Prolonged exposure therapy for combat-related posttraumatic stress disorder: An examination of treatment effectiveness for veterans of the wars in Afghanistan and Iraq

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Abstract

The Veteran's Health Administration (VHA) has launched a large-scale initiative to promote prolonged exposure (PE) therapy, an evidence-based treatment for PTSD. While existing randomized controlled trials (RCTs) unambiguously support the efficacy of PE in civilian and some military populations, there is a need to better understand the course of treatment for combat Veterans of the current wars receiving PE in normative mental healthcare settings. The current study investigates 65 Veterans receiving care at an urban VA medical center. All Veterans were diagnosed with PTSD via a structured interview and treated with PE. Measures of PTSD and depression were collected pre- and post-treatment and every two sessions during treatment. Dependent means t-tests were used to estimate pre- and post-treatment d-type effect sizes. Additionally, hierarchical linear models (HLM) were used to investigate treatment effects over time, relationships between patient characteristics and outcomes, and to provide estimates of R2-type effect sizes. Results indicate that PE in regular VA mental healthcare contexts can be as effective as when implemented in carefully conducted RCTs.

Research highlights

▶ Existing RCTs support the efficacy of PE; however, no studies have included meaningful numbers of OEF/OIF Veterans or meaning numbers of veterans receiving PE in normative healthcare contexts. ▶ The current study investigates 65 Veterans diagnosed with combat-related PTSD receiving PE. ▶ Treatment effect sizes were statistically significant and large. Both d-type and R2-type effect sizes are provided. ▶ Patient characteristics, including race, age, gender, baseline severity, and service connection disability were not meaningfully associated with treatment outcomes or the slope of outcomes over time. ▶ A quadratic time-in-treatment term, indicative of a steeper slope of improvement earlier in treatment, was statistically significant and accounted for a meaningful portion of variance in outcomes over time-in-treatment alone. ▶ Results indicate that PE in regular VA mental healthcare contexts can be as effective as when implemented in carefully conducted RCTs.

Section snippets

Study overview

The current investigation is a post hoc effectiveness study using archival data from patients treated by a PTSD Clinical Team (PCT) in an urban VA Medical Center (VAMC). All Veterans were diagnosed with combat-related PTSD and treated with PE as part of their routine clinical care. Measures of PTSD and depression were collected pre- and post-treatment, as well as every 2 weeks during treatment. Veterans were not subject to protocol-driven exclusion criteria or given incentives to participate in

Treatment completion and duration

Forty-three Veterans (66%) met criteria as treatment completers. The mean number of sessions for treatment completers was 10 (SD = 4). The mean number of sessions for the total ITT sample was 7 (SD = 5) with 52 patients (80%) attending 10 or fewer sessions, 61 patients (94%) attending 15 or fewer sessions, and 4 patients (6%) attending between 16 and 25 sessions. Twenty-two patients (34%) did not complete at least 6 sessions and were classified as non-completers, these patients were retained for

Summary

Results of the present study indicate that PE is an effective treatment for combat-related PTSD. Moreover, the study shows that PE can be effectively implemented in a VAMC setting with veterans of the wars in Iraq and Afghanistan. Treatment retention was adequate, suggesting that PE can be well tolerated by OEF/OIF Veterans. Treatment effect sizes for both the ITT sample and the treatment completer group were statistically significant and large. Patient characteristics, including race, age,

Acknowledgements

Dr. Tuerk is supported by Veterans Health Administration, Office of Research and Development, Clinical Sciences Research and Development Award, CDA-2-0003; and by the South Carolina Clinical & Translational Research Institute, Medical University of South Carolina's CTSA, NIH/NCRR Grant Number UL1RR029882; Dr. Grubaugh is supported by a Veterans Health Administration, Health Services and Research and Development CDA-2 Award, Dr. Acierno is supported by VA HSR&D Merit grant IIR-04-421 (PI: Egede)

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