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Original Investigation |

Effectiveness of National Implementation of Prolonged Exposure Therapy in Veterans Affairs Care

Afsoon Eftekhari, PhD1; Josef I. Ruzek, PhD1; Jill J. Crowley, PhD1; Craig S. Rosen, PhD1; Mark A. Greenbaum, MS, MA2; Bradley E. Karlin, PhD3
[+] Author Affiliations
1National Center for PTSD, Dissemination and Training Division, VA Palo Alto Health Care System, Menlo Park, California
2Sierra-Pacific Mental Illness Research, Education, and Clinical Center, VA Palo Alto Health Care System, Palo Alto, California
3Mental Health Services, US Department of Veterans Affairs Central Office, Washington, DC
JAMA Psychiatry. 2013;70(9):949-955. doi:10.1001/jamapsychiatry.2013.36.
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Importance  Posttraumatic stress disorder (PTSD) is a pervasive and often debilitating condition that affects many individuals in the general population and military service members. Effective treatments for PTSD are greatly needed for both veterans returning from Iraq and Afghanistan and veterans of other eras. Prolonged exposure (PE) therapy has been shown to be highly efficacious in clinical trials involving women with noncombat trauma, but there are limited data on its effectiveness in real-world clinical practice settings and with veterans.

Objective  To evaluate the effectiveness of PE as implemented with veterans with PTSD in a large health care system.

Design, Setting, and Participants  This evaluation included 1931 veterans treated by 804 clinicians participating in the Department of Veterans Affairs (VA) PE Training Program. After completing a 4-day experiential PE training workshop, clinicians implemented PE (while receiving consultation) with a minimum of 2 veteran patients who had a primary diagnosis of PTSD.

Main Outcomes and Measures  Changes in PTSD and depression symptoms were assessed with the PTSD Checklist and the Beck Depression Inventory II, measured at baseline and at the final treatment session. Multiple and single imputation were used to estimate the posttest scores of patients who left treatment before completing 8 sessions. Demographic predictors of treatment dropout were also examined.

Results  Intent-to-treat analyses indicate that PE is effective in reducing symptoms of both PTSD (pre-post d = 0.87) and depression (pre-post d = 0.66), with effect sizes comparable to those reported in previous efficacy trials. The proportion of patients screening positive for PTSD on the PTSD Checklist decreased from 87.6% to 46.2%.

Conclusions  Clinically significant reductions in PTSD symptoms were achieved among male and female veterans of all war eras and veterans with combat-related and non–combat-related PTSD. Results also indicate that PE is effective in reducing depression symptoms, even though depression is not a direct target of the treatment.

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