Brief Cognitive Behavioral Treatment of Deployment-Related PTSD in Primary Care Settings: A Randomized Controlled Trial
Jeffrey Cigrang, PhD (Lt Col, US Air Force, Ret.)
Evaluate a condensed cognitive behavioral therapy (CBT) for PTSD that can be implemented by mental health providers working in an integrated primary care setting. Determine whether this treatment delivery method is well received by military personnel; its efficacy in reducing PTSD symptoms; and the level of PTSD severity that is appropriate for this form of treatment.
Just as the nature of their jobs makes active-duty military personnel more likely to experience trauma and associated posttraumatic stress, it also can make them less likely to seek the help they need to cope with that stress and heal from its effects. Fearing a stigma associated with seeking mental health treatment, members of the military may face concerns that they will be viewed negatively by their peers or that their supervisors will consider them unfit for continued duty or for a desired promotion. They might also be unable to set aside the amount of time required for the treatment programs currently available through mental health clinics.
The two evidence-based therapies with the most empirical support for their efficacy in treating PTSD – Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) – were both developed for use in specialty mental health clinics, and both are typically delivered in weekly 90-minute individual sessions over a 10- to 12-week period. This model of care may not be feasible for an active-duty member of the military who is working long hours in a job that provides limited opportunity to commit extended time to medical appointments; it also might be a deterrent to someone who wishes to be discreet about seeking mental health treatment. Thus, time-intensive psychotherapy delivered in a traditional mental health setting might not reach a significant portion of military members in need of assistance.
Increasing accessibility to PTSD treatment
In an effort to overcome the barriers faced by military personnel who need mental health care for PTSD, Lt Col Jeffrey Cigrang, PhD, at Wright-Patterson Air Force Base, Ohio, has developed a novel study for STRONG STAR. This study is testing the feasibility, safety and efficacy of providing psychotherapy treatment within the primary care setting, which may prove to be a more favorable environment both in terms of acceptability and reach to military members for a variety of reasons.
For one, the military services have already developed and implemented post-deployment health surveys that screen for PTSD using the primary care clinic. Also, in recent years, behavioral health consultants (BHCs) have been integrated into primary care clinics both in military and civilian settings. These developments increase opportunities to identify PTSD early on and to intervene before symptoms or conditions become chronic. Dr. Cigrang believes that early interventions with less symptomatic patients may allow for evidence-based treatments for PTSD to be adapted to fit within the time constraints of primary care clinics and still obtain clinically significant effects. In addition, he believes this type of care will be better utilized by men and women in uniform, because anecdotal evidence indicates that military personnel feel less stigmatized when accessing mental health services in primary care.
For this study, Dr. Cigrang has developed and is evaluating a brief cognitive-behavioral therapy (CBT) protocol for treating PTSD that can be implemented by mental health providers working in an integrated primary care setting. The protocol includes intervention methods from both Prolonged Exposure and Cognitive Processing Therapy that have proven effective in the mental health setting, but these methods have been adapted for use in the time-constrained environment of primary care. For example, rather than being treated in 60- or 90-minute sessions, patients are scheduled for 30-minute appointments.
The study investigators initiated a pilot study to examine feasibility of the experimental CBT protocol and initial effectiveness with OIF/OEF veterans. The pilot study measured within subject changes in a series of clinical cases which allowed the investigators to evaluate the general effectiveness of this treatment approach when used in clinical practice in military primary care settings.
Pilot study findings showed that the primary care treatment reduced symptoms of PTSD and depression, and overall mental health functioning improved. Cigrang et.al. 2011
This investigation will be used to determine:
- whether Operation Iraqi Freedom/Operation Enduring Freedom/Operation New Dawn veterans with PTSD will accept an offer of CBT treatment in the primary care setting;
- if this type of brief CBT protocol will significantly reduce patients’ PTSD symptoms in comparison to a minimal contact condition, and if the degree of improvement compares favorably with that seen by patients who receive care in specialty mental health settings; and
- whether there are characteristics of patients at pretreatment that predict how well they will respond to PTSD treatment in primary care.
Ultimately, the investigators hope to deliver another very effective means of fighting the battle against PTSD being waged by a significant portion of active-duty and veteran military personnel.