Cognitively Augmented Behavioral Activation for Veterans With Comorbid TBI/PTSD (CABA)

The primary objective of this study is to evaluate the efficacy of Cognitively Augmented Behavioral Activation (CABA), a new hybrid treatment for Veterans diagnosed with comorbid mild Traumatic Brain Injury (mTBI) and posttraumatic stress disorder (PTSD). The study's specific goals are to determine whether: 1) CABA reduces PTSD symptoms in Veterans with mTBI/PTSD, 2) CABA reduces cognitive-related functional impairment in Veterans with mTBI/PTSD, 3) CABA results in improvements in depression symptoms, cognitive functioning, and quality of life in Veterans with mTBI/PTSD; and 4) CABA is an acceptable treatment for Veterans with mTBI/PTSD. The overall goal is to develop an evidence-based manualized treatment for comorbid mTBI/PTSD that can be readily implemented in Veterans Health Administration (VHA) treatment settings.

Study Overview

• Status: Completed
• Conditions: Traumatic Brain Injury; Posttraumatic Stress Disorder
• Intervention / Treatment: Behavioral: Cognitively Augmented Behavioral Activation; Behavioral: Treatment as Usual

Detailed Description

Veterans historically exhibit high rates of comorbid mTBI/PTSD. Given the comorbidity and neuropsychiatric symptom overlap of these disorders, it can be difficult to determine whether problems and disruptions in functioning are due to mTBI, PTSD, or both. Hence, it is challenging for providers to know how to prioritize these patients' clinical issues and how to effectively treat them. Currently, there are no evidence-based treatments for comorbid mTBI/PTSD. Further, it is unclear to what extent existing treatments for each disorder can be adherently and effectively implemented for the other. As such, most current treatment recommendations suggest a holistic or integrated approach to treatment for comorbid mTBI/PTSD targeting symptoms and functionality rather than underlying etiology. Investigators are proposing a treatment for comorbid mTBI and PTSD that directly targets daily functioning and quality of life.

The study design makes use of the convergent availability of resources at the two participating Veterans Administration Health Care Systems in Portland, Oregon, and Seattle, Washington to conduct a Randomized Controlled Trial (RCT) of CABA. The study will recruit a total of 192 Veterans less than or equal to 55 years of age, 96 participants at each site, enrolled at participating VA Medical Centers (VAMCs) who are diagnosed with both mTBI and PTSD. Eligible participants will be randomly assigned to either the CABA or Treatment as Usual (TAU) group. Participants in the CABA group will receive the CABA intervention during the first 14 weeks of their participation in the study, whereas TAU participants will continue to receive TAU (usual care in a PTSD specialty treatment clinic, but no CABA) during their participation in the study. Both groups will undergo evaluations at baseline, 7 weeks (mid-treatment), 14 weeks (post-treatment), and 39 weeks (6 month follow-up). During their study participation, all participants will continue to receive their usual medical care.

• Study Type: Interventional
• Enrollment (Actual): 73
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • Oregon
    • Portland, Oregon, United States, 97239
      • VA Portland Health Care System, Portland, OR
  • Washington
    • Seattle, Washington, United States, 98108
      • VA Puget Sound Health Care System Seattle Division, Seattle, WA

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 55 years (Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Veterans 55 years of age enrolled at participating VA sites able to provide informed consent.
• Diagnosis of PTSD based on the Clinician Administered PTSD Scale.
• Positive screen on the Structured Interview for Collecting Head Trauma Event Characteristics as per the VA/Department of Defense (DoD) Clinical Practice Guideline for Management of Concussion/mTBI; AND endorsed any of the Neurobehavioral Symptom Inventory (NSI) cognitive symptoms items (items 13-17).
• English speaking, able to travel to the primary care clinics weekly for 10 sessions and for the follow-up assessments, and willing to refrain from the initiation of additional mental health treatment during the first 3 1/2 months of the active phase of treatment if they are assigned to the CABA condition.
• Willingness to participate in audio-recorded sessions. (for treatment adherence)

Exclusion Criteria:

• Current diagnosis of moderate or severe substance (alcohol) use disorder using DSM-5 criteria within the past 30 days.
• Individuals with other psychiatric diagnoses will not be excluded except for bipolar disorder and psychotic disorders (requirement to refrain from additional treatments might be harmful).
• Veterans with a history indicated by medical record review of a diagnosis of moderate, severe, or penetrating TBI, or self-reported history on the Structured Interview for Collecting Head Trauma Event Characteristics of TBI with Post-Traumatic Amnesia (PTA) greater than 24 hours or loss of consciousness (LOC) greater than 30 minutes.
• Active suicidal intent indicating significant clinical risk, which would suggest that a treatment specifically targeting this intent was indicated. Clients who report suicidal ideation without imminent risk will be admitted into the study.
• Initiated psychotropic medication, including Prazosin, within 4 weeks or changed dosage within 2 weeks prior to the first assessment, as this would make it difficult to determine which treatment contributed to change in the CABA condition; additionally, started or changed dosage of sleep medication or low dosages of tricyclic antidepressant or trazodone for pain or sleep within 1 week prior to the first assessment. Participants could be reconsidered for eligibility after stability on medication was achieved. Enrollees will be asked to hold the doses of the current medications stable over the course of enrollment (though changes in medications after enrollment will not exclude them from on-going participation).
• Auditory or visual impairments that would compromise ability to participate or benefit.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: CABA; CABA uses Behavioral Activation (BA) to identify meaningful goals and activities while learning cognitive skills to aid in working toward those goals. Early sessions of CABA focus on learning about mTBI, PTSD, and lifestyle skills that can improve thinking abilities and mood. Cognitive skills taught each week include internal and external skills to help manage problems with memory, attention, and regulation of thinking processes. Investigators and patients will spend a part of each session applying the cognitive skills to managing real life situations and getting patients active in the service of personal goals.	Behavioral: Cognitively Augmented Behavioral Activation; CABA uses Behavioral Activation (BA) to identify meaningful goals and activities while learning cognitive skills to aid in working toward those goals. Early sessions of CABA focus on learning about mTBI, PTSD, and lifestyle skills that can improve thinking abilities and mood. Cognitive skills taught each week include internal and external skills to help manage problems with memory, attention, and regulation of thinking processes. Investigators and patients will spend a part of each session applying the cognitive skills to managing real life situations and getting patients active in the service of personal goals.; Other Names: CABA
Placebo Comparator: TAU; Treatment as Usual (TAU) is the usual care that patients would normally receive at the VA. TAU care involves psychotherapy (counseling) provided by a specialist in the treatment of PTSD. Patients will be offered individual appointments with an experienced provider on the PTSD Clinical Team (PCT). Beyond this, the specific approach will be determined by the patient and his/her provider and may include skills for managing PTSD and/or a chance for the patient to "process" his/her traumatic experiences. Additional treatments may be offered to patients, such as group classes and medications. TAU care may also include additional evaluation and/or treatment of mTBI, provided by the usual care offered in Portland or Seattle's respective neuropsychology clinics. Treatment for mTBI includes individual or group sessions, and is based on clinical need.	Behavioral: Treatment as Usual; TAU care involves psychotherapy (counseling) provided by a specialist in the treatment of PTSD. Patients will be offered individual appointments with an experienced provider on the PTSD Clinical Team (PCT). Beyond this, the specific approach will be determined by the patient and his/her provider and may include skills for managing PTSD and/or a chance for the patient to "process" his/her traumatic experiences. Additional treatments may be offered to patients, such as group classes and medications. TAU care may also include additional evaluation and/or treatment of mTBI, provided by the usual care offered in Portland or Seattle's respective neuropsychology clinics. Treatment for mTBI includes individual or group sessions, and is based on clinical need.; Other Names: TAU

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
PTSD Symptoms From Baseline as Measured by the Clinician Administered PTSD Scale - 5	The Clinician Administered PTSD Scale (CAPS-IV; Blake et al., 1995; Weathers, Keane, & Davidson, 2001) was used to assess initial PTSD diagnosis (DSM-IV; APA, 2000) and PTSD symptom severity across assessment time points. The CAPS is considered a "gold standard" for assessing PTSD. Items are ranked on Likert scales according to both frequency (0-4) and intensity of symptoms (0-4), yielding an overall severity score based on the sum of frequency and intensity ratings across 17 items (range 0-136) . For this study, a diagnosis of PTSD was based on a scoring rule for items to be considered present of at least a "1" on frequency and "2" on intensity, with an overall severity score of at least 45 (Weathers, Ruscio, & Keane, 1999).	0 weeks
PTSD Symptoms at 14 Weeks as Measured by the Clinician Administered PTSD Scale - 5	The Clinician Administered PTSD Scale (CAPS-IV; Blake et al., 1995; Weathers, Keane, & Davidson, 2001) was used to assess initial PTSD diagnosis (DSM-IV; APA, 2000) and PTSD symptom severity across assessment time points. The CAPS is considered a "gold standard" for assessing PTSD. Items are ranked on Likert scales according to both frequency (0-4) and intensity of symptoms (0-4), yielding an overall severity score based on the sum of frequency and intensity ratings across 17 items (range 0-136) . For this study, a diagnosis of PTSD was based on a scoring rule for items to be considered present of at least a "1" on frequency and "2" on intensity, with an overall severity score of at least 45 (Weathers, Ruscio, & Keane, 1999).	14 weeks
PTSD Symptoms From Baseline as Measured by the PTSD Checklist-5	The Posttraumatic Stress Disorder Checklist-Fifth Edition (PCL-5; Blanchard, Jones-Alexander, Buckley, & Forneris, 1996; Weathers, Litz, Herman, Huska, & Keane, 1993; Weathers et al., 2013) was used to assess participants subjective PTSD related distress. The PCL-5 is a 20 item self-report measure that assesses the presence of DSM-5 PTSD symptoms. Items are rated on a 5-point Likert scale ranging from 0 to 4 according to how much the symptom bothered the respondent over the past month. Total scores with scores range from 0-80, with higher scores indicating more symptomatic distress. Scores totaling 31 or more are associated with presumptive PTSD among military populations.	0 weeks
PTSD Symptoms at 14 Weeks as Measured by the PTSD Checklist-5	The Posttraumatic Stress Disorder Checklist-Fifth Edition (PCL-5; Blanchard, Jones-Alexander, Buckley, & Forneris, 1996; Weathers, Litz, Herman, Huska, & Keane, 1993; Weathers et al., 2013) was used to assess participants subjective PTSD related distress. The PCL-5 is a 20 item self-report measure that assesses the presence of DSM-5 PTSD symptoms. Items are rated on a 5-point Likert scale ranging from 0 to 4 according to how much the symptom bothered the respondent over the past month. Total scores with scores range from 0-80, with higher scores indicating more symptomatic distress. Scores totaling 31 or more are associated with presumptive PTSD among military populations.	14 weeks
Baseline Memory as Measured by the Hopkins Verbal Memory Test - Revised	The Hopkins Verbal Memory Test-Revised (HVLT-R; Brandt, 1991) is a measure of uncontextualized verbal learning and delayed recall. This score is converted to a standardized T-score (mean =50, S =10). The lower the T-score, the worse the performance.	0 weeks
Memory at 14 Weeks as Measured by the Hopkins Verbal Memory Test - Revised	The Hopkins Verbal Memory Test-Revised (HVLT-R; Brandt, 1991) is a measure of uncontextualized verbal learning and delayed recall. This score is converted to a standardized T-score (mean =50, S =10). The lower the T-score, the worse the performance.	14 weeks
Attention and Working Memory From Baseline as Measured by the Wechsler Adult Intelligence Scale-4th Edition, Digit Span Subtest	The Wechsler Adult Intelligence Scale-4th Edition, Digit Span subtest (WAIS-IV; Wechsler, D., 2008) is a measure of attention and working memory. A higher total score indicates a higher level of performance (range 0-48). Raw scores are converted to scaled scores (e.g., 1-20), with higher scaled scores indicating a higher level of performance.	0 weeks
Attention and Working Memory at 14 Weeks as Measured by the Wechsler Adult Intelligence Scale-4th Edition, Digit Span Subtest	The Wechsler Adult Intelligence Scale-4th Edition, Digit Span subtest (WAIS-IV; Wechsler, D., 2008) is a measure of attention and working memory. A higher total score indicates a higher level of performance (range 0-48). Raw scores are converted to scaled scores (e.g., 1-20), with higher scaled scores indicating a higher level of performance.	14 weeks
Verbal Fluency From Baseline as Measured by the Controlled Oral Word Association Test	The Controlled Oral Word Association Test (COWAT; Ruff et al., 1996; Spreen, 1998) is a commonly used phonemic and semantic fluency word production test. A higher score indicates a higher level of performance (range 0-patient maximum).	0 weeks
Verbal Fluency at 14 Weeks as Measured by the Controlled Oral Word Association Test	The Controlled Oral Word Association Test (COWAT; Ruff et al., 1996; Spreen, 1998) is a commonly used phonemic and semantic fluency word production test. A higher score indicates a higher level of performance (range 0-patient maximum).	14 weeks
Delis-Kaplan Executive Functions Scale (DKEFS) - Trails Subtest at Baseline	The Delis-Kaplan Executive Function System, Trail Making subtest (D-KEFS; Delis, Kaplan, & Kramer, 2001; Delis, Kramer, Kaplan, & Holdnack, 2004) is a visual-motor task used to measure flexibility in thinking (executive function) and processing speed. Raw scores are converted to scaled scores (e.g., 1-20). A higher score indicates a higher level of performance. This scale is measuring Trial 4.	0 weeks
Processing Speed at 14 Weeks as Measured by Delis-Kaplan Executive Functions Scale (DKEFS) Trails Subtest	The Delis-Kaplan Executive Function System, Trail Making subtest (D-KEFS; Delis, Kaplan, & Kramer, 2001; Delis, Kramer, Kaplan, & Holdnack, 2004) is a visual-motor task used to measure flexibility in thinking (executive function) and processing speed. Raw scores are converted to scaled scores (e.g., 1-20). A higher score indicates a higher level of performance. This scale is measuring Trial 4.	14 weeks

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Symptoms of Depression From Baseline as Measured by the Beck Depression Inventory -II	The Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996) is a 21-item measure of subjective levels of depression. Items are rated on a 3-point Likert scale with higher scores reflecting greater severity of symptoms (range 0-63).	0 weeks
Symptoms of Depression at 14 Weeks as Measured by the Beck Depression Inventory -II	The Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996) is a 21-item measure of subjective levels of depression. Items are rated on a 3-point Likert scale with higher scores reflecting greater severity of symptoms (range 0-63).	14 weeks
Global Life Satisfaction From Baseline as Measured by the Satisfaction With Life Scale	The Satisfaction with Life Scale (SWLS; Diener, Emmons, Larsen, & Griffin, 1985) is a brief measure of global life satisfaction or quality of life. Items are rated on a 7-point Likert scale with higher scores indicating greater satisfaction (range 5-35).	0 weeks
Global Life Satisfaction at 14 Weeks as Measured by the Satisfaction With Life Scale	The Satisfaction with Life Scale (SWLS; Diener, Emmons, Larsen, & Griffin, 1985) is a brief measure of global life satisfaction or quality of life. Items are rated on a 7-point Likert scale with higher scores indicating greater satisfaction (range 5-35).	14 weeks
Postconcussion Symptoms From Baseline as Measured by the Neurobehavioral Symptom Inventory	The Neurobehavioral Symptom Inventory (NSI; Cicerone, K.D. & Kalmer, K., 1995) is a post-concussive symptom measure recommended for use in military studies. Items are rated on a 4-point Likert scale with higher scores reflecting greater severity of symptom disturbance since time of injury (range 0-66).	0 weeks
Postconcussion Symptoms at 14 Weeks as Measured by the Neurobehavioral Symptom Inventory	The Neurobehavioral Symptom Inventory (NSI; Cicerone, K.D. & Kalmer, K., 1995) is a post-concussive symptom measure recommended for use in military studies. Items are rated on a 4-point Likert scale with higher scores reflecting greater severity of symptom disturbance since time of injury (range 0-66).	14 weeks
Client Satisfaction Questionnaire (CSQ)	The CSQ is an 8-item questionnaire rated on a Likert scale of 1-4 used to assess client's treatment satisfaction. Scores range from 8-32, with higher scores equaling greater satisfaction.	14 weeks

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Use of Cognitive Strategies From Baseline as Measured by the Memory Compensation Questionnaire	Memory Compensation Questionnaire (MCQ)70. Rates the extent to which patients use various strategies to improve memory performance. 44 Items are rated on a 5-point Likert scale with higher scores indicating grater use of compensatory strategies (range 0-176).	0 weeks
Use of Cognitive Strategies at 14 Weeks as Measured by the Memory Compensation Questionnaire	Memory Compensation Questionnaire (MCQ)70. Rates the extent to which patients use various strategies to improve memory performance. 44 Items are rated on a 5-point Likert scale with higher scores indicating grater use of compensatory strategies (range 0-176).	14 weeks
Postconcussion Symptoms From Baseline as Measured by the Rivermead Postconcussive Questionnaire	Rivermead Post Concussive Symptom Questionnaire (RPQ) will be used to measure postconcussive symptoms. Items are rated on a 5-point Likert scale with a higher number indicating more severe PCS (range 0-64).	0 weeks
Postconcussion Symptoms at 14 Weeks as Measured by the Rivermead Postconcussive Questionnaire	Rivermead Post Concussive Symptom Questionnaire (RPQ) will be used to measure postconcussive symptoms. Items are rated on a 5-point Likert scale with a higher number indicating more severe PCS (range 0-64).	14 weeks
Symptoms of Anxiety From Baseline as Measured by the Brief Symptom Inventory	Brief Symptom Inventory 18 (BSI 18) is a measure of anxiety symptoms. 18 items are rated on a 5-point Likert scale with higher scores indicating more severe symptoms (range 0-72).	0 weeks
Symptoms of Anxiety at 14 Weeks as Measured by the Brief Symptom Inventory	Brief Symptom Inventory 18 (BSI 18) is a measure of anxiety symptoms. 18 items are rated on a 5-point Likert scale with higher scores indicating more severe symptoms (range 0-72).	14 weeks
Health Related Quality of Life From Baseline as Measured by the Neuro-Quality of Life Satisfaction With Social Roles and Activities.	Neuro-QOL Satisfaction with Social Roles and Activities is a health-related quality of life assessment tool. Eight items are rated on a 5-point Likert scale. Scores were converted to T-scores (mean = 50; SD = 10). Lower T-scores indicate greater dissatisfaction.	0 weeks
Health Related Quality of Life at 14 Weeks as Measured by the Neuro-Quality of Life Satisfaction With Social Roles and Activities.	Neuro-QOL Satisfaction with Social Roles and Activities is a health-related quality of life assessment tool. Eight items are rated on a 5-point Likert scale. Scores were converted to T-scores (mean = 50; SD = 10). Lower T-scores indicate greater dissatisfaction.	14 weeks
Functional Impairment From Baseline as Measured by the Sheehan Disability Scale	The Sheehan Disability Scale is a brief self-report measure of functional impairment across three primary life domains: work/school, social life, and family life/home responsibilities. Participants rated how much their symptoms bothered or distress them over the past week on a scale from 0 (not at all) to 10 (extremely), with higher scores indicating greater functional impairment. Total scores (possible range 0-30) were used in analyses.	0 weeks
Functional Impairment at 14 Weeks as Measured by the Sheehan Disability Scale	The Sheehan Disability Scale is a brief self-report measure of functional impairment across three primary life domains: work/school, social life, and family life/home responsibilities. Participants rated how much their symptoms bothered or distress them over the past week on a scale from 0 (not at all) to 10 (extremely), with higher scores indicating greater functional impairment. Total scores (possible range 0-30) were used in analyses.	14 weeks

Collaborators and Investigators

• Sponsor: VA Office of Research and Development
• Investigators: Principal Investigator: Megan Callahan, PsyD, VA Portland Health Care System, Portland, OR

Study record dates

Study Major Dates

• Study Start (Actual): May 4, 2015
• Primary Completion (Actual): March 31, 2021
• Study Completion (Actual): September 30, 2023

Study Registration Dates

• First Submitted: February 17, 2015
• First Submitted That Met QC Criteria: March 11, 2015
• First Posted (Estimated): March 18, 2015

Study Record Updates

• Last Update Posted (Actual): July 8, 2024
• Last Update Submitted That Met QC Criteria: April 2, 2024
• Last Verified: April 1, 2024

More Information

Terms related to this study

• Keywords: PTSD; TBI; Brain injury; Polytrauma
• Additional Relevant MeSH Terms: Mental Disorders; Brain Diseases; Central Nervous System Diseases; Nervous System Diseases; Wounds and Injuries; Craniocerebral Trauma; Trauma, Nervous System; Trauma and Stressor Related Disorders; Stress Disorders, Traumatic; Brain Injuries; Stress Disorders, Post-Traumatic; Brain Injuries, Traumatic
• Other Study ID Numbers: D1189-I

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No