Treatment response trajectories in a three-week CPT-Based intensive treatment for veterans with PTSD

Held, Philip; Smith, Dale L.; Bagley, Jenna M.; Kovacevic, Merdijana; Steigerwald, Victoria L.; Horn, Rebecca; Karnik, Niranjan S.

doi:10.1016/j.jpsychires.2021.07.004

Cited by 15 publications

(15 citation statements)

References 34 publications

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“…Although previous research reported large symptom reductions over the course of and following a CPT-based ITP (Held et al, 2020(Held et al, , 2021Zalta et al, 2018), the present study results indicated that the majority (80%-87%) of treatment completers reported at least some PTSD and depression residual symptoms at posttreatment. Residual PTSD and depression were even reported by those who exhibited clinically meaningful change over the course of the ITP.…”

Section: Discussioncontrasting

confidence: 93%

“…Participation in ITPs has been associated with high completion rates and large short- and long-term reductions in self-reported PTSD symptoms, negative posttraumatic cognitions, and depression symptoms (Held et al, 2020; Rauch et al, 2021; Zalta et al, 2018). Although the majority of ITP completers were likely to experience treatment gains, the large variability in PTSD symptom severity at posttreatment and the presence of a subset of minimal responders to treatment suggested the presence of clinically significant symptoms at posttreatment (Held et al, 2021). Although these studies generally suggested that residual symptoms exist, we are not aware of any studies to date that have explicitly examined which PTSD residual symptoms remain following ITP completion.…”

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confidence: 99%

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Posttraumatic stress disorder and depression residual symptoms among veterans and service members who completed a 3-week cognitive processing therapy-based intensive treatment program.

Kovacevic¹,

Bravo²,

Held³

2023

Psychological Trauma: Theory, Research, Practice, and Policy

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Objective. While previous studies have documented that evidence-based treatments for posttraumatic stress disorder (PTSD) are efficacious, treatment completers often continue to experience residual symptoms. However, no studies to date have assessed residual symptoms following intensive treatment programs (ITPs) for PTSD, which combine evidence-based PTSD treatment along with adjunctive interventions. The present study examined residual symptoms of PTSD and depression in 482 veterans and service members who completed a 3-week Cognitive Processing Therapy-based ITP. Method. Residual symptoms were examined at posttreatment and 3 months following ITP completion. Frequency analyses and logistic regressions were conducted to discern the presence of residual symptoms among (a) the total sample and (b) participants who did and did not experience clinically meaningful change in PTSD symptom severity over the course of treatment. Results. Study results indicated that the majority of participants (80%–87%) reported some PTSD and depression residual symptoms at ITP completion, which commonly continued to be endorsed at 3 months following ITP completion. At both treatment completion and 3 months following treatment, participants who experienced clinically meaningful changes during the ITP exhibited statistically lower odds of PTSD and depression residual symptoms as compared to participants who did not experience clinically meaningful changes. However, regardless of whether clinically meaningful changes in PTSD symptoms were experienced, participants most commonly endorsed residual symptoms in the hyperarousal cluster of PTSD and general depression symptoms at high rates. Conclusions. Findings suggest the need to further examine functional impairment and coping skill use associated with these long-standing residual symptoms.

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Section: Discussioncontrasting

confidence: 93%

mentioning

confidence: 99%

Posttraumatic stress disorder and depression residual symptoms among veterans and service members who completed a 3-week cognitive processing therapy-based intensive treatment program.

Kovacevic¹,

Bravo²,

Held³

2023

Psychological Trauma: Theory, Research, Practice, and Policy

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“…Based on insight from previous work (Held et al, 2022b), we used Dirichlet, rather than uniform, priors for variable selection probabilities. This allows models to adapt to the existence of more useful predictors in the dataset, thus accommodating the expectation that clinical features and updated PTSD severity values are likely to be more useful in prediction than demographic features (Held et al, 2021(Held et al, , 2022b. As a Bayesian analytic method, MixBART approaches inference by sampling from the posterior distribution generated computationally utilizing existing data and relevant priors.…”

Section: Analytic Strategymentioning

confidence: 99%

Moving toward precision PTSD treatment: predicting veterans' intensive PTSD treatment response using continuously updating machine learning models

Smith

Held²

2022

Psychol. Med.

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Background Considerable heterogeneity exists in treatment response to first-line posttraumatic stress disorder (PTSD) treatments, such as Cognitive Processing Therapy (CPT). Relatively little is known about the timing of when during a course of care the treatment response becomes apparent. Novel machine learning methods, especially continuously updating prediction models, have the potential to address these gaps in our understanding of response and optimize PTSD treatment. Methods Using data from a 3-week (n = 362) CPT-based intensive PTSD treatment program (ITP), we explored three methods for generating continuously updating prediction models to predict endpoint PTSD severity. These included Mixed Effects Bayesian Additive Regression Trees (MixedBART), Mixed Effects Random Forest (MERF) machine learning models, and Linear Mixed Effects models (LMM). Models used baseline and self-reported PTSD symptom severity data collected every other day during treatment. We then validated our findings by examining model performances in a separate, equally established, 2-week CPT-based ITP (n = 108). Results Results across approaches were very similar and indicated modest prediction accuracy at baseline (R2 ~ 0.18), with increasing accuracy of predictions of final PTSD severity across program timepoints (e.g. mid-program R2 ~ 0.62). Similar findings were obtained when the models were applied to the 2-week ITP. Neither the MERF nor the MixedBART machine learning approach outperformed LMM prediction, though benefits of each may differ based on the application. Conclusions Utilizing continuously updating models in PTSD treatments may be beneficial for clinicians in determining whether an individual is responding, and when this determination can be made.

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“…However, the results of this study are consistent with other research showing that compressed treatment formats result in more patients completing treatment, reduced treatment dropouts, and overall improved outcomes. 14,[44][45][46][47] Although both compressed PE treatments in this study yielded similar results, the IOP-PE intervention was undoubtedly more expensive and required more participant and clinician effort. It is unclear if the additional costs are warranted for the better maintenance of the treatment benefits with the IOP-PE treatment.…”

Section: Limitationsmentioning

confidence: 56%

Massed vs Intensive Outpatient Prolonged Exposure for Combat-Related Posttraumatic Stress Disorder

et al. 2023

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ImportanceImproved, efficient, and acceptable treatments are needed for combat-related posttraumatic stress disorder (PTSD).ObjectiveTo determine the efficacy of 2 compressed prolonged exposure (PE) therapy outpatient treatments for combat-related PTSD.Design, Setting, and ParticipantsThis randomized clinical trial was conducted among military personnel and veterans at 4 sites in Texas from 2017 to 2019. Assessors were blinded to conditions. Data were analyzed from November 2020 to October 2022.InterventionsThe interventions were massed-PE, which included 15 therapy sessions of 90 minutes each over 3 weeks, vs intensive outpatient program PE (IOP-PE), which included 15 full-day therapy sessions over 3 weeks with 8 treatment augmentations. The IOP-PE intervention was hypothesized to be superior to massed-PE.Main Outcomes and MeasuresCoprimary outcomes included the Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) (CAPS-5) and the PTSD Checklist for DSM-5 (PCL-5) administered at baseline and posttreatment follow-ups. Measures ranged from 0 to 80, with higher scores indicating greater severity. Diagnostic remission and reliable change were secondary outcomes.ResultsAmong 319 military personnel and veterans screened, 234 were randomized (mean [SD] age, 39.20 [7.72] years; 182 [78%] male participants), with 117 participants randomized to IOP-PE and 117 participants randomized to massed-PE. A total of 61 participants (26%) were African American, 58 participants (25%) were Hispanic, and 102 participants (44%) were White; 151 participants (65%) were married. Linear mixed-effects models found that CAPS-5 scores decreased in both treatment groups at the 1-month follow-up (IOP-PE: mean difference, −13.85 [95% CI, −16.47 to −11.23]; P &lt; .001; massed-PE: mean difference, −14.13 [95% CI, −16.63 to −11.62]; P &lt; .001). CAPS-5 change scores differed from 1- to 6-month follow-ups (mean difference, 4.44 [95% CI, 0.89 to 8.01]; P = .02). PTSD symptoms increased in massed-PE participants during follow-up (mean difference, 3.21 [95% CI, 0.65 to 5.77]; P = .01), whereas IOP-PE participants maintained treatment gains (mean difference, 1.23 [95% CI, −3.72 to 1.27]; P = .33). PCL-5 scores decreased in both groups from baseline to 1-month follow-up (IOP-PE: mean difference, −21.81 [95% CI, −25.57 to −18.04]; P &lt; .001; massed-PE: mean difference, −19.96 [95% CI, −23.56 to −16.35]; P &lt; .001) and were maintained at 6 months (IOP-PE: mean change, −0.21 [95% CI, −3.47 to 3.06]; P = .90; massed-PE: mean change, 3.02 [95% CI, −0.36 to 6.40]; P = .08). Both groups had notable PTSD diagnostic remission at posttreatment (IOP-PE: 48% [95% CI, 36% to 61%] of participants; massed-PE: 62% [95% CI, 51% to 73%] of participants), which was maintained at 6 months (IOP-PE: 53% [95% CI, 40% to 66%] of participants; massed-PE: 52% [95% CI, 38% to 66%] of participants). Most participants demonstrated reliable change on the CAPS-5 (61% [95% CI, 52% to 69%] of participants) and the PCL-5 (74% [95% CI, 66% to 81%] of participants) at the 1-month follow-up.Conclusions and RelevanceThese findings suggest that PE can be adapted into compressed treatment formats that effectively reduce PTSD symptoms.Trial RegistrationClinicalTrials.gov Identifier: NCT03529435

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Treatment response trajectories in a three-week CPT-Based intensive treatment for veterans with PTSD

Cited by 15 publications

References 34 publications

Posttraumatic stress disorder and depression residual symptoms among veterans and service members who completed a 3-week cognitive processing therapy-based intensive treatment program.

Posttraumatic stress disorder and depression residual symptoms among veterans and service members who completed a 3-week cognitive processing therapy-based intensive treatment program.

Moving toward precision PTSD treatment: predicting veterans' intensive PTSD treatment response using continuously updating machine learning models

Massed vs Intensive Outpatient Prolonged Exposure for Combat-Related Posttraumatic Stress Disorder

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