Military sexual trauma (MST) and post-traumatic stress disorder (PTSD) are each reported by at least 20% of female Veterans and negatively affect their mental and physical health and quality of life (QOL). Both MST and PTSD are associated with a variety of mental health disorders and multiple physical symptoms, foremost among them, sleep disturbances and chronic pain. Given the associations among MST, PTSD, poor health and reduced quality of life (QOL), targeted treatment for this population is particularly critical. However existing treatment methods for PTSD are sometimes ineffective and unacceptable to as many as 50% of patients, suggesting the need for innovative approaches to PTSD treatment. Yoga is emerging as an acceptable and beneficial approach to reduce many distressing symptoms associated with PTSD, for example, depression, anxiety, insomnia, and pain, and may be helpful for female Veterans and other women with PTSD. This HSR&D Nursing Research Initiative-funded study, "Yoga for Female Veterans with PTSD and Military Sexual Trauma Exposure (NRI-12-417)," began to address the current gap in evidence-based PTSD treatment options, particularly for female Veterans who experienced MST.
The objectives of this study were to: (a) evaluate the feasibility of conducting a study of a trauma-sensitive yoga intervention in a sample of female veterans with symptoms of PTSD related to MST; insomnia; and chronic pain; (b) assess the feasibility of obtaining objective biological and psychophysiological data and to evaluate these as outcome measures for future studies of this intervention in this population; and (c) to explore the potential effectiveness of this yoga intervention.
To achieve these objectives, we conducted a mixed-methods feasibility study of a trauma-sensitive yoga intervention. We used a longitudinal design to evaluate study recruitment and retention, randomization, and intervention acceptability and implementation and to explore the feasibility of collecting biologic and psycho-physiologic markers as outcome measures, in addition to qualitative data and self-report data. Female Veterans (N = 42) who were seeking PTSD treatment in the VA who experienced MST were randomized to a 10-week trauma-sensitive yoga intervention or a 12-week Cognitive-Processing Therapy-Cognitive (CPT-C) intervention. Data were collected at four time points, yielding data on participants for a total of six months. Outcome measures included PTSD symptoms, sleep disturbance, chronic pain and biological and physiological responses. Measurement included symptom self-report; objective measures, including heart rate variability, dark enhanced startle response, wrist actigraphy to assess sleep disturbance, and inflammatory cytokines; and clinician administered psychological measures (SCID and CAPS). Qualitative data were collected via focus groups and individual interviews to assess intervention and data collection acceptability to the participants. Quantitative data analyses included descriptive analysis and analysis of change scores, but did not included analysis for intervention effectiveness using parametric statistics, given the limited sample size.
The mean age of the sample was 46.12 (yoga group) and 44.2 (CPT-C group) years. The majority of participants identified as African-American (65% and 75%, for yoga and CPT-C groups, respectively). Participants in both groups had clinically significant symptoms of PTSD, major depression, and chronic pain, though yoga participants' symptoms were more severe. Study retention was higher in the yoga group (58.8%) than in the CPT-C group (32.0%). Intervention retention rates were also higher in the yoga group (58.8%) than in the CPT-C group (36.0%). All data collection was feasible with the exception of sleep actigraphy. Analyses demonstrated a strong trend toward effectiveness of yoga versus CPT-C at baseline compared to 2-weeks post-intervention in reducing PTSD symptoms (PCL: 25% decrease v. 8% increase; CAPS: 39% v. 16% decrease) and significantly decreasing depression (BDI: 45% decrease v. 17% increase), and chronic pain (39% decrease v. 19% increase). Cytokine data analysis was not possible due to the small sample size. Qualitative results indicated that the yoga intervention and overall study design were acceptable to participants, though participants noted that the data collection burden was high.
By establishing the feasibility of conducting a study of yoga for PTSD among female Veterans, this study supported the design of a larger study to evaluate the effectiveness of trauma-sensitive yoga in reducing PTSD and depression symptoms, improving sleep, decreasing chronic pain and decreasing biological and physiological stress in female Veterans who experienced MST. These positive effects would likely improve quality of life (QOL) and minimize the significant medical consequences of PTSD, including cardiovascular and metabolic diseases. The next study, which has been funded by the VA, will be a four-year randomized-controlled trial of this intervention versus current evidence-based treatment, specifically CPT-C. This clinical study may provide sufficient evidence to support clinical guidelines for innovative, complementary and alternative PTSD treatment for female Veterans, which could be disseminated to VA Medical Centers nationwide to supplement the currently limited effective modalities to treat PTSD in this population.
- Kelly UA, Patel M, Bradley B, Corwin EJ, Norrholm S, McCullough S, Forbus L. Trauma-Sensitive Yoga for Women Veterans with PTSD who Experienced Military Sexual Trauma: A Feasibility Study. Presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 8; Philadelphia, PA.
- Forbus L, Kelly UA, McCullough S, Patel M. Screening for obstructive sleep apnea in female Veterans with posttraumatic stress disorder and military sexual trauma. Presented at: Nursing Network on Violence Against Women Annual International Conference; 2015 Apr 9; Atlanta, GA.