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Little is known about client attitudes, especially Veterans', toward the types of structured interventions that are increasingly being offered in public sector and VA mental health clinics, nor is the possible impact these attitudes may have on treatment engagement well understood. Previous work indicates that attitudes of African Americans and European Americans toward treatment may differ in important ways. Attitudes toward treatment have been a proposed explanation for lower treatment engagement and higher dropout rates among African Americans compared to European Americans. Yet to date, the relationship between race and attitudes toward treatment and treatment outcomes has been understudied, and findings inconclusive. The purpose of this study was to explore African American and European American Veteran attitudes toward mental health care, especially as they relate to structured treatments. Separate focus groups were conducted with 24 African American and 37 European American military Veterans. In general, both groups reported similar reasons to seek treatment and similar thoughts regarding the purpose of therapy. Differences emerged primarily regarding therapist preferences. In both groups, some participants expressed favorable opinions of structured treatments and others expressed negative views; treatment preferences did not appear to be influenced by race.

Of troops returning from Iraq and Afghanistan, approximately 5–20% have PTSD, and another 11–23% have traumatic brain injury (TBI). Cognitive-behavioral therapies (CBTs) are empirically validated treatment strategies for PTSD. However, cognitive limitations may interfere with the ability to adhere to, and benefit from, CBTs. Co-morbid TBI has not been systematically taken into consideration in PTSD outcome research or in treatment planning guidance. We hypothesized that poorer pre-treatment cognitive abilities would be associated with poorer treatment outcomes from CBTs for PTSD. The present study was a naturalistic examination of "treatment as usual" in an outpatient clinic that provides manualized CBTs for PTSD to military service members and veterans. Participants were 23 veterans aged 18–50 years with combat-related PTSD and symptom duration more than 1 year; 16 of whom had mild TBI. Our predictor variables were well-normed objective tests of cognitive ability measured at baseline; our outcome variables were: a) individual slopes of change of the PTSD Checklist 5 (PCL-5) and the Clinician Assessment of PTSD Scale (CAPS-5) over weeks of treatment; and b) pre- to post-treatment change (Δ) in PCL-5 and CAPS-5. Contrary to our prediction, neither pre-treatment cognitive performance, nor the presence of co-morbid mild TBI, predicted poorer response to CBTs for PTSD. Our results discourage any notion of excluding PTSD patients with poorer cognitive ability from CBTs. Study limitations include a naturalistic treatment design, which did not allow for control of confounders, and an inability to completely rule out type II error because of small sample size.

Although there are a number of effective treatments for posttraumatic stress disorder (PTSD), there is a need to develop more efficient evidence-based PTSD treatments to address barriers to seeking and receiving treatment. Written exposure therapy (WET) is a potential alternative that is a 5-session treatment without any between-session assignments. WET has demonstrated efficacy, and low treatment dropout rates. However, prior studies with WET have primarily focused on civilian samples. Identifying efficient PTSD treatments for military service members is critical given the high prevalence of PTSD in this population. The current ongoing randomized clinical trial builds upon the existing literature by investigating whether WET is equally efficacious as Cognitive Processing Therapy (CPT) in a sample of 150 active duty military service members diagnosed with PTSD who are randomly assigned to either WET (n = 75) or CPT (n = 75). Participants are assessed at baseline and 10, 20, and 30 weeks after the first treatment session. The primary outcome measure is PTSD symptom severity assessed with the Clinician Administered PTSD Scale for DSM-5. Given the prevalence of PTSD and the aforementioned limitations of currently available first-line PTSD treatments, the identification of a brief, efficacious treatment that is associated with reduced patient dropout would represent a significant public health development.

IMPORTANCE: Posttraumatic stress disorder (PTSD) occurs more commonly among military service members than among civilians; however, despite the availability of several evidence-based treatments, there is a need for more efficient evidence-based PTSD treatments to better address the needs of service members. Written exposure therapy is a brief PTSD intervention that consists of 5 sessions with no between-session assignments, has demonstrated efficacy, and is associated with low treatment dropout rates, but prior randomized clinical trials of this intervention have focused on civilian populations. OBJECTIVE: To investigate whether the brief intervention, written exposure therapy, is noninferior in the treatment of PTSD vs the more time-intensive cognitive processing therapy among service members diagnosed with PTSD. DESIGN, SETTING, AND PARTICIPANTS: The study used a randomized, noninferiority design with a 1:1 randomization allocation. Recruitment for the study took place from August 2016 through October 2020. Participants were active-duty military service members diagnosed with posttraumatic stress disorder. The study was conducted in an outpatient setting for service members seeking PTSD treatment at military bases in San Antonio or Killeen, Texas. INTERVENTIONS: Participants received either written exposure therapy, which consisted of 5 weekly sessions, or cognitive processing therapy, which consisted of 12 twice-weekly sessions. MAIN OUTCOMES AND MEASURES: Participants were assessed at baseline and at 10, 20, and 30 weeks after the first treatment session. The primary outcome measure was PTSD symptom severity assessed with the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5). Noninferiority was defined as the difference between the 2 groups being less than the upper bound of the 1-sided 95% CI–specified margin of 10 points on the CAPS-5. RESULTS: Overall, 169 participants were included in the study. Participants were predominantly male (136 [80.5%]), serving in the Army (167 [98.8%]), with a mean (SD) age ...

Combat-related trauma exposures have been associated with increased risk for posttraumatic stress disorder (PTSD) and comorbid mental health conditions. Cognitive Processing Therapy (CPT) is a 12-session manualized cognitive-behavioral therapy that has emerged as one of the leading evidence-based treatments for combat-related PTSD among military personnel and veterans. However, rates of remission have been less in both veterans and active duty military personnel compared to civilians, suggesting that studies are needed to identify strategies to improve upon outcomes in veterans of military combat. There is existing evidence that varying the number of sessions in the CPT protocol based on patient response to treatment improves outcomes in civilians. This paper describes the rationale, design, and methodology of a clinical trial examining a variable-length CPT intervention in a treatment-seeking active duty sample with PTSD to determine if some service members would benefit from a longer or shorter dose of treatment, and to identify predictors of length of treatment response to reach good end-state functioning. In addition to individual demographic and trauma-related variables, the trial is designed to evaluate factors related to internalizing/externalizing personality traits, neuropsychological measures of cognitive functioning, and biological markers as predictors of treatment response. This study attempts to develop a personalized approach to achieving positive treatment outcomes for service members suffering from PTSD. Determining predictors of treatment response can help to develop an adaptable treatment regimen that returns the greatest number of service members to full functioning in the shortest amount of time.

BACKGROUND: The purpose of this study was to examine demographic, psychological, military, and deployment variables that might predict posttraumatic stress disorder (PTSD) symptom improvement in a sample of active duty service members who received either group or individual cognitive processing therapy (CPT). METHODS: Data were analyzed from 165 active duty service members with pre- and posttreatment data participating in a randomized controlled trial comparing group with individual CPT. Pretreatment variables were examined as predictors of change in PTSD severity from baseline to posttreatment, assessed using the PTSD Symptom Scale-Interview Version (PSS-I). Predictors of PSS-I change were first evaluated using Pearson correlations, followed by partial and multiple correlations to clarify which associations remained when effects of other predictors were controlled. Multiple regression analyses were used to test for interactions between pretreatment variables and treatment format. RESULTS: Only age was a significant predictor of PTSD symptom change after controlling for other variables and statisitically correcting for testing multiple variables. There was also an interaction between age and treatment format. CONCLUSIONS: Younger participants had greater symptom improvement, particularly if they received individual treatment. Other pretreatment variables did not predict outcome. CPT appears to be robust across most pretreatment variables, such that comorbid disorders, baseline symptom severity, and suicidal ideation do not interfere with application of CPT. However, individual CPT may be a better option particularly for younger service members.