A multisite randomized controlled effectiveness trial of cognitive processing therapy for military-related posttraumatic stress disorder☆
Highlights
► A randomized controlled trial (RCT) of cognitive processing therapy (CPT) was conducted. ► CPT was more effective for military-related PTSD than treatment as usual (TAU). ► CPT also produced greater improvements in anxiety, depression and relationships than TAU. ► This is the first fully naturalistic RCT of CPT in an existing community service.
Introduction
Posttraumatic stress disorder (PTSD) is a common psychiatric condition for military veterans with rates of PTSD among troops returning from conflicts from Vietnam through to the present day estimated to be as high as between 20 and 30% (Richardson et al., 2010, Thomas et al., 2010). Indeed the nature of the events to which military personnel are exposed in more recent deployments is becoming increasingly complex. Distinguishing enemy combatants from noncombatants is often difficult, particularly where the conflicts are taking place in urban environments (Maguen et al., 2010). As such, military personnel are not only exposed to a high likelihood of direct contact with enemy combatants but also at significant risk of being responsible for deaths of noncombatants (Hoge et al., 2004). In addition, military personnel may also be exposed to non-deployment related events that occur within their military service such as training accidents, assault and sexual assault and body recovery in the aftermath of disaster (e.g., Ikin et al., 2005). Such experiences are associated with increased risk for PTSD and associated difficulties including anger, guilt, substance abuse and relationship problems (Maguen et al., 2010, Thomas et al., 2010).
Over the past decade there have been considerable advances in the treatment of PTSD, with international clinical practice guidelines unanimously identifying trauma-focused cognitive behavior therapy (TFCBT) as a first line treatment (Foa et al., 2008, Forbes et al., 2010). One of the treatments included in this TFCBT recommendation is cognitive processing therapy (CPT; Resick, Monson, & Chard, 2007). CPT is a 12-session cognitive-behavioral manualized treatment for PTSD that systematically addresses key posttraumatic themes, including safety, trust, power and control, self-esteem and intimacy. The systematic manner in which CPT identifies key themes and issues associated with a broad array of reactions to the trauma makes it highly suitable for addressing the more complex psychiatric sequelae emerging from these recent military conflicts. Randomized controlled trials (RCTs) have indicated CPT's applicability to survivors of a range of traumatic events, including military trauma (Monson et al., 2006, Resick et al., 2002) and childhood sexual abuse (Chard, 2005). Less controlled studies have also applied a modified CPT to refugees (Schulz, Resick, Huber, & Griffin, 2006), veterans (Chard, Schumm, Owens, & Cottingham, 2010), and motor vehicle accident survivors (Galovski & Resick, 2008).
Given the widespread adoption of CPT as a routine clinical intervention, there is a critical need for trials to evaluate the extent to which it is effective in real-world settings. Effectiveness trials test treatments in naturalistic clinical settings under varying levels of controlled conditions with varying levels of client and clinician selectiveness. Very rarely, however, are psychological treatment trials conducted in naturalistic settings that use all four of the following elements: (1) fully randomized controlled designs; (2) comparing the experimental treatment against usual treatment; (3) with clinicians drawn non-selectively from the local treatment service and (4) participants who are routine clients of that service. To date, only a few randomized controlled full effectiveness trials have been published, and these have focused respectively on exposure therapy within a sexual assault treatment setting (Foa et al., 2005) and exposure and present centered therapy in a veteran treatment setting (Schnurr et al., 2007, Schnurr et al., 2003). Such studies are essential in providing the level of evidence required for confidence that a treatment is effective in naturalistic environments.
Monson et al. (2006), in the only RCT published to date of CPT in the treatment of veterans, demonstrated the effectiveness of CPT compared with a waitlist control condition, using CBT trained therapists. Building on this work, the current study used a randomized controlled design to test whether CPT, compared with treatment as usual, benefits treatment-seeking veterans with PTSD presenting at three veterans’ treatment clinics across Australia. Importantly, participating clinicians in this study included any from within the service that chose to participate regardless of discipline, paradigm or orientation of choice, or level of experience. An important additional feature in establishing an evidence base for interventions is the demonstrated effectiveness of these interventions across countries and cultures. The current study also extends the existing literature by representing the first study examining outcomes for CPT drawn from an RCT in a non-US sample.
The study hypothesis was that whilst improvements in PTSD symptoms would be significant for both CPT and usual treatment conditions, there would be a more substantial improvement in the CPT condition. It was also hypothesized that CPT would demonstrate greater gains than usual treatment in associated measures of comorbid anxiety and depression and general functioning.
Section snippets
Participants
Consecutive presentations of veterans from any conflict or military service to the Veterans and Veterans’ Families Counseling Service (VVCS) offices in three states of Australia were screened for PTSD and potential inclusion in the study between October 2007 and January 2010. Trial participation was explicitly not solicited through advertising or invitation to ensure participants were representative of veteran clients regularly presenting at the community clinical service. Exclusion criteria
Demographic and baseline characteristics of the sample
Statistics for the demographic and baseline characteristics are shown in Table 1. At baseline, CPT and TAU groups differed only on CAPS total severity score, which was greater for the CPT group (F(1,57) = 2.35, p < 0.05). No significant differences were evident between the two conditions in treatment credibility (CPT: M = 18.96, SD = 5.91; TAU: M = 19.64, SD = 4.90; F(1,44) = 0.17, p = 0.667, ES = 0.12, 95%CI = −0.71,0.46) or expectancy (CPT: M = 16.91, SD = 5.10; TAU: M = 18.55, SD = 3.90; F(1,44) = 1.45, p = 0.236, ES =
Discussion
Demonstrating the effectiveness of psychological treatments in naturalistic settings is critical in ensuring that evidence based treatments are applicable to real world clinical environments. It cannot simply be assumed that outcomes from RCTs, conducted under rigorous conditions with greater selectivity in therapist (and at times client) selection, often in highly specialized clinics, can be replicated in routine clinical practice settings. This study delivered CPT under fully randomized
Conclusions
This trial reports the first RCT evidence that CPT (recently rolled out across US veterans services) is a highly effective treatment for military-related PTSD and co-morbidity when administered by community practitioners to regular clients in veterans’ community based mental health services under fully controlled conditions.
Conflict of interest
None for any author. The Australian Centre for Posttraumatic Mental Health is partially funded by the Australian Government, Department of Veterans Affairs.
Acknowledgments
Funding for this study was provided by the Australian Department of Veterans Affairs Applied Research Program, June 2007. David Forbes had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The Australian Department of Veterans Affairs assisted in the design and conduct of the study, and gave permission for collection of the data and has approved the final version of the manuscript. The Australian Department
References (46)
- et al.
The alcohol use disorders identification test: guidelines for use in primary health care
(1989) - et al.
Beck Depression Inventory
(1996) Comparative fit indexes in structural models
Psychological Bulletin
(1990)- et al.
The development of a clinician administered PTSD scale
Journal of Traumatic Stress
(1995) - et al.
Psychometric properties of the PTSD checklist (PCL)
Behaviour Research and Therapy
(1996) - et al.
Alternative ways of assessing model fit
An evaluation of cognitive processing therapy for the treatment of posttraumatic stress disorder related to childhood sexual abuse
Journal of Consulting and Clinical Psychology
(2005)- et al.
A comparison of OEF and OIF veterans and Vietnam veterans receiving cognitive processing therapy
Journal of Traumatic Stress
(2010) Statistical power analysis for the behavioral sciences
(1988)ClinTools software for Windows: version 4.1 [Computer program]
(2007)
Psychometric properties of the credibility/expectancy questionnaire
Journal of Behavior Therapy and Experimental Psychiatry
The posttraumatic cognitions inventory (PTCI): development and validation
Psychological Assessment
Randomized trial of prolonged exposure for posttraumatic stress disorder with and without cognitive restructuring: outcome at academic and community clinics
Journal of Consulting and Clinical Psychology
Treating the trauma of rape: cognitive-behavioral therapy for PTSD
Behavioral/cognitive conceptualizations of post-traumatic stress disorder
Behavior Therapy
The validity of the PTSD checklist as a measure of symptomatic change in combat-related PTSD
Behaviour Research and Therapy
A guide to guidelines for the treatment of PTSD and related conditions
Journal of Traumatic Stress
A concise measure of anger in combat-related posttraumatic stress disorder
Journal of Traumatic Stress
Cognitive processing therapy for posttraumatic stress disorder secondary to a motor vehicle accident: a single-subject report
Cognitive and Behavioral Practice
Estimation of effect size from a series of independent experiments
Psychological Bulletin
Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care
New England Journal of Medicine
War zone stress without direct combat: the Australian Naval experience of the Gulf War
Journal of Traumatic Stress
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Trial registered with the Australian New Zealand Clinical Trials Registry www.anzctr.org.au ACTRN12609000910202.