A meta-analytic review of cognitive processing therapy for adults with posttraumatic stress disorder

Numerous studies have demonstrated the efficacy of cognitive processing therapy (CPT) for treating posttraumatic stress disorder (PTSD). Two prior meta-analyses of studies are available but used approaches that limit conclusions that can be drawn regarding the impact of CPT on PTSD outcomes. The current meta-analysis reviewed outcomes of trials that tested the efficacy of CPT for PTSD in adults and evaluated potential moderators of outcomes. All published trials comparing CPT against an inactive control condition (i.e. psychological placebo or wait-list) or other active treatment for PTSD in adults were included, resulting in 11 studies with a total of 1130 participants. CPT outperformed inactive control conditions on PTSD outcome measures at posttreatment (mean Hedges’ g = 1.24) and follow-up (mean Hedges’ g = 0.90). The average CPT-treated participant fared better than 89% of those in inactive control conditions at posttreatment and 82% at follow-up. Results also showed that CPT outperformed inactive control conditions on non-PTSD outcome measures at posttreatment and follow-up and that CPT outperformed other active treatments at posttreatment but not at follow-up. Effect sizes of CPT on PTSD symptoms were not significantly moderated by participant age, number of treatment sessions, total sample size, length of follow-up, or group versus individual treatment; but, older studies had larger effect sizes and percent female sex moderated the effect of CPT on non-PTSD outcomes. These meta-analytic findings indicate that CPT is an effective PTSD treatment with lasting benefits across a range of outcomes.     

Therapeutic response to Cognitive Processing Therapy in White and Black female veterans with military sexual trauma-related PTSD

Cognitive Processing Therapy (CPT) is an evidence-based treatment (EBT) for posttraumatic stress disorder (PTSD) which has been validated for female veterans with military-related PTSD. Existing trials have enrolled predominantly White veterans with some studies documenting higher rates of early termination from EBTs among Black females when compared to White females. Data from a previously published randomized clinical trial were used to evaluate the effectiveness of CPT for Black female veterans with military sexual trauma (MST)-related PTSD. Reductions in PTSD symptom severity, number of sessions attended, and early termination rates were compared between Black (n = 20) and White (n = 16) female veterans. A hierarchical linear modeling approach was used, with PTSD symptom severity over the course of treatment and follow-up entered as a level-1 variable and race (Black or White) entered as a level-2 predictor. Piecewise growth curves analyses revealed that both Black and White female veterans experienced significant reductions in PTSD symptom severity over the course of treatment and gains were maintained up to 6 months post-treatment. Race was not found to be a significant predictor of change in the slope of PTSD symptom severity over the course of CPT treatment. Additionally, number of sessions attended and rates of early termination did not significantly differ based on race. Results suggest that CPT was a well-tolerated and effective psychotherapeutic treatment for this sample regardless of racial self-identification.     

Effectiveness of Acceptance–Commitment Therapy on Craving Beliefs in Patients on Methadone Maintenance Therapy: A Pilot Study

The present study is designed to evaluate the efficacy of acceptance–commitment therapy (ACT) on craving beliefs in opioid dependent patients on methadone maintenance treatment (MMT). Twenty-eight opioid dependent participants, aged 18–50 years, who were on MMT based on Iran’s Ministry of Health and Medical Education published protocol, were evaluated in Mashhad during 2011–2012. The treatment group comprised fourteen participants, who received eight sessions of individual ACT alongside MMT while fourteen participants of the control group received just MMT. The effectiveness of the intervention was assessed by the craving beliefs questionnaire (CBQ), the action and acceptance questionnaire (AAQ-I) and the mean dosage of methadone the participants consumed in the last 3 days. Assessment was performed three times; the first was before the initiation of ACT (as pretest), the second was 2 weeks after ACT was terminated (as posttest), and the third one was 12 weeks after the termination of ACT (as follow-up). The extracted data were analyzed by two way ANOVA and ANCOVA using SPSS-20. While there was no significant difference in the mean methadone dosage between the treatment and the control group at pretest (p = 0.067), patients in the treatment group had a significantly lower methadone dosage at posttest (p < 0.001) and follow-up (p < 0.001) compared to the control group. There was a significant reduction in the CBQ scores between treatment and control groups at posttest (p = 0.047) and follow-up (p = 0.014). There was also a significant difference in AAQ-I score between treatment and control at posttest (p < 0.001) and follow-up (p < 0.001). It seems that short-term individual ACT is associated with a significant decline in craving beliefs in substance-dependent patients, which lasts for at least 12 weeks after the termination of ACT.     

Using Client Narratives to Identify Predictors of Outcome in Written Exposure Therapy and Cognitive Processing Therapy

Written exposure therapy (WET) is a brief, five-session treatment for posttraumatic stress disorder (PTSD) that aims to improve access to care. WET has been demonstrated to be an efficacious PTSD treatment with lower rates of dropout and noninferior PTSD symptom outcome compared to cognitive processing therapy (CPT), a 12-session, gold-standard treatment. To identify predictors of treatment outcome in both WET and CPT, the current study examined the content of participants’ written narratives. Participants were 123 adults with PTSD who were randomly assigned to receive WET (n = 61) or CPT (n = 62). The Change and Growth Experiences Scale (CHANGE) coding system was used to code all available narratives in both treatment conditions for variables hypothesized to be relevant to therapeutic change. Linear regression analyses revealed that in WET, higher average levels of accommodated (healthy, balanced) beliefs and an increase in accommodated beliefs from the first to the final impact statement predicted better PTSD symptom outcome at 12 weeks postrandomization. In CPT, higher average levels of overgeneralized and accommodated beliefs and lower levels of avoidance expressed in the narratives predicted better PTSD outcome. There were no significant predictors of outcome in analyses of change from the first to final impact statement in CPT. These findings add to research identifying predictors of change in WET and CPT by highlighting the importance of low avoidance in CPT and of trauma-related cognitions in both CPT and WET, even though WET is a brief written intervention that does not explicitly target cognitive change.     

Building Solutions in Youth: Evaluation of the Human–Animal Resilience Therapy Intervention

The effectiveness of the human-animal resilience therapy (HART) intervention was examined using a randomized comparison group design with youth ages 10–18 (n = 29). Paired samples t-test analyses revealed statistically significant differences between pretest and posttest scores for anxiety, depression, and disruptive behavior inventories for participants in both the treatment and comparison groups. No significant differences were found for the self-concept or anger inventories. An analysis of variance on gain scores of the treatment and comparison groups revealed no between group differences. The implications of the findings are discussed.     

Massed Cognitive Processing Therapy in Active-Duty Military: A Case Series

Despite consistent evidence that Cognitive Processing Therapy (CPT) is an efficacious treatment for posttraumatic stress disorder (PTSD), the effects among active-duty service members and veterans have been smaller than for civilians. Modifications to standard delivery may be needed to increase treatment engagement and completion, which could improve outcomes in this population. Delivering CPT in a massed format may reduce barriers to care and enable more rapid symptom reduction, yet clinicians and patients may have concerns about the tolerability and practicality of such interventions. This case series describes a course of CPT delivered in 5 days in a mixed group and individual format among 4 active-duty military service members as part of a larger randomized clinical trial. Although the pattern of symptom change differed between patients, most demonstrated clinically significant reductions in PTSD and depression symptoms during the 5-day treatment. Patients reported that the pace was tolerable and that the mixed group and individual format was beneficial. Although further research is needed to understand the longer-term outcomes of massed CPT, this therapy format has important implications for the future delivery of treatments for PTSD.     

Intensive Cognitive Processing Therapy Associated With Reduced PTSD Treatment Dropout in a Case-Controlled Study of Treatment-Seeking Veterans

Cognitive Processing Therapy (CPT) is an empirically supported psychotherapy for posttraumatic stress disorder (PTSD). The complex issue of treatment attrition is a frequently cited concern regarding CPT and other evidence-based psychotherapies for PTSD. The current study investigated the feasibility and effectiveness of “intensive” CPT, a treatment-consistent modification of CPT in which sessions are conducted more frequently than standard protocol. Fifty-four military veterans (20% female; M_age = 46; 80% Caucasian) seeking outpatient treatment for PTSD were included in this study. Patients who elected to receive intensive CPT (n = 27) were matched with archival records of individuals who received standard CPT (n = 27). Patients across treatment conditions were matched based on baseline symptom severity as measured by the PTSD Checklist for DSM-5 (PCL-5; M_PCL-5 = 52.61). Treatment outcomes were compared and longitudinal multilevel modeling was used to compare rate of symptom change over time. Patients who elected to engage in intensive CPT were twice as likely to complete treatment (88.9%) as those who received standard CPT (44.4%), X²(1, N = 54) = 12.00, p = .001. On average, intensive CPT patients completed treatment in about 25% of the time as standard CPT patients (33.8 days vs. 125.7 days). Patients in intensive CPT also demonstrated greater benefit: 81.4% reported a clinically significant improvement in PCL-5 scores compared to 51.8% of those in standard CPT, X²(1, N = 54) = 5.33, p = .020, φ = −0.314. Intensive and standard CPT performed comparably in regard to final PCL-5 score, change over time, and screening cutoff. In addition, there were no differences in treatment outcomes based on licensure status of the provider nor whether treatment was delivered in person or virtually. Intensive CPT represents a novel, treatment-consistent adaptation that was utilized to treat a group of veterans with PTSD with minimal treatment dropout. Patients who elected to engage in more frequent treatment were more likely to complete treatment, did so in one quarter of the time, and reported similar to better treatment outcomes. Providers may consider encouraging their patients to participate in treatment as frequently as they are able. However, preliminary findings are based on a nonrandom sample and design limitations temper conclusions.     

Eye movement desensitization and reprocessing (EMDR) therapy in the treatment of victims of domestic violence: A pilot study

IntroductionThe purpose of this study was to determine the effectiveness of EMDR in reducing PTSD symptoms, anxiety and depression.MethodThirty-six women participated in this study; 12 were treated with EMDR, 12 received eclectic psychotherapy, and 12 were assigned to the control group.ResultWomen in the EMDR condition showed significantly reduced PTSD and anxiety compared with those in the eclectic psychotherapy condition. The two psychotherapy approaches led to significantly reduced scores (PTSD, depression, anxiety) after treatment compared to the control group. These effects were maintained at the 6-month follow-up. Finally, effect sizes for the IES and STAI scores were greater for the subjects in the EMDR condition.ConclusionThis study met our expectations in the sense that our findings confirm the advantages and the potential of EMDR.     

Mental health of the bisexual Veteran

Despite evidence showing that bisexual individuals may be at greater risk for mental health issues than lesbian and gay individuals, they are often combined into a single group, with lesbian and gay individuals the actual focus of the research. This study aims to address this gap in the literature among US Veterans. Using data collected from a multicity purposive sample (N = 4,493), logistic regression was used to analyze whether the following groups differ in current posttraumatic stress disorder (PTSD) and depression: (a) bisexual (n = 101) vs. heterosexual Veterans (n = 4,271); (b) bisexual vs. lesbian/gay Veterans (n = 121); (c) lesbian/gay vs. heterosexual Veterans; and (d) combined group of lesbian, gay, and bisexual (LGB; n = 222) vs. heterosexual Veterans. Controlling for significant covariates, bisexual Veterans had 2.5 times the risk of severe depression (95% confidence interval [CI] = 1.34–4.67; p = 0.004) and 2.3 times the odds of PTSD (95% CI = 1.40–3.77; p = 0.001) relative to heterosexual Veterans. Bisexual Veterans had 3 times the risk of severe depression (95% CI = 1.22–7.44; p = 0.017) and 1.9 times the risk of PTSD (95% CI = 1.02–3.70; p = 0.045) compared to lesbian/gay Veterans. Lesbian/gay Veterans had no significant difference in risk for depression compared to heterosexual Veterans. However, the combined group of LGB Veterans had 1.6 times the odds of PTSD (95% CI = 1.12–2.15; p = 0.008) compared to heterosexual Veterans. These findings suggest that past research showing mental health disparities between LGB and heterosexual individuals may be driven by the inclusion of bisexual individuals. Research should assess bisexual individuals as a distinct group, and future studies should explore factors leading to depression and PTSD among bisexual Veterans.     

Cognitive Processing Therapy Versus Supportive Counseling for Acute Stress Disorder Following Assault: A Randomized Pilot Trial

The study tested the efficacy and tolerability of cognitive processing therapy (CPT) for survivors of assault with acute stress disorder. Participants (N = 30) were randomly allocated to CPT or supportive counseling. Therapy comprised six individual weekly sessions of 90-min duration. Independent diagnostic assessment for PTSD was conducted at posttreatment. Participants completed self-report measures of posttraumatic stress, depression, and negative trauma-related beliefs at pre-, posttreatment, and 6-month follow-up. Results indicated that both interventions were successful in reducing symptoms at posttreatment with no statistical difference between the two; within and between-group effect sizes and the proportion of participants not meeting PTSD criteria was greater in CPT. Treatment gains were maintained for both groups at 6-month follow-up.     

Cognitive Behaviour Therapy for Schizophrenia in Patients with Mild to Moderate Substance Misuse Problems

Rates of substance misuse are high among patients with schizophrenia. Cognitive therapies have been developed separately for both problems but little is known about outcome for this group of dual diagnosed patients. Data from a major trial of cognitive behaviour therapy for psychosis was therefore sub‐analysed to determine whether this therapy is effective in those with schizophrenia and mild to moderate substance misuse. During the original study patients received a brief cognitive behaviour therapy‐based intervention for schizophrenia delivered by trained and supervised nurses. The control group received care as usual. The outcome measures included: total psychopathology using the Comprehensive Psychopathological Rating Scale (CPRS) and Health of the Nation Outcome Scale (HoNOS), change in schizophrenic positive symptoms using Schizophrenia Change Scale (SCR), anxiety using the Brief Scale for Anxiety (BAS), depression using the Montgomery‐Asberg Depression Rating Scale (MADRS) and insight using the Assessment of Insight Scale, at baseline and end of therapy. In the original study, patients who received cognitive behaviour therapy showed improvement in overall symptomatology (p = 0.01), insight (p = 0.00) and depression (p = 0.00) compared with the control group. In the present sub‐analysis, no interaction was found between treatment group and presence or absence of substance misuse. There was a reduction in substance misuse after treatment in both the cognitive behaviour therapy and control groups but this did not differ between them. It appears that mild to moderate degrees of substance misuse did not change the outcome of cognitive behaviour therapy for psychosis in this sub‐analysis.     

Weekly Changes in Blame and PTSD Among Active-Duty Military Personnel Receiving Cognitive Processing Therapy

Both negative posttraumatic cognitions and posttraumatic stress disorder (PTSD) symptoms decrease over the course of cognitive-behavior therapy for PTSD; however, further research is needed to determine whether cognitive change precedes and predicts symptom change. The present study examined whether weekly changes in blame predicted subsequent changes in PTSD symptoms over the course of cognitive processing therapy (CPT). Participants consisted of 321 active duty U.S. Army soldiers with PTSD who received CPT in one of two clinical trials. Symptoms of PTSD and blame were assessed at baseline and weekly throughout treatment. Bivariate latent difference score modeling was used to examine temporal sequential dependencies between the constructs. Results indicated that changes in self-blame and PTSD symptoms were dynamically linked: When examining cross-construct predictors, changes in PTSD symptoms were predicted by prior changes in self-blame, but changes in self-blame were also predicted by both prior levels of and prior changes in PTSD. Changes in other-blame were predicted by prior levels of PTSD, but changes in other-blame did not predict changes in PTSD symptoms. Findings highlight the dynamic relationship between self-blame and PTSD symptoms during treatment in this active military sample.     

Does EMDR reduce post‐traumatic stress disorder symptomatology in combat veterans?

Prior meta‐analyses have suggested that eye‐movement desensitization and reprocessing (EMDR) may be effective in alleviating the symptoms of post‐traumatic stress disorder (PTSD). EMDR is now being recommended as a treatment for military combat veterans who suffer from PTSD. We provide a review of published outcome studies that appeared in print from 1987 – April, 2008 which examined the specific effects of EMDR on PTSD among military combat veterans. Studies were identified through electronic bibliographic databases, web sites, and manual searches of article reference lists. A total of six randomized controlled trials (RCTs) and three quasi‐experimental studies met our inclusionary criteria and are reviewed. The evidence supporting the use of EMDR to treat combat veterans suffering from PTSD is sparse and equivocal, and does not rise to the threshold of labeling the therapy as an empirically supported treatment. It is premature to incorporate EMDR into routine care for veterans to alleviate combat‐related PTSD. EMDR needs a considerably stronger evidentiary foundation which includes large‐scale RCTs involving credible placebo controlled treatment conditions. Copyright © 2009 John Wiley & Sons, Ltd.     

Cognitive behaviour therapy versus eye movement desensitization and reprocessing for post-traumatic disorder – is it all in the homework then?

IntroductionTreatment of choice for post-traumatic stress disorder (PTSD) is either eye movement desensitization and reprocessing (EMDR) or trauma-focused cognitive behaviour therapy (TFCBT).ObjectiveThe aim of the present meta-analysis was to determine whether there are any differences between these two treatments with respect to efficacy and efficiency in treating PTSD.MethodWe performed a comprehensive literature search using several electronic search engines as well as manual searches of other review papers. Eight original studies involving 227 participants were identified in this manner.ResultsThere were no differences between EMDR and TFCBT on measures of PTSD. However, there was a significant advantage for EMDR over TFCBT in reducing depression (Hedge's g = 0.63). The analysis also indicated a difference in the prescribed homework between the treatments. Meta-regression analyses were conducted to examine the relationship between hours of homework and gains in depression and PTSD symptoms.ConclusionThese findings are discussed in terms of efficacy and cost-effectiveness and the use of homework in therapy.     

Sudden Gains in Two Trauma-Focused Treatments for Posttraumatic Stress Disorder

In the current study, we examined the degree to which sudden gains (large, rapid, and stable symptom reduction in a one-session interval) predicted treatment outcome in adults randomized to two different trauma-focused treatments. Adults diagnosed with PTSD were randomized to either written exposure therapy (WET; n = 63), a brief, exposure-based treatment for posttraumatic stress disorder (PTSD), or the more time-intensive Cognitive Processing Therapy (CPT; n = 63). Findings showed that 20.6% of participants who received WET and 17.5% of participants who received CPT experienced sudden gains. Sudden gains occurred earlier in WET (M session = 2.69, SD = 0.75) than in CPT (M session = 5.64, SD = 3.01). However, there were no treatment condition differences in the magnitude of the sudden gains. Treatment outcomes were significantly better for those who experienced sudden gains compared with those who did not, regardless of treatment assignment. Exploratory analyses of participants’ trauma narratives revealed that expressing more negative emotion predicted the occurrence of sudden gains in both treatment conditions. Negative beliefs about the self and others did not predict sudden gains. The findings are discussed in terms of how they may help identify individual early response patterns that predict outcomes in trauma-focused treatments.     

Internet-based self-help treatment for panic disorder: a randomized controlled trial comparing mandatory versus optional complementary psychological support

Panic disorder (PD) is one of the most common psychiatric disorders. Web-based self-help treatments for PD have had promising results. These online treatments seem to have larger effect sizes (ESs) when professional support is added. However, the amount of support or how it should be administered is not yet clear. The aim of this trial was to study two ways of administering psychological support provided by phone as a part of Internet-based self-help treatment for PD based on cognitive behavioral therapy. Seventy-seven participants diagnosed with PD were randomly assigned to one of three experimental conditions: a waiting list control group; a treatment group with non-scheduled psychological support; or a treatment group with scheduled psychological support. PD symptoms of participants who received treatment improved significantly compared to the control group (mean ES d = 1.18, p < .05). In addition, there were statistically and clinically significant differences between treatment groups (Mean difference = ?3.20, p = .005, 95% CI [?5.62, ?.79]). The scheduled group showed a larger ES, a lower dropout rate, and better adherence to treatment than the non-scheduled group. Scheduled support seems to be indicated for patients who seek Web-based treatment for PD, and their symptoms of panic, anxiety, and depression improve at post-treatment and six-month follow-up. In contrast, when support depends on patient demand, they receive less support and so, the therapeutic effect is poorer.     

Changes in suicidal ideation following cognitive processing therapy in a VA residential treatment program

ABSTRACT

In 2015, suicide accounted for over 44,000 deaths and was the 10th leading cause of mortality in the US. Although Veterans, in general, are at a high risk for suicide, Veterans with Posttraumatic Stress Disorder (PTSD) are at even greater risk. While evidence suggests that PTSD symptoms are reduced by Cognitive Processing Therapy (CPT), little is known about how this treatment impacts changes in suicidal ideation across residential treatment. Studies with active duty personnel have found reductions in suicidal ideation following CPT treatment; however, only one study to date has examined this question in a Veteran sample. The current study examined (a) changes in suicidal ideation across a residential CPT treatment program and (b) the influence of demographic variables on change in suicidal ideation across treatment. Participants (N = 303) were admitted to a residential PTSD treatment in a VA medical center and completed pre-, mid-, and post-treatment assessments. Multilevel modeling of archival data revealed that suicidal ideation significantly decreased over the course of CPT (B = ?0.153, SE =0.028, 95%CI =[?0.21, ?0.10], t= ?5.40, p< .001); however, this change did not differ based on age, marital status, sex, or race/ethnicity. Clinical and research implications are discussed.     

Using Explicit Case Formulation to Improve Cognitive Processing Therapy for PTSD

We investigated the utility of explicit case formulation (CF) within Cognitive Processing Therapy (CPT) for individuals with posttraumatic stress disorder (PTSD). An uncontrolled pre-posttreatment design was used. Participants attended 12–16 weekly sessions of CPT with explicit CF, where CF guided treatment length and treatment components. Treatment was completed by 19 of the 23 participants who started therapy. Results revealed significant reductions in PTSD and depression severity as well as unhelpful PTSD-related beliefs from pre- to posttreatment (ds between 1.10 – 1.92) and treatment gains were maintained at 3-month follow-up. Of the participants available at posttreatment for assessment, 69% (n = 11/16) met good end-state functioning for PTSD and 62% (n = 8/13) did so at follow-up. Finally, 72% (n = 13/18) of those interviewed at posttreatment no longer met criteria for PTSD and this was found for 93% of those assessed at follow-up (n = 14/15). Treatment, and CF in particular, was found to be acceptable by participants. Explicit case formulation did not interfere with positive outcomes of Cognitive Processing Therapy for PTSD. Further clinical implications and future directions for research are discussed.     

A study of the effects of cranial electrical stimulation on attention and concentration

There have been several anecdotal accounts that cranial electrical stimulation (CES) enhances attention and the ability to learn new tasks in a normal population, but only one published investigation confirms that CES improves attention using the Alpha Stim CES (Madden and Kirsch, 1987). The purpose of this study was to corroborate the findings of Madden and Kirsch, using more precise measures of attention, such as a Continuous Performance Test (CPT). A pretest and posttest CPT was given to two groups using the LISS CES device. The control group consisted of twenty-one subjects who received the placebo treatment. The experimental group of thirty-one subjects received twenty minutes of CES. Four measures of the CPT show significant gains in attention: Number of Hits,p=.010 Hit RT ISI Change,p=.016, Risk Taking,p=.055; and Attentiveness,p=.054. Based on subjects who demonstrated improvement by one standard deviation on two different measures of the CPT, thirty-one percent of the experimental group improved versus four percent of the control group. The use of CES as a method of increasing attention is a promising are that requires further investigation.