Cognitive Processing Therapy Research Articles

Depression Suppresses Treatment Response for Traumatic Loss-Related Posttraumatic Stress Disorder in Active Duty Military Personnel.

There are multiple well-established evidence-based treatments for posttraumatic stress disorder (PTSD). However, recent clinical trials have shown that combat-related PTSD in military populations is less responsive to evidence-based treatments than PTSD in most civilian populations. Traumatic death of a close friend or colleague is a common deployment-related experience for active duty military personnel. When compared with research on trauma and PTSD in general, research on traumatic loss suggests that it is related to higher prevalence and severity of PTSD symptoms. Experiencing a traumatic loss is also related to the development of prolonged grief disorder, which is highly comorbid with depression. This study examined the association between having traumatic loss-related PTSD and treatment response to cognitive processing therapy in active duty military personnel. Participants included 213 active duty service members recruited across two randomized clinical trials. Results showed that service members with primary traumatic loss-related PTSD (n = 44) recovered less from depressive symptoms than those who reported different primary traumatic events (n = 169), B = -4.40. Tests of mediation found that less depression recovery suppressed recovery from PTSD symptoms in individuals with traumatic loss-related PTSD, B = 3.75. These findings suggest that evidence-based treatments for PTSD should better accommodate loss and grief in military populations.

Developing an integrated intervention to address intimate partner violence and psychological distress in Congolese refugee women in Tanzania

BackgroundMulti-sectoral, integrated interventions have long been recommended for addressing mental health and its social determinants (e.g., gender-based violence) in settings of ongoing adversity. We developed an integrated health and protection intervention to reduce psychological distress and intimate partner violence (IPV), and tested its delivery by lay facilitators in a low-resource refugee setting.MethodsFormative research to develop the intervention consisted of a structured desk review, consultation with experts and local stakeholders (refugee incentive workers, representatives of humanitarian agencies, and clinical experts), and qualitative interviews (40 free list interviews with refugees, 15 key informant interviews). Given existing efforts by humanitarian agencies to prevent gender-based violence in this particular refugee camp, including with (potential) perpetrators, we focused on a complementary effort to develop an integrated intervention with potential to reduce IPV and associated mental health impacts with female IPV survivors. We enrolled Congolese refugee women with elevated psychological distress and past-year histories of IPV (n = 60) who received the intervention delivered by trained and supervised lay refugee facilitators. Relevance, feasibility and acceptability of the intervention were evaluated through quantitative and qualitative interviews with participants. We assessed instrument test-retest reliability (n = 24), inter-rater reliability (n = 5 interviews), internal consistency, and construct validity (n = 60).ResultsWe designed an 8-session intervention, termed Nguvu (‘strength’), incorporating brief Cognitive Processing Therapy (focused on helping clients obtaining skills to overcome negative thoughts and self-perceptions and gain control over the impact these have on their lives) and Advocacy Counseling (focused on increasing autonomy, empowerment and strengthening linkages to community supports). On average, participants attended two-thirds of the sessions. In qualitative interviews, participants recommended adaptations to specific intervention components and provided recommendations regarding coordination, retention, safety concerns and intervention participation incentives. Analysis of the performance of outcome instruments overall revealed acceptable reliability and validity.ConclusionsWe found it feasible to develop and implement an integrated, multi-sectoral mental health and IPV intervention in a refugee camp setting. Implementation challenges were identified and may be informative for future implementation and evaluation of multi-sectoral strategies for populations facing ongoing adversity.Trial registrationISRCTN65771265, June 27, 2016.

A Case Report of Cognitive Processing Therapy Delivered Over a Single Week

Although evidence-based treatments for posttraumatic stress disorder (PTSD), such as Cognitive Processing Therapy (CPT), have been developed and widely disseminated, the rate of veterans engaging in and completing these therapies is low. Alternative methods of delivery may be needed to help overcome key barriers to treatment. Delivering evidence-based therapies intensively may address practical barriers to treatment attendance as well as problems with avoidance. This report details the case of a combat veteran who received 10 sessions of Cognitive Processing Therapy delivered twice per day over a single, 5-day workweek (CPT-5). Posttreatment, the veteran reported large and clinically meaningful decreases in PTSD and depression symptom severity as well as in guilt cognitions, which is a purported mechanism of successful treatment. These effects persisted 6 weeks after treatment ended. Despite the intensive nature of the treatment, the veteran found CPT-5 tolerable and could cite many benefits to completing therapy in 1 workweek. In conclusion, CPT-5 holds promise as a way to efficiently deliver an evidence-based therapy that is both clinically effective and acceptable to patients, although more rigorous clinical trials are needed to test this treatment delivery format.

Bidirectional Relationships Between Posttraumatic Stress Disorder and Social Functioning During Cognitive Processing Therapy

This study investigated temporal relationships between posttraumatic stress symptoms and two indicators of social functioning during cognitive processing therapy. Participants were 176 patients (51.5% female, M age = 39.46 [SD = 11.51], 89.1% White, 42.6% active duty military/veteran) who participated in at least two assessment time points during a trial of cognitive processing therapy. Posttraumatic stress disorder (PTSD) symptoms (PTSD Checklist for DSM-IV) and interpersonal relationship and social role functioning problems (Outcome Questionnaire–45) were assessed prior to each of 12 sessions. Multivariate multilevel lagged analyses indicated that interpersonal relationship problems predicted subsequent PTSD symptoms (b = .22, SE = 0.09, cr = 2.53, p = .01, pr = .46) and vice versa (b = .05, SE = 0.02, cr = 2.11, p = .04, pr = .16); and social role functioning problems predicted subsequent PTSD symptoms (b = .21, SE = 0.10, cr = 2.18, p = .03, pr = .16) and vice versa (b = .06, SE = 0.02, cr = 3.08, p < .001, pr = .23). Military status moderated the cross-lag from social role functioning problems to PTSD symptoms (b = –.35, t = –2.00, p = .045, pr = .16). Results suggest a robust association between PTSD symptoms and social functioning during cognitive processing therapy with a reciprocal relationship between PTSD symptoms and social functioning over time. Additionally, higher social role functioning problems for patients with military status indicate smaller reductions in PTSD symptoms from session to session.

Therapist stuck points during training in cognitive processing therapy: Changes over time and associations with training outcomes.

Therapist stuck points during training in cognitive processing therapy: Changes over time and associations with training outcomes.

Patterns of Treatment Disengagement and Personality Traits Associated With Posttraumatic Stress Disorder in Recent-Era U.S. Veterans Receiving Cognitive Processing Therapy.

Low treatment engagement is a barrier to implementation of empirically supported treatments for posttraumatic stress disorder (PTSD) among veterans. Understanding personality traits that predict dropout may help focus attempts to improve engagement. The current study included 90 veterans who served in recent conflicts in Iraq and/or Afghanistan and participated in a trial of cognitive processing therapy for PTSD. Goals were to characterize (a) personality correlates of PTSD, (b) patterns of engagement (i.e., attendance and homework completion), and (c) personality correlates of reduced engagement. Higher levels of PTSD symptoms were associated with a range of characteristics, including affective lability, r = .44 p < .001; anxiety, r = .38, p < .001; identity problems, r = .57, p < .001; intimacy problems, r = .34, p = .001; low affiliation, r = .33, p = .002; oppositionality, r = .36, p = .001; restricted expression, r = .35, p = .001; and suspiciousness, r = .50, p < .001. Notably, veterans with worse PTSD symptoms endorsed more cognitive dysregulation, r = .40, p < .001; and less insecure attachment, r = .14, p = .190, than expected. Only 52.2% of veterans completed the 12-session course of treatment and 31.0% of participants completed fewer than six sessions. Personality traits did not predict attendance or homework completion. Disengagement continues to be a significant issue in trauma-focused treatment for veterans with PTSD. Understanding veteran-level factors, such as personality traits, may be useful considerations for future research seeking to understand and improve engagement.

Adapting Evidence-Based Psychotherapies While Maintaining Fidelity

Extensive resources have been devoted to implementing evidence-based psychotherapies (EBPs) to facilitate the best available treatments to clients. Yet, when treatment settings or client characteristics do not align with the contexts in which an EBP was developed and tested, adaptations may be indicated. The purpose of this article is to provide a summary of the adaptation literature and highlight key issues, using Cognitive Processing Therapy as an example throughout the paper. Informed by the literature to date, we use Stirman and colleagues’ Framework for Reporting Adaptations and Modifications (FRAME) to organize current thinking and provide a guide for conceptualizing different types of adaptations. Broadly, we discuss (1) why adapt, (2) goals of the adaptation, (3) who is involved in the adaptation process, (4) when to adapt, (5) forms of adaptation, and (6) measurement and evaluation. As effective interventions for PTSD are developed and identified, implementation in routine care settings will increase access for underserved populations, who may not have been well-represented in the research that originally established efficacy or effectiveness of the EBP. However, a careful process of EBP adaptation, informed by theory, research, and program-level evaluation, can result in successful implementation. Stakeholder-informed, carefully-evaluated adaptation can allow more individuals to benefit from treatment.

Pilot Trial of a Combined Cognitive Processing Therapy and Smoking Cessation Treatment.

Posttraumatic stress disorder (PTSD) and smoking are often comorbid. Combining PTSD and smoking cessation treatments could increase access to each treatment and could provide improved rates of smoking cessation through reductions in PTSD and depressive symptoms. Participants were veterans with current PTSD who smoked cigarettes and were willing to initiate treatment for both problems. We conducted a randomized pilot trial (n = 40) to explore feasibility and estimate effect sizes of a treatment combining trauma-focused Cognitive Processing Therapy (CPT) with smoking cessation counseling and pharmacotherapy, relative to the same smoking cessation treatment without CPT. Rates of bioverified 7-day point prevalence smoking abstinence at the end of treatment or at 6-month follow-up were similar across treatments. Relative to the comparison, the combined CPT and smoking cessation treatment were associated with moderate-to-large effect sizes at end of treatment for reductions in PTSD symptoms, Cohen's d = 0.718, 95% confidence interval (CI) = 0.078-1.358, that decreased by the 6-month follow-up, Cohen's d = 0.306, 95% CI = -0.334 to 0.946; and large reductions in depressive symptoms that were maintained to the 6-month follow-up, Cohen's d = 1.007, 95% CI = 0.367-1.647. This pilot trial did not detect a difference in smoking cessation when combining CPT to smoking cessation treatment, relative to smoking cessation treatment without CPT. However, results suggest that combining CPT and smoking cessation treatment was associated with both reductions of psychiatric symptoms along with smoking abstinence rates similar to previous smoking cessation trials in veterans with PTSD.

Changes in suicidal ideation following cognitive processing therapy in a VA residential treatment program

ABSTRACT In 2015, suicide accounted for over 44,000 deaths and was the 10th leading cause of mortality in the US. Although Veterans, in general, are at a high risk for suicide, Veterans with Posttraumatic Stress Disorder (PTSD) are at even greater risk. While evidence suggests that PTSD symptoms are reduced by Cognitive Processing Therapy (CPT), little is known about how this treatment impacts changes in suicidal ideation across residential treatment. Studies with active duty personnel have found reductions in suicidal ideation following CPT treatment; however, only one study to date has examined this question in a Veteran sample. The current study examined (a) changes in suicidal ideation across a residential CPT treatment program and (b) the influence of demographic variables on change in suicidal ideation across treatment. Participants (N = 303) were admitted to a residential PTSD treatment in a VA medical center and completed pre-, mid-, and post-treatment assessments. Multilevel modeling of archival data revealed that suicidal ideation significantly decreased over the course of CPT (B = −0.153, SE =0.028, 95%CI =[−0.21, −0.10], t= −5.40, p< .001); however, this change did not differ based on age, marital status, sex, or race/ethnicity. Clinical and research implications are discussed.

Summary of the clinical practice guideline for the treatment of posttraumatic stress disorder (PTSD) in adults.

The American Psychological Association (APA) developed a clinical practice guideline (CPG) to provide recommendations on psychological and pharmacological treatments for posttraumatic stress disorder (PTSD) in adults. This paper is a summary of the CPG, including the development process. Members of the guideline development panel (GDP) used a comprehensive systematic review conducted by the Research Triangle Institute-University of North Carolina Evidence-based Practice Center (RTI-UNC EPC) as its primary evidence base (Jonas et al., 2013). The GDP consisted of health professionals from psychology, psychiatry, social work, and family medicine as well as community members who self-identified as having had PTSD. PTSD symptom reduction and serious harms were selected by the GDP as critical outcomes for making recommendations. The GDP strongly recommends use of the following psychotherapies/interventions (in alphabetical order) for adults with PTSD: cognitive-behavioral therapy, cognitive processing therapy, cognitive therapy, and prolonged exposure therapy. The GDP conditionally recommends the use of brief eclectic psychotherapy, eye movement desensitization and reprocessing (EMDR), and narrative exposure therapy (NET). For medications, the GDP conditionally recommends the following (in alphabetical order): fluoxetine, paroxetine, sertraline, and venlafaxine. There is insufficient evidence to recommend for or against offering Seeking Safety, relaxation, risperidone, and topiramate. A subgroup of the GDP reviewed studies published after the systematic review for those treatments that received substantive recommendations; the GDP concluded that future systematic reviews that incorporated those new studies could change the recommendations for EMDR and NET from conditional to strong. For all other treatments, results of the update indicated that recommendations were unlikely to change or that there were no new trials for comparison. The target audience for this CPG includes clinicians, researchers, patients, and policymakers. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Weekly Changes in Blame and PTSD Among Active-Duty Military Personnel Receiving Cognitive Processing Therapy

Both negative posttraumatic cognitions and posttraumatic stress disorder (PTSD) symptoms decrease over the course of cognitive-behavior therapy for PTSD; however, further research is needed to determine whether cognitive change precedes and predicts symptom change. The present study examined whether weekly changes in blame predicted subsequent changes in PTSD symptoms over the course of cognitive processing therapy (CPT). Participants consisted of 321 active duty U.S. Army soldiers with PTSD who received CPT in one of two clinical trials. Symptoms of PTSD and blame were assessed at baseline and weekly throughout treatment. Bivariate latent difference score modeling was used to examine temporal sequential dependencies between the constructs. Results indicated that changes in self-blame and PTSD symptoms were dynamically linked: When examining cross-construct predictors, changes in PTSD symptoms were predicted by prior changes in self-blame, but changes in self-blame were also predicted by both prior levels of and prior changes in PTSD. Changes in other-blame were predicted by prior levels of PTSD, but changes in other-blame did not predict changes in PTSD symptoms. Findings highlight the dynamic relationship between self-blame and PTSD symptoms during treatment in this active military sample.

Overlap Between PTSD, TBI Symptoms Creates Challenges for Diagnosing Patients

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessOverlap Between PTSD, TBI Symptoms Creates Challenges for Diagnosing PatientsAaron LevinAaron LevinSearch for more papers by this authorPublished Online:27 Jun 2019https://doi.org/10.1176/appi.pn.2019.6b20AbstractA patient’s symptoms and history of trauma are not enough for determining a diagnosis.Traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD) often overlap, both in their traumatic cause and in their symptoms; thus, differentiating between the two can be critical for treatment and determination of disability.Teasing out the symptomatic differences and similarities between PTSD and TBI―especially in patients diagnosed with both―requires great care, said panelists (from left) Elspeth Cameron Ritchie, M.D., M.P.H., Keith Caruso, M.D., Jeffrey Guina, M.D., and U.S. Air Force Capt. Brandon Withers.David HathcoxPeople with either condition may exhibit sleep problems, depression, flashbacks, avoidance, light or noise sensitivity, or irritability.Several physiological mechanisms come into play to produce those outcomes, said U.S. Air Force Capt. Brandon Withers, administrative chief resident in the Department of Psychiatry at Wright State University in Dayton, Ohio, during a session at APA’s 2019 Annual Meeting in San Francisco. The immune system is activated in the face of tissue damage and imminent threat, as are neuroendocrine and catecholaminergic mechanisms, he said.“It’s difficult to tease out which of these systems you’re dealing with based only on symptoms and a history of trauma,” said Withers. “Rating scales designed to measure PTSD versus postconcussion syndrome symptoms should not be presumed specific in the setting of potential comorbidity.”Application for disability status in the armed forces is diametrically opposite from the civilian world, said Jeffrey Guina, M.D., a former Air Force psychiatrist now at the Center for Forensic Psychiatry in Saline, Mich. In the U.S. military, the claimant gets the benefit of the doubt. Among civilians, the burden of proof is on the claimant.As a private disability consultant for the insurance company Lincoln Financial Group, Keith Caruso, M.D., of Brentwood, Tenn., is often called on to evaluate claims of disability by individuals with PTSD or TBI.“Neuropsychological findings found in both PTSD and TBI include deficits in attention, verbal memory, and response inhibition, although cognitive deficits in PTSD are typically less severe than in TBI,” said Caruso. Neuropsychological testing can reveal findings specific to TBI, such as changes in IQ or memory problems, processing speed, and executive function. Headaches, dizziness, tinnitus, and disequilibrium are also common. Comparing those symptoms with those of PTSD, even when there is some overlap, can help differentiate the two conditions and guide appropriate treatment.In military populations, the overlap is unsurprising, given the frequency of roadside bomb attacks during the recent conflicts in Iraq and Afghanistan, said former U.S. Army psychiatrist Elspeth Cameron Ritchie, M.D., M.P.H.“PTSD always has comorbidities,” said Ritchie. Soldiers who survive a bomb attack may have both concussive symptoms but also other physical wounds ranging from genital injuries to facial burns. They may already be sleep deprived and may develop depression or alcohol abuse.There are three types of treatment, said Ritchie: “Medications, psychotherapy, and everything else.”Only sertraline and paroxetine have been approved for use with PTSD but sometimes other medications are used, too. Ritchie has found success with bupropion because it does not induce weight gain and can reverse the sexual side effects of selective serotonin reuptake inhibitors, she said. Low doses of a second-generation antipsychotic like quetiapine may help with trauma-induced nightmares, although their use is controversial. Prazosin has also been used to reduce nightmares.Patients seen at the Veterans Health Administration seeking psychotherapy most commonly receive cognitive-behavioral therapy and cognitive processing therapy. Patients tend to benefit most from these therapies when informed in advance of treatment that it involves extended discussion of the traumatic episode.Patients with PTSD and TBI also may benefit from acupuncture, exercise, virtual reality technology, yoga, or working with dogs or horses—all based on the idea that the patients have some control over their therapy, Ritchie said. ■ ISSUES NewArchived

Videoconferencing psychotherapy for veterans with PTSD: Results from a randomized controlled non-inferiority trial

Introduction Veterans with post-traumatic stress disorder (PTSD) face significant barriers that make it less likely for them to pursue treatment. A randomized controlled non-inferiority trial was used to determine if providing psychotherapy for PTSD via videoconference (VC) is as effective as in-person (IP) psychotherapy. Methods All eligible veterans (n = 207) received cognitive processing therapy (CPT) to treat PTSD symptoms in one of the two treatment modalities. Participant symptoms were collected at baseline, post-treatment, and six months after treatment completion. The primary outcome measure, the Clinician-Administered PTSD Scale (CAPS), was used to assess PTSD diagnosis and symptom severity. Secondary outcomes included two self-report measures of symptom severity, the Post-traumatic Stress Disorder Checklist – Specific (PCL–S) for PTSD and the Patient Health Questionnaire – 9 (PHQ–9) for depressive symptoms. A linear mixed-effects model was used to assess non-inferiority for participants who completed treatment (completers) and those who were randomized to treatment (intention-to-treat (ITT)). Results Both completer and ITT analyses showed that improvement in CAPS scores in the VC condition was non-inferior to that in the IP condition at six-month follow-up, but VC was inferior to IP for improvement in CAPS at post-treatment. Non-inferiority was supported by completer analyses for PCL–S and PHQ–9 in both post-treatment change and six-month follow-up change, and the ITT analysis supported the significant non-inferiority for PCL at post-treatment change. Discussion These findings generally suggest that CPT delivered via VC can be as effective as IP for reducing the severity of PTSD symptoms.

Evaluating an Internet-based video cognitive processing therapy intervention for veterans with PTSD: A pilot study

Introduction There remain a number of UK military veterans who are not able to access psychological therapies for post-traumatic stress disorder (PTSD). Some of these barriers are practical, including the need to balance work and other life commitments with attendance at residential or outpatient appointments. There is a need to investigate more accessible and flexible methods of delivering psychological therapies to veterans. One such alternative is to use remote-access video technology, often referred to as tele-therapy. The aims of the present study were to explore the feasibility of using tele-therapy in this population, whilst also reporting mental health outcomes for those who accessed the intervention. Methods Participants were recruited from a UK veterans mental health charity. The intervention consisted of 12 sessions of cognitive processing therapy delivered via Skype. Participants completed various measures of mental health, including PTSD at three time points: pre-treatment, post-treatment and at three months follow-up. A measure of therapeutic alliance was also completed by participants and the clinician. Results A total of 27 participants engaged in tele-therapy, with a treatment completion rate of 79% and a ‘did not attend’ rate of 12%, which compared well against similar outpatient services. All mental health outcomes showed maintained improvement at three months follow-up, with the highest effect size recorded for PTSD. Therapeutic alliance was also rated highly by both participants and the clinician. Discussion The findings suggest that tele-therapy could provide a viable alternative format for delivering trauma-focused psychological therapies to veterans. Limitations and recommendations for future research are also presented.

Culturally modified cognitive processing therapy for Karen refugees with posttraumatic stress disorder: A pilot study.

Karen refugees, many originating from Myanmar, have suffered one of the longest civil wars in history and have thus witnessed and experienced substantial trauma. Refugees from Myanmar are currently one of the largest refugee groups being resettled in Western countries. This study investigated the feasibility and acceptability of a modified cognitive processing therapy (CPT) group program for Karen refugees with posttraumatic stress disorder (PTSD; N =7). It was found that the CPT program was well accepted, with high satisfaction and no drop-outs. At posttreatment all participants no longer met PTSD diagnostic criteria and had a reliable improvement in PTSD symptoms when compared with pretreatment scores. At 3-month follow-up four participants (57% of sample) did not meet PTSD diagnostic criteria and three participants (43%) had a reliable improvement in PTSD symptoms when compared with pretreatment scores. However, at follow-up four participants (57% of the sample) had a reliable worsening in PTSD symptoms when compared with their posttreatment PTSD symptom levels. Although the study found that the modified CPT was acceptable and feasible, future research is needed to develop and enhance strategies to ensure that refugees benefit from empirically supported treatments.

Brief novel therapies for PTSD: Written Exposure Therapy.

Written Exposure Therapy (WET) is a 5-session exposure-based intervention for the treatment of posttraumatic stress disorder (PTSD). WET was developed through a series of systematic evaluations of the expressive writing procedure. It is an efficient intervention, requiring limited patient and therapist time and no between-session assignments. The treatment results in statistically and clinically significant symptom change among individuals, including veterans, with PTSD. WET has been shown to be non-inferior to Cognitive Processing Therapy (CPT), a more intensive form of PTSD treatment. Additionally, WET resulted in substantially lower rates of treatment dropout compared to CPT (6% versus 39%). Moderator analyses of the rate of symptom change during treatment indicated that WET performed equally well for participants regardless of age, gender, comorbid depression, or estimated full scale IQ. WET represents a viable option for the efficacious, brief treatment of PTSD and may have significant strengths compared to other manualized psychotherapeutic approaches.

Mild traumatic brain injury characteristics do not negatively influence cognitive processing therapy attendance or outcomes

Some providers have expressed hesitation about the appropriateness of PTSD treatment for veterans with a history of mild traumatic brain injury (mTBI), given concerns that TBI-related sequelae may negatively affect PTSD treatment and/or should be the focus of treatment instead. However, research suggests that those with a history of mTBI can benefit from evidence-based PTSD treatment. To extend these findings, we examined whether specific mTBI injury markers were associated with PTSD treatment attendance and response. Iraq/Afghanistan-era veterans with PTSD and history of mTBI (N = 88) all received Cognitive Processing Therapy (CPT; either standard CPT without the trauma account or SMART-CPT, a modified version of CPT that included cognitive rehabilitation strategies). Analyses examined whether time since injury, presence of loss of consciousness (LOC) or posttraumatic amnesia (PTA), and number and mechanism of mTBIs were associated with treatment attendance or response. None of the five injury variables examined were associated with number of treatment sessions attended. Multilevel modeling indicated that injury variables did not moderate treatment response (across treatment conditions) in terms of change in PTSD and depression symptoms. There was a three-way interaction showing that individuals who denied ever experiencing LOC exhibited a greater decrease in PTSD and depression symptoms in standard CPT relative to those in the SMART-CPT. Thus, a history of mTBI should not preclude individuals from receiving standard CPT, regardless of injury characteristics. In fact, PTSD treatment should often be a first line of treatment for these veterans, given evidence of a mental health etiology to persistent post-concussive symptoms.

Testing a variable-length Cognitive Processing Therapy intervention for posttraumatic stress disorder in active duty military: Design and methodology of a clinical trial.

Combat-related trauma exposures have been associated with increased risk for posttraumatic stress disorder (PTSD) and comorbid mental health conditions. Cognitive Processing Therapy (CPT) is a 12-session manualized cognitive-behavioral therapy that has emerged as one of the leading evidence-based treatments for combat-related PTSD among military personnel and veterans. However, rates of remission have been less in both veterans and active duty military personnel compared to civilians, suggesting that studies are needed to identify strategies to improve upon outcomes in veterans of military combat. There is existing evidence that varying the number of sessions in the CPT protocol based on patient response to treatment improves outcomes in civilians. This paper describes the rationale, design, and methodology of a clinical trial examining a variable-length CPT intervention in a treatment-seeking active duty sample with PTSD to determine if some service members would benefit from a longer or shorter dose of treatment, and to identify predictors of length of treatment response to reach good end-state functioning. In addition to individual demographic and trauma-related variables, the trial is designed to evaluate factors related to internalizing/externalizing personality traits, neuropsychological measures of cognitive functioning, and biological markers as predictors of treatment response. This study attempts to develop a personalized approach to achieving positive treatment outcomes for service members suffering from PTSD. Determining predictors of treatment response can help to develop an adaptable treatment regimen that returns the greatest number of service members to full functioning in the shortest amount of time.

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

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

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