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February 1, 2022

Longer PTSD Treatment Strongly Linked to Beneficial Response for Military Personnel and Veterans

Author Affiliations
  • 1Contributing Editor, JAMA Health Forum
JAMA Health Forum. 2022;3(2):e220193. doi:10.1001/jamahealthforum.2022.0193

A longer stint of treatment is strongly associated with a beneficial response from posttraumatic stress disorder (PTSD) among active military service members and veterans, a new report from The RAND Corporation has found.

The 277-page report synthesizes evidence from 70 studies that examined whether certain patient traits or specific features of treatment programs are associated with an increased likelihood of patients staying in treatment, responding to treatment, or experiencing remission of PTSD.

An estimated 6% to 7% of adults in the US general population experience PTSD during their lifetimes, but the prevalence is higher in military populations. Nearly 11% of veterans receiving care through the Veterans Health Administration in 2016 had a diagnosis of PTSD. Among veterans who served in Iraq, Afghanistan, or both, nearly 27% of those seeking care through the Veterans Health Administration are diagnosed with PTSD.

“To match patients with the most appropriate treatment, it is important to know which treatment program characteristics and pretreatment patient characteristics are predictors of treatment retention and response,” the researchers noted. Such knowledge could help clinicians design more effective programs, and identifying patient traits that suggest who may be more likely to drop out of treatment or need to be more closely monitored “would be a valuable tool for clinical practice,” they said.

The researchers conducted a US Department of Defense–commissioned systematic review of PTSD in military populations to identify any patient or program characteristics that are associated with better retention in treatment, such as a longer stay or completing a minimum length of treatment; response to treatment, namely a reduction in PTSD severity; and remission from PTSD, with their condition improved and no longer meeting diagnostic criteria. They searched various databases and other sources for published reports of studies on the effectiveness of PTSD interventions, identified 84 articles reporting on 70 studies that included the relevant criteria, and rated the quality of 21 of the 70 studies as good, 33 as fair, and 16 as poor.

Based on high-quality evidence, the strongest predictor of treatment response was retention length—length of stay in treatment, whether patients were receiving residential, inpatient, or outpatient treatment. In addition, the researchers noted, “individual therapy was found statistically superior to group therapy.”

Although evidence suggests that certain patient characteristics are associated with longer length of treatment—older age, being married, higher treatment expectations, having more severe PTSD at baseline, and additional mental health conditions—age was the only patient trait that had a large body of evidence supporting the association. Characteristics associated with worse retention included depression and having a service-connected disability.

Although few treatment-related factors were assessed in more than 1 study, some evidence suggests that the distance between a patient’s home and the treatment facility is inversely associated with retention in PTSD treatment. In addition, although patients who attended more treatment sessions had a greater response, evidence suggests that there is no significant difference in benefit (in retention or in treatment response) between receiving therapy in person or via telehealth, although the quality of that evidence is low. Findings from one study comparing virtual reality exposure (which uses virtual reality technology to immerse a patient into a 3-dimensional setting that recreates a traumatic memory) with standard prolonged exposure therapy (a type of therapy that teaches patients to gradually approach trauma-related memories, feelings, and situations) found there was no significant difference between the two approaches in retention or response.

The analysis also found that certain patient-related factors are associated with a better or worse treatment response. Moderate-quality evidence indicates that having worse mental health (including depression and higher PTSD severity) at baseline or a history of higher levels of combat exposure is associated with a lower response to treatment; low-quality evidence suggests that participation in atrocities is associated with worse response to treatment.

Patient characteristics associated with a better treatment response include having higher levels of education, being employed, being married, having more social support, and having better physical and mental health at baseline—although the quality of evidence supporting these associations was low, the authors wrote.

“Better social function and physical health are significantly associated with remission, while co-occurring psychiatric diagnosis has a significant negative association,” the researchers said. However, they noted that evidence for these predictors was rated insufficient because the findings have not been replicated in other studies.

Because patients with military service–connected disability are less likely to complete treatment, the authors recommend identifying such patients at admission and focusing on efforts to retain them. They also said they found no studies of the relationship between patient pain and response to PTSD treatment and flagged this as an important area for future study.

The authors note that they found few studies of predictors of remission during or after PTSD treatment, and of these, none followed patients more than a year after treatment entry.

“Thus, no conclusions could be made regarding predictors of remission in military personnel or veterans,” they said, highlighting the need to conduct longitudinal analyses of VA data with respect to PTSD remission after treatment “to shed light on this important area.”

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Article Information

Published: February 1, 2022. doi:10.1001/jamahealthforum.2022.0193

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Stephenson J. JAMA Health Forum.

Corresponding Author: Joan Stephenson, PhD, Consulting Editor, JAMA Health Forum (Joan.Stephenson@jamanetwork.org).

Conflict of Interest Disclosures: None reported.