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Shortened PTSD therapy still effective in active duty military personnel

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More research needed on PTSD therapies

Guidelines for the management of PTSD currently recommend trauma-focused psychotherapies, such as prolonged exposure therapy and cognitive processing therapy, as the first line of treatment for PTSD ahead of medications. However barriers to care, dropouts, and stigma remain challenges to uptake of these therapies.

The finding that trauma-focused and non–trauma-focused therapy achieve similar outcomes adds to a growing body of evidence that the differences between these approaches are small to negligible. But while current guidelines support present-centered therapy as a second-line approach, recommending it as a primary treatment is a perplexing evolution for a therapy originally developed as a therapy control condition for randomized controlled trials.

It is clear that more substantive evolution in PTSD treatments is needed and that individual variability in mechanisms of recovery and therapeutic preferences – as well as longer-term strategies – must be taken into account when deciding on a therapeutic approach

Charles W. Hoge, MD, is from the Walter Reed Army Institute of Research, Silver Spring, Md., and Kathleen M. Chard, PhD, is from the Trauma Recovery Center at Cincinnati VA Medical Center. These comments are taken from an accompanying editorial (JAMA. 2018 January 23;319:343-5). No conflicts of interest were declared.



A compressed 2-week version of prolonged exposure therapy for posttraumatic stress disorder in active duty military personnel delivers results similar to those seen in an 8-week course of treatment, new research suggested.

However, the four-arm clinical trial, published in JAMA, also found that the standard 8-week course of prolonged exposure therapy offered no significant benefits above present-centered therapy, prompting the suggestion that it may be less effective in military personnel.

The trial enrolled 366 military personnel – 12% female – on active duty and with PTSD who had returned from Iraq and/or Afghanistan. They were randomized to prolonged exposure therapy, which is a form of cognitive-behavioral therapy involving repeat exposure to traumatic memories and reminders, delivered in this study as either massed therapy over 2 weeks or spaced therapy over 8 weeks; to non–trauma-focused present-centered therapy over 8 weeks; or to a minimal-contact control consisting of once-weekly telephone calls from therapists for 4 weeks.

At 2 weeks after treatment, individuals who underwent massed exposure therapy showed a mean decrease in PTSD Symptom Scale–Interview (PSS-I) score from baseline of 7.13 points, compared with a mean decrease of 7.29 in the spaced-therapy group, thereby meeting the criteria for noninferiority.

At 12 weeks after treatment, the massed-therapy group showed a 6.32-point mean decrease and the spaced-therapy group had a 6.97-point mean decrease in PSS-I scores.

By comparison, individuals in the minimal-contact control group showed a mean decrease of 3.43 points at 2 weeks after treatment.

When the spaced version of the prolonged exposure therapy was compared with present-centered therapy, researchers saw no significant difference in changes in mean levels of PSS-I between the two groups at posttreatment follow-up.

Edna B. Foa, PhD, from the department of psychiatry at the University of Pennsylvania, Philadelphia, and her coauthors wrote that prolonged exposure therapy for PTSD has been shown to be effective in civilians and veterans, but its use in active duty military personnel has only been explored in case studies.

“One barrier to implementation of prolonged exposure therapy in the military is treatment length (8-15 weeks), which can conflict with military obligations,” they wrote. “A shorter course of therapy could hasten amelioration of PTSD, with the added benefit of facilitating military readiness.”

There had been concerns that the massed-therapy approach would be too emotionally taxing because it involved daily sessions on 10 consecutive weekdays, with patients participating in repeated recounting of the most disturbing traumatic memory followed by processing the thoughts and feelings associated with that memory.

“The noninferiority of massed therapy to spaced therapy is particularly important for the military because 2-week treatment not only is associated with more rapid symptom improvement but also may reduce interference with the demanding military schedule,” the authors wrote.

However, the researchers noted that the effect of both the massed and spaced therapy in this study population was less than that seen in previous studies.

“This suggests that well-established evidence-based treatments for PTSD may be less efficacious for active duty military personnel with PTSD and that modifications to these treatments, or alternative treatments, may be needed to achieve better outcomes.”

The study was conducted with the support of the Department of Defense. Eight authors declared funding from bodies including the Department of Defense, and one author received royalties from books on PTSD treatments.

SOURCE: Foa EB et al. JAMA. 2018 Jan 23. doi: 10.1001/jama.2017.21242.

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