Effectiveness of National Implementation of Prolonged Exposure Therapy in Veterans Affairs Care

Abstract

osttraumatic stress disorder (PTSD) affects more than 6% of the US population and up to 13% of US military personnel returning from deployment in Iraq and Afghanistan. 1-3 It is associated with substantially reduced quality of life through both impaired role functioning and higher risk of cardiovascular disease, diabetes mellitus, and substance use conditions. 4-8 There is an especially critical need for effective treatments for PTSD as increasing numbers of veterans return from Iraq and Afghanistan. Since 2001, the number of veterans with diagnosed PTSD receiving care in the Veterans Health Administration (VHA), the health care arm of the US Department of Veterans Affairs (VA), has tripled. 9 In recent years, there have been significant advances in the treatment of PTSD, with development of a variety of efficacious treatments. Exposure-based psychotherapies are among the treatments with the most empiric al support. 10-16 Exposure therapy is recommended as a firstline treatment for PTSD in all clinical treatment guidelines in the United States and other countries. 17 A rigorous review of P TSD treatments conduc ted by the Institute of Medicine 18 concluded that exposure therapy was the only psychological or psychopharmacological intervention with sufficient data to support its efficacy in the treatment of PTSD. IMPORTANCE Posttraumatic stress disorder (PTSD) is a pervasive and often debilitating condition that affects many individuals in the general population and military service members. Effective treatments for PTSD are greatly needed for both veterans returning from Iraq and Afghanistan and veterans of other eras. Prolonged exposure (PE) therapy has been shown to be highly efficacious in clinical trials involving women with noncombat trauma, but there are limited data on its effectiveness in real-world clinical practice settings and with veterans. OBJECTIVE To evaluate the effectiveness of PE as implemented with veterans with PTSD in a large health care system. DESIGN, SETTING, AND PARTICIPANTS This evaluation included 1931 veterans treated by 804 clinicians participating in the Department of Veterans Affairs (VA) PE Training Program. After completing a 4-day experiential PE training workshop, clinicians implemented PE (while receiving consultation) with a minimum of 2 veteran patients who had a primary diagnosis of PTSD. MAIN OUTCOMES AND MEASURES Changes in PTSD and depression symptoms were assessed with the PTSD Checklist and the Beck Depression Inventory II, measured at baseline and at the final treatment session. Multiple and single imputation were used to estimate the posttest scores of patients who left treatment before completing 8 sessions. Demographic predictors of treatment dropout were also examined. RESULTS Intent-to-treat analyses indicate that PE is effective in reducing symptoms of both PTSD (pre-post d= 0.87) and depression (pre-post d= 0.66), with effect sizes comparable to those reported in previous efficacy trials. The proportion of patients screening positive for PTSD on the PTSD Checklis...

Fear Memory

“…Most mental health practitioners who use it view it as the only effective and reliable procedure to allay the mentally crippling symptoms of PTSD and related syndromes (60, 156,535). The major problems with exposure therapy have been listed by Singewald et al (602): "A significant proportion of patients either 1) have difficulties bearing the demanding and exhausting process of this therapy; 2) do not, or not sufficiently, respond to the therapy -failing to substantially reduce their fear responses; or 3) respond initially, but suffer from return of fear phenomena hampering remission and full recovery" in spite of it being the best or the only effective treatment for PTSD and for other major disturbances involving fear memory.…”

Effectiveness of Cognitive Processing Therapy and Prolonged Exposure in the Department of Veterans Affairs

“…Multiple studies have been conducted with combat veterans in the VA system (Eftekhari et al, 2013;Goodson et al, 2013;Rauch et al, 2009;Tuerk et al, 2011;Yoder et al, 2012). All of the effectiveness studies carried out with vetrans have shown that PE is an effective treatment for PTSD.…”

“…All of the effectiveness studies carried out with vetrans have shown that PE is an effective treatment for PTSD. Eftekhari et al's (2013) study is noteworthy because it evaluated the national implementation of PE throughout the VA system and included a sample of over 1900 veterans. An important finding from Yoder et al's (2012) study was that Persian Gulf War veterans responded significantly less well to treatment than both…”

“…However, the above effectiveness studies tend to have similar limitations. Studies either tend to have a relatively small sample size (n =115 or lower) (e.g., Goodson et al,2013;Rauch et al, 2009;Tuerk et al, 2011) and/or a pre-post design that does not enable the tracking of treatment non-completers over time (e.g., Eftekhari et al, 2013). Initial PTSD Symptom Severity.…”

Effectiveness of PTSD treatments for military service members and veterans

“…It is important to prolong the exposure until the anxiety reduces [22]. In one of the studies regarding a PE's ef icacy, it has been shown to be effective in 60% of veterans [23].…”