Elsevier

Behavior Therapy

Volume 51, Issue 6, November 2020, Pages 882-894
Behavior Therapy

A Nonrandomized Trial of Prolonged Exposure and Cognitive Processing Therapy for Combat-Related Posttraumatic Stress Disorder in a Deployed Setting,☆☆,☆☆☆,☆☆☆☆

https://doi.org/10.1016/j.beth.2020.01.003Get rights and content

Highlights

  • Few studies have evaluated trauma-focused treatments for PTSD during deployments.

  • This study evaluated the use of PE and CPT for PTSD during a military deployment.

  • Twelve deployed U.S. military service members were treated with PE or CPT.

  • Both treatments demonstrated clinically significant reductions in PTSD symptoms.

  • Modified forms of PE and CPT can be used effectively in deployed settings.

Abstract

For many decades, the U.S. military’s general operational guideline has been to limit the use of trauma-focused treatments for combat and operational stress reactions in military service members until they have returned from deployment. Recently, published clinical trials have documented that active-duty military personnel with combat-related posttraumatic stress disorder (PTSD) can be treated effectively in garrison. However, there are limited data on the treatment of combat and operational stress reactions or combat-related PTSD during military deployments. This prospective, nonrandomized trial evaluated the treatment of active-duty service members (N = 12) with combat and operational stress reactions or combat-related PTSD while deployed to Afghanistan or Iraq. Service members were treated by deployed military behavioral health providers using modified Prolonged Exposure (PE; n = 6) or modified Cognitive Processing Therapy (CPT; n = 6), with protocol modifications tailored to individual mission requirements. The PTSD Checklist–Military Version (PCL-M) total score was the primary outcome measure. Results indicated that both groups demonstrated clinically significant change in PTSD symptoms as indicated by a reduction of 10 points or greater on the PCL-M. Participants treated with modified PE had significant reductions in PTSD symptoms, t = -3.83, p = .01; g = -1.32, with a mean reduction of 18.17 points on the PCL-M. Participants treated with modified CPT had a mean PCL-M reduction of 10.00 points, but these reductions were not statistically significant, t = -1.49, p = .12; g = -0.51. These findings provide preliminary evidence that modified forms of PE and CPT can be implemented in deployed settings for the treatment of combat and operational stress reactions and combat-related PTSD.

Section snippets

participants

Research participants were treatment-seeking active-duty military personnel (N = 12) who reported combat operational stress reaction symptoms or PTSD symptoms after being exposed to a combat-related traumatic event while deployed to Iraq or Afghanistan between 2009 and 2013. All participants voluntarily presented to the deployed behavioral health clinic through the regular referral process established at each of the five deployed locations. Prior to starting treatment, individuals were assessed

Results

Detailed treatment outcomes for PE and CPT are reported in Table 2. Prior to the primary analyses, the prevalence and symptom severity of PTSD and depression were examined at pretreatment in the PE and CPT groups. Overall, 83% of participants (n = 5/6) in the PE group endorsed symptoms indicative of a PTSD diagnosis using the combined PCL-M total symptom severity score and moderate or greater symptom ratings on each of the DSM-IV-TR criteria. Additionally, 67% of participants (n = 4/6) in the

Discussion

Deployed military behavioral health providers working in the combat theater frequently work with service members exposed to combat-related traumas. Providers conduct assessments to determine whether patients can be treated while deployed and returned to duty or whether they require psychiatric aeromedical evacuation out of theater (Baker et al., 2017; Peterson et al., 2018; Peterson, McCarthy, Busheme, Campise, & Baker, 2011; Peterson, Shah, Lara-Ruiz, & Ritchie, 2019). The limited data on

Conclusions

The results of the present study provide initial data to support the use of modified versions of PE and CPT for the treatment of combat-related PTSD—or what is often called combat and operational stress reactions—in deployed military personnel. There are a number of potential benefits of evidence-based treatments for delivery in the deployed combat theater. More service members may receive treatment, and there may be a decrease in the stigma of seeking care. If individuals are treated more

Conflict of Interest Statement

The authors declare no conflicts of interest.

References (54)

  • American Psychiatric Association

    Diagnostic and statistical manual of mental disorders

    (2000)
  • M.T. Baker et al.

    Psychiatric aeromedical evacuations: Clinical characteristics of deployed U.S. military personnel during Operation Iraqi Freedom

    Military Behavioral Health

    (2017)
  • A.T. Beck et al.

    Manual for the Beck Depression Inventory-II

    (1996)
  • A.T. Beck et al.

    An inventory for measuring depression

    Archives of General Psychiatry

    (1961)
  • E.B. Blanchard et al.

    Psychometric properties of the PTSD Checklist (PCL)

    Behavior Research and Therapy

    (1996)
  • E.V. Borah et al.

    Implementation outcomes of military provider training in cognitive processing therapy and prolonged exposure therapy for posttraumatic stress disorder

    Military Medicine

    (2013)
  • S. Bruijniks et al.

    The implementation and adherence to evidence-based protocols for psychotherapy for depression: The perspective of therapists in Dutch specialized mental healthcare

    BMC Psychiatry

    (2018)
  • R.A. Bryant et al.

    Treatment of acute stress disorder: A randomized controlled trial

    Archives of General Psychiatry

    (2008)
  • J.A. Cigrang et al.

    Three American troops in Iraq: Evaluation of a brief exposure therapy treatment for the secondary prevention of combat-related PTSD

    Pragmatic Case Studies in Psychotherapy

    (2005)
  • J.A. Cigrang et al.

    Treatment of active-duty military with PTSD in primary care: Early findings

    Psychological Services

    (2011)
  • J.A. Cigrang et al.

    Treatment of active duty military with PTSD in primary care: A follow-up report

    Journal of Anxiety Disorders

    (2015)
  • J.A. Cigrang et al.

    Moving effective treatment for posttraumatic stress disorder to primary care: A randomized controlled trial with active duty military

    Families, Systems, & Health

    (2017)
  • J. Cohen

    Statistical power analysis for the behavioral sciences

    (1988)
  • M. Creamer et al.

    Psychometric properties of the Impact of Event Scale - Revised

    Behaviour Research and Therapy

    (2003)
  • Department of the Army

    Leaders’ manual for combat stress control (Field Manual 22-51)

    (1994)
  • Department of the Army

    Combat stress (Field Manual 6-22.5)

    (2000)
  • Department of the Army

    Combat and operational stress control (Field Manual No. 4-02.51 [8-51])

    (2006)
  • Department of the Army

    A leader’s guide to soldier health and fitness (Army Techniques Publication No. 6-22.5)

    (2016)
  • S. Dukes et al.

    Finishing what was started: An analysis of theater research conducted from 2010 to 2012

    Military Medicine

    (2015)
  • A. Eftekhari et al.

    Effectiveness of national implementation of prolonged exposure therapy in Veterans Affairs care

    JAMA Psychiatry

    (2013)
  • P.D. Ellis

    The essential guide to effect sizes: Statistical power, meta-analysis, and the interpretation of research results

    (2010)
  • E.B. Foa et al.

    Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences therapist guide

    (2007)
  • E.B. Foa et al.

    Effect of prolonged exposure therapy delivered over 2 weeks vs 8 weeks vs present-centered therapy on PTSD symptom severity in military personnel: A randomized clinical trial

    Journal of the American Medical Association

    (2018)
  • D. Forbes et al.

    The validity of the PTSD Checklist as a measure of symptomatic change in combat-related PTSD

    Behaviour Research and Therapy

    (2001)
  • J.J. Fulton et al.

    The prevalence of posttraumatic stress disorder in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans: A meta-analysis

    Journal of Anxiety Disorders

    (2015)
  • T. Hoyt et al.

    Providing treatment services for PTSD at an Army FORSCOM installation

    Military Psychology

    (2011)
  • T. Hoyt et al.

    Behavioral health trends throughout a 9-month brigade combat team deployment to Afghanistan

    Psychological Services

    (2015)
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      Citation Excerpt :

      No analyses were reported to determine the degree of exposure or stress that participants endured (e.g., if they were working at this, how long they worked) and whether this had an influence on PTSD symptoms. In their nonrandomized trial, Peterson et al. (2020) studied the effects of CPT and prolonged exposure on 12 active duty service members who were on deployment in Afghanistan or Iraq and had experienced a combat-related traumatic event in Afghanistan or Iraq between 2009 and 2013. Participants were assigned to prolonged exposure (n = 6) or CPT (n = 6) based on the discretion of the military behavioral health specialist.

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    The authors would like to thank Julie Collins and Joel Williams for their assistance in editing this manuscript.

    ☆☆

    This work was supported by the Department of Defense through the U.S. Army Medical Research and Materiel Command, Congressionally Directed Medical Research Programs, Psychological Health and Traumatic Brain Injury Research Program award W81XWH-08-02-109 (Alan L. Peterson, Principal Investigator).

    ☆☆☆

    The grant sponsor played no role in study design; the collection, analysis, and interpretation of data; the writing of this paper; or the decision to submit this paper for publication.

    ☆☆☆☆

    The views expressed herein are solely those of the authors and do not represent an endorsement by or the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, the Department of the Air Force, the Department of Defense, the Department of Veterans Affairs, or the United States Government.

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