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2019 HSR&D/QUERI National Conference Abstract

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1065 — When to Modify Evidence-Based PTSD Treatment: An Analysis of Diminishing Returns in VA Patients undergoing PE and CPT

Lead/Presenter: Rebecca Sripada,  COIN - Ann Arbor
All Authors: Sripada RK (VA Center for Clinical Management Research), Ready, DJ (Emory University Department of Psychiatry and Behavioral Sciences, Atlanta VA Medical Center), Ganoczy, D (VA Center for Clinical Management Research) Astin, MC (Emory University Department of Psychiatry and Behavioral Sciences, Atlanta VA Medical Center) Rauch, SAM (Emory University Department of Psychiatry and Behavioral Sciences, Atlanta VA Medical Center)

Objectives:
Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) are trauma-focused evidence-based psychotherapies for PTSD that are recommended as first line treatments by the American Psychological Association, the Department of Veteran Affairs (VA) and Department of Defense, and the International Society for Traumatic Stress Studies. However, a significant portion of veterans who engage in EBPs fail to respond adequately. Determining when it is advisable to modify or discontinue an EBP that is not promoting significant change could lead to better treatment outcomes for veterans. EBPs are designed to be short-term treatments, and many patients report clinically significant improvement within eight sessions. However, some patients take longer to respond and a better understanding of predictors of later response can help guide treatment.

Methods:
The cohort consisted of all VA patients with a PTSD diagnosis who received at least eight sessions of documented evidenced-based treatment within a six-month period in FY16-FY17 and had at least two PTSD symptom assessments. We examined the proportion of patients who achieved meaningful change (defined as at least 50% reduction in self-reported PTSD symptoms), both within the first eight sessions and subsequently.

Results:
Fourteen percent of patients achieved meaningful change within eight sessions and 10% subsequently. Of those who did not have at least 10% symptom reduction by session eight, only 19% went on to achieve meaningful change. Symptom change within the first eight sessions highly predicted subsequent change. Patients receiving service-connected disability compensation were less likely and white patients more likely to achieve meaningful change.

Implications:
If patients do not have at least ten percent reduction in PTSD symptoms by session eight, they are unlikely to achieve meaningful change without finding a means of enhancing current treatment or changing to another treatment.

Impacts:
A central question remaining for future study is what to recommend to clinicians who have patients that are unlikely to achieve meaningful change by continuing with the current EBP based on self-report scores at session eight. It could be fruitful to examine to what degree modifying versus switching treatment could help achieve meaningful change after session eight.