A multisite randomized controlled effectiveness trial of cognitive processing therapy for military-related posttraumatic stress disorder

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Abstract

Cognitive processing therapy (CPT) is currently applied in military veteran mental health services in many countries. This study tests the effectiveness of community-administered CPT for military-related PTSD under randomized controlled conditions. Fifty-nine treatment-seeking veterans with military-related PTSD were randomly allocated to receive 12 twice-weekly 60 min sessions of CPT or an equivalent period of usual treatment at veterans’ community based counseling services. Intent to treat analyses found significantly greater improvement for participants receiving CPT over usual treatment at post-treatment and 3 month follow-up. CPT also produced greater improvements in anxiety, depression, social and dyadic relationships than usual treatment. No CPT related adverse events occurred during the trial. This trial reports the first randomized controlled trial evidence that CPT is an effective treatment for military PTSD and co-morbid conditions when compared to usual treatment and delivered in community settings by clinicians from diverse disciplines, preferred treatment orientation and levels of experience.

Highlights

► A randomized controlled trial (RCT) of cognitive processing therapy (CPT) was conducted. ► CPT was more effective for military-related PTSD than treatment as usual (TAU). ► CPT also produced greater improvements in anxiety, depression and relationships than TAU. ► This is the first fully naturalistic RCT of CPT in an existing community service.

Introduction

Posttraumatic stress disorder (PTSD) is a common psychiatric condition for military veterans with rates of PTSD among troops returning from conflicts from Vietnam through to the present day estimated to be as high as between 20 and 30% (Richardson et al., 2010, Thomas et al., 2010). Indeed the nature of the events to which military personnel are exposed in more recent deployments is becoming increasingly complex. Distinguishing enemy combatants from noncombatants is often difficult, particularly where the conflicts are taking place in urban environments (Maguen et al., 2010). As such, military personnel are not only exposed to a high likelihood of direct contact with enemy combatants but also at significant risk of being responsible for deaths of noncombatants (Hoge et al., 2004). In addition, military personnel may also be exposed to non-deployment related events that occur within their military service such as training accidents, assault and sexual assault and body recovery in the aftermath of disaster (e.g., Ikin et al., 2005). Such experiences are associated with increased risk for PTSD and associated difficulties including anger, guilt, substance abuse and relationship problems (Maguen et al., 2010, Thomas et al., 2010).

Over the past decade there have been considerable advances in the treatment of PTSD, with international clinical practice guidelines unanimously identifying trauma-focused cognitive behavior therapy (TFCBT) as a first line treatment (Foa et al., 2008, Forbes et al., 2010). One of the treatments included in this TFCBT recommendation is cognitive processing therapy (CPT; Resick, Monson, & Chard, 2007). CPT is a 12-session cognitive-behavioral manualized treatment for PTSD that systematically addresses key posttraumatic themes, including safety, trust, power and control, self-esteem and intimacy. The systematic manner in which CPT identifies key themes and issues associated with a broad array of reactions to the trauma makes it highly suitable for addressing the more complex psychiatric sequelae emerging from these recent military conflicts. Randomized controlled trials (RCTs) have indicated CPT's applicability to survivors of a range of traumatic events, including military trauma (Monson et al., 2006, Resick et al., 2002) and childhood sexual abuse (Chard, 2005). Less controlled studies have also applied a modified CPT to refugees (Schulz, Resick, Huber, & Griffin, 2006), veterans (Chard, Schumm, Owens, & Cottingham, 2010), and motor vehicle accident survivors (Galovski & Resick, 2008).

Given the widespread adoption of CPT as a routine clinical intervention, there is a critical need for trials to evaluate the extent to which it is effective in real-world settings. Effectiveness trials test treatments in naturalistic clinical settings under varying levels of controlled conditions with varying levels of client and clinician selectiveness. Very rarely, however, are psychological treatment trials conducted in naturalistic settings that use all four of the following elements: (1) fully randomized controlled designs; (2) comparing the experimental treatment against usual treatment; (3) with clinicians drawn non-selectively from the local treatment service and (4) participants who are routine clients of that service. To date, only a few randomized controlled full effectiveness trials have been published, and these have focused respectively on exposure therapy within a sexual assault treatment setting (Foa et al., 2005) and exposure and present centered therapy in a veteran treatment setting (Schnurr et al., 2007, Schnurr et al., 2003). Such studies are essential in providing the level of evidence required for confidence that a treatment is effective in naturalistic environments.

Monson et al. (2006), in the only RCT published to date of CPT in the treatment of veterans, demonstrated the effectiveness of CPT compared with a waitlist control condition, using CBT trained therapists. Building on this work, the current study used a randomized controlled design to test whether CPT, compared with treatment as usual, benefits treatment-seeking veterans with PTSD presenting at three veterans’ treatment clinics across Australia. Importantly, participating clinicians in this study included any from within the service that chose to participate regardless of discipline, paradigm or orientation of choice, or level of experience. An important additional feature in establishing an evidence base for interventions is the demonstrated effectiveness of these interventions across countries and cultures. The current study also extends the existing literature by representing the first study examining outcomes for CPT drawn from an RCT in a non-US sample.

The study hypothesis was that whilst improvements in PTSD symptoms would be significant for both CPT and usual treatment conditions, there would be a more substantial improvement in the CPT condition. It was also hypothesized that CPT would demonstrate greater gains than usual treatment in associated measures of comorbid anxiety and depression and general functioning.

Section snippets

Participants

Consecutive presentations of veterans from any conflict or military service to the Veterans and Veterans’ Families Counseling Service (VVCS) offices in three states of Australia were screened for PTSD and potential inclusion in the study between October 2007 and January 2010. Trial participation was explicitly not solicited through advertising or invitation to ensure participants were representative of veteran clients regularly presenting at the community clinical service. Exclusion criteria

Demographic and baseline characteristics of the sample

Statistics for the demographic and baseline characteristics are shown in Table 1. At baseline, CPT and TAU groups differed only on CAPS total severity score, which was greater for the CPT group (F(1,57) = 2.35, p < 0.05). No significant differences were evident between the two conditions in treatment credibility (CPT: M = 18.96, SD = 5.91; TAU: M = 19.64, SD = 4.90; F(1,44) = 0.17, p = 0.667, ES = 0.12, 95%CI = −0.71,0.46) or expectancy (CPT: M = 16.91, SD = 5.10; TAU: M = 18.55, SD = 3.90; F(1,44) = 1.45, p = 0.236, ES = 

Discussion

Demonstrating the effectiveness of psychological treatments in naturalistic settings is critical in ensuring that evidence based treatments are applicable to real world clinical environments. It cannot simply be assumed that outcomes from RCTs, conducted under rigorous conditions with greater selectivity in therapist (and at times client) selection, often in highly specialized clinics, can be replicated in routine clinical practice settings. This study delivered CPT under fully randomized

Conclusions

This trial reports the first RCT evidence that CPT (recently rolled out across US veterans services) is a highly effective treatment for military-related PTSD and co-morbidity when administered by community practitioners to regular clients in veterans’ community based mental health services under fully controlled conditions.

Conflict of interest

None for any author. The Australian Centre for Posttraumatic Mental Health is partially funded by the Australian Government, Department of Veterans Affairs.

Acknowledgments

Funding for this study was provided by the Australian Department of Veterans Affairs Applied Research Program, June 2007. David Forbes had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The Australian Department of Veterans Affairs assisted in the design and conduct of the study, and gave permission for collection of the data and has approved the final version of the manuscript. The Australian Department

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    Trial registered with the Australian New Zealand Clinical Trials Registry www.anzctr.org.au ACTRN12609000910202.

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