Intensive outpatient prolonged exposure effective for combat related posttraumatic stress disorder
1. For military personnel and veterans with PTSD, intensive outpatient prolonged exposure (IOP-PE) therapy had a significantly greater reduction at 6 months follow-up in clinician-rated symptoms, compared to patients randomized to massed prolonged exposure (massed-PE) therapy.
2. Approximately half of patients treated in both IOP-PE or massed-PE groups maintained diagnostic remission at 6 months follow-up.
3. There were no significant differences in self-rated symptoms and functioning between IOP-PE and massed-PE patients.
Evidence Rating Level: 1 (Excellent)
Posttraumatic stress disorder (PTSD) is the leading psychological condition experienced by military combat personnel in the United States. One treatment for combat-related PTSD is prolonged exposure (PE) therapy. A previous RCT compared a standard delivery of 10 weekly PE sessions to a massed delivery of 10 daily PE sessions over 2 weeks, which found significant symptom reductions in both groups, but improved efficiency and fewer dropouts in the daily sessions group. However, no RCTs have examined the effectiveness of intensive outpatient programs (IOPs), one of the highest levels of delivery of care for PTSD patients. Therefore, this current RCT compared massed-PE and IOP-PE models delivered over 3 weeks, with the hypothesis that IOP-PE would be more effective in reducing clinician and self-rated PTSD symptoms. The study population consisted of US military veterans and personnel who had been deployed after September 11, 2001, randomized to either treatment. Both protocols consisted of 15 90-minute daily sessions over 3 weeks, whereas the IOP-PE protocol added 8 adaptations that would address issues specific to combat-related PTSD. Outcomes were measured using the 80-point Clinician-Administered PTSD Scale (CAPS-5) and a number of self-reported measures including the 20-item PCL-5 for PTSD symptoms, 3-item Sheehan Disability Scale (SDS) for functional impairment, and 7-item Brief Inventory of Psychosocial Functioning (B-IPF). These were done at baseline and at 1, 3, and 6-month follow-ups. In total, there were 234 participants, with 117 randomized to either group. Both groups had similar treatment completion rates of over 90%. The results showed that mean CAPS-5 scores had significant reductions at 1-month follow-up in both groups (-13.85, 95% CI -16.47 to -11.23, p < 0.001 for IOP-PE; -14.13, 95% CI -16.63 to -11.62, p < 0.001 for massed-PE). At 1 month, there were no differences in clinician-rated symptoms between groups. Between 1 and 6 months however, the IOP-PE group maintained reduction of symptoms (-1.23, 95% CI -3.72 to 1.27, p = 0.33) while the massed-PE group had an increase in symptoms (3.21, 95% CI 0.65-5.77, p = 0.01). At 6 months, the IOP-PE group had a significantly lower CAPS-5 score than the massed-PE group (mean difference 4.44, 95% CI 0.86-8.01, p = 0.01). Additionally, diagnostic remission was achieved in 53% of IOP-PE patients (95% CI 40-66%) and 52% of massed-PE patients (95% CI 38-66%) at 6 months, and were not significantly different between groups at any timepoint. Furthermore, there was no significant difference between groups on the PCL-5, SDS, or B-IPF scores. Overall, this study demonstrated that the IOP-PE delivery model was associated with a greater reduction in clinician-rated PTSD symptoms at 6 months compared to massed-PE, but there were no differences in diagnostic remission or self-rated symptoms and functioning between groups.
Click to read the study in JAMA Network Open
Image: PD
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