Jeffrey S. Yarvis

Effect of group vs individual cognitive processing therapy in active-duty military seeking treatment for posttraumatic stress disorder: A randomized clinical trial

Importance Cognitive processing therapy (CPT), an evidence-based treatment for posttraumatic stress disorder (PTSD), has not been tested as an individual treatment among active-duty military. Group CPT may be an efficient way to deliver treatment. Objective To determine the effects of CPT on PTSD and co-occurring symptoms and whether they differ when administered in an individual or a group format. Design, Setting, and Participants In this randomized clinical trial, 268 active-duty servicemembers consented to assessment at an army medical center from March 8, 2012, to September 23, 2014, and were randomized to group or individual CPT. Inclusion criteria were PTSD after military deployment and stable medication therapy. Exclusion criteria consisted of suicidal or homicidal intent or psychosis. Data collection was completed on June 15, 2015. Analysis was based on intention to treat. Interventions Participants received CPT (the version excluding written accounts) in 90-minute group sessions of 8 to 10 participants (15 cohorts total; 133 participants) or 60-minute individual sessions (135 participants) twice weekly for 6 weeks. The 12 group and individual sessions were conducted concurrently. Main Outcomes and Measures Primary measures were scores on the Posttraumatic Symptom Scale–Interview Version (PSS-I) and the stressor-specific Posttraumatic Stress Disorder Checklist (PCL-S); secondary measures were scores on the Beck Depression Inventory–II (BDI-II) and the Beck Scale for Suicidal Ideation (BSSI). Assessments were completed by independent evaluators masked to treatment condition at baseline and 2 weeks and 6 months after treatment. Results Among the 268 participants (244 men [91.0%]; 24 women [9.0%]; mean [SD] age, 33.2 [7.4] years), improvement in PTSD severity at posttreatment was greater when CPT was administered individually compared with the group format (mean [SE] difference on the PSS-I, −3.7 [1.4]; Cohen d = 0.6; P = .006). Significant improvements were maintained with the individual (mean [SE] PSS-I, −7.8 [1.0]; Cohen d = 1.3; mean [SE] PCL-S, −12.6 [1.4]; Cohen d = 1.2) and group (mean [SE] PSS-I, −4.0 [0.97]; Cohen d = 0.7; mean [SE] PCL-S, −6.3 [1.4]; Cohen d = 0.6) formats, with no differences in remission or severity of PTSD at the 6-month follow-up. Symptoms of depression and suicidal ideation did not differ significantly between formats. Conclusions and Relevance Individual treatment resulted in greater improvement in PTSD severity than group treatment. Depression and suicidal ideation improved equally with both formats. However, even among those receiving individual CPT, approximately 50% still had PTSD and clinically significant symptoms. In the military population, improving existing treatments such as CPT or developing new treatments is needed. Trial Registration clinicaltrials.gov identifier: NCT02173561

Residual sleep disturbances following PTSD treatment in active duty military personnel.

OBJECTIVE Sleep disturbances, including nightmares and insomnia, are frequently reported symptoms of posttraumatic stress disorder (PTSD). Insomnia is one of the most common symptoms to persist after evidence-based PTSD treatment. The purpose of this study was to examine the prevalence of sleep disturbances in a sample of active duty military personnel before and after receiving therapy for PTSD in a clinical trial and to explore the associations of insomnia and nightmares with PTSD diagnosis after treatment. METHOD Sleep parameters were evaluated with the PTSD Checklist in 108 active duty U.S. Army soldiers who had completed at least one deployment in support of the wars in Iraq and Afghanistan and who participated in a randomized clinical trial comparing Group Cognitive Processing Therapy-Cognitive Only Version with Group Present-Centered Therapy. RESULTS Insomnia was the most frequently reported symptom before and after treatment, with 92% reporting insomnia at baseline and 74%-80% reporting insomnia at follow-up. Nightmares were reported by 69% at baseline and by 49%-55% at follow-up. Among participants who no longer met criteria for PTSD following treatment, 57% continued to report insomnia, but only 13% continued to report nightmares. At baseline, 54% were taking sleep medications, but sleep medication use did not affect the overall results. CONCLUSIONS Insomnia was found to be one of the most prevalent and persistent problems among service members receiving PTSD treatment. Nightmares were relatively more positively responsive to treatment. For some service members with PTSD, the addition of specific treatments targeting insomnia and/or nightmares may be indicated. (PsycINFO Database Record

EVALUATING POTENTIAL IATROGENIC SUICIDE RISK IN TRAUMA-FOCUSED GROUP COGNITIVE BEHAVIORAL THERAPY FOR THE TREATMENT OF PTSD IN ACTIVE DUTY MILITARY PERSONNEL.

To determine whether group cognitive processing therapy‐cognitive only version (CPT‐C) is associated with iatrogenic suicide risk in a sample of active duty US Army personnel diagnosed with posttraumatic stress disorder (PTSD). Possible iatrogenic effects considered include the incidence and severity of suicide ideation, worsening of preexisting suicide ideation, incidence of new‐onset suicide ideation, and incidence of suicide attempts among soldiers receiving group CPT‐C. Comparison with group present‐centered therapy (PCT) was made to contextualize findings.

Predictors of suicidal ideation among active duty military personnel with posttraumatic stress disorder

BACKGROUND Given the alarming rate of military suicides, it is critical to identify the factors that increase risk of suicidal thoughts and behaviors among active duty military personnel. METHODS This study examined a predictive model of suicidal ideation among 366 treatment-seeking active duty military personnel with posttraumatic stress disorder (PTSD) following deployments to or near Iraq or Afghanistan. Structural equation modeling was employed to examine the relative contribution of combat exposure, social support, PTSD severity, depressive symptoms, guilt, and trauma-related cognitions on suicidal ideation. RESULTS The final structural equation model had a highly satisfactory fit [χ2 (2) =2.023, p=.364; RMSEA =.006; CFI =1; GFI =.998]. PTSD severity had an indirect effect on suicidal ideation via trauma-related cognitions. Depression had a direct positive effect on suicidal ideation; it also had an indirect effect via trauma-related cognitions and interpersonal support. Among participants who had made a previous suicide attempt, only depression symptom severity was significantly linked to suicidal ideation. LIMITATIONS Data are cross-sectional, precluding causal interpretations. Findings may only generalize to treatment seeking active duty military personnel with PTSD reporting no more than moderate suicidal ideation. CONCLUSIONS These findings suggest that depression and trauma-related cognitions, particularly negative thoughts about the self, play an important role in suicidal ideation among active duty military personnel with PTSD. Negative cognitions about the self and interpersonal support may be important targets for intervention to decrease suicidal ideation.

Effect of Prolonged Exposure Therapy Delivered Over 2 Weeks vs 8 Weeks vs Present-Centered Therapy on PTSD Symptom Severity in Military Personnel: A Randomized Clinical Trial

Importance Effective and efficient treatment is needed for posttraumatic stress disorder (PTSD) in active duty military personnel. Objective To examine the effects of massed prolonged exposure therapy (massed therapy), spaced prolonged exposure therapy (spaced therapy), present-centered therapy (PCT), and a minimal-contact control (MCC) on PTSD severity. Design, Setting, and Participants Randomized clinical trial conducted at Fort Hood, Texas, from January 2011 through July 2016 and enrolling 370 military personnel with PTSD who had returned from Iraq, Afghanistan, or both. Final follow-up was July 11, 2016. Interventions Prolonged exposure therapy, cognitive behavioral therapy involving exposure to trauma memories/reminders, administered as massed therapy (n = 110; 10 sessions over 2 weeks) or spaced therapy (n = 109; 10 sessions over 8 weeks); PCT, a non–trauma-focused therapy involving identifying/discussing daily stressors (n = 107; 10 sessions over 8 weeks); or MCC, telephone calls from therapists (n = 40; once weekly for 4 weeks). Main Outcomes and Measures Outcomes were assessed before and after treatment and at 2-week, 12-week, and 6-month follow-up. Primary outcome was interviewer-assessed PTSD symptom severity, measured by the PTSD Symptom Scale–Interview (PSS-I; range, 0-51; higher scores indicate greater PTSD severity; MCID, 3.18), used to assess efficacy of massed therapy at 2 weeks posttreatment vs MCC at week 4; noninferiority of massed therapy vs spaced therapy at 2 weeks and 12 weeks posttreatment (noninferiority margin, 50% [2.3 points on PSS-I, with 1-sided &agr; = .05]); and efficacy of spaced therapy vs PCT at posttreatment. Results Among 370 randomized participants, data were analyzed for 366 (mean age, 32.7 [SD, 7.3] years; 44 women [12.0%]; mean baseline PSS-I score, 25.49 [6.36]), and 216 (59.0%) completed the study. At 2 weeks posttreatment, mean PSS-I score was 17.62 (mean decrease from baseline, 7.13) for massed therapy and 21.41 (mean decrease, 3.43) for MCC (difference in decrease, 3.70 [95% CI,0.72 to 6.68]; P = .02). At 2 weeks posttreatment, mean PSS-I score was 18.03 for spaced therapy (decrease, 7.29; difference in means vs massed therapy, 0.79 [1-sided 95% CI, −∞ to 2.29; P = .049 for noninferiority]) and at 12 weeks posttreatment was 18.88 for massed therapy (decrease, 6.32) and 18.34 for spaced therapy (decrease, 6.97; difference, 0.55 [1-sided 95% CI, −∞ to 2.05; P = .03 for noninferiority]). At posttreatment, PSS-I scores for PCT were 18.65 (decrease, 7.31; difference in decrease vs spaced therapy, 0.10 [95% CI, −2.48 to 2.27]; P = .93). Conclusions and Relevance Among active duty military personnel with PTSD, massed therapy (10 sessions over 2 weeks) reduced PTSD symptom severity more than MCC at 2-week follow-up and was noninferior to spaced therapy (10 sessions over 8 weeks), and there was no significant difference between spaced therapy and PCT. The reductions in PTSD symptom severity with all treatments were relatively modest, suggesting that further research is needed to determine the clinical importance of these findings. Trial Registration clinicaltrials.gov Identifier: NCT01049516

Ethnoracial differences in PTSD symptoms and trauma-related cognitions in treatment-seeking active duty military personnel for PTSD

Objective: It is uncertain whether ethnoracial factors should be considered by clinicians assessing and treating posttraumatic stress disorder (PTSD) among service members. The purpose of this study was to shed light on ethnoracial variation in the presentation of PTSD symptoms, trauma-related cognitions, and emotions among treatment-seeking active duty military personnel. Method: Participants were 303 male active duty military members with PTSD participating in a clinical trial (60% were self-identified as White, 19% as African American, and 21% as Hispanic/Latino). In the parent study, participants completed a baseline assessment that included clinician-administered and self-report measures of PTSD, trauma-related cognitions, and emotions. Results: Multivariate hierarchical regression models were used to examine ethnoracial differences in these variables, covarying age, education, military grade, combat exposure, and exposure to other potentially traumatic events. Hispanic/Latino and African American participants reported more reexperiencing symptoms, more fear, and more guilt and numbing than White participants. All effect sizes were in the small to medium range. Conclusions: These findings suggest ethnoracial variation in PTSD symptom burden and posttraumatic cognitions among treatment-seeking service members with PTSD. Attending to cultural factors related to differences in PTSD presentation and cognitive coping strategies during the assessment and treatment process could increase rapport and lead to more comprehensive trauma processing.

Cognitive Emotion Regulation Strategies Associated With the DSM-5 Posttraumatic Stress Disorder Criteria

Maladaptive cognitive emotion regulation strategies have been proposed to contribute to the maintenance of posttraumatic stress disorder (PTSD). Prior work has focused on the relationship between these strategies and PTSD as a whole, rather than on how they are related to each PTSD symptom cluster. The purpose of the current study was to determine whether cognitive emotion regulation strategies are predictive of certain PTSD symptom clusters under the Diagnostic and Statistical Manual of Mental Disorders 5th ed. (DSM-5; American Psychiatric Association, 2013) criteria (intrusive thoughts, avoidance, negative alterations in cognitions and mood, and hyperarousal). Participants included 365 treatment-seeking, active-duty military personnel with PTSD. The negative alterations in cognitions and mood cluster were associated with dysfunctional cognitions: greater negative cognitions about the self, negative cognitions about the world, and self-blame, as well as catastrophizing (Rc2 = .519). The negative alterations in cognitions and mood cluster did not show a strong relationship with blaming others, possibly due to the complex nature of self- and other-blame in this primarily deployment-related PTSD sample. Finally, the intrusive thoughts cluster was associated with catastrophizing (Rc2 = .211), suggesting an association between frequent intrusive memories and excessively negative interpretation of those memories.

Distinct Trauma Types in Military Service Members Seeking Treatment for Posttraumatic Stress Disorder

We examined the frequency of trauma types reported in a cohort of service members seeking treatment for posttraumatic stress disorder (PTSD) and compared symptom profiles between types. In this observational study, 999 service members (9.2% women; Mage = 32.91 years; 55.6% White) were evaluated using a standardized assessment procedure to determine eligibility for clinical trials. Participants were evaluated for DSM-IV-TR-defined PTSD using the PTSD Symptom Scale-Interview; all participants reported a Criterion A event. Independent evaluators rated descriptions of Criterion A events as belonging to trauma types at a high degree of reliability, κ = 0.80. Aggregated non-life-threat primary trauma types were more frequently endorsed than aggregated life-threat types, 95% CI [17.10%, 29.20%]. Participants who endorsed moral injury-self traumas had a higher level of reexperiencing (d = 0.39), guilt (hindsight bias, d = 1.06; wrongdoing, d = 0.93), and self-blame (d = 0.58) symptoms, relative to those who reported life threat-self. Participants who experienced traumatic loss had greater reexperiencing (d = 0.39), avoidance (d = 0.22), guilt (responsibility, d = 0.39), and greater peri- and posttraumatic sadness (d = 0.84 and d = 0.70, respectively) symptoms, relative to those who endorsed life threat-self. Relative to life threat-self, moral injury-others was associated with greater peri- (d = 0.36) and posttraumatic (d = 0.33) betrayal/humiliation symptoms, and endorsement of aftermath of violence was associated with greater peri- (d = 0.84) and posttraumatic sadness (d = 0.57) symptoms. War zone traumas were heterogeneous, and non-life-threat traumas were associated with distinct symptoms and problems.

Ethnic and racial differences in clinically relevant symptoms in active duty military personnel with posttraumatic stress disorder

Previous research has shown racial/ethnic differences in Vietnam veterans on symptoms related to posttraumatic stress disorder (PTSD). The current study explored racial/ethnic differences in PTSD symptoms and clinically relevant symptoms. Resilience and social support were tested as potential moderators of racial/ethnic differences in symptoms. The sample included 303 active duty male service members seeking treatment for PTSD. After controlling for age, education, military grade, and combat exposure, Hispanic/Latino and African American service members reported greater PTSD symptoms compared to non-Hispanic White service members. Higher alcohol consumption was endorsed by Hispanic/Latino service members compared to non-Hispanic White or African American service members, even after controlling for PTSD symptom severity. No racial/ethnic differences were found with regard to other variables. These results suggest that care should be made to thoroughly assess PTSD patients, especially those belonging to minority groups, for concurrent substance use problems that may impede treatment utilization or adherence.

The Influence of Posttraumatic Stress Disorder on Health Functioning in Active‐Duty Military Service Members

Researchers have suggested that posttraumatic stress disorder (PTSD) is associated with significant healthcare burden and utilization of medical services. The purpose of this study was to examine the impact of PTSD symptoms on health functioning among active-duty military personnel. Participants in the study were 366 treatment-seeking service members who had returned from deployment and were participating in a larger PTSD treatment study. Assessments included measures of PTSD symptom severity, combat experiences, life stress, health functioning, alcohol use, and depression. We hypothesized that at baseline, PTSD severity and its symptom clusters would be significantly associated with poorer physical and mental health functioning. We conducted separate hierarchical multiple regressions to examine the predictive contribution the hypothesized factors would have on the variance in physical and mental health scores. Consistent with previous literature, we found that PTSD severity was significantly associated with poorer mental health functioning, B = -0.25, SE = 0.08, β = -0.15, t(342) = -3.07, R2 = .37, p = .002; however, contrary to our hypotheses, PTSD severity was not associated with poorer physical health functioning. Further, the hyperarousal symptom cluster was significantly associated with poorer physical health functioning, B = -0.83, SE = 0.26, β = -0.18, t(340) = -3.16, R2 = .11, p = .002, but not mental health functioning. Limitations of our study included the use of self-report measures only and lack of objective measures. Future directions for study include examination of how health functioning perceptions change over a longer duration of PTSD symptoms and after treatment.