ارزیابی درمان اختلال استرس پس از سانحه با درمان پردازش شناختی و مواجهه درمانی طولانی مدت در یک کلینیک تخصصی VHA
|کد مقاله||سال انتشار||مقاله انگلیسی||ترجمه فارسی||تعداد کلمات|
|32345||2014||7 صفحه PDF||سفارش دهید||5590 کلمه|
Publisher : Elsevier - Science Direct (الزویر - ساینس دایرکت)
Journal : Journal of Anxiety Disorders, Volume 28, Issue 1, January 2014, Pages 108–114
This retrospective chart review evaluates the effectiveness of manualized cognitive processing therapy (CPT) protocols (individual CPT, CPT group only, and CPT group and individual combined) and manualized prolonged exposure (PE) therapy on veterans’ posttraumatic stress disorder (PTSD) symptoms in one Veterans Health Administration (VHA) specialty clinic. A total of 517 charts were reviewed, and analyses included 178 charts for CPT and 85 charts for PE. Results demonstrated CPT and PE to significantly reduce PTSD Checklist (PCL) scores. However, PE was significantly more effective than CPT after controlling for variables of age, service era, and ethnicity. Additional findings included different outcomes among CPT formats, decreased treatment dropouts for older veterans, and no significant differences in outcome between Hispanic and White veterans. Study limitations and future research directions are discussed.
Posttraumatic stress disorder (PTSD) is highly prevalent and disabling affecting veterans of all service eras. One study found between 15% and 17% of veterans returning from Afghanistan and Iraq at 1-year follow-up met screening criteria for PTSD (Hoge, Terhakopian, Castro, Messer, & Engel, 2007). Prevalence estimates for Vietnam veterans include a 9.1% current and a 19% lifetime prevalence (Dohrenwend et al., 2007). A rate of 10.1% has been estimated for veterans of Operation Desert Storm (Kang, Natelson, Mahan, Lee, & Murphy, 2003). Because of this high prevalence of PTSD in combat veterans, a need was identified to deliver evidence-based psychotherapies for PTSD in Veterans Health Administration (VHA) settings immediately following the start of the wars in Afghanistan and Iraq (Rosen et al., 2004). VHA began a national initiative in 2006 to formally train clinicians in cognitive processing therapy (CPT) and prolonged exposure (PE) therapy (Karlin et al., 2010 and Ruzek and Rosen, 2009). Although there are increasing numbers of clinicians trained in CPT and PE, there has been limited systematic evaluation of the effectiveness of these treatments in VHA settings (Alvarez et al., 2011, Chard et al., 2010, Morland et al., 2011, Rauch et al., 2009, Schnurr et al., 2007, Tuerk et al., 2011 and Yoder et al., 2012). There is strong support for the efficacy and tolerability of cognitive-behavioral therapies for PTSD treatment (Bisson and Andrew, 2007, Bradley et al., 2005, Mendes et al., 2008 and Ponniah and Hollon, 2009). Both CPT and PE are efficacious treatments for PTSD related to non-combat and combat traumas alike (Foa et al., 2002, Hembree et al., 2003a, Monson et al., 2006, Resick et al., 2002 and Schnurr et al., 2007). This finding is reflected in the revised VA/Department of Defense (DoD) Clinical Practice Guideline which strongly recommends CPT and PE for PTSD treatment (VA/DoD, 2010). Although data are limited, trials directly comparing CPT and PE have demonstrated similar efficacy between the two treatments (Nishith et al., 2002 and Resick et al., 2002). One long-term study has demonstrated lasting improvement in PTSD symptoms at 10-year follow-up for both treatments (Resick, Williams, Suvak, Monson, & Gradus, 2011). Further, similar outcomes have been found between variations of CPT conducted with and without a written trauma account (CPT-C) (Resick et al., 2008). Translation of CPT and PE into clinical practice has raised some interesting implementation questions regarding dropout rates and treatment response by service era and ethnicity. Two studies demonstrated Vietnam veterans less likely to drop out of treatment, but there were differing results for treatment outcomes by service era (Chard et al., 2010 and Yoder et al., 2012). Chard and colleagues found greater improvement in outcome for Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) veterans treated with CPT as compared to Vietnam veterans. Yoder and colleagues found no difference in outcome between the two service eras for PE. Studies of CPT and PE in veterans have not demonstrated differences in outcome by ethnicity, though Hispanic veterans have been underrepresented (Chard et al., 2010, Monson et al., 2006 and Tuerk et al., 2011). This is the first study the authors are aware of comparing CPT and PE in veterans. The study identified 528 records for review of veterans who received CPT or PE in one VHA specialty clinic. In particular, treatment outcome and drop outs for CPT and PE were examined. Features unique to this program included a large number of Hispanic veterans and veterans of different service eras receiving differing treatments based upon patient and therapist preferences. Most Vietnam veterans in this program received CPT and most OEF/OIF/OND veterans received PE. The following study hypotheses were evaluated for this article based upon the literature reviewed above: 1) Both CPT and PE show equal benefit for PTSD symptoms. 2) Differing CPT formats are equally effective. 3) Dropout rates are higher for the OEF/OIF/OND veterans as compared to veterans of other eras. 4) OEF/OIF/OND veterans show greater reduction in their PTSD symptoms than veterans of other eras. 5) Hispanic and White veterans respond similarly to treatment. The implications and limitations of the study findings are discussed for clinical practice and future research.