Cognitive Processing Therapy For Veterans Research Articles

Quetiapine augmentation of cognitive processing therapy in veterans with posttraumatic stress disorder. Design and methodology of a pilot study

Background: The limited efficacy of first-line treatment of Posttraumatic Stress Disorder (PTSD) with selective serotonergic reuptake inhibitors commonly leads to the use of multiple medications that still fail to achieve symptomatic remission. VA/DOD guidelines identify trauma-focused psychotherapies as the evidence-based treatment for PTSD, but overall effectiveness is limited by reduced levels of patient engagement. Cognitive Processing Therapy (CPT) is the most widely-used trauma-focused therapy in the VA system for Veterans with PTSD. Our previous results based on a case series suggested that quetiapine mono therapy, but not risperidone or valproate, could increase engagement in CPT, thereby improving clinical outcomes through direct medication effects and indirectly through greater engagement in CPT.

Residential PTSD treatment outcomes during cognitive processing therapy for veterans with and without recent histories of cannabis use.

Prior evidence has suggested that cannabis use is associated with greater posttraumatic stress disorder (PTSD) symptom severity and worse outcomes following trauma-focused treatment. However, lack of high-quality randomized studies necessitates the use of clinical data to clarify the relationship between cannabis use and PTSD treatment to help inform clinical practice. A total of 114 veterans completed cognitive processing therapy in a residential PTSD treatment program. Differences in treatment response between cannabis users and nonusers were evaluated for measures of PTSD, depression, and posttraumatic growth using analysis of covariance to control for pretreatment scores and other drug use. At baseline, cannabis users reported higher levels of PTSD symptom severity relative to nonusers but reported similar levels of depression and posttraumatic growth. Significant differences between groups in the amount of change were not observed on any of the measures from before to after treatment; however, the total sample reported significant improvements in all measures of interest. These results suggest that PTSD treatment outcomes for cannabis users may be similar to nonusers when use is stopped during treatment. Additional data are needed regarding whether outcomes remain similar at follow-up, whether cannabis users maintain abstinence after treatment, and the impact of resumed cannabis use on PTSD symptoms. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Zonisamide as an Adjunctive Treatment to Cognitive Processing Therapy for Veterans With Posttraumatic Stress Disorder and Comorbid Alcohol Use Disorder: A Pilot Study.

There are high rates of comorbid alcohol use disorder (AUD) among those who have posttraumatic stress disorder (PTSD). Ideally, treatment for comorbidity should address both disorders simultaneously. Zonisamide, an anticonvulsant, may be effective in decreasing alcohol use and may attenuate symptoms of PTSD. Treatment strategies can include medication in combination with a proven evidence-based psychotherapy designed to treat PTSD, such as cognitive processing therapy (CPT). This 12-week pilot study was designed to test feasibility, acceptability, and preliminary efficacy of zonisamide (400 mg) as an adjunct to CPT for veterans with PTSD and comorbid AUD. Veterans (n = 24) with PTSD and current alcohol dependence were randomized in a 3:1 ratio to receive zonisamide or placebo in a double-blind fashion. All subjects received CPT enhanced to include sessions addressing drinking behavior. Subjects overall reported a significant decrease in drinking outcomes, craving, and symptoms of PTSD. Zonisamide was well-tolerated and easily administered with CPT, which was also well-tolerated. Exploratory analysis of comparison of groups suggests there was no advantage of zonisamide vs placebo in drinking or PTSD outcomes. There was a numeric but nonsignificant higher rate of abstinence with zonisamide (50%) vs placebo (33%). The interpretation of the results is limited by the pilot nature of this study. The combination of psychosocial treatment with medication management mimics real-world treatment. In order to isolate the individual contributions of medication vs psychotherapy a much larger study would need to be conducted. (Am J Addict 2020;29:515-524).

Cognitive Processing Therapy for Veterans with Posttraumatic Stress Disorder: What is the Median Effective Dose?

ObjectiveCognitive Processing Therapy (CPT) has been disseminated in the Veterans Health Administration (VHA) to treat posttraumatic stress disorder (PTSD). Identifying the median effective dose (MED) of CPT, the number of sessions at which the probability of experiencing clinically meaningful improvement (CMI) is 50%, can assist with treatment. MethodFrom a cohort of Iraq and Afghanistan war veterans who received PTSD psychotherapy in VHA between 2001-2017, veterans who received CPT with available PTSD symptom outcomes (PTSD Checklist; PCL) were identified using natural language processing (n=26,189). Cox proportional hazards regression was used to examine how number of CPT sessions, together with covariates, influenced CMI (10-point PCL reduction). Kaplan-Meier curves were plotted to determine MED. ResultsAt eight sessions, there was a 50% probability of experiencing CMI. The Cox proportional hazard regression indicated a greater likelihood of CMI in fewer sessions for veterans who received individual-only CPT versus any group CPT (HR:1.31, 95%CI:1.23-1.39). Kaplan-Meier curves indicated a 50% probability of experiencing CMI at seven sessions for veterans who received individual-only CPT versus ten sessions for veterans receiving any group CPT. LimitationsPCL data was not available for all veterans who received CPT or at each potential assessment point. Not all veterans continued in CPT until CMI was observed. ConclusionsThe MED of CPT was eight sessions. Fewer sessions were needed to reach MED for veterans who received individual versus group CPT. These results may help those who treat, research, and are recovering from PTSD through accurately anchoring treatment expectations and providing a marker of initial treatment response.

Predictors of change in cognitive processing therapy for veterans in a residential PTSD treatment program.

Cognitive processing therapy is an evidence-based treatment for posttraumatic stress disorder (PTSD); however, questions remain regarding variability in treatment response. A total of 123 veterans participated in group-based cognitive processing therapy (CPT) in residential PTSD treatment. Change over time in PTSD symptoms was modeled as a function of selected demographic and clinical variables. PTSD checklist (PCL) scores decreased by an average of 1 point per session (standard deviation [SD] = 0.1). Initial PCL scores were predicted by the Beck Depression Inventory-II (γ01 = 0.25; standard error [SE] = 0.08), Insomnia Severity Index (γ02 = 0.53; SE = 0.15), and Infrequency (F) scale of the Minnesota Multiphasic Personality Inventory-2 (γ03 = 0.09; SE = 0.04). Rate of change was predicted by the Somatic Complaints (RC1) scale (γ11 = -0.03; SE = 0.01) and the Antisocial Behavior (RC4) scale (γ12 = 0.02; SE = 0.01). These results provide insight into characteristics that may influence degree of benefit received from group-based CPT.

Predictors of differential PTSD treatment outcomes between veteran and civilian women after cognitive processing therapy.

This study used data from a recent randomized clinical trial (RCT) that found differences between women veterans and civilians in posttraumatic stress disorder (PTSD) treatment response, with civilians demonstrating greater improvement than did veterans. Despite having similar PTSD severity scores at baseline, veterans scored roughly 18 points higher than civilians did on the Clinician-Administered PTSD Scale (CAPS) at posttreatment (p < .01). This study sought to identify the clinical and treatment variables that were associated with the differential response to treatment demonstrated by the women in the RCT. Veteran (n = 21) and civilian (n = 105) women with PTSD received cognitive processing therapy (CPT) for PTSD. These secondary data analyses used structural equation modeling to investigate the role of 7 clinical and treatment variables to explain the reduced treatment response to CPT in veterans compared to civilians. Using structural equation modeling, we found that differences in CAPS scores at posttreatment were largely mediated by negative posttraumatic cognitions, as measured by the Posttraumatic Cognition Inventory (PTCI). Although veterans and civilians had similar PTCI scores at baseline, civilians had significantly lower PTCI scores at posttreatment, which predicted lower CAPS scores at posttreatment. This mediation appeared to be at least in part explained by lower treatment expectancies by veterans compared to civilians. Future research should be focused on further understanding and addressing these 2 treatment outcome predictors in an effort to reduce the gap in PTSD treatment outcomes between veterans and civilians. (PsycINFO Database Record

Repetitive TMS to augment cognitive processing therapy in combat veterans of recent conflicts with PTSD: A randomized clinical trial

BackgroundThe objective was to test whether repetitive Transcranial Magnetic Stimulation (rTMS) just prior to Cognitive Processing Therapy (CPT) would significantly improve the clinical outcome compared to sham rTMS prior to CPT in veterans with PTSD. MethodsVeterans 18–60 years of age with current combat-related PTSD symptoms were randomized, using a 1:1 ratio in a parallel design, to active (rTMS+CPT) versus sham (sham+CPT) rTMS just prior to weekly CPT for 12–15 sessions. Blinded raters evaluated veterans at baseline, after the 5th and 9th treatments, and at 1, 3, and 6 months post-treatment. Clinician Administered PTSD Scale (CAPS) was the primary outcome measure with the PTSD Checklist (PCL) as a secondary outcome measure. The TMS coil (active or sham) was positioned over the right dorsolateral prefrontal cortex (110% MT, 1Hz continuously for 30min, 1800 pulses/treatment). ResultsOf the 515 individuals screened for the study, 103 participants were randomized to either active (n = 54) or sham rTMS (n = 49). Sixty-two participants (60%) completed treatment and 59 (57%) completed the 6-month assessment. The rTMS+CPT group showed greater symptom reductions from baseline on both CAPS and PCL across CPT sessions and follow-up assessments, t(df ≥ 325) ≤ −2.01, p ≤ 0.023, one-tailed and t(df ≥ 303) ≤ −2.14, p ≤ 0.017, one-tailed, respectively. LimitationsParticipants were predominantly male and limited to one era of conflicts as well as those who could safely undergo rTMS. ConclusionsThe addition of rTMS to CPT compared to sham with CPT produced significantly greater PTSD symptom reduction early in treatment and was sustained up to six months post-treatment.

Safe and secure: Spiritually enhanced cognitive processing therapy for veterans with posttraumatic stress disorder.

Safe and secure: Spiritually enhanced cognitive processing therapy for veterans with posttraumatic stress disorder.

Response to Cognitive Processing Therapy in Veterans With and Without Obstructive Sleep Apnea.

Recent studies have called attention to the need for enhancing treatment outcome in trauma-focused psychotherapies, such as cognitive processing therapy (CPT), with veterans. Given the prevalence of posttraumatic-related sleep disturbances, and the role of sleep in emotional learning and processing, sleep quality may be a target for improving CPT outcome. Elevated rates of obstructive sleep apnea (OSA) have been reported in samples of veterans with posttraumatic stress disorder (PTSD); however, the impact of OSA on response to CPT is unclear. In this study, CPT outcome was examined in veterans with and without a diagnosis of OSA. Following chart review, 68 OSA-positive and 276 OSA-negative veterans were identified. Generalized estimating equations were used to compare between-group differences in weekly self-reported PTSD symptomatology. The OSA-positive veterans reported greater PTSD severity over the course of treatment and at posttreatment compared with veterans without OSA (B = -0.657). Additionally, OSA-positive veterans with access to continuous positive airway pressure (CPAP) therapy reported less PTSD severity relative to OSA-positive veterans without access to CPAP (B = -0.421). Apnea appears to be a contributing factor to the reduced effectiveness of evidence-based psychotherapy for veterans with PTSD; however, preliminary evidence indicates that CPAP therapy may help mitigate the impact of OSA on treatment outcome.

Alternative Intensive Therapy for PTSD

Alternative Intensive Therapy for PTSD

Latent class differences explain variability in PTSD symptom changes during cognitive processing therapy for veterans.

Latent class differences explain variability in PTSD symptom changes during cognitive processing therapy for veterans.

Cognitive Processing Therapy for veterans with comorbid PTSD and alcohol use disorders

Posttraumatic stress disorder (PTSD) and alcohol-use disorders (AUD) frequently present comorbidly in veteran populations. Traditionally those with alcohol dependence have been excluded from PTSD treatment outcome studies, thus we do not know how those with alcohol dependence may tolerate or respond to PTSD-specific interventions; no studies to date have examined the extent to which cognitive PTSD interventions are tolerated or effective for those with comorbid PTSD/AUD. The present study examines the extent to which CPT is tolerated by and effective in treating PTSD symptoms for veterans with PTSD and AUD, as compared to veterans with PTSD only in an outpatient treatment setting. Data were obtained through chart review of 536 veterans diagnosed with PTSD who had received at least 1 session of CPT at a Midwestern US Veterans Affairs hospital. Nearly half (n=264, 49.3%) of the veterans in the study exhibited a current or past AUD diagnosis. Participants were grouped into the following diagnostic groups: current AUD (past 12months), past AUD (prior to 12months), and no AUD. Participants completed an average of 9 sessions of CPT with no significant difference between AUD diagnostic groups on the number of CPT sessions completed. Individuals with past AUD had higher initial symptoms of self-reported PTSD symptoms than those with no AUD. All groups reported significant reductions in PTSD symptoms and depression over time. Overall, the results suggest that CPT appears well tolerated among veterans with comorbid AUD and is associated with significant reductions in symptoms of PTSD and depression in an outpatient treatment setting.

A Randomized Clinical Trial of Cognitive Processing Therapy for Veterans With PTSD Related to Military Sexual Trauma

In this randomized controlled clinical trial, the authors evaluated the effectiveness of cognitive processing therapy (CPT) in the treatment of self-reported and clinician-assessed posttraumatic stress disorder (PTSD) related to military sexual trauma (MST), along with depressive symptoms. Eighty-six veterans (73 female, 13 male) randomly assigned to receive 12 individual sessions of either CPT or present-centered therapy (PCT) were included in analyses. Blinded assessments occurred at baseline, posttreatment, and 2, 4, and 6 months posttreatment. Mixed-effects model analysis revealed a significant interaction between groups (p = .05, d = -0.85): At posttreatment, veterans who received CPT had a significantly greater reduction in self-reported, but not clinician-assessed, PTSD symptom severity compared to veterans who received PCT. All three primary outcome measures improved significantly, both clinically and statistically, across time in both treatment groups. Pre- and posttreatment effect sizes were mostly moderate to large (d = 0.30-1.02) and trended larger in the CPT group. Although the study was impacted by treatment fidelity issues, results provide preliminary evidence for the effectiveness of CPT in reducing self-reported PTSD symptoms in a population of veterans with MST, expanding on established literature that has demonstrated the effectiveness of CPT in treating PTSD related to sexual assault in civilian populations.

Supplemental Material for Latent Class Differences Explain Variability in PTSD Symptom Changes During Cognitive Processing Therapy for Veterans

Supplemental Material for Latent Class Differences Explain Variability in PTSD Symptom Changes During Cognitive Processing Therapy for Veterans

Cognitive processing therapy for veterans with military-related posttraumatic stress disorder.

Sixty veterans (54 men, 6 women) with chronic military-related posttraumatic stress disorder (PTSD) participated in a wait-list controlled trial of cognitive processing therapy (CPT). The overall dropout rate was 16.6% (20% from CPT, 13% from waiting list). Random regression analyses of the intention-to-treat sample revealed significant improvements in PTSD and comorbid symptoms in the CPT condition compared with the wait-list condition. Forty percent of the intention-to-treat sample receiving CPT did not meet criteria for a PTSD diagnosis, and 50% had a reliable change in their PTSD symptoms at posttreatment assessment. There was no relationship between PTSD disability status and outcomes. This trial provides some of the most encouraging results of PTSD treatment for veterans with chronic PTSD and supports increased use of cognitive- behavioral treatments in this population.