The Veteran's Health Administration (VHA) has launched a large-scale initiative to promote prolonged exposure (PE) therapy, an evidence-based treatment for PTSD. While existing randomized controlled trials (RCTs) unambiguously support the efficacy of PE in civilian and some military populations, there is a need to better understand the course of treatment for combat Veterans of the current wars receiving PE in normative mental healthcare settings. The current study investigates 65 Veterans receiving care at an urban VA medical center. All Veterans were diagnosed with PTSD via a structured interview and treated with PE. Measures of PTSD and depression were collected pre- and post-treatment and every two sessions during treatment. Dependent means t-tests were used to estimate pre- and post-treatment d-type effect sizes. Additionally, hierarchical linear models (HLM) were used to investigate treatment effects over time, relationships between patient characteristics and outcomes, and to provide estimates of R2-type effect sizes. Results indicate that PE in regular VA mental healthcare contexts can be as effective as when implemented in carefully conducted RCTs.
As of December 2009 over two million Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) U.S. troops have been deployed overseas (Defense Manpower Data Center, 2009). Of those who have returned, as many as 20% appear to be suffering from mental health difficulties, inclusive of combat-related posttraumatic stress disorder (PTSD; Hoge et al., 2006, OEF, 2008 and Rand Center for Military Health Policy, 2008); and as many as half of those meeting criteria for PTSD or depression seek mental healthcare (Rand Center for Military Health Policy, 2008). Within the next decade, there will likely be hundreds of thousands of Veterans seeking psychiatric services within the Veteran's Health Administration (VHA). In anticipation of this potential influx, the VHA has increased efforts to address the trauma-related symptoms of its Veterans, including large scale initiatives to train VA clinicians in the use of empirically supported treatments for PTSD (VA, 2009).
Existing studies support efficacy of exposure therapy for civilians (Foa et al., 1999, Foa et al., 2005, Marks et al., 1998 and Resick et al., 2002) and Veterans (Cooper and Clum, 1989, Keane et al., 1989 and Schnurr et al., 2007) with PTSD. The most recent VA/Department of Defense (DoD) Clinical Practice Guidelines identified exposure therapy as one of the four evidence-based psychotherapies for PTSD (VA/DoD, 2004), and the Institute of Medicine recognized exposure therapies as the only treatment approach with sufficient efficacy data for combat-related PTSD (IOM, 2007). In this regard, exposure therapy is broadly considered the frontline intervention for combat-related PTSD.
Despite the evidence base for efficacy of exposure-oriented therapies, it has been noted that such interventions are not routinely incorporated into VA clinical practice. In a survey of six large VA Medical Centers (VAMCs), Rosen et al. (2004) found that use of psycho-education and coping skills training were frequently reported by VA clinicians. However, few clinicians (i.e., less than 5%) reported routine use of exposure-based interventions for PTSD. These study findings are consistent with the broader dissemination literature that suggests many public-sector settings do not adequately or consistently use evidence based practices, particularly with regard to the treatment of PTSD (Drake et al., 2001, Frueh et al., 2001, Frueh et al., 2009 and Hanson et al., 2002).
In light of the anticipated influx of returning Veterans with PTSD and VHA's recent initiatives to incorporate the use of empirically supported treatments for PTSD into clinical practice, there is a need to better understand how OEF/OIF Veterans receiving services at VAMC's will respond to empirically validated treatment. Few recent PTSD treatment outcome studies within the VA have included meaningful numbers of OEF/OIF Veterans (Frueh et al., 2007, Rauch et al., 2009, Ready et al., 2008, Schnurr et al., 2007 and Tuerk et al., 2010). Beyond questions about how OEF/OIF Veterans, in particular, will respond to evidence-based treatment, there is also a need to ensure that empirically supported treatments, such as exposure therapy, can be effectively implemented in VA healthcare settings by VA providers. Such data would serve to bridge the longstanding gap between research and practice and assist Veterans to receive the best possible care for their trauma-related mental health needs.
The current study presents clinical outcome data on 65 OEF/OIF Veterans treated with the manualized Prolonged Exposure (PE) intervention for PTSD (PE; Foa, Hembree, & Rothbaum, 2007) by VA clinicians. These data are timely as, to the authors’ knowledge, there are no published studies on the efficacy or effectiveness of exposure therapy for combat-related PTSD using an exclusive sample of OEF/OIF Veterans. However, given recent dissemination efforts within VA healthcare settings, we anticipate a number of effectiveness studies in the near future. The results of the current investigation, and of those to come, can be used to inform a broad understanding of the relative effectiveness of PE for OEF/OIF-related PTSD as well as an understanding of how patient characteristics may interact with treatment outcomes.
