Study findings out today in JAMA Network Open show an important step forward in treating the psychological injuries of war.
Researchers report that treatment for combat-related post-traumatic stress disorder (PTSD), which affects hundreds of thousands of U.S. military personnel and veterans, can be both fast and effective for a majority of patients. Their study showed clinically significant reductions in PTSD symptoms in more than 60 percent of patients and long-term remission of the diagnosis in more than 50 percent after three weeks of outpatient Prolonged Exposure therapy. Study participants similarly showed significant improvements in related disability and daily functioning.
Results were comparable whether patients received traditional Prolonged Exposure, also called PE, condensed into three weeks of daily treatment or an intensive outpatient format including several enhancements to address specific challenges of PTSD in war fighters.
The research team, led by Alan Peterson, PhD, of The University of Texas Health Science Center at San Antonio (UT Health San Antonio), conducted the randomized clinical trial with 234 military personnel and veterans recruited from four locations in South and Central Texas. The effort was part of the work of the Consortium to Alleviate PTSD (CAP), a national network jointly funded by the U.S. Departments of Defense and Veterans Affairs.
Dr. Peterson, professor of psychiatry and behavioral sciences at UT Health San Antonio and director of the CAP and the STRONG STAR Consortium, said the findings advance the group's previous research and significantly improve upon earlier outcomes.
Improving outcomes for our war fighters
We're excited to see a more than 10-point increase in PTSD remission rates compared to a previous PE study we conducted, when we initiated the first ever clinical trials evaluating PTSD treatments in active-duty military populations."
Dr. Alan Peterson, PhD, University of Texas Health Science Center at San Antonio
That first study tested the standard PE protocol, with 10 sessions of 90 minutes each over the course of eight weeks, as well as a massed format, with daily 90-minute sessions over two weeks. The two delivery formats proved equally effective in reducing symptoms and leading to a loss of diagnosis, with remission rates under 50 percent initially after treatment, and treatment gains maintained by about 40 percent of patients six months later. The massed format had much lower dropout rates.
"Those initial results were encouraging, indicating that PE is effective for combat-related PTSD," said Dr. Peterson. "But with much lower success rates than in civilians treated with this therapy, we wanted to make and test treatment adaptations potentially to address unique aspects of combat-related PTSD and improve outcomes," he said. That is what the current study did.
Design and rationale of the current study
Prolonged Exposure includes patients' repeated retelling of their trauma stories along with homework assignments to engage in activities 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.
It was thought that, in the original study – particularly with the massed format – patients may not have had adequate time to complete homework assignments and may also have faced a number of distractions. So, for both arms of the current study, patients took leave from work or other daily responsibilities to devote themselves full-time to treatment and recovery.
Also with the current study, treatment time in both arms was expanded from two weeks to three, with the consideration that combat-related PTSD is more difficult to treat, and patients may need additional time to process traumatic memories.
The comparison arm, called Massed-PE, had these treatment delivery changes only. The other arm, called Intensive Outpatient or IOP-PE, had several additional enhancements that researchers hypothesized would improve treatment outcomes with combat-related PTSD.
Dr. Peterson explained one example. "Oftentimes, a civilian trauma involves a one-time traumatic event, such as an accident, or a repeated trauma of a certain type, such as abuse," he said. "In the course of one or more combat deployments, service members may experience hundreds of traumatic events involving different types of traumas. They also may have experienced other types of trauma outside the combat environment. And so we wanted to adapt the traditional PE protocol, in which a patient focuses only on one primary trauma during treatment, and allow patients in this study to work with therapists on their three top traumas."
He said the treatment involved starting with the least distressing of those three traumas to gain confidence in the therapy, then working up to the most distressing trauma. Some of the other modifications included team-based treatment, with more than one clinician supporting a patient's care; clinic-based completion of homework assignments to decrease avoidance; brief therapist feedback sessions during the day for added support and increased opportunities for processing; involvement of a family member or friend during educational sessions to help improve social support; and post-treatment booster sessions to help maintain treatment gains.
Findings, implications and next steps
Outcomes differed from researchers' expectations in that both arms showed similar levels of reductions in PTSD symptoms and related disability, as well as similar increases in PTSD remission rates and improved psychosocial functioning over time. With some measures, Massed-PE led to greater improvements initially that decreased by the six-month follow-up. IOP-PE patients were more likely to maintain their improvements six months after treatment.
Since long-term outcomes did not differ significantly, researchers say the additional investment of resources needed for the IOP-PE format may not be warranted, but the overall study findings are highly positive.
"With about two thirds of participants reporting clinically meaningful symptom improvement and more than half losing their PTSD diagnosis, this study provides important new evidence that combat-related PTSD can be effectively treated – in as little as three weeks," said Dr. Peterson.
He and his colleagues stated that, while condensed treatments may not be feasible for everyone, "results show that compressed formats adapted to the military context resulted in significant, meaningful and lasting improvements in PTSD, disability and functional impairments for most participants."
They say this makes condensed treatments an important option for U.S. service members and veterans after two decades of military operations in Iraq and Afghanistan. These treatments also could gain attention now as the war in Ukraine has raised international concerns about the risk of PTSD in military personnel and civilians.
Moving forward, the study team notes that their findings show room for continued improvement in treating combat-related PTSD. They add that the compressed treatment formats evaluated in this study are well suited for the evaluation of new, alternative modes of therapy combining cognitive-behavioral treatments with medications and medical devices. "We have those types of studies already underway," said Dr. Peterson.
Collaboration on this important study was extensive, involving study team members from The University of Texas Health Science Center at San Antonio, South Texas Veterans Health Care System, Central Texas Veterans Health Care System, Brooke Army Medical Center at JBSA-Fort Sam Houston, C.R. Darnall Army Medical Center at Fort Hood, University of Pennsylvania, Stanford University, Duke University, Boston University, the VA's National Center for PTSD, and VA Health Care Systems in Boston, Mass.; Durham, N.C.; and Menlo Park, Calif.
Peterson, A.L., et al. (2023) Massed vs intensive outpatient prolonged exposure for combat-related posttraumatic stress disorder. JAMA Network Open. doi.org/10.1001/jamanetworkopen.2022.49422.