By: Carly Yasinski, PhD, Andrew M. Sherrill, PhD, Jessica L. Maples-Keller, PhD, Sheila A.M. Rauch, PhD ABPP, and Barbara O. Rothbaum PhD ABPP
Exposure-based psychotherapies are highly effective and strongly recommended by APA and VA/DOD Clinical Practice Guidelines as first-line treatments for posttraumatic stress disorder (PTSD) (American Psychological Association, 2017; VA/DOD, 2017) Unfortunately treatment completion rates, particularly among Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) veterans and service members, are low, with 30 to 46% of patients dropping out (Kehle-Forbes, Meis, Spoont, & Polusny, 2016; Mott et al., 2014). New approaches to improve retention of patients in empirically-supported therapies (ESTs) for PTSD are needed.
Recent evidence suggests that having fewer days between sessions may be associated with better outcomes in ESTs for PTSD (Gutner, Suvak, Sloan, & Resick, 2016). While no randomized controlled trials directly comparing massed sessions, which usually occur daily, to spaced or weekly sessions (the current standard) for exposure-based therapy for PTSD have been published, a case study has demonstrated good outcome from a massed two-week course of Prolonged Exposure therapy (PE) for PTSD (Blount, Cigrang, Foa, Ford, & Peterson, 2014) and multiple studies have demonstrated excellent results from massed treatments for other fear-based disorders (e.g. specific phobia; Ost, Brandberg, & Alm, 1997; Ost, Alm, Brandberg, & Breitholtz, 2001). Extant studies comparing outcomes from massed vs. spaced ESTs for depressive and anxiety disorders have demonstrated similar long-term outcomes but shown that massed treatments are associated with faster rates of improvement (Cuijpers, Huibers, Ebert, Koole, & Andersson, 2013; Storch et al., 2008). This increased speed of recovery may be particularly important for post-9/11 veterans and service members who may be hesitant to complete longer-term treatments due to employment and family responsibilities or deployment and duty-station changes. Furthermore, massed sessions may reduce the likelihood of avoidance, a core symptom of PTSD which can interfere with motivation to complete treatment, as patients may see improvements sooner and have more frequent contact with service providers who can help them label and effectively counter avoidant tendencies.
Intensive treatment programs for PTSD, which include frequent sessions and multiple forms of provider support, are one possible strategy for improving engagement, dropout rates, and treatment outcomes for veterans and service members. The Emory Healthcare Veterans Program (EHVP) is a two-week intensive outpatient program (IOP) that offers daily PE and clinically indicated adjunctive interventions. The IOP was created as an alternative or adjunct to traditional outpatient treatment in order to enhance treatment completion and provide comprehensive, focused, multidisciplinary care to military veterans and service members with PTSD across the country. The EHVP is part of the Warrior Care Network that is funded by the Wounded Warrior Project (WWP) and currently includes four treatment programs focused on the invisible wounds of war [https://www.woundedwarriorproject.org/programs/warrior-care-network]. The EHVP IOP program offers treatment to qualified post-9/11 veterans and service members free of charge (i.e., all costs not paid for by patients’ insurance are paid by WWP).
Program Structure
IOP patients are referred from a variety of sources, including WWP, federal and private mental healthcare providers, and self-referral. To determine fit and eligibility, interested veterans and service members complete self-report questionnaires and a two-hour intake assessment (via telehealth or in person), which includes semi-structured interviews of PTSD symptoms (the Clinician Administered PTSD Scale for DSM-5; Weathers, Blake, et al., 2013) and other psychiatric disorders (Mini International Neuropsychiatric Interview; Sheehan et al., 2015) and collection of service, medical, psychosocial, and treatment history. Appropriate IOP patients are those for whom PTSD is the primary presenting concern and who are sufficiently medically and psychiatrically stable to participate in intensive trauma-focused treatment. Program acceptance and treatment planning is completed by a multidisciplinary team based on assessment results and review of medical records.
The primary goal of the program is to reduce PTSD symptoms through intensive individual and group therapy and enhance maintenance of gains through engagement with adjunctive treatments. This two-week program utilizes a modified intensive outpatient approach to Prolonged Exposure therapy (Blount et al., 2014) that was adapted from a group-based version (Smith et al., 2015). This approach involves daily individual imaginal exposure (repeated visiting of trauma memories in the imagination) and daily group in vivo exposure (repeated confrontation of objectively safe, trauma-related situations that the patient avoids). Common in vivo exposure targets for post-9/11 veterans and service members include crowded public places (e.g., malls, large retail stores, festivals), sitting with one’s back toward open spaces or other people, loud or sudden noises, and being in the presence of smells, people, or places that are reminiscent of the Middle East (e.g., smells of certain spices, people wearing traditional Islamic dress). Exposure takes places both within the office, for targets that are easily accessible such as imaginal exposure or recorded auditory and visual stimuli, or outside of the office, for targets such as crowded public places. The goal of both imaginal and in vivo exposure strategies is to facilitate extinction of fear responses through corrective learning and generate adaptive perspectives of the trauma, self and others, and the future.
Each weekday while in the program, patients complete one 90-minute individual imaginal exposure session and one 120-minute group in vivo exposure session. Additionally, patients are assigned daily out-of-session practice exercises, including in vivo exposure and listening to imaginal exposure recordings. All IOP patients are assigned to a social worker who provides individualized case management and support, and regular team communication occurs between the individual therapist, group leader, and case manager to coordinate treatment planning and to provide updates regarding progress. In addition, patients are involved in recreational activities during the week and on the weekend with veteran outreach coordinators, combat veterans who provide peer support and camaraderie throughout the program. Potential adjunctive services, usually occurring one to three times each per week while in the program include (but are not limited to) family treatment, medication management, yoga, cognitive assessment and rehabilitation services for traumatic brain injury, sleep assessment and intervention, and pain assessment and intervention. These services provide a holistic, integrative, and individualized approach to supporting patients as they complete PTSD-focused treatment and prepare to maintain gains after treatment.
Results
The IOP opened in February 2016. Between February and December 2016, 49 patients entered the program. Patients averaged 40.67 years of age (SD = 7.84) and 71% were male. The majority served for the Army (67%), followed by the Marine Corps (12%), Navy (12%), Air Force (6%), and multiple branches (2%). Most patients had been separated from the military (41% discharged, 22% retired, 20% medically retired). Only 12% were active duty and 4% were in the Army National Guard. Traumatic experiences targeted during therapy were primarily combat and military sexual traumas. Of the 49 patients who began the program, 42 received an adequate dose of PE, defined as either completing two weeks of individual and group PE or demonstrating significant gains prior to the end of the two weeks (e.g., sufficient habituation to trauma memory and avoided stimuli). Of the seven who did not, five patients (10%) were determined not to have primary PTSD upon arrival, and therefore alternative treatment approaches (e.g., cognitive behavioral therapy for depression or anxiety) were used. Two patients (4%) did not complete the program: one (2%) dropped out of treatment and another (2%) violated program rules and was discharged early.
To assess treatment outcome, symptom severity was measured at baseline (day 1) and completion (day 13). Severity of PTSD symptoms over the past week was measured with the PTSD Checklist for DSM-5 (PCL-5; Weathers, Litz, et al., 2013) and severity of depressive symptoms over the past week was measured with the Patient Health Questionnaire (PHQ-9; Kroenke, Spitzer, & Williams, 2001). Data at baseline and completion were available for 30 patients who received an adequate dose of PE.
We first calculated reliable symptom reduction, defined as statistically significant change in symptom severity on the PCL-5 and PHQ-9 (i.e., change ≥ 1.96 the standard error of difference between two time points). Fifty-three percent of patients (n = 16) who completed the IOP PE exhibited reliable reduction in PTSD symptoms over the two-week treatment period and 37% (n = 11) exhibited reliable reduction in depression symptoms. Using traditional PCL-5 cut-scores to screen for a PTSD diagnosis, 80% of patients were marked as positive at baseline and 43% were marked as positive at treatment completion. Using traditional PHQ-9 cut-scores to screen for a major depressive disorder, 90% of patients were marked as positive at baseline and 47% were marked as positive at treatment completion. The baseline-completion effect sizes were large for PTSD (Cohen’s d = 1.31) and depression (Cohen’s d = 1.25). Lastly, in an anonymous survey at treatment completion, 95% of patients reported overall satisfaction with the program and 84% reported that treatment improved their clinical concerns.
Conclusion
Initial outcome data suggests that a PE-based IOP model of treatment for PTSD in veterans leads to large improvements in PTSD and depression symptoms in two weeks. These improvements are comparable to those found in standard outpatient PE but occurred in a much shorter time (two weeks vs. at least 8-12 weeks). Furthermore, treatment dropout was notably lower in the current sample than in comparable samples of outpatient PTSD treatment for OEF/OIF/OND veterans (4% vs. 30-45%). Given concerns from some clinicians regarding patients’ ability to tolerate exposure therapy for PTSD (Ruzek et al., 2016), it is notable that almost all patients were able to complete intensive daily PE and most demonstrated strong benefit from treatment and reported very high treatment satisfaction. The current results are limited by small sample size and lack of a control group, both of which should be addressed in future research. Despite these limitations, our findings suggest that the EHVP IOP model might provide a new, effective, and highly efficient way to treat veterans and service members with PTSD.
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Dr. Carly Yasinski is a Postdoctoral Fellow in clinical psychology at the Emory Healthcare Veterans Program at Emory University School of Medicine. Dr. Yasinski earned her PhD from the University of Delaware and completed her clinical internship at the Medical College of Georgia and Charlie Norwood VA Medical Center consortium in Augusta, Georgia. Dr. Yasinski’s clinical interests are in cognitive-behavioral and mindfulness-based approaches to treating depression and PTSD. Her research interests focus on better understanding the process of change during psychotherapy for these disorders.
Dr. Andrew Sherrill is a postdoctoral fellow in clinical psychology at the Emory Healthcare Veterans Program at Emory University School of Medicine. Dr. Sherrill earned his PhD from the Northern Illinois University and completed his clinical internship at Veterans Affairs Puget Sound Health Care System, American Lake Division. Dr. Sherrill’s clinical interests include exposure- and mindfulness-based treatments for emotion dysfunction, namely PTSD. His research leverages theories and methodologies from cognitive psychology to better understand the etiology and treatment of trauma-related psychopathology and problematic aggression.
Dr. Jessica Maples-Keller is a postdoctoral fellow at Emory University School of Medicine with the Emory Healthcare Veteran’s Program and the Grady Trauma Project. Dr. Maples-Keller earned her PhD from the University of Georgia and completed her clinical internship at the Medical University of South Carolina. Her research interests include investigating factors that confer risk or impact treatment response for PTSD and anxiety disorders and how translational models of fear and anxiety can be used to understand and improve exposure therapy.
Dr. Sheila A. M. Rauch is an associate profession in the Department of Psychiatry and Behavioral Sciences at the Emory University School of Medicine. She also serves as a Prolonged Exposure Therapy Roll Out Trainer with the Department of Veterans Affairs. Her research focuses on translational treatment outcomes and modifications of proven treatments for use in alternate settings, such as primary care. She has published scholarly articles and book chapters in the areas of anxiety disorders and PTSD focusing on neurobiology and factors involved in the development, maintenance, and treatment of anxiety disorders, psychosocial factors in medical settings, and the relation between physical health and anxiety.
Dr. Barbara Olasov Rothbaum is a professor in psychiatry and Associate Vice Chair of Clinical Research at the Emory School of Medicine in the Department of Psychiatry and Behavioral Sciences and director of the Emory Healthcare Veterans Program and the Trauma and Anxiety Recovery Program at Emory and holds the Paul A. Janssen Chair in Neuropsychopharmacology. Dr. Rothbaum specializes in research on the treatment of individuals with anxiety disorders, particularly focusing on PTSD. She has authored over 300 scientific papers and chapters, has published 5 books on the treatment of PTSD and edited 3 others on anxiety, and received the Diplomate in Behavioral Psychology from the American Board of Professional Psychology.
Dr. Barbara Olasov Rothbaum is a professor in psychiatry and Associate Vice Chair of Clinical Research at the Emory School of Medicine in the Department of Psychiatry and Behavioral Sciences and director of the Emory Healthcare Veterans Program and the Trauma and Anxiety Recovery Program at Emory and holds the Paul A. Janssen Chair in Neuropsychopharmacology. Dr. Rothbaum specializes in research on the treatment of individuals with anxiety disorders, particularly focusing on PTSD. She has authored over 300 scientific papers and chapters, has published 5 books on the treatment of PTSD and edited 3 others on anxiety, and received the Diplomate in Behavioral Psychology from the American Board of Professional Psychology.
