Posttraumatic Stress Disorder Treatment Outcomes Research Articles

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).

The effect of perceived life stress on posttraumatic stress disorder treatment outcome.

Life stress following trauma exposure is a consistent predictor of the development of posttraumatic stress disorder (PTSD). However, there is a dearth of research on the effect of life stress on PTSD treatment outcomes. The current study examined the effects of pretreatment levels of perceived life stress on treatment outcome in a sample of 200 individuals with PTSD who were randomized to receive either prolonged exposure (PE) therapy or sertraline as part of a clinical trial. Life stress over the year prior to treatment significantly interacted with treatment type to predict higher residual PTSD symptom severity, as assessed using the PTSD Symptom Scale-Interview, among participants who received sertraline but not those who received PE, β = .24, p = .017, ∆R2 = .03. These findings were similar for self-reported depression severity, β = .27, p = .008, ∆R2 = .04. Adherence to either PE homework or sertraline compliance did not mediate this association nor did life stress predict treatment retention for either treatment arm. Higher levels of perceived life stress may serve as a prescriptive predictor of PTSD treatment outcome, with PE remaining efficacious regardless of heightened pretreatment life stress. These findings encourage clinician confidence when providing PE to individuals with higher levels of life stress. Future researchers should examine the impact of PTSD treatment on perceived and objective measures of life stress to improve treatment for individuals who experience chronic stress.

A Longitudinal Exploration of Self-Reported Hearing Loss, Tinnitus, and Posttraumatic Stress Disorder Treatment Outcomes in Australian Veterans.

Tinnitus, hearing loss, and posttraumatic stress disorder (PTSD) are common conditions among veterans. Shared underlying symptoms, such as hypervigilance and heightened sense of threat, may interfere with talk-based psychological treatments. The aim was to investigate the prevalence and risk factors for self-reported tinnitus and hearing loss among Australian treatment-seeking veterans, as well as links with PTSD symptoms and quality of life (QOL) after treatment. Australian veterans participating in hospital-based PTSD treatment (n = 523) completed self-report measures of subjective hearing impairment, service-related factors, PTSD symptoms, and QOL at treatment intake and discharge, as well as 3- and 9-month follow-ups. Univariate analyses of covariance modeled symptom change over time. More than half of veterans on PTSD treatment self-reported doctor-diagnosed hearing loss or tinnitus, whereas 43% reported both. However, 75% reported subjective mild to moderate hearing impairment, and only 1% reported severe impairment. Service-related factors, such as longer length of service and exposure to explosions, were risk factors for having any hearing condition. After controlling for intake scores, there were no significant differences on PTSD or QOL outcomes over time between those with and without hearing conditions. Although self-reported tinnitus and hearing loss are prevalent among veterans, those with severe hearing impairments are unlikely to be represented in this context. There is a need for psychological treatments that are accessible to patients with severe hearing impairments, which should be examined routinely among military members accessing psychological treatments.

Interleukin-6 secretion upon acute psychosocial stress as a potential predictor of psychotherapy outcome in posttraumatic stress disorder.

Posttraumatic stress disorder (PTSD) is a severe mental disorder that can develop after a traumatic event. PTSD has been reported to be associated with activation of the innate immune system, as measured by increased levels of pro-inflammatory cytokines. While it is well known that PTSD patients display increased levels of interleukin 6 (IL-6) when compared with healthy controls, the relationship between cytokine secretion and treatment outcome has been hardly investigated yet. The aim of this study was to assess the potential association of inflammatory activation and therapy outcome in PTSD. Before therapeutic intervention, we applied the Trier Social Stress Test (TSST) as a method to elicit psychosocial stress and an acute inflammatory response. IL-6 levels were measured in blood plasma of PTSD patients at different time points before and after the TSST. Severity of depressive, trauma-related, and somatic symptoms was assessed before and 8 weeks after trauma-focused treatment in a multimodal day clinic setting. We showed that high reactivity of IL-6 to psychosocial stress at the beginning of the therapy was associated with a negative therapy outcome in PTSD, especially regarding depressive symptoms. This study suggests plasma IL-6 reactivity as a potential molecular marker to predict treatment outcome in PTSD.

Treatment outcome of posttraumatic stress disorder: A white matter tract analysis

Despite the development of empirically supported treatments for posttraumatic stress disorder (PTSD), many individuals remain symptomatic following therapy or dropout prematurely. Neuroimaging studies examining PTSD treatment outcome may offer valuable insights into possible mechanisms that may impact treatment efficacy. To date, few studies of PTSD have used neuroimaging to examine symptom change following completed treatment, and most have focused on gray matter. Studies of white matter are equally important, as changes in white matter integrity (WMI) are connected to a host of detrimental outcomes. The current study examined symptom change of 21 women with PTSD as a result of interpersonal violence who received baseline diffusion tensor imaging (DTI) scans and completed 12 weeks of Cognitive Processing Therapy (CPT). After controlling for baseline PTSD severity, fractional anisotropy (FA) in the left internal capsule, posterior limb of the internal capsule, left cingulate gyrus, superior longitudinal fasciculus, and splenium of the corpus callosum was predicted by PTSD symptom change. Results contribute to understanding neural changes within therapy and may assist in predicting individual treatment response. Namely, by identifying areas potentially impacted by PTSD treatment, future studies may be able to connect the function of these white matter areas to better predict patient PTSD treatment outcome.

Factors contributing to veterans’ satisfaction with PTSD treatment delivered in person compared to telehealth

Introduction Telehealth is an increasingly popular treatment delivery modality for mental healthcare, including evidence-based treatment for complex and intense psychopathologies such as post-traumatic stress disorder (PTSD). Despite the growing telehealth literature, there is a need for more confirmatory research on satisfaction with PTSD telehealth treatment, particularly among veterans, for whom the most rapid and permanent expansion of telehealth services has been implemented through the Department of Veterans Affairs. Methods The current paper integrates data from two concurrent PTSD treatment outcome studies that compared prolonged exposure therapy delivered both in person and via telehealth for veterans (N = 140). Using two different measures of satisfaction (the Charleston Psychiatric Outpatient Satisfaction Scale-Veteran Affairs Version (CPOSS) and the Service Delivery Perception Questionnaire (SDPQ)), we hypothesized that PTSD improvement would predict satisfaction, but that delivery modality (in person vs telehealth) would not. Results Results only partially supported the hypotheses, in that PTSD symptom improvement was associated with greater satisfaction, and in-person treatment modality was associated with satisfaction as measured by the CPOSS (but not the SDPQ). Subgroup differences by sex were found, such that male veterans, typically with combat-related trauma, were more satisfied with their PTSD treatment compared to female veterans, who were most frequently seen in this study for military sexual trauma. Discussion Altogether, results illustrate a need for additional satisfaction studies with diverse samples and large sample sizes. Future research may benefit from examining satisfaction throughout treatment, identifying predictors of greater PTSD improvement, and further examining demographic subgroups.

Latent Profiles of Comorbid Depression as Predictors of PTSD Treatment Outcome

Posttraumatic stress disorder (PTSD) frequently co-occurs with major depressive disorder, and empirically supported PTSD treatments consistently improve depression. However, both diagnoses are heterogeneous and specific patterns of symptom overlap may be related to worse treatment outcome. Two hundred individuals with chronic PTSD participated in a doubly randomized preference trial comparing prolonged exposure and sertraline. Latent Profile Analysis was used to identify classes based on PTSD and depression symptoms prior to starting treatment. A three-class model best fit the data, with a high depression and PTSD severity class (distressed), a moderate depression and low PTSD avoidance class (depressive), and a low depression and high PTSD avoidance class (avoidant). The avoidant class showed the lowest rates of major depressive disorder diagnosis and transdiagnostic vulnerabilities to depression. Patients in the distressed class experienced more robust PTSD treatment response, with no differences between prolonged exposure and sertraline. These findings highlight the role of avoidance in nondepressed PTSD presentations while also demonstrating that co-occurring depression is not contraindicated in evidence-based PTSD treatment.

Do morally injurious experiences and index events negatively impact intensive PTSD treatment outcomes among combat veterans?

ABSTRACT Background: It has been suggested that current frontline posttraumatic stress disorder (PTSD) treatments are not effective for the treatment of moral injury and that individuals who have experienced morally injurious events may respond differently to treatment than those who have not. However, these claims have yet to be empirically tested. Objective: This study evaluated the rates of morally injurious event exposure and morally injurious index trauma and their impact on PTSD (PCL-5) and depression symptom (PHQ-9) reductions during intensive PTSD treatment. Method: Data from 161 USA military combat service members and veterans (91.3% male; mean age = 39.94 years) who participated in a 3-week Cognitive Processing Therapy (CPT)-based intensive PTSD treatment programme (ITP) was utilized. Morally injurious event exposure was established via the Moral Injury Event Scale (MIES). Index traumas were also coded by the treating clinician. Linear mixed effects regression analyses were conducted to examine if differences in average effects or trends over the course of treatment existed between veterans with morally injurious event exposure or index trauma and those without. Results: Rates of morally injurious event exposure in this treatment sample were high (59.0%-75.2%). Morally injurious event exposure and the type of index trauma did not predict changes in symptom outcomes from the ITP and veterans reported large reductions in PTSD (d = 1.35–1.96) and depression symptoms (d = 0.95–1.24) from pre- to post-treatment. Non-inferiority analyses also demonstrated equivalence across those with and without morally injurious event exposure and index events. There were no significant gender differences. Conclusions: The present study suggests that PTSD and depression in military veterans with morally injurious event exposure histories may be successfully treated via a 3-week CPT-based ITP.

Predicting outcome of daycare cognitive behavioural therapy in a naturalistic sample of patients with PTSD: a machine learning approach

ABSTRACT Background: Identifying predictors for treatment outcome in patients with posttraumatic stress disorder (PTSD) is important in order to provide an effective treatment, but robust and replicated treatment outcome predictors are not available up to now. Objectives: We investigated predictors of treatment outcome in a naturalistic sample of patients with PTSD admitted to an 8-week daycare cognitive behavioural therapy programme following a wide range of traumatic events. Method: We used machine learning (linear and non-linear regressors and cross-validation) to predict outcome at discharge for 116 patients and sustained treatment effects 6 months after discharge for 52 patients who had a follow-up assessment. Predictions were based on a wide selection of demographic and clinical assessments including age, gender, comorbid psychiatric disorders, trauma history, posttraumatic symptoms, posttraumatic cognitions, depressive symptoms, general psychopathology and psychosocial functioning. Results: We found that demographic and clinical variables significantly, but only modestly predicted PTSD treatment outcome at discharge (r = 0.21, p = .021 for the best model) and follow-up (r = 0.31, p = .026). Among the included variables, more severe posttraumatic cognitions were negatively associated with treatment outcome. Early response in PTSD symptomatology (percentage change of symptom scores after 4 weeks of treatment) allowed more accurate predictions of outcome at discharge (r = 0.56, p < .001) and follow-up (r = 0.43, p = .001). Conclusion: Our results underscore the importance of early treatment response for short- and long-term treatment success. Nevertheless, it remains an unresolved challenge to identify variables that can robustly predict outcome before the initiation of treatment.

Impact of hazardous alcohol use on intensive PTSD treatment outcomes among veterans

ABSTRACT Background: Intensive treatment programmes (ITPs) for posttraumatic stress disorder (PTSD) produce large symptom reductions and have generally higher completion rates compared to traditional weekly care. Although ITPs do not appear to increase substance use, it has yet to be determined whether their effectiveness differs for veterans with and without hazardous alcohol use (HAU). Objective: This study examined the effectiveness of a 3-week Cognitive Processing Therapy-based ITP for 538 veterans with PTSD (66.0% male; mean age = 41.22 years) and with (n = 193) or without HAU (n = 343) for reducing PTSD and depression symptoms. Method: Veterans’ PTSD (PCL-5) and depression (PHQ-9) symptoms were assessed at pre-treatment, during treatment, and at post-treatment. HAU (AUDIT-C total score ≥4 for males; ≥3 for females) was measured at intake. Results: Treatment completion rates were high for both individuals who endorsed HAU (92.68%) and those who did not (93.37%), likely due to veterans being housed near the treatment facility. Mixed effects regression models revealed a significant time by alcohol use interaction when predicting both PCL-5 (p < .001) and PHQ-9 (p = .003), suggesting time-trends over the course of the ITP differed based on alcohol use. Veterans who endorsed HAU improved to a statistically significantly lesser extent. However, endpoint differences between groups for both outcomes were small (Cohen’s ds between 0.15 and 0.20). Conclusions: Veterans with and without HAU reported significant reductions in PTSD and depression symptoms and completed the ITP at comparably high rates. Findings support the effectiveness of intensive PTSD treatment programmes for individuals with PTSD and HAU. Future studies should utilize controlled designs to evaluate whether intensive PTSD treatment can reduce HAU.

Treatment of comorbid sleep disorders and posttraumatic stress disorder in active duty military: Design and methodology of a randomized clinical trial

Many individuals with posttraumatic stress disorder (PTSD) also suffer from insomnia and nightmares, which may be symptoms of PTSD or constitute partially independent comorbid disorders. Sleep disturbances are resistant to current treatments for PTSD, and those suffering from PTSD, insomnia, and nightmares have worse PTSD treatment outcomes. In addition, insomnia and nightmares are risk factors for depression, substance abuse, anxiety, and suicide. Cognitive-Behavioral Therapy for Insomnia and Nightmares (CBT-I&N) and Cognitive Processing Therapy (CPT) for PTSD are first line treatments of these conditions. CPT does not typically address insomnia or nightmares, and CBT-I&N does not typically address other symptoms of PTSD. There are limited scientific data on how best to provide these therapies to individuals suffering with all three disorders. This project aims to inform the most effective way to treat individuals suffering from PTSD, insomnia, and nightmares, potentially changing the standard of care. U.S. military personnel and recently discharged Veterans who served in support of combat operations following 9/11 aged 18–65 with PTSD, insomnia, and nightmares (N = 222) will be randomly assigned to one of the following 18-session individual treatment conditions delivered over 12-weeks: (1) 6 sessions of CBT-I&N followed by 12 sessions of CPT; (2) 12 sessions of CPT followed by 6 sessions of CBT-I&N; or (3) 12 sessions of CPT followed by an additional 6 sessions of CPT. All participants will be assessed at baseline, during treatment, and at 1-week, 1-month, 3-months, and 6-months posttreatment. The primary outcome will be PTSD symptom severity.

4065 Preferences, Expectancies, and Stigma among Treatment Seeking Combat PTSD Patients

OBJECTIVES/GOALS: Cognitive Processing Therapy (CPT) is a cognitive behavioral treatment for posttraumatic stress disorder (PTSD). CPT is effective in treating combat-related PTSD among Veterans and active duty service members. It is unknown whether improvement in PTSD is related to accommodation of patient preference of the modality of therapy, such as in-office, telehealth, and in-home settings. An equipoise-stratified randomization design allows for complete randomization of participants who are interested and eligible for all three treatment arms. It also allows participants to reject one treatment arm if they are not interested or eligible. Participants who elect to opt out of one arm are randomized to one of the two remaining treatment arms. The primary aim of this study was to evaluate differences in patient satisfaction, treatment stigma beliefs, and credibility beliefs based on patient treatment modality preference. The second aim of this study was to examine if baseline satisfaction, stigma beliefs, and credibility beliefs predicted PTSD treatment outcomes. METHODS/STUDY POPULATION: Active duty service members and veterans with PTSD (N = 123) were randomized to one of three arms using an equipoise stratified randomization. Participants underwent diagnostic interviews for PTSD at baseline and post-treatment and completed self-report measures of satisfaction, stigma, credibility and expectancies of therapy. RESULTS/ANTICIPATED RESULTS: A series of ANOVAs indicated that there were group differences on patient stigma beliefs regarding mental health, F = 5.61, p = .001, and therapist credibility, F = 5.11, p = .002. Post hoc analyses revealed that participants who did not opt of any treatment arm demonstrated lower levels of stigma beliefs compared to participants who opted-out of in-office, p = .001. Participants who opted out of in-home viewed the therapist as less credible compared to participants who did not opt of any arm, p = .004. Multiple regression analysis found that baseline patient satisfaction, stigma beliefs, and credibility beliefs were not predictive of PTSD treatment outcomes, p &gt; .05. DISCUSSION/SIGNIFICANCE OF IMPACT: Combat PTSD patients may opt out of in-office therapy due to mental health stigma beliefs, and visibility in mental health clinics may be a concern. For patients who opted out of in-home therapy, lack of credibility may have decreased participants’ desire for therapists to enter their home. Despite concerns of mental health stigma and the credibility of the therapy in certain treatment arms, patients in each treatment arm significantly improved in PTSD symptomotology. Moreover, patient characteristics, including satisfaction, stigma, and credibility of the therapy, did not significantly predict treatment outcomes, which demonstrates the robustness of Cognitive Processing Therapy.

Addressing Diversity in PTSD Treatment: Disparities in Treatment Engagement and Outcome Among Patients of Color

Posttraumatic stress disorder (PTSD) is a prevalent mental disorder characterized by difficulty recovering from exposure to a traumatic event. The prevalence of PTSD varies by race/ethnicity, with studies in US samples indicating higher prevalence and lower treatment use among some racial and ethnic minority groups compared with Whites. Clarifying the extent to which race and ethnicity influence PTSD treatment outcomes is crucial to delivering treatments that are equitably effective and culturally relevant. There are few rigorous studies of racial/ethnic differences in PTSD treatment-related outcomes, making it difficult to draw conclusions. Evidence suggests that, compared with Whites, there may be lower treatment initiation and retention among Black/African American and Hispanic/Latino/a individuals. The bulk of evidence does not support racial/ethnic differences in treatment-related symptom reduction, though findings are contradictory. Cultural adaptations of evidence-based treatments for PTSD warrant further research. There is a critical need for research that is designed to answer questions about racial/ethnic differences and the experiences of People of Color in PTSD treatment. In clinical settings, widely implementing culturally relevant assessment and treatment, enhancing cultural competence of clinicians, and increasing representation of clinicians of Color are crucial steps toward improving PTSD treatment for People of Color.

The Effectiveness of Trauma-Focused Psychodrama in the Treatment of PTSD in Inpatient Substance Abuse Treatment.

This single group pretest-posttest study explores the effectiveness of trauma-focused psychodrama in the treatment of post-traumatic stress disorder (PTSD) at an inpatient addiction treatment center. The results contribute to the limited research bases of both psychodrama and PTSD treatment outcomes in inpatient addiction treatment. The present study supports the potential effectiveness of two trauma-focused psychodrama models, the Therapeutic Spiral Model and the Relational Trauma Repair Model. Findings of the research demonstrate clinically significant reductions in overall PTSD symptoms (over 25% change) and each PTSD symptom cluster (i.e., re-experiencing and intrusion, avoidance and numbing, and hyper-arousal). Additionally, patient satisfaction exit survey data support overall treatment effectiveness and highlight its tolerability, and capacity for establishing emotional safety, connection, and group cohesion. Patients even described the trauma-focused psychodrama treatment approach as enjoyable and helpful. Overall, the results of this study are promising, and support continued clinical application of trauma-focused psychodrama treatment with other subpopulations diagnosed with PTSD. However, the ability to isolate effects of trauma-focused psychodrama in this study is compromised due to the absence of a control group and participants’ involvement in other inpatient treatment services.

Sleep problems in active duty military personnel seeking treatment for posttraumatic stress disorder: presence, change, and impact on outcomes.

To examine sleep disorder symptom reports at baseline and posttreatment in a sample of active duty U.S. Army Soldiers receiving treatment for posttraumatic stress disorder (PTSD). Explore sleep-related predictors of outcomes. Sleep was evaluated in 128 participants in a parent randomized clinical trial comparing Spaced formats of Prolonged Exposure (PE) or Present Centered Therapy and a Massed format of PE. In the current study, Spaced formats were combined and evaluated separately from Massed. At baseline, the average sleep duration was < 5 h per night on weekdays/workdays and < 6 h per night on weekends/off days. The majority of participants reported clinically significant insomnia, clinically significant nightmares, and probable sleep apnea and approximately half reported excessive daytime sleepiness at baseline. Insomnia and nightmares improved significantly from baseline to posttreatment in all groups, but many patients reported clinically significant insomnia (>70%) and nightmares (>38%) posttreatment. Excessive daytime sleepiness significantly improved only in the Massed group, but 40% continued to report clinically significant levels at posttreatment. Short sleep (Spaced only), clinically significant insomnia and nightmares, excessive daytime sleepiness, and probable sleep apnea (Massed only) at baseline predicted higher PTSD symptoms across treatment course. Short weekends/off days sleep predicted lower PTSD symptom improvement in the Spaced treatments. Various sleep disorder symptoms were high at baseline, were largely unchanged with PTSD treatment, and were related to worse PTSD treatment outcomes. Studies are needed with objective sleep assessments and targeted sleep disorders treatments in PTSD patients. NCT01049516.

Examining Insomnia During Intensive Treatment for Veterans with Posttraumatic Stress Disorder: Does it Improve and Does it Predict Treatment Outcomes?

Previous research has demonstrated that sleep disturbances show little improvement with evidence-based psychotherapy for posttraumatic stress disorder (PTSD); however, sleep improvements are associated with PTSD treatment outcomes. The goal of the current study was to evaluate changes in self-reported insomnia symptoms and the association between insomnia symptoms and treatment outcome during a 3-week intensive treatment program (ITP) for veterans with PTSD that integrated cognitive processing therapy (CPT), mindfulness, yoga, and other ancillary services. As part of standard clinical procedures, veterans (N = 165) completed self-report assessments of insomnia symptoms at pre- and posttreatment as well as self-report assessments of PTSD and depression symptoms approximately every other day during treatment. Most veterans reported at least moderate difficulties with insomnia at both pretreatment (83.0%-95.1%) and posttreatment (69.1-71.3%). Statistically significant reductions in self-reported insomnia severity occurred from pretreatment to posttreatment; however, the effect size was small, d = 0.33. Longitudinal mixed-effects models showed a significant interactive effect of Changes in Insomnia × Time in predicting PTSD and depression symptoms, indicating that patients with more improvements in insomnia had more positive treatment outcomes. These findings suggest that many veterans continued to struggle with sleep disruption after a 3-week ITP, and successful efforts to improve sleep could lead to better PTSD treatment outcomes. Further research is needed to establish how adjunctive sleep interventions can be used to maximize both sleep and PTSD outcomes.

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

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

Improving outcomes for a 3-week intensive treatment program for posttraumatic stress disorder in survivors of military sexual trauma

BackgroundThe experience of Military Sexual Trauma (MST) in the form of sexual assault and sexual harassment is common during service in the U.S. Armed Forces and often leads to adverse health outcomes including posttraumatic stress disorder (PTSD). Improving treatment of MST-related PTSD across settings is important to optimize treatment for survivors. The delivery of Cognitive Processing Therapy (CPT) in an intensive treatment program (ITP) shows promise for rapid reduction of PTSD symptoms for veterans and service members (veterans). However, a recent outcome study suggested that this modality is significantly less effective in reducing symptoms of PTSD for survivors of MST compared to veterans recovering from combat trauma. Methods-The current study examines the utility of modifications made to a CPT-based ITP designed to treat PTSD secondary to MST in a mixedgender sample (N = 285). Treatment modifications included the introduction of skills-based groups in emotion regulation and interpersonal domains. Individual skills-consultation sessions were also offered to participants on an as-needed basis. Further, training was provided to both clinical and non-clinical staff to increase understanding of the unique experiences and needs of MST survivors. ResultsProgram changes proved beneficial, resulting in PTSD treatment outcomes that were comparable for survivors of MST and combat traumas. LimitationsFurther research is needed to determine which of these specific program changes were most impactful in improving symptom outcomes. ConclusionsOur findings suggest that short-term, intensive PTSD treatment for MST survivors may be improved by integrating present-focused, skills-based therapies and staff sensitivity training.

The efficacy of written exposure therapy versus imaginal exposure delivered online for posttraumatic stress disorder: Design of a randomized controlled trial in Veterans

Adapting evidence-based treatments for online delivery has potential to significantly increase the reach of effective care to Veterans with posttraumatic stress disorder (PTSD). This paper describes the rationale for and methods of a randomized controlled trial comparing the efficacy and efficiency of written exposure therapy versus imaginal exposure for PTSD delivered in a novel online and variable length format. Participants will be 300 Veterans seeking treatment for clinically significant symptoms of PTSD. Participants will be randomly assigned to either written exposure or imaginal exposure via verbal recounting and will complete between 4 and 8 online therapy sessions facilitated by trained peer support specialists. Treatment is terminated before session 8 if the PTSD symptom improvement criterion is met. Assessments will be conducted at baseline, post-treatment, and at 3-month follow-up. The primary hypotheses are that written exposure therapy will be noninferior to imaginal exposure with respect to treatment efficacy and efficiency. Secondary hypotheses relate to identifying and comparing potential mediators of PTSD treatment outcome, including trauma-related cognitions and emotion regulation.

Understanding the impact of complicated grief on combat related posttraumatic stress disorder, guilt, suicide, and functional impairment in a clinical trial of post-9/11 service members and veterans.

Complicated grief (CG) is a bereavement-specific syndrome distinct from but commonly comorbid with posttraumatic stress disorder (PTSD). While bereavement is common among military personnel (Simon et al., 2018), there is little research on the impact of CG comorbidity on PTSD treatment outcomes. To evaluate the impact of comorbid CG on PTSD treatment outcomes we analyzed data from a randomized trial comparing prolonged exposure, sertraline, and their combination in veterans with a primary diagnosis of combat-related PTSD (n = 194). Assessment of PTSD, trauma-related guilt, functional impairment, and suicidal ideation and behavior occurred at baseline and weeks 6, 12, and 24 during the 24-week trial. CG was associated with lower PTSD treatment response (odds ratio (OR) = 0.29, 95% confidence interval (CI) [0.12, 0.69], p = 0.005) and remission (OR = 0.28, 95% CI [0.11, 0.71], p = 0.007). Those with CG had greater severity of PTSD (p = 0.005) and trauma-related guilt (<0.001) at baseline and endpoint. In addition, those with CG were more likely to experience suicidal ideation during the study (CG: 35%, 14/40 vs. no CG 15%, 20/130; OR = 3.01, 95% CI [1.29, 7.02], p = 0.011). Comorbid CG is associated with elevated PTSD severity and independently associated with poorer endpoint treatment outcomes in veterans with combat-related PTSD, suggesting that screening and additional intervention for CG may be needed.