In its first-ever randomized clinical trial with an active-duty military population, Prolonged Exposure (PE), a top treatment for post-traumatic stress disorder (PTSD), was found effective for combat PTSD. The therapy led to significant symptom reductions and a loss of PTSD diagnosis in nearly half of study participants, with treatment gains largely maintained over time.
These positive results proved true whether PE was delivered in its traditional format over the course of eight weeks or in a newly tested, intensive format of daily treatment for two weeks.
Findings were published in the Journal of the American Medical Association, or JAMA, on Jan. 23 by researchers with the University of Pennsylvania, The University of Texas Health Science Center at San Antonio (UT Health San Antonio), and other institutions affiliated with the STRONG STAR Consortium. STRONG STAR is a multi-institutional research network funded by the Department of Defense (DOD) to find the most effective methods to prevent and treat combat-PTSD and related conditions.
Investigators say the study’s findings validate PE, already the treatment with the most scientific support for its efficacy with civilians and veterans, as an effective treatment for service members with combat PTSD. It also offers a rapid treatment option with this top therapy that may make it more appealing and accessible to military personnel and ultimately help speed recovery for the hundreds of thousands of service members returning with PTSD following post-9/11 deployments. This would in turn enhance military operational readiness.
Edna Foa, PhD, professor of clinical psychology in psychiatry in the Perelman School of Medicine at the University of Pennsylvania, led the study. It was conducted at Fort Hood in Killeen, Texas, in collaboration with Carl R. Darnall Army Medical Center. The study involved 370 active duty service members seeking PTSD treatment.
Dr. Foa developed Prolonged Exposure, a form of cognitive-behavioral therapy involving exposure to trauma memories and to daily-life trauma reminders. In PE, as patients repeatedly and safely recall and confront traumatic memories, they are able to process thoughts about their trauma, calm the anxiety the memories provoke and regain control of their lives.
The STRONG STAR study looked at outcomes with two delivery methods of PE: Massed-PE, which involved PE administered in 10 sessions over two weeks; and Spaced-PE, the traditional method, administered in 10 sessions over eight weeks. It then compared outcomes with Spaced-PE to those with Present-Centered Therapy (PCT), a non-trauma-focused therapy that involves identifying and discussing daily stressors, similarly delivered in 10 sessions over eight weeks. It also compared outcomes with Massed-PE to those with a Minimal Contact Control (MCC) group. MCC consisted of supportive phone calls from therapists once weekly for four weeks.
Researchers found that Massed-PE was superior to Minimal Contact Control and equivalent to Spaced-PE. In addition, Massed-PE, Spaced-PE and Present-Centered Therapy were all about equally effective in reducing combat PTSD symptoms and leading to loss of PTSD diagnosis. All led to significant reductions in PTSD symptoms. Likewise, loss of PTSD diagnosis was similar among the three groups, with rates at the end of treatment at 49 percent with Spaced-PE, 45 percent with Massed-PE and 40 percent with PCT. Treatment gains were largely maintained over time, continuing through the six-month follow-up with about 40 percent of patients in all three treatment conditions.
Describing this as the largest study with PE to date and the largest clinical trial ever conducted with active military with PTSD, Dr. Foa said, “Findings show that Prolonged Exposure is effective for PTSD in military personnel. In addition, the shorter, two-week treatment with PE is as effective as the longer treatment. The shorter treatment is an optimal intervention for military personnel with PTSD, as it minimizes the time and inconvenience entailed by a longer treatment before continuing their military career or returning to civilian life.”
These findings are important, Dr. Foa explained, because of the great need for fast and effective PTSD treatments. “In the last two decades, the number of individuals suffering from trauma and resulting PTSD has increased dramatically in the U.S. and around the world as a result of massive natural disasters, increased terror attacks, and the wars in Iraq and Afghanistan. This increase has resulted in an urgent need to disseminate evidence-based treatments to mental health professionals around the world,” she said.
Alan Peterson, Ph.D., professor of psychiatry with UT Health San Antonio and director of the STRONG STAR Consortium, said the need is particularly great for the DOD, which has had almost 2 million service members deploy in support of combat operations since 9/11. Up to 20 percent of these service members are believed to suffer from PTSD. “That is why now, based on these study findings, the DOD already has made policy recommendations and is acting quickly to make PE more widely available at its clinics,” said Dr. Peterson.
As positive as these study findings are, investigators say the results show that more work remains if PE and other top treatments are to be as effective for combat-PTSD as they are with civilians, among whom previous studies have shown up to 80 percent recovery rates. Among veterans, success rates have been similar to the current study, at about 50 percent.
Dr. Peterson said, “This seminal study validates that combat-related PTSD can be effectively treated in active-duty military personnel and it sets a high benchmark to which future studies will be compared. However, we need to do more. Even with our most effective PTSD treatments, we’re seeing greater challenges to successful recovery from combat-related PTSD. Our findings are good news – about half of those treated can be treated into remission. This is critical for the hundreds of thousands of post-9/11 combat veterans affected by PTSD and can do so much to improve lives and assist with military readiness. Still, we need to identify the specific factors with combat-PTSD – the things that make it more difficult to treat – and then enhance the treatments to tackle those challenges. That is the mission of STRONG STAR, and with several other studies that we currently have underway, we’re doing just that.”
In particular, Dr. Peterson described a separate, ongoing study by the Consortium to Alleviate PTSD, a partnering research network with STRONG STAR that is jointly funded by the Departments of Defense and Veterans Affairs. Called “Project Remission,” it follows up on the current study to see how Massed-PE might be incorporated into an intensive outpatient treatment with even higher success rates. It is comparing Massed-PE delivered daily for three weeks to a stepped-up version of the same treatment that has additional adaptations and enhancements to increase its efficacy with combat-PTSD. The study is open to service members and veterans and is operating at sites in San Antonio, Waco and Fort Hood.
“The idea is that the therapy might be used at specialized treatment centers where service members and veterans could go for three weeks of intensive treatment with excellent hope for recovery,” said Dr. Peterson. “That fits with the ultimate goal of all STRONG STAR research. We want to find the best treatments for combat-PTSD, as well as the best ways of delivering those treatments, so that we can help more of our nation’s war-fighters recover from their psychological wounds and maintain or resume full, productive lives.”
For more information on all STRONG STAR studies, visit www.strongstar.org/treatment.