A randomized controlled trial of cognitive-behavioral treatment for posttraumatic stress disorder in severe mental illness.

Abstract

A cognitive-behavioral therapy (CBT) program for PTSD was developed to address its high prevalence in persons with severe mental illness receiving treatment at community mental health centers. CBT was compared to treatment as usual (TAU) in a randomized controlled trial with 108 clients with PTSD and either major mood disorder (85%) or schizophrenia or schizoaffective disorder (15%), of whom 25% also had borderline personality disorder. Eighty-one percent of clients assigned to CBT participated in the program. Intent-to-treat analyses showed that CBT clients improved significantly more than clients in TAU at blinded post-treatment and 3-and 6-month follow-up assessments in PTSD symptoms, other symptoms, perceived health, negative trauma-related beliefs, knowledge about PTSD, and case manager working alliance. The effects of CBT on PTSD were strongest in clients with severe PTSD. Homework completion in CBT predicted greater reductions in symptoms. Changes in trauma-related beliefs in CBT mediated improvements in PTSD. The findings suggest that clients with severe mental illness and PTSD can benefit from CBT, despite severe symptoms, suicidal thinking, psychosis, and vulnerability to hospitalizations. Keywordsposttraumatic stress disorder; severe mental illness; cognitive behavioral therapy; mood disorder; schizophrenia People with severe mental illnesses such as schizophrenia, bipolar disorder, and treatmentrefractory major depression are more likely to have experienced adverse events in childhood such as sexual and physical abuse, and to be victimized in adulthood, compared to the general population (Bebbington et al., 2004;Goodman, Rosenberg, Mueser, & Drake, 1997;Shevlin, Dorahy, & Adamson, 2007). As a presumed result of this high vulnerability to trauma, surveys of posttraumatic stress disorder (PTSD) in treatment samples of people with prolonged and severe mental illness have reported rates of current PTSD ranging between 29% and 48% (Calhoun et al., 2007;Cascardi, Mueser, DeGiralomo, & Murrin, 1996;Craine, Henson, Colliver, & MacLean, 1988;Howgego et al., 2005;Mueser et al., 1998;Mueser et al., 2001;Mueser et al., 2004c;Switzer et al., 1999). These rates far exceed the prevalence of PTSD in the general population, estimated to be 3.5% over 12-months (Kessler, Chiu, Demler, & Walters, 2005b) and 7 to 12% over the lifetime (Breslau, Davis, Andreski, & Peterson, 1991;Breslau, Peterson, Poisson, Schultz, & Lucia, 2004;Kessler et al., 2005a;Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995;Resnick, Kilpatrick, Dansky, Saunders, & Best, 1993).Persons with severe mental illness may experience psychotic distortions or delusions with themes involving sexual or physical abuse (Coverdale & Grunebaum, 1998), raising questions about the reliability and validity of self-reports of trauma and PTSD in this population. However, research addressing this question supports the validity of self-reports (Read, van Os, Morrison, & Ross, 2005). Self-reports of trauma in clients with severe mental illness are reliable over ...

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the management of schizophrenia and related disorders

“…Psychoeducation and cognitive and behavioural strategies to reduce anxiety may be helpful (Frueh et al, 2009;Mueser et al, 2008). Exposure therapy and other specific therapies to address post-traumatic stress disorder in people with schizophrenia require further research before they can be recommended as treatments for schizophrenia.…”

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