Click to Enlarge: CAPS-5 indicates Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5); IOP-PE, intensive outpatient program prolonged exposure; M-PE, massed prolonged exposure; and PCL-5, PTSD Checklist for DSM-5. Source: JAMA Network Open
SAN ANTONIO — Outpatient prolonged exposure therapy, a type of cognitive behavioral therapy that teaches individuals to gradually approach trauma-related memories, feelings and situations, is a fast and effective treatment for combat-related post-traumatic stress disorder (PTSD) in active-duty military and veterans, according to a new study.
The randomized clinical trial published in JAMA Network Open was designed to determine the efficacy of two compressed prolonged exposure therapy outpatient treatments for combat-related PTSD. Improved, efficient and acceptable treatments are needed for combat-related PTSD.1
The interventions tested in the study were massed prolonged exposure, which included 15 therapy sessions of 90 minutes each over three weeks, and intensive outpatient program prolonged exposure, which included 15 full-day therapy sessions over three weeks with eight treatment augmentations. The intensive outpatient program prolonged exposure intervention was hypothesized to be superior to massed prolonged exposure.
Study participants included 234 military personnel and veterans recruited from four locations in south and central Texas, including two DoD military treatment facilities and two VA facilities. Participants were recruited by referral from DoD and VA behavioral health providers at the respective medical treatment facilities. The study was part of the work of the Consortium to Alleviate PTSD (CAP), a national network jointly funded by the DoD and VA.
After three weeks of outpatient prolonged exposure therapy, the study showed clinically significant reductions in PTSD symptoms in more than 60% of patients and long-term remission of diagnosis in more than 50%. Study participants also showed significant improvements in related disability and daily functioning.
The results were comparable whether patients received traditional prolonged exposure condensed into three weeks of daily treatment or an intensive outpatient format including several enhancements to address specific challenges of PTSD in military personnel who were involved in war.
“Most patients with combat- or deployment-related PTSD in both DoD and VA treatment facilities are treated using an individual weekly outpatient treatment format delivered over a 10- to 12-week period,” Alan Peterson, PhD, professor of psychiatry and behavioral sciences at The University of Texas Health Science Center at San Antonio (UT Health San Antonio) and director of the CAP and the STRONG STAR Consortium. “Although these trauma-focused cognitive behavioral treatments – often based on prolonged exposure or cognitive processing therapy – have been demonstrated to be efficacious for some patients, they have been criticized for often having a high drop-out rate from treatment, often found to be between 40% to 50%.”
“The current study found that PTSD can be effectively treated in active duty military and veteran populations in three-week massed prolonged exposure and intensive outpatient program formats, with very low drop-out rates (e.g., 15% or less),” Peterson told U.S. Medicine. “Both treatment groups had clinically significant reductions in PTSD symptoms in about three-fourths of participants. The participants in the intensive outpatient program arm tended to have a better maintenance of their treatment gains at the three- and six-month follow-up points.”
PTSD is a signature wound of war and the most common psychological health condition associated with combat deployments. Combat-related PTSD affects hundreds of thousands of U.S. military personnel and veterans. Between 4% and 17% of U.S. military veterans from the era after the September 11, 2001, terrorist attacks (approximately 120,000 to 510,000 individuals) may have combat-related PTSD, the study reports.
Processing Trauma
Prolonged exposure, the treatment approach for combat-related PTSD used in this study, includes patients repeatedly retelling their trauma stories along with homework assignments to engage in activities that patients otherwise avoid because they trigger traumatic memories or anxious feelings. The goal is to help patients process thoughts about their trauma, calm the anxiety the memories provoke, and regain control of their lives. Patients took leave from work or other daily responsibilities to devote themselves full-time to treatment and recovery.
This study is the first randomized clinical trial in history to evaluate the efficacy of an intensive outpatient treatment program for PTSD, Peterson explained in an email. There are many intensive outpatient programs for PTSD across the nation in both DoD and VA medical treatment facilities. However, the format (e.g., three weeks full-time vs. six weeks part-time) and content of these intensive outpatient programs vary widely. Most are offered in a group treatment format, and most have a primary focus on psychoeducation and group support. The current treatment was delivered individually to participants and was based on prolonged exposure, an evidence-based treatment for PTSD with the strongest scientific support for its efficacy.
“PTSD can be effectively treated in up to 75% of active duty military and veteran patients using intensive, daily treatment protocols based on prolonged exposure therapy,” Peterson wrote in an email. “These three week, daily treatment programs are not meant to replace standard weekly treatment programs, but may be an excellent option for patients who have not responded to other traditional PTSD treatment formats.”
The study’s results are significant because PTSD in servicemembers and veterans is often thought to be a chronic, lifelong disorder that is very difficult to treat. The results of the current study are important because they can provide hope to patients and family members that PTSD can be effectively treated. The results also add one additional treatment tool to the clinician’s tool kit.
With outpatient prolonged exposure therapy, PTSD in active duty military members and veterans can be effectively treated, so they can remain fully fit for military and civilian occupations, Peterson explained in an email. He emphasizes the benefits for active duty military and veterans who are battling combat-related PTSD.
“Similar to the treatment of cancer, there are many treatment options for PTSD,” Peterson wrote in an email. “If service members and veterans have previously engaged in treatments that have not sufficiently reduced their symptoms, they should consider pursuing other evidence-based treatments and treatment formats. Service members and veterans with PTSD should not be expected to “just live with it,” any more than cancer patients should just live with their cancer. Like cancer, PTSD can be treated into remission to allow service members and veterans to pursue productive and fulfilling lives. Nonetheless, additional research is needed in both DoD and VA settings to continue to improve treatment outcomes.”
- Peterson AL, Blount TH, Foa EB, et al. Massed vs Intensive Outpatient Prolonged Exposure for Combat-Related Post-traumatic Stress Disorder: A Randomized Clinical Trial. JAMA Netw Open. 2023;6(1):e2249422. doi:10.1001/jamanetworkopen.2022.49422
