Combat Veterans With PTSD Benefit From Online CBT

A test of self-managed cognitive-behavioral therapy (CBT) conducted live over the Internet with therapists may expand treatment options for military personnel with posttraumatic stress disorder, if results from a small, proof-of-concept trial are any indication.

“Most people don't get the help they need following mass trauma or war,” said Brett Litz, Ph.D., lead author on the study, which appeared in the November American Journal of Psychiatry, in an interview.“ They need constant face-to-face care with experts, and that's not a reality.”

Most studies on PTSD treatments have been carried out among veterans or civilian victims of trauma. To his knowledge, this was only the second randomized, controlled study of a mental health intervention held within the Department of Defense.

The trial was not “computer therapy,” Litz emphasized. Computers and the Internet were simply the vehicles for delivering the service. The real work involved interactions between patients and clinicians, he said. “At the 'back end,' therapists could follow each patient, monitor any regression, and produce daily ratings.”

Litz, of the Boston Veterans Affairs Healthcare, Boston University School of Medicine, and the National Center for Posttraumatic Stress Disorder, collaborated with Charles Engel, M.D., M.P.H., of the Uniformed Services University of the Health Sciences; Richard Bryant, Ph.D., of the University of New South Wales in Australia; and Anthony Papa, Ph.D., of Boston University School of Medicine.

The intervention was geared toward the needs of military service members, who are often short of spare time and are concerned about the stigma attached to issues of mental illness, said Litz.

Their patients were service members who developed PTSD following the September 11 attack on the Pentagon or after combat in Iraq or Afghanistan. The researchers screened 141 volunteers and recruited 45 for random assignment, of whom 33 completed the treatment protocol. Subjects were initially assessed in face-to-face sessions with therapists using the PTSD Symptom Scale–Interview Version, the Beck Depression Inventory-II, and the Beck Anxiety Inventory. They were evaluated again after eight weeks of treatment (permitting up to 56 possible sessions), and at three and six months after baseline.

Litz and colleagues titled their program DESTRESS—DElivery of Self-TRaining and Education for Stressful Situations—as a way of reducing stigma and emphasizing self-care aspects.

In the CBT arm, patients learned coping skills through homework assignments to handle the inevitable stressful situations they encountered in daily life, said Litz.

After learning those stress-management strategies, they began graduated exposure to the triggers, followed by seven online sessions during which they wrote about their traumas. “The goal was to promote mastery and reduce avoidance,” said the researchers. They also had access by phone or e-mail to their therapists, who included psychologists and a social worker.

The second study arm consisted of a control group of 21 patients who received supportive counseling and were asked to monitor nontrauma-related, present-day concerns and write about those experiences. Both groups also had Web access to educational materials about PTSD, stress, trauma, depression, and strategies to manage anger or sleep problems.

The PTSD symptoms of patients improved in both study arms, although the CBT intervention produced a sharper decline in severity. Of the 33 patients who completed the eight weeks of CBT treatment, 24 were assessed at the three-month follow-up, and 18 at the six-month follow-up. At three months, there was no difference between those who did or did not complete the protocol, but at six months, completers in the self-management CBT arm had significantly fewer PTSD, depression, and anxiety symptoms.

The difference at six months between the two arms might be explained by the better strategies absorbed by the CBT patients, said Litz.

“They learn to manage challenges,” he said. “That ability sinks in with sufficient successful experience, and it builds confidence in self-efficacy.”

The intervention also made good use of the therapists' time. They were able to look after more patients than they would in a similar number of office visits, said Litz. “The net time per case probably averaged about 15 minutes per week over the course of the eight weeks.”

This study is just the beginning of research using this style of intervention, said Litz. Members of the research team will continue to study its utility in U.S. Marines newly returned from Iraq and also in primary care settings at Fort Bragg, N.C., and at the Charleston (S.C.) Veterans Affairs Medical Center.

“A Randomized, Controlled Proof-of-Concept Trial of an Internet-Based, Therapist-Assisted Self-Management Treatment for Posttraumatic Stress Disorder” is posted at<http://ajp.psychiatryonline.org/cgi/content/full/164/11/1676>.▪