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Cited by 358Posttraumatic Stress Disorder ResearchPsychotherapy Techniques and ApplicationsSleep and related disorders

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Effect of Prolonged Exposure Therapy Delivered Over 2 Weeks vs 8 Weeks vs Present-Centered Therapy on PTSD Symptom Severity in Military Personnel: A Randomized Clinical Trial

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Foa, Edna B., McLean, Carmen P., Zang, Yinyin, Rosenfield, David, Yadin, Elna, Yarvis, Jeffrey S., Mintz, Jim, Young-McCaughan, Stacey, Borah, Elisa V., Dondanville, Katherine A., Fina, Brooke A., Hall-Clark, Brittany N., Lichner, Tracey, Litz, Brett T., Roache, John, Wright, Edward C., Peterson, Alan L., for the STRONG STAR Consortium·2018·JAMA
DOI 10.1001/jama.2017.21242PMC PMC5833566
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Abstract

Importance: Effective and efficient treatment is needed for posttraumatic stress disorder (PTSD) in active duty military personnel. Objective: To examine the effects of massed prolonged exposure therapy (massed therapy), spaced prolonged exposure therapy (spaced therapy), present-centered therapy (PCT), and a minimal-contact control (MCC) on PTSD severity. Design, Setting, and Participants: Randomized clinical trial conducted at Fort Hood, Texas, from January 2011 through July 2016 and enrolling 370 military personnel with PTSD who had returned from Iraq, Afghanistan, or both. Final follow-up was July 11, 2016. Interventions: Prolonged exposure therapy, cognitive behavioral therapy involving exposure to trauma memories/reminders, administered as massed therapy (n = 110; 10 sessions over 2 weeks) or spaced therapy (n = 109; 10 sessions over 8 weeks); PCT, a non-trauma-focused therapy involving identifying/discussing daily stressors (n = 107; 10 sessions over 8 weeks); or MCC, telephone calls from therapists (n = 40; once weekly for 4 weeks). Main Outcomes and Measures: Outcomes were assessed before and after treatment and at 2-week, 12-week, and 6-month follow-up. Primary outcome was interviewer-assessed PTSD symptom severity, measured by the PTSD Symptom Scale-Interview (PSS-I; range, 0-51; higher scores indicate greater PTSD severity; MCID, 3.18), used to assess efficacy of massed therapy at 2 weeks posttreatment vs MCC at week 4; noninferiority of massed therapy vs spaced therapy at 2 weeks and 12 weeks posttreatment (noninferiority margin, 50% [2.3 points on PSS-I, with 1-sided α = .05]); and efficacy of spaced therapy vs PCT at posttreatment. Results: Among 370 randomized participants, data were analyzed for 366 (mean age, 32.7 [SD, 7.3] years; 44 women [12.0%]; mean baseline PSS-I score, 25.49 [6.36]), and 216 (59.0%) completed the study. At 2 weeks posttreatment, mean PSS-I score was 17.62 (mean decrease from baseline, 7.13) for massed therapy and 21.41 (mean decrease, 3.43) for MCC (difference in decrease, 3.70 [95% CI,0.72 to 6.68]; P = .02). At 2 weeks posttreatment, mean PSS-I score was 18.03 for spaced therapy (decrease, 7.29; difference in means vs massed therapy, 0.79 [1-sided 95% CI, -∞ to 2.29; P = .049 for noninferiority]) and at 12 weeks posttreatment was 18.88 for massed therapy (decrease, 6.32) and 18.34 for spaced therapy (decrease, 6.97; difference, 0.55 [1-sided 95% CI, -∞ to 2.05; P = .03 for noninferiority]). At posttreatment, PSS-I scores for PCT were 18.65 (decrease, 7.31; difference in decrease vs spaced therapy, 0.10 [95% CI, -2.48 to 2.27]; P = .93). Conclusions and Relevance: Among active duty military personnel with PTSD, massed therapy (10 sessions over 2 weeks) reduced PTSD symptom severity more than MCC at 2-week follow-up and was noninferior to spaced therapy (10 sessions over 8 weeks), and there was no significant difference between spaced therapy and PCT. The reductions in PTSD symptom severity with all treatments were relatively modest, suggesting that further research is needed to determine the clinical importance of these findings. Trial Registration: clinicaltrials.gov Identifier: NCT01049516.

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Authors
Foa, E. B., McLean, C. P., Zang, Y., Rosenfield, D., Yadin, E., Yarvis, J. S., Mintz, J., Young-McCaughan, S., Borah, E. V., Dondanville, K. A., Fina, B. A., Hall-Clark, B. N., Lichner, T., Litz, B. T., Roache, J., Wright, E. C., Peterson, A. L., & for the STRONG STAR Consortium
Affiliations
  • University of Pennsylvania (US)
  • VA Palo Alto Health Care System (US)
  • Southern Methodist University (US)
  • Carl R. Darnall Army Medical Center (US)
  • The University of Texas at San Antonio Health Science Center (US)
  • Department of Psychiatry, School of Medicine, University of Texas Health Science Center at San Antonio
  • Boston University (US)
  • Harvard University (US)
Corresponding author
Foa, Edna B.
ORCID
Venue
JAMA
Publisher
American Medical Association (AMA)
Published
2018-01-23
Volume
319
Issue
4
Pages
354
ISSN
  • 0002-9955 (ISSN-L)
  • 0098-7484
DOI
10.1001/jama.2017.21242
PMC
PMC5833566
OpenAlex
W2787126648
Cited by
357
References
41
Citations by year
2026: 32 · 2025: 29 · 2024: 32 · 2023: 54 · 2022: 45 · 2021: 49 · 2020: 53 · 2019: 43 · 2018: 19
FWCI
48.18
Type
journal article
Language
en
Open access
Locations
  • JAMA (publishedVersion)
  • Europe PMC (PubMed Central) (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
Funders
  • U.S. Department of Defense (W81XWH‐08‐02‐0114, W81XWH-08-02-0111, W81XWH, W81XWH-08-02-109)
  • U.S. Department of Veterans Affairs
  • University of Pennsylvania
  • Strong
  • University of Texas Health Science Center at San Antonio
  • Congressionally Directed Medical Research Programs (W81XWH-08-02-109, W81XWH-08-02-0111, W81XWH-08-02-0114)
  • Medical Research and Materiel Command (W81XWH-08-02-109, W81XWH‐08‐02‐0111, W81XWH‐08‐02‐0114)
Topics
  • Social Sciences › Psychology › Clinical Psychology › Posttraumatic Stress Disorder Research
  • Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
Keywords
post-traumatic stress disorder, prolonged exposure therapy, present-centered therapy, military personnel, Iraq and Afghanistan veterans, PTSD symptom severity, treatment duration, non-inferiority, telephone-delivered therapy, cognitive behavioral therapy, trauma-focused psychotherapy
MeSH terms
Adult, Female, Humans, Implosive Therapy, Male, Military Personnel, Psychotherapy, Severity of Illness Index, Stress Disorders, Post-Traumatic, Time Factors, Linear Models, Iraq War, 2003-2011, Afghan Campaign 2001-

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