ADAA 2009: Exposure Therapy for PTSD May Benefit Older Veterans

Pilot Study Results Show Promise

Mary Beth Nierengarten

March 18, 2009

March 18, 2009 (Santa Ana Pueblo, New Mexico) — Results from a small study suggests prolonged exposure therapy may benefit older veterans suffering from posttraumatic stress disorder (PTSD).

Presented here at the Anxiety Disorders Association of America 2009 Annual Conference, the pilot study, which included 8 subjects, showed exposure therapy reduced symptoms of PTSD, including anxiety, depression, distress, and anger, and improved cognition.

Steven R. Thorp, PhD, from the University of San Diego, in California, told Medscape Psychiatry that he undertook this research after a literature search failed to turn up any studies on the use of psychotherapy in the treatment of PTSD in older adults.

He pointed out that although the current study includes only 8 patients, it is the largest of its kind to date.

Despite the lack of data, he said, "people have strong opinions about older adults being too frail or not being able to handle exposure therapies."

Average Duration of PTSD 39 Years

The study included 11 men aged 55 years or older with chronic, primary PTSD, who were either self-referred or referred by a healthcare provider.

Individuals were excluded from the enrolling in the study if they were currently undergoing treatment for PTSD, had a change in psychotropic medicine in the past 2 months, had unmanaged psychosis or manic episodes in the past year, or had substance or alcohol dependence during the past year. Of the original 11 subjects, 3 dropped out.

The mean age of the study participants was 63 years. Of these, 88% were white, 63% were married, and 88% were retired. The mean number of years of education was 14, and the average duration of PTSD was 39 years. Prior treatment included psychiatric medications (38%), some psychotherapy (50%), and hospitalizations for psychiatric reasons (25%).

All patients completed 12 sessions of exposure therapy, which included 2 types — in vivo experience, in which patients are exposed to fears out in the world, and imaginary exposure.

Efficacy of therapy was evaluated by comparing pre- and posttreatment assessments that included a structured interview using the Clinician-Administered PTSD Scale (CAPS) as well as self-report questionnaires, in which the participants rated their own symptoms. In the preassessment phase, participants also underwent evaluation using the Mini Mental State Examination (MMSE).

Significant Clinical Improvement

The investigators found a significant reduction in the mean CAPS score from an average pretreatment score of 94 prior to a posttreatment score of 48 (P < 0.05).

To put this in context, Dr. Thorp said a drop in a CAPS score of 15 points is considered clinically significant. The significant reduction on this scale was seen for all PTSD symptoms, including reexperiencing, avoidance/numbing, and hyperarousal, in all 8 patients. Following treatment, 75% of the patients no longer met PTSD criteria.

Overall, the data showed that patients experienced a clinical improvement in most PTSD symptoms. Data from the Impact of Event Scale–Revised (IES-R) showed that patients had a significant reduction in total PTSD symptoms, along with individual symptoms of avoidance and hyperarousal (P < .05).

Data from the Beck Depression Inventory (BDI) and State-Trait Anxiety Inventory Scores (STAI-S) showed a clinically significant improvement in both depression and anxiety, and the Posttraumatic Cognitions Inventory (PTCI) showed clinical improvement in cognition (eg, self-blame, seeing the world as dangerous).

Following therapy, said Dr. Thorp, the men were able to "do things they hadn't done in years."

"We Need to Know How to Treat These People"

For Murray Stein, MD, from the University of California, San Diego, the study brings into question the "dogma" that older adults should not be treated with exposure therapy and provides very promising data on how to improve PTSD symptoms in older patients.

"There are lots of people with PTSD who fought in prior wars or who have the condition for other reasons, who have pushed it aside and coped pretty well throughout their lives. Then a spouse dies, they retire or become medically ill, and their PTSD is something they no longer can put aside, and they need help. We need to know how to treat these people."

Dr. Thorp is planning a larger 5-year randomized clinical trial that will compare prolonged exposure therapy with relaxation training in 100 older adults with PTSD.

Anxiety Disorders Association of America 2009 Annual Conference: Poster 118R. Presented March 14, 2009.


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