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Clinicis's Trauma Update Issue 5(1) Feb 2012

Clinicis's Trauma Update Issue 5(1) Feb 2012

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Clinicis's Trauma Update Issue 5(1) Feb 2012
Clinicis's Trauma Update Issue 5(1) Feb 2012

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Published by: Canadian_Veterans_Ad on Feb 23, 2012
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ISSUE 6(1)February 2012
In This Issue:
TreatmentOEF/OIF/OND VeteransCo-Occurring ProblemsC&P Issues
containssummaries of clinicallyrelevant researchpublications including linksto the full article (Troubleaccessing? See bottom of last page) and the PILOTSID number for easy access.(What is PILOTS?)
Editorial Members:
Paula P. Schnurr, PhD
Senior Associate Editor 
Barbara A. Hermann, PhD
Associate Editor 
Erin R. Barnett, PhD
Gains after cognitive-behavioraltherapy for PTSD maintainedyears later 
Cognitive-behavioral therapy is an effectivetreatment for PTSD. But how long do thebenefits last? Clinical trials, which typicallymonitor patients for 6-9 months find that im-provements made during treatment are main-tained. A new study shows that these im-provements can last years—good news for patients and clinicians alike. A team led byinvestigators at the National Center for PTSDat the Boston VAMC followed up with femalesexual assault survivors who had beentreated 5-10 years earlier with either CognitiveProcessing Therapy or Prolonged Exposure.The 126 participants were comparable to the171 participants in the original trial. All of thewomen had PTSD before treatment. Whenassessed an average of 6 years later, 80% nolonger had PTSD—22.2% of the CPT groupand 17.5% of the PE group. Almost 90% hadexperienced a drop of at least 20 points onthe Clinician-Administered PTSD Scale; theaverage decrease was just under 50 points.The benefits of CPT and PE did not differ for PTSD, depression, or other outcomes, andwere not explained by treatment that patientsreceived after the original study. These find-ings convincingly demonstrate that PTSDdoes not need to be a chronic disorder. Al-though the study was conducted with nonvet-eran women, the results offer hope for Veter-ans because both of the treatments studieshave been shown to be effective in Veteransamples. Read more...http:// www.ptsd.va.gov/professional/articles/article-pdf/id37854.pd
Resick, P. A., Williams, L. F., Suvak, M. K., Mon-son, C. M., & Gradus, J. L. (2011, December 19).Long-term outcomes of cognitive–behavioral treat-ments for posttraumatic stress disorder amongfemale rape Survivors.
Journal of Consulting and Clinical Psychology 
. Advance online publication.PILOTS ID: 37854
Enhancing the effects of psychotherapy with medication
A new study by investigators at ColumbiaUniversity reports that the antidepressant par-oxetine increased the benefits of ProlongedExposure in a sample of men and women withPTSD related to the 9/11 attacks on the WorldTrade Center. The study is important be-cause few trials have examined the effect of combined treatment relative to psychotherapyalone, despite the combined use of medica-tion and psychotherapy in both clinical prac-tice and research. The investigators random-ized 37 patients to receive either paroxetine or placebo while undergoing 10 sessions of PE.Average improvement was substantial: 50
Special Notice:
Survey of Soldier Health and Behavioral Issues
:On January 19
, the Army released
a 3-year study on physical andbehavioral health, disciplinary problems, and policy in the Army Force. Findings indicate that the number of suicides decreased in the past year and more Soldiers are seeking treatment for their problems. Data onPTSD, TBI, substance use, violent crimes, and other issues are also covered.
U.S. Department of Veterans Affairs
ISSUE 6(1) February 2012www.ptsd.va.govPAGE 1
points on the Clinician-Administered PTSD Scale in the par-oxetine group and 30 points in the placebo group. As thesenumbers suggest, the amount of improvement was greater inthe paroxetine group. At 10 weeks, patients who received par-oxetine were more likely to achieve remission too: 42% versus17% of those who received placebo. The groups had similar decreases in depression, but the paroxetine group had greater improvement in quality of life. After PE ended, 26 patients en-tered a 12-week maintenance phase in which they continued toreceive their assigned medication. There were no differencesbetween groups during this phase, which suggests that theplacebo group caught up to the paroxetine group. However, itis difficult to draw definitive conclusions because the mainte-nance sample was self-selected and also smaller than thesample in the original study. Replicating the findings in a larger,more diverse sample of trauma survivors would help cliniciansand patients determine whether combined treatment should beused more often. Read more...http://dx.doi.org/10.1176/ appi.ajp.2011.11020321 
Schneier, F. R., Neria, Y., Pavlicova, M., Hembree, E., Suh, E. J., Am-sel, L., & Marshall, R. D. (2012).Combined prolonged exposure ther-apy and paroxetine for PTSD related to the world trade center attack: Arandomized controlled trial.
 American Journal of Psychiatry, 169
, 80-88. PILOTS ID: 37261
Prolonged exposure for Veterans with mild tomoderate TBI
we reported on a studyfrom the Cincinnati VAMC showing that Veterans with mild,moderate, or severe traumatic brain injury and PTSD canbenefit from Cognitive Processing Therapy. Preliminary find-ings from a study on Prolonged Exposure provide additionalsupport for the use of evidence-based treatments for PTSDamong Veterans with TBI. The study used a clinical sample of 10 male OEF/OIF Veterans treated in outpatient OEF/OIF,polytrauma, and PTSD clinics at 2 VA Medical Centers. Allpatients had a documented history of TBI, ongoing cognitivedeficits, and current diagnosis of PTSD. Based on a compre-hensive TBI evaluation, 6 of the patients met criteria for mildTBI and 4 for moderate TBI. Modifications to the standard PEprotocol included increased structure (e.g., mid-week phonecontact), use of memory-enhancing strategies (e.g., electroniccalendars), and extending session length by 30 minutes. Theaverage number of sessions was 13.4. Reductions in PTSDand depression symptoms were significant and large (PCL:
=3.64; Beck Depression Inventory-II:
= 1.82), with 9 out of 10Veterans no longer meeting criteria for PTSD based on a PCLof 
50 at posttreatment. Whether the Veterans would haveimproved just as much without the treatment modifications isunknown. However, the study clearly shows that prolongedexposure with minimal procedural enhancements is feasible for treating PTSD and depression in Veterans with TBI. Readmore...http://dx.doi.org/10.1097/HTR.0b013e31823cd01
Wolf, G. K., Strom, T. Q., Kehle, S. M., & Eftekhari, A. (2012).A pre-liminary examination of prolonged exposure therapy with Iraq and Af-ghanistan veterans with a diagnosis of posttraumatic stress disorder and mild to moderate traumatic brain injury.
Journal of Head TraumaRehabilitation, 27 
, 26-32. PILOTS ID: 37922
Efficacy of group therapy for PTSD
Group therapy is frequently used to treat PTSD patients in VAand non-VA settings. Literature reviews of this approach sug-gest positive outcomes but no rigorous meta-analysis of theresearch had been done, until now. Results of the new studywere mixed. A team led by the National Center for PTSD atthe Boston VAMC indentified randomized controlled trials of outpatient group therapy for either PTSD or trauma survivors.The final sample of 16 was limited to studies that included aPTSD-related symptom measure and sufficient information tocalculate an effect size. The investigators adjusted effect sizesto statistically account for the effect of group clustering for the13 studies that had failed to do so (omitting this correction canyield an overestimate of the treatment effect). The overall pre-post effect size was .71, which is smaller than the 1.0-1.5 typi-cally observed in studies of individual therapy. The between-group effect size was small (
= .24); effect sizes were greater when group treatment was compared with wait-list (
= .56)versus active treatment conditions (
= .09). No studies com-pared group therapy with individual therapy or examined treat-ments such as group Cognitive Processing Therapy. The find-ings suggest that group therapies for PTSD (69% of whichwere cognitive behavioral therapy) are better than no treatmentin reducing PTSD but comparable to other active group treat-ments such as supportive therapy and less effective than indi-vidual therapy. When interpreting these results it is importantto remember that the investigators examined PTSD outcomesonly. The findings of limited benefit may not generalize toother important outcomes. Read more...http:// www.ptsd.va.gov/professional/articles/article-pdf/id37918.pd
Sloan, D. M., Feinstein, B. A., Gallagher, M. W., Beck, J. G., & Keane,T. M. (2011, November 7).Efficacy of Group Treatment for Posttrau-matic Stress Disorder Symptoms: A Meta-Analysis.
Psychological Trauma: Theory, Research, Practice, and Policy 
. Advance online publi-cation. PILOTS ID: 37918
Decreasing use of benzodiazepines amongVeterans with PTSD
Benzodiazepines are often prescribed for immediate relief of anxiety and insomnia. Lack of evidence for their efficacy as atreatment for PTSD and possible long-term harms led the VAand DoD to specifically recommend against benzodiazepineuse in the2010 Clinical Practice Guideline for PTSD. A recentanalysis of VA national administrative data reveals that pre-scribing practices are heading in the right direction but at aslow pace. Investigators linked inpatient and outpatient en-counter datasets with prescription records from fiscal years1999 through 2009. During this time, the number of Veterans
ISSUE 6(1) February 2012www.ptsd.va.govPAGE 2
receiving care for PTSD in the VA increased nearly 3-fold.Analyses revealed that the overall frequency of benzodi-azepine use in Veterans with PTSD decreased steadily from36.7% in 1999 to 30.6% in 2009. The percentage of long-termusers (defined as greater than 90 days of continuous treatmentand at least 2 refills) declined slightly, from 69.2% in 2000 to64.1%. Although the likelihood of receiving benzodiazepineswas lowest for patients newly diagnosed with PTSD (20.5% in2009) and highest for patients with at least 3 years of PTSDtreatment (36.2% in 2009), each group had a decline in pre-scribing over the study period. Promoting the use of evidence-based pharmacotherapy for PTSD among providers and Veter-ans, along with guidance on safe discontinuation of benzodi-azepines, may encourage the trend toward reduced reliance onbenzodiazepines. Read more...http://www.ptsd.va.gov/ professional/articles/article-pdf/id37919.pdf  
Lund, B. C., Bernardy, N. C., Alexander, B., & Friedman, M. J. (2011,November 29).Declining benzodiazepine use in veterans with post-traumatic stress disorder.
Journal of Clinical Psychiatry 
. Advanceonline publication. PILOTS ID: 37919
Mindfulness via telehealth for combat PTSD
Asurvey by the VA Healthcare Analysis & Information Group in2011found that 89% of VA facilities offered some type of Com-plementary and Alternative Medicine (CAM), most commonlymeditation. However, a2011 review by HSR&D’s EvidenceSynthesis Programfound limited evidence on the effectivenessof meditation for PTSD—which makes the results of a newstudy by researchers from the National Center for PTSD andVA Boston especially useful. The investigators randomized 33male Veterans with PTSD to receive mindfulness meditationtraining or psychoeducation. Both interventions consisted of 245-minute face-to-face sessions, followed by 6 20-minute tele-phone sessions that reviewed content from treatment-specificpatient handbooks. The mindfulness group was also providedwith CDs of guided mindfulness exercises. Twenty-seven Vet-erans (82%) completed treatment. Both interventions receivedhigh satisfaction ratings. There were no significant changes inPTSD at any time for the psychoeducation group. The mindful-ness group experienced clinically meaningful pre- to posttreat-ment improvement on the Clinician Administered PTSD Scaleand the PTSD Checklist. However, PCL scores returned topretreatment levels at the 6-week follow-up (the CAPS was notre-administered). Participants completed more mindfulnesspractice during treatment than assigned (
= 137 minutes per week). Amount of practice correlated with improvement inCAPS scores (
= -.66). Although practice was not assessed atfollow-up, the investigators speculated that lack of practice mayhave caused the increase in PTSD symptoms after treatment.This study suggests that a mindfulness-based intervention for PTSD, with minimal therapist contact but significant skills prac-tice, is feasible and associated with short-term benefit. Readmore...http://www.ptsd.va.gov/professional/articles/article-pdf/ id37920.pd
Niles, B. L., Klunk-Gillis, J., Ryngala, D. J., Silberbogen, A. K., Pays-nick, A., & Wolf, E. J. (2011, November 14).Comparing mindfulnessand psychoeducation treatments for combat-related PTSD using atelehealth approach.
Psychological Trauma: Theory, Research, Prac-tice, and Policy 
. Advance online publication. PILOTS ID: 37920
OEF/OIF/OND Veterans
Veterans transitioning into student life facemental health challenges
Many OEF/OIF Veterans are choosing to enter college rather than the work force, in part due to the enactment of the 9/11 GIBill. Although most of these Veterans are navigating the transi-tion into student life, a recent study suggests that many arealso struggling with PTSD symptoms and other readjustmentdifficulties. <BREAK> Six hundred twenty-eight members of Student Veterans of America, a student led organization incolleges and universities across the country, responded to anon-line mental health survey. One in five Veterans reportedsuicidal ideation with a plan, nearly a quarter endorsed moder-ate depression, over a third indicated high levels of anxiety,and close to half (46%) experienced significant PTSD symp-toms (PCL > 28). The authors highlight outreach from collegeadministration and student organizations as one solution, alongwith equipping counseling centers with relevant informationand training. However, these efforts are not likely to reachVeterans enrolled in on-line or 2-year programs that do notoffer such resources or the large proportion of student Veter-ans who do not seek care at campus counseling centers. Toaddress these challenges, a new VA website for Veteran stu- dents and their familiesoffers fact sheets and links to re-sources. Read more...http://dx.doi.org/10.1037/a0025164
Rudd, M. D., Goulding, J., & Bryan, C. J. (2011).Student veterans: Anational survey exploring psychological symptoms and suicide risk.
Professional Psychology: Research and Practice, 42 
, 354-360. PI-LOTS ID: 37921
Co-Occurring Problems
A promising strategy for reducing unemploy-ment in Veterans with PTSD
For some individuals, work problems are one of the most sig-nificant consequences of PTSD. PTSD can decrease the abil-ity to get and keep a job, and can lead to impaired work per-formance. Prior research has demonstrated poor outcomesamong Veterans with PTSD who participated in compensatedwork therapy, an approach that provides sheltered jobs. A newstudy led by investigators at the Tuscaloosa VAMC suggeststhat helping Veterans engage in competitive employmentthrough individual placement and support (IPS) is a better strategy to help unemployed Veterans return to the workforce.
ISSUE 6(1) February 2012www.ptsd.va.govPAGE 3

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