Brittany N. Hall-Clark, Brooke A. Fina, Brett T. Litz, Jim Mintz, Stacey Young-McCaughan and Alan L. Peterson (Psychological Trauma: Theory, Research, Practice, and Policy, 2021[Sep], Vol 13[6], 621-631). In the original article, "for the STRONG STAR Consortium" was missing from the end of the author line. In addition, the numbering and text of the affiliations for Edward C. Wright, Brittany N. Hall-Clark, Brooke A. Fina, Brett T. Litz, Jim Mintz, Stacey Young-McCaughan, and Alan L. Peterson were incorrect because of duplicated affiliation details and associated typographical errors. Finally, in the References, "for the STRONG STAR Consortium" and "on behalf of the STRONG STAR Consortium" were missing from the ends of the author lists for Foa et al. (2018) and Resick et al. (2015), respectively. The online version of this article has been corrected. (The following abstract of the original article appeared in record 2020-86687-001). OBJECTIVE: Web-based treatments address many of the logistical and stigma-related barriers to in-person behavioral health care. Prior studies of web-based treatments for posttraumatic stress disorder (PTSD) did not employ gold-standard treatments and have not compared to in-person therapy. METHOD: We compared a web version of Prolonged Exposure Therapy, "Web-PE," to in-person Present-Centered Therapy (PCT) in a randomized controlled trial (RCT) with 40 military personnel with PTSD seeking treatment at Fort Hood, Texas. Due to recruitment challenges, we terminated the RCT and subsequently examined the effects of Web-PE in an uncontrolled open trial with 34 service members and veterans recruited nationwide. Both studies assessed PTSD, depressive symptoms, and health functioning at baseline and 1 and 3 months posttreatment; the RCT also included a 6-month assessment. RESULTS: Results of the RCT showed no differential impact for Web-PE and PCT, although more PCT participants achieved clinically significant change at one of the follow-up assessments. Both treatment conditions significantly reduced self-reported and blind independent interviewer-assessed symptoms of PTSD. Results of the open trial showed that Web-PE was associated with significant reductions in self-reported PTSD symptoms, with a much larger effect size than in the RCT. CONCLUSIONS: Web-PE significantly reduced PTSD symptoms in both studies, although the reductions in PTSD symptoms were greater among open trial participants, who were specifically seeking a web-based treatment. Future research should evaluate Web-PE relative to another web-based treatment. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Comparison of Prolonged Exposure vs Cognitive Processing Therapy for Treatment of Posttraumatic Stress Disorder Among US Veterans: A Randomized Clinical Trial.

Importance: Posttraumatic stress disorder (PTSD) is a prevalent and serious mental health problem. Although there are effective psychotherapies for PTSD, there is little information about their comparative effectiveness. Objective: To compare the effectiveness of prolonged exposure (PE) vs cognitive processing therapy (CPT) for treating PTSD in veterans. Design, Setting, and Participants: This randomized clinical trial assessed the comparative effectiveness of PE vs CPT among veterans with military-related PTSD recruited from outpatient mental health clinics at 17 Department of Veterans Affairs medical centers across the US from October 31, 2014, to February 1, 2018, with follow-up through February 1, 2019. The primary outcome was assessed using centralized masking. Tested hypotheses were prespecified before trial initiation. Data were analyzed from October 5, 2020, to May 5, 2021. Interventions: Participants were randomized to 1 of 2 individual cognitive-behavioral therapies, PE or CPT, delivered according to a flexible protocol of 10 to 14 sessions. Main Outcomes and Measures: The primary outcome was change in PTSD symptom severity on the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) from before treatment to the mean after treatment across posttreatment and 3- and 6-month follow-ups. Secondary outcomes included other symptoms, functioning, and quality of life. Results: Analyses were based on all 916 randomized participants (730 [79.7%] men and 186 [20.3%] women; mean [range] age 45.2 [21-80] years), with 455 participants randomized to PE (mean CAPS-5 score at baseline, 39.9 [95% CI, 39.1-40.7] points) and 461 participants randomized to CPT (mean CAPS-5 score at baseline, 40.3 [95% CI, 39.5-41.1] points). PTSD severity on the CAPS-5 improved substantially in both PE (standardized mean difference [SMD], 0.99 [95% CI, 0.89-1.08]) and CPT (SMD, 0.71 [95% CI, 0.61-0.80]) groups from before to after treatment. Mean improvement was greater in PE than CPT (least square mean, 2.42 [95% CI, 0.53-4.31]; P = .01), but the difference was not clinically significant (SMD, 0.17). Results for self-reported PTSD symptoms were comparable with CAPS-5 findings. The PE group had higher odds of response (odds ratio [OR], 1.32 [95% CI, 1.00-1.65]; P < .001), loss of diagnosis (OR, 1.43 [95% CI, 1.12-1.74]; P < .001), and remission (OR, 1.62 [95% CI, 1.24-2.00]; P < .001) compared with the CPT group. Groups did not differ on other outcomes. Treatment dropout was higher in PE (254 participants [55.8%]) than in CPT (215 participants [46.6%]; P < .01). Three participants in the PE group and 1 participant in the CPT group were withdrawn from treatment, and 3 participants in each treatment dropped out owing to serious adverse events. Conclusions and Relevance: This randomized clinical trial found that although PE was statistically more effective than CPT, the difference was not clinically significant, and improvements in PTSD were meaningful in both treatment groups. These findings highlight the importance of shared decision-making to help patients understand the evidence and select their preferred treatment. Trial Registration: ClinicalTrials.gov Identifier: NCT01928732.

Perceptions and experiences of web-prolonged exposure for posttraumatic stress disorder: A mixed-methods study.

OBJECTIVE: Web-based prolonged exposure therapy (Web-PE) has potential to increase the reach of effective posttraumatic stress disorder (PTSD) treatment. While there is initial support for the efficacy of Web-PE, no studies have examined the perceptions and experiences of participants receiving PE in this novel, Web based format. METHOD: We used a mixed-methods convergent design to examine and integrate quantitative and qualitative data of participant perceptions and experiences of Web-PE. Treatment-seeking active duty military personnel or veterans (N = 29) who received Web-PE completed posttreatment surveys about perceptions of Web-PE and a brief qualitative interview. Thematic coding was used to identify qualitative themes, which were integrated with quantitative data in a joint display. RESULTS: Although many were initially skeptical of experiencing benefit, participants reported that Web-PE was helpful. They appreciated the flexibility of online therapy and reported that self-motivation was important for engagement. Web-PE therapists were well-regarded, although additional therapist support and technical improvements to the Web-PE program were suggested. Scores on the perceptions of Web-PE survey, PTSD survey, and other quantitative data corroborated the qualitative themes. CONCLUSION: Perceptions and experience of Web-PE are favorable and help to highlight the strengths (e.g., flexibility) and challenges (e.g., requiring self-motivation) associated with Web-treatment for PTSD. The results of this study may inform further development of Web-PE or other Web-based treatment programs. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Maintenance of Wellness in Patients With Obsessive-Compulsive Disorder Who Discontinue Medication After Exposure/Response Prevention Augmentation: A Randomized Clinical Trial.

IMPORTANCE: Serotonin reuptake inhibitors (SRIs) are the only medications approved for obsessive-compulsive disorder (OCD), yet most patients taking SRIs exhibit significant symptoms. Adding exposure/response prevention (EX/RP) therapy improves symptoms, but it is unknown whether patients maintain wellness after discontinuing SRIs. OBJECTIVE: To assess whether patients with OCD who are taking SRIs and have attained wellness after EX/RP augmentation can discontinue their SRI with noninferior outcomes compared with those who continue their SRI therapy. DESIGN, SETTING, AND PARTICIPANTS: A 24-week, double-blind, randomized clinical trial was performed from May 3, 2013, to June 25, 2018. The trial took place at US academic medical centers. Participants included 137 adults with a principal diagnosis of OCD (≥1 year) who were taking an SRI (≥12 weeks), had at least moderate symptoms (defined as Yale-Brown Obsessive-Compulsive Scale [Y-BOCS] score ≥18 points), and received as many as 25 sessions of EX/RP therapy. Those who attained wellness (Y-BOCS score ≤14 points; 103 patients [75.2%]) were study eligible. Data were analyzed from June 29, 2019, to October 2, 2021. INTERVENTION: Participants were randomly assigned either to receive taper to placebo (taper group) or to continue their SRI (continuation group) and monitored for 24 weeks. MAIN OUTCOME AND MEASURES: The Y-BOCS score (range, 0-40 points) was the primary outcome; the Hamilton Depression Rating Scale (HDRS; range, 0-52 points) and the Quality-of-Life Enjoyment and Satisfaction Questionnaire-Short Form (Q-LES-Q-SF; range, 0%-100%) scores were secondary outcomes. Outcomes were assessed at 8 time points by independent evaluators who were blinded to randomization. The taper regimen was hypothesized to be noninferior to continuation at 24 weeks using a 1-sided α value of .05. RESULTS: A total of 101 patients (mean [SD] age, 31.0 [11.2] years; 55 women [54.5%]) participated in the trial: 51 patients (50.5%) in the taper group and 50 patients (49.5%) in the continuation group. At 24 weeks, patients in the taper group had noninferior results compared with patients in the continuation group (mean [SD] Y-BOCS score: taper group, 11.47 [6.56] points; continuation group: 11.51 [5.97] points; difference, -0.04 points; 1-sided 95% CI, -∞ to 2.09 points [below the noninferiority margin of 3.0 points]; mean [SD] HDRS score: taper group, 5.69 [3.84] points; continuation group, 4.61 [3.46] points; difference, 1.08 points; 1-sided 95% CI, -∞ to 2.28 points [below the noninferiority margin of 2.5 points]; mean [SD] Q-LES-Q-SF score: taper group, 68.01% [15.28%]; continuation group, 70.01% [15.59%]; difference, 2.00%; 1-sided 95% CI, -∞ to 6.83 [below the noninferiority margin of 7.75]). However, the taper group had higher rates of clinical worsening (23 of 51 [45%] vs 12 of 50 [24%]; P = .04). CONCLUSIONS AND RELEVANCE: Results of this randomized clinical trial show that patients with OCD who achieve wellness after EX/RP therapy could, on average, discontinue their SRI with noninferior outcomes compared with those who continued their SRI. Those who tapered the SRI had higher clinical worsening rates. Future research should evaluate if SRI half-life alters these rates. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01686087.