Rapid Response to PTSD Therapy May Predict Long-term Improvement

Nancy A. Melville

April 06, 2020

Patients who experience a rapid response to cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) have a greater likelihood of sustained improvement, new research suggests.

A study of 136 veterans with PTSD showed that those who responded quickly to a 3-week CPT program were significantly more likely to report lower symptom scores 3 months post treatment compared with those participants who responded more slowly.

The results add to previous evidence that intensified, short-term treatment programs can accomplish long-term benefits, the investigators, led by Jenna Bagley, BS, Rush University Medical Center, Chicago, Illinois, note.

"These findings show promise for the success of condensed evidence-based, trauma-focused interventions," they add.

Bagley was scheduled to present the study last month at the Anxiety and Depression Association of America (ADAA) Conference 2020. That conference was canceled because of the coronavirus pandemic.

Reducing High Dropout Rates

PTSD treatments such as CPT and prolonged exposure have been shown to have high efficacy, but they have also been shown to have a nearly 40% dropout rate, the researchers note.

This problem has prompted a focus on shorter-term interventions that can deliver intensified treatment before participants drop out. However, evidence has been lacking as to the sustainability of symptom improvements that occur in a short period.

The researchers evaluated data on 136 veterans (66% men; mean age, 41 years) with PTSD who completed a non-Veterans Affairs, 3-week CPT-based intensive treatment program. Follow-up assessments were carried out at 3 months.

Symptom reduction rates represented the number of days from intake in the program to the first day a reduction was reported of at least 15 points on the PTSD Checklist for DSM-5 (PCL-5), which was indicative of a clinically meaningful improvement.

Results showed the longer that participants took to achieve a 15-point reduction from baseline on the PCL-5, the higher their PCL-5 score at the 3-month follow-up, representing greater ongoing symptoms (P = .04).

The amount of time to reach the 15-point reduction also predicted symptom reductions at the 3-month follow-up, even when controlling for the total change in PCL-5 score during the program (P = .03) and when controlling for type of trauma, such as combat or military sexual trauma.

Another Puzzle Piece?

Commenting on the study for Medscape Medical News, David C. Rozek, PhD, assistant professor at the University of Central Florida, Orlando, said the findings are encouraging, particularly in terms of improvements seen with shorter treatment programs.

"Sudden gains are important to look at in all treatments," said Rozek, who was not involved with the research.

"Seeing that these sudden gains occur in intensive treatment and predict long-term outcome provides another piece of the puzzle and provides additional support to intensive treatments," he added.

Rozek noted that he has also observed this with patients. However, they, along with mental health practitioners, often question whether short-term improvements will last.

"There is some concern that a rapid drop in a patient's symptoms could be an increased risk for a rebound," he said.

"However, that is when the skills learned in therapy can kick in and provide [patients] tools to use in their everyday life and to help continue recovering," he added.

Rozek was scheduled to report results from a pilot study on his own experience at the canceled ADAA meeting. The study was about an even shorter, 7-day intensive CPT program (CPT-7) conducted through the National Center for Veterans Studies.

The program involved one daily individual CPT-7 session with a mental health provider in the morning followed by optional group recreational activities in the afternoon. Twelve military personnel in two cohorts with either PTSD or subthreshold PTSD, defined as having all but one symptom cluster present, were included in the study.

Keep Patients Engaged

Preliminary results showed reductions in PCL-5 scores from pre- to post-treatment of approximately 40% (P < .001).

"Just over 50% of patients left [the program] with symptoms below probable PTSD diagnosis on a self-report measure," Rozek said.

Importantly, none of the participants dropped out of the treatment, but Rozek said that that was not necessarily surprising because of the nature of the program.

"These patients are brought in as a cohort and form some bonds, as they all have experienced traumatic events, although often [they have had] very different traumas," he said.

"We've found that by doing daily treatment, it is more accessible and removes barriers, as it is often easier to take a week or a few weeks off at a time and participate in treatment than the logistics of weekly treatment," he added.

Rozek said he suspects two key factors may predict treatment response in such programs ― cognitive flexibility and emotion regulation.

"Patients who come into treatment and are extremely rigid in their thinking and are unable to manage their emotions may be slower to respond to treatment," he noted.

"That being said, there are a variety of treatments that target these factors in different ways. Now we need to do the work to determine which treatments work for whom."

The findings on longer-term durability of rapid improvement bode well for the program. "Although the work in treatment is hard, they patients really start to see the gains quickly, within a week or weeks instead of months," Rozek said.

"This is rewarding in itself, and I would say is a strong factor for keeping patients engaged," he concluded.

Rozek has received research funding from the National Institutes of Health, the Department of Defense, the Bob Woodruff Foundation, and the Boeing Corporation.

Anxiety and Depression Association of America (ADAA) Conference 2020. Abstract S1-069.

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