Active-duty military find PTSD relief through individual cognitive therapy

Although both group and individual therapy can ease post-traumatic stress disorder (PTSD) symptoms in active-duty military service members, individual therapy relieved PTSD symptoms better and quicker, according to a study led by a Duke University School of Medicine researcher.

The randomized clinical trial is the largest to date to examine an evidence-based treatment for active-duty military service members, with 268 participants from the U.S. Army's Fort Hood in Killeen, Texas. Findings will be published Nov. 23 in JAMA Psychiatry.

The study analyzed the effectiveness of six weeks of Cognitive Processing Therapy (CPT), and found that nearly half the participants in one-on-one therapy improved so much they no longer carried a PTSD diagnosis. Almost 40 percent of the participants in group sessions also dropped their PTSD diagnoses after six weeks.

"For some of the participants, you can see a change just by looking at them -- as though they have been unburdened," said Patricia Resick, Ph.D., the study's lead author, who developed CPT in the 1980s for victims of rape and other interpersonal trauma and is now a professor of psychiatry and behavioral sciences at the Duke University School of Medicine.

"Some people think you have to go to therapy for years to address PTSD, but in this large-scale clinical trial with CPT, we saw a large percentage of patients show significant improvements and even recover from PTSD in a matter of weeks," Resick said.

CPT examines how an individual thinks about a traumatic event and how that affects their emotions, Resick said.

"We look at what people have been saying to themselves about the trauma, which in people with PTSD can be distorted," Resick said. "Many of them think there's something they could have done differently to prevent the trauma. We teach them how to examine their thoughts and feel their natural emotions instead of feelings, such as guilt or blame that may result from distorted thinking. We go back and look at the evidence. Once they think in a more balanced, factual way, their emotions and symptoms of PTSD subside."

To measure effectiveness in active-duty military members, the trial was established through STRONG STAR Consortium, a multi-institutional initiative to develop and evaluate effective prevention, detection and treatment of combat-related PTSD. The consortium is funded by the U.S. Department of Defense.

"Cognitive-behavioral therapies such as CPT and Prolonged Exposure therapy are the leading treatments for PTSD, with the most scientific support for their effectiveness," said Alan Peterson, Ph.D., director of the STRONG STAR Consortium and professor of psychiatry at the University of Texas Health Science Center San Antonio.

"However, both were developed primarily for civilians, and until the STRONG STAR Consortium was developed, they had never been evaluated in clinical trials with an active-duty military population," said Peterson, who is also a retired lieutenant colonel of the U.S. Air Force. "This study shows that CPT is effective, but it still needs to be adapted and tailored in ways that increase its effectiveness with combat-related PTSD so that more patients can fully recover."

About half of the participants were assigned to group therapy, attending 90-minute sessions twice a week for six weeks. The other half met one-on-one with a therapist for 60-minute sessions twice a week for six weeks.

Independent evaluators used standard PTSD diagnostic tools to measure the severity of PTSD and associated conditions such as depression and suicidal thoughts. The participants were evaluated before and during treatment, with a follow-up six months after the treatment was over.

For all participants, PTSD-related symptoms such as nightmares, intrusive thoughts or being easily startled improved. Overall, about 50 percent of participants experienced such improvement that they no longer met the criteria for a PTSD diagnosis, although many still had some symptoms, particularly trouble sleeping, Resick said.

Those who attended individual therapy saw more significant improvements in the severity of their PTSD symptoms and the improvements were seen more quickly, Resick said.

The study also showed that whether subjects received group or individual therapy, they had equal reductions in depression and suicidal thinking. These results continued through a six-month follow-up.

The findings are based on the total 268 participants who enrolled and intended to complete the full six-week program. Overall results include about 9 percent of participants who did not begin treatment due to military deployment or other reasons, and participants who received fewer than 12 sessions (full details included in manuscript).

The findings, although encouraging, show that many participants still had lingering symptoms after six weeks of treatment, and about half retained their PTSD diagnosis. Further research will allow researchers to refine the therapy, considering any specific adjustments for active-duty service members such as varying the number of weeks patients would participate. Researchers with the STRONG STAR Consortium will also expand on the research by evaluating the roles of substance abuse and traumatic brain injury on patients' outcomes.

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In addition to Resick and Peterson, study authors include Jennifer Schuster Wachen, Ph.D.; Katherine A. Dondanville, Psy.D.; Kristi E. Pruiksma, Ph.D.; Jeffrey S. Yarvis, Ph.D.; Jim Mintz, Ph.D.; and the STRONG STAR Consortium.

The research was supported by the U.S. Department of Defense through the U.S. Army Medical Research and Materiel Command, Congressionally Directed Medical Research Programs, and the Psychological Health and Traumatic Brain Injury Research Program (W81XWH-08-02-0116, W81XWH-08-02-109, W81XWH-08-02-0114).

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