Improving Function Through Primary Care Treatment of PTSD (PE-PC)

February 1, 2023 updated by: VA Office of Research and Development
The proposed project will examine a promising brief therapy for PTSD for use in VHA Primary Care and its impact on functional outcomes. This intervention will provide an alternative point of access to effective PTSD treatment and improved function that does not require referral to specialty mental health and accomplishes improved function in a short-term, brief protocol. Many Veterans prefer to receive mental health care, including PTSD service in primary care. The current protocol would allow them to access effective therapy options in addition to the medication management that is currently the standard of care for PTSD in primary care. In addition, this brief protocol may reduce the number of specialty mental health referrals as many Veterans may not require additional PTSD specific treatment after completion. Thus, if effective, this protocol will greatly increase Veteran treatment choice and improve functional outcomes and access while also increasing efficiency of allocation of specialty PTSD services.

Study Overview

Detailed Description

Posttraumatic stress disorder (PTSD) is a debilitating and costly mental health issue (Greenberg, Sisitsky et al. 1999, Hoge, Terhakopian et al. 2007). RAND reported an estimated two-year cost of $4.0 to $6.2 billion US dollars for mental health issues from the current conflicts in Iraq and Afghanistan and further estimated that providing evidence-based treatments for PTSD and depression could save an estimated $86.2 million (Tanielian, et al. 2008). Even modest reductions in PTSD severity have been related to increased probability of positive function outcomes (Smith, et al. 2005). Prolonged Exposure (PE) therapy (Foa, et al. 2000, Foa, et al. 2005, Schnurr, et al. 2007) is an effective, first-line treatment for PTSD (IOM 2007, VA/DOD 2010). While highly effective, PE is provided in specialty mental health settings typically in 8 to 15, weekly 90 minute individual sessions. Veterans with PTSD are often reluctant to seek care in specialty mental health, and, as a result, many are treated solely in primary care and do not have access to this effective intervention (Possemato, et al. 2011). While the DoD and VA have actively integrated behavioral health providers into their primary care clinics (Maguen, et al. 2010, Seal, et al. 2011), current behavioral interventions for PTSD in primary care are often inconsistent with clinical practice guidelines and/or not effective (Possemato, et al. 2011). Since functional outcomes are critical, the investigators intend to extend beyond assessing the impact of PE-PC on clinical outcomes to function. Thus, there is a clear and urgent need to further develop, validate, and disseminate evidence-based psychotherapeutic treatments for PTSD in integrated VHA PC-MHI with a focus on functional outcomes. To fill this need and gap in care the study investigators developed a Brief Prolonged Exposure for Primary Care (PE-PC) treatment protocol with 4, 30-minute sessions for use in a stepped care model. A pilot study in military treatment facilities found PE-PC resulted in reductions in PTSD that were maintained at 6- and 12-month follow-up (Cigrang, et al, 2015). Preliminary results from a randomized controlled trial (RCT; PI: Cigrang; CoI: Rauch) of PE-PC compared to minimal attention control (MAC, including continuation of any PC initiated treatment) found a significantly larger reduction in PTSD severity (measured by PCL) in PE-PC than MAC (between group d = .78, p = .01). The strength of these initial findings is limited by lack of functional outcomes and examination of impact in VHA. While Service Members and Veterans have many similarities, potential differences in motivation for treatment and other factors may influence the efficacy of the protocol especially when examining changes in function. The proposed study will randomize 120 Veterans at Ralph H. Johnson VAMC presenting in primary care with PTSD who meet minimal inclusion/exclusion criteria to 6 weeks of PE-PC or PC-MHI-treatment as usual (TAU). Recruitment will occur over 36 months. All Veterans will complete a baseline assessment prior to randomization and post-treatment follow-up assessments at Weeks 6, 12, and 24 post-randomization. Primary outcome will be function assessed as self-reported role function in several domains. In addition, the investigators will examine symptoms severity and effectiveness, acceptability, and utilization associated with PE-PC or PCMHI-TAU in the 6 months prior to randomization and 6 months following treatment completion. PE-PC may allow access to effective treatment and efficient allocation of PTSD specialty treatment resources in the VHA. This topic is of key relevance to Veteran mental health care and can provide a new access point for high quality PTSD care to improve function allowing many more Veterans to experience improvement.

Study Type

Interventional

Enrollment (Actual)

120

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

    • Georgia
      • Decatur, Georgia, United States, 30033-4004
        • Atlanta VA Medical and Rehab Center, Decatur, GA
    • South Carolina
      • Charleston, South Carolina, United States, 29401-5799
        • Ralph H. Johnson VA Medical Center, Charleston, SC

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

18 years and older (ADULT, OLDER_ADULT)

Accepts Healthy Volunteers

No

Genders Eligible for Study

All

Description

Inclusion Criteria:

  • Any era Veterans seeking care in VA PC for PTSD symptoms (PCL-5 28) and PTSD confirmed based on CAPS
  • English speaking
  • Report significant impairment in function related to PTSD symptoms as noted on intake WHODAS
  • Report that they want treatment for PTSD
  • If individuals are taking psychotropic medication, 2-weeks on stable dose will be required prior to enrollment

Exclusion Criteria:

  • Other primary clinical issue that would interfere with PTSD treatment
  • Level of suicidal risk as determined by the Columbia Suicide Severity Rating Scale (C-SSRS (46)) that requires:

    • PTSD + interested and consent to study
  • PCP Screen:

    • PC-PTSD + Intake
  • PCMHI Provider:

    • [PCL 28] + brief interview

      • No PTSD OR
      • Not interested in treatment OR
      • Not interested in study
  • Severe cognitive impairment that, in the judgment of the investigator, makes it unlikely that the patient can adhere to the study regimen
  • Psychosis or unmanaged bipolar disorder
  • Moderate to severe substance use disorder in the past 8 weeks
  • Patients who are currently receiving talk therapy for trauma-related symptoms

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: TREATMENT
  • Allocation: RANDOMIZED
  • Interventional Model: PARALLEL
  • Masking: SINGLE

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
EXPERIMENTAL: Prolonged Exposure for Primary Care (PE-PC)
Brief version of PE provided in 30 minute sessions in PC
Brief version of PE provided in 30 minute sessions in PC
Other Names:
  • PE-PC
ACTIVE_COMPARATOR: Treatment as Usual (TAU)
Veterans assigned to PCMHI-TAU will receive standard PCMHI care for PTSD in PC that does not include any PTSD-specific therapy in PCMHI but may include referral for specialty care (including specialty MH), medication management or general supportive contact while awaiting referral. All PTSD care received during the study will be collected and monitored as TAU.
Veterans assigned to PCMHI-TAU will receive standard PCMHI care for PTSD in PC that does not include any PTSD-specific therapy in PCMHI but may include referral for specialty care (including specialty MH), medication management or general supportive contact while awaiting referral. All PTSD care received during the study will be collected and monitored as TAU.
Other Names:
  • TAU

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
World Health Organization Disability Assessment Scale Change
Time Frame: Week 0 to Week 6
Change in total score between time points
Week 0 to Week 6
World Health Organization Disability Assessment Scale
Time Frame: Week 12
total score with higher scores indicating more impairment and scores above 40 indicating clinically significant functional impairment in a VA PTSD population
Week 12
World Health Organization Disability Assessment Scale
Time Frame: Week 24
total score with higher scores indicating more impairment and scores above 40 indicating clinically significant functional impairment in a VA PTSD population
Week 24

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Clinician Administered PTSD Scale for DSM 5 (CAPS5) Change
Time Frame: Week 0, 6, 12, 24
Total score ranges from 0 to 80 with higher more severe; cut points for this measure have not yet been established
Week 0, 6, 12, 24
PTSD Checklist for DSM5 (PCL-5) Change
Time Frame: Week 0, 6, 12, 24
Total score ranges from 0 to 80 with higher more severe; cut points for this measure have not yet been established
Week 0, 6, 12, 24
Patient Health Questionnaire- 9 (PHQ-9) Change
Time Frame: Week 0, 6, 12, 24
Total score ranges from 0 to 27 with higher more severe; Minimal 1-4; Mild 5-9; moderate 10-14; Moderately sever 15-19; Severe 20+
Week 0, 6, 12, 24
Clinician Administered PTSD Scale for DSM 5 (CAPS5)
Time Frame: Week 12
Total score ranges from 0 to 80 with higher more severe; cut points for this measure have not yet been established
Week 12
Clinician Administered PTSD Scale for DSM 5 (CAPS5
Time Frame: Week 24
Total score ranges from 0 to 80 with higher more severe; cut points for this measure have not yet been established
Week 24
PTSD Checklist for DSM5 (PCL-5)
Time Frame: Week 12
Total score ranges from 0 to 80 with higher more severe; cut points for this measure have not yet been established
Week 12
PTSD Checklist for DSM5 (PCL-5)
Time Frame: Week 24
Total score ranges from 0 to 80 with higher more severe; cut points for this measure have not yet been established
Week 24
Patient Health Questionnaire- 9 (PHQ-9)
Time Frame: Week 12
Total score ranges from 0 to 27 with higher more severe; Minimal 1-4; Mild 5-9; moderate 10-14; Moderately sever 15-19; Severe 20+
Week 12
Patient Health Questionnaire- 9 (PHQ-9)
Time Frame: Week 24
Total score ranges from 0 to 27 with higher more severe; Minimal 1-4; Mild 5-9; moderate 10-14; Moderately sever 15-19; Severe 20+
Week 24

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Investigators

  • Principal Investigator: Sheila A.M. Rauch, PhD, Atlanta VA Medical and Rehab Center, Decatur, GA

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (ACTUAL)

April 1, 2019

Primary Completion (ACTUAL)

September 12, 2022

Study Completion (ACTUAL)

September 12, 2022

Study Registration Dates

First Submitted

June 27, 2018

First Submitted That Met QC Criteria

June 27, 2018

First Posted (ACTUAL)

July 10, 2018

Study Record Updates

Last Update Posted (ACTUAL)

February 6, 2023

Last Update Submitted That Met QC Criteria

February 1, 2023

Last Verified

January 1, 2023

More Information

Terms related to this study

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

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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