Evidenced Based Treatments forPTSD, Depression, and Suicidal Behavior:

An Overview

Center for Deployment PsychologyUniformed Services University of the Health Sciences

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The opinions expressed in this article are the author's own and do not necessarily reflect the view of the United States Government, the United States Department of Defense, The United States Navy, or The United States Navy Bureau of Medicine and Surgery. 

The study protocol was approved by the Naval Medical Center San Diego Institutional Review Board in compliance with all applicable Federal regulations governing the protection of human subjects.

I am an employee of the U.S. Government. This work was prepared as part of my official duties. Title 17 U.S.C. §105 provides that ‘copyright protection under this title is not available for any work of the United States Government.’ Title 17 U.S.C §101 defines U.S. Government work as a work prepared by a military service member or employee of the U.S. Government as part of that person’s official duties.

Overview of Evidence-Based Treatments

for PTSD

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Evidence-Based Treatments for PTSD Recommended by DoD/VHA Practice Guideline

• Trauma-Focused Psychotherapies:– Exposure-based therapies (e.g., Prolonged Exposure)– Cognitive-based therapies (e.g., Cognitive Processing Therapy,

Cognitive Restructuring)– Eye Movement Desensitization Processing (EMDR)– Combinations of cognitive and exposure therapy

• Stress Inoculation Training (SIT): Anxiety management package

VA/DoD Clinical Practice Guideline for The Management of PTSD (2010)59

2013 Meta-Analysis of RCTs on PTSD

Psychotherapy:• CBT

Primarily cognitive Primarily exposure Mixed exposure SIT & Desensitization

• Eye movement desensitization and reprocessing

• Psychodynamic Therapy• Hypnotherapy• Self-help• Biofeedback• Group

Somatic:• Acupunctu

re• Transcrani

al magnetic stimulation

Medications:• Antidepressants

• Paroxetine• Fluoxetine• Sertraline• Citalopram

• Atypical antipsychotics• Risperidone• Olanzapine

• Mood stabilizers• AntiAdrenergic agents

• Prazosin• Guanfacine

• Benzodiazepines

Watts et al (2013)6

Main Findings

• Treatments that were effective and had the largest amount of evidence were:– Cognitive Behavioral Therapies (CBTs)– Eye Movement Desensitization Reprocessing (EMDR)– Medications

• Antidepressants• Atypical antipsychotics

• Studies with more women or fewer veterans had larger effects. This was true for psychotherapy studies and medication trials.

Watts et al (2013)7

Main Findings

• For CBTs: Primarily cognitive therapies (CPT, other cognitive therapy)

were most studied and had largest effects (g=1.08-1.63) Primarily exposure therapies (PE, simulator-based exposure

therapy, other exposure therapy, and narrative exposure therapy) had large effects (g=.80-1.69)

Mixed CBT (exposure and skills therapy, exposure and cognitive therapy, exposure and psychodynamic) had large effects (g=102-1.52)

SIT and desensitization were less studied (g=.73-1.37)

Watts et al (2013) 8

Less Studied Modalities

• Psychotherapies– Psychodynamic– Hypnotherapy – Self-Help– Biofeedback– Resilience therapy – Group

• Somatic– Acupuncture – Transcranial magnetic

stimulation

Watts et al (2013)9

Top 5 Reasons Returning US Military Personnel

Fail to Seek Treatment for Mental Health Problems

1. Medications have significant side effects.

2. Treatment could negatively affect their career.

3. Treatment could cause denial of security clearance.

4. Family and friends are more helpful than mental health providers

5. Coworkers may lose confidence in their ability10Harrison et al (2010)

Projection of Resources Necessary to Treat US Troop Forces Deployed in Iraq for PTSD

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$1,097,312,949

Based on RAND, 2008 as cited in Harrison et al., 2010Calculated using PTSD per case cost of $10,151

PTSD cases represent 15% of the number of troops deployed to Iraq per year

2003-2008

PTSD Treatments We Will Discuss

1. Prolonged Exposure Therapy (PE)2. Cognitive Processing Therapy (CPT)3. Eye Movement Desensitization

Reprocessing Therapy (EMDR)

We will also quickly review supplemental, free apps to help manage PTSD symptoms.

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Prolonged Exposure Therapy (PE)

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Prolonged Exposure Therapy (PE)

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Two main factors serve to prolong and worsen post-trauma problems:

1) Avoidance of trauma-related material including triggers, feelings, activities, thoughts, images, and situations.

2) The presence of inaccurate or unrealistic thoughts and beliefs.“The world is unpredictably dangerous.”

“I can’t cope.”

Avoidance prevents the client from processing the trauma and modifying cognitions.

Prolonged Exposure Therapy (PE)

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Breathing Retraining

Education about Common Reactions

In-Vivo Exposure

Imaginal Exposure

• Approx. 10 sessions

• 90 minutes each

• Structured

• Homework

• Taping /recording

Confront, confront, confront what you want to avoid!

PE Coach app

• Installed on client’s phone/tablet• Used as adjunct to PE treatment

–Rationale handouts–Homework assignment, tracking sheets–Record/review session audio–Appointment scheduling

• Free on iOS and Android platforms

16bit.ly/QUpirQhttp://bit.ly/Q9lCDt

Cognitive Processing Therapy

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Cognitive Processing Therapy Is…

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a short-term evidence-based

treatment for PTSD

a specific protocol that is a form of

cognitive behavioral treatment

predominantly cognitive and may or

may not include a written account

a treatment that can be conducted in

groups or individually

Phases of CPT Treatment

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CPT and PE Follow-up

Resick et al (2012)

Pre Post 3 mo 9 mo 5+ yr 10+ yr0

10

20

30

40

50

60

70

80

CPTPE

PTSD

Sev

erity

– C

APS

Scor

e

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Eye Movement Desensitization

Reprocessing (EMDR)

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Eye Movement Desensitization Reprocessing (EMDR)

• Imagine the traumatic event• Engage in lateral eye movements• Focus on changes to image• Repeat eye movements• Generate alternative cognitive appraisal• Focus on the alternative appraisal• Repeat eye movements

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Eye Movement Desensitization Reprocessing (EMDR)

Steps:

• History and treatment planning• Preparation• Assessment• Reprocessing, Desensitization and

Installation• Same as Step 4• Body Scan• Closure• Reevaluation

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Eye Movement Desensitization Reprocessing (EMDR)

Step 3: AssessmentTherapist asks patient to identify: a. Target or visual image of the trauma memory and related emotions and sensationsb. Negative belief related to the trauma memoryc. Positive belief he /she would like to have about self

Steps 4 & 5: Reprocessing, Desensitization, and Installationa. Therapist has patient recall target image while using a set of rapid bilateral eye movements for brief periodb. Therapist asks patient for reactions and associations. c. Therapist repeats procedures to facilitate “digestion” of trauma

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PE and EMDR Outcomes

25Rothbaum et al (2005)

Take Home Points

• Various effective evidence-based treatments for PTSD are available, including PE, CPT, EMDR, and medication.

• Service Members and Veterans deserve access to these treatments.

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Treatments for Depression

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Course/Phases of Depression

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6-12 weeks 4-9 mo’s 1 year +

Symptom

Severity

Kupfer (1991)

MDD Psychotherapies

Efficacious and Specific• Cognitive Behavior

Therapy (CBT)• Behavior Therapy• Interpersonal

Psychotherapy (IPT)Possibly Efficacious

• Brief Dynamic Therapy• Emotion-Focused Therapy

Hollon & Ponniah (2010)29

CBT for Depression:Data from a Meta-Analysis

• Studied in over 75 clinical trials since 1977.• Superior in comparison to waiting list or placebo

controls.• No difference in comparison to Behavior Therapy.• Modestly superior in comparison to other therapies.• Significantly better than anti-depressant medication.• Associated with a “preventative” effect.

30Butler et al. (2006); Gloaguen et al. (1998)

Cognitive Model: Example

SituationA member of the National Guard finds out that he did not get an expected military

promotion.

Automatic Thoughts & ImagesI’ll never amount to anything.

ReactionEmotional: Depressed mood

Physiological: Feels weighed downBehavioral: Decreased concentration at work 31

Core Beliefs

Intermediate Beliefs

Situation

Automatic Thoughts

Reaction

Expanded Cognitive Model

32Beck (2011); Wenzel et al. (2011)

Common Cognitive Distortions of Military Personnel

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“I should have saved

his life”

“The Army doesn’t care about me”

“What I did was unforgiveable”

“If I was driving, my CO would have lived”

“Civilians don’t care about my sacrifice”

“We shouldn’t be fighting over there”

“You can’t trust anyone”

“I’m a coward”

Behavioral Experiments

Behavioral experiments can modify a patient’s negative beliefs more powerfully than verbal techniques.

• Designed collaboratively• Occur during therapy & between sessions• Goal = an experience that disconfirms the

validity of a cognition

34Beck (2011)

Cognitive Therapy

Treatment Approach • Identify, evaluate, and modify underlying assumptions/

dysfunctional beliefs• Learn adaptive coping skills• Break down large problems in smaller steps• Decision-making via cost-benefit analysis• Activity scheduling, self-monitoring of mastery and

pleasure, and graded task assignments are often used early in therapy

Beck, Rush, Shaw, and Emery (1979); Butler & Beck (1995); Butler & Beck (1995)

35Beck et al (1979); Butler & Beck (1995)

Cognitive Therapy

Session Structure1. Brief Mood/ Symptom Check2. Agenda Setting3. Bridge from Previous Session4. Homework Review5. Discussing Issues on Agenda6. Setting New Homework7. Summarizing/ Soliciting Feedback from Patient

Beck, Rush, Shaw, and Emery (1979); Butler & Beck (1995); Butler & Beck (1995)

36Beck et al (1979); Butler & Beck (1995)

Behavioral Theoryof Depression

• Behavioral patterns associated with depression:– Low rate of response-contingent positive reinforcement– High rate of punishment

• Central Tenet = Depressed individuals do not get enough positive reinforcement from their interactions with the environment to maintain adaptive behavior.

37Lewinsohn et al. (1980); Wenzel et al. (2011)

Cycle of Depression

Decreased Engagement

Depression

Reduced Activity

Increased Depression

Even Less Activity

Even More Depression

38Adapted from Lewinsohn et al. (1986)

Behavior Therapy: Behavioral Activation

• Help patients understand the environmental sources of their depression

• Target behaviors that might maintain or worsen the depression

• Working assumption: Negative life events can lead to individuals experiencing low levels of positive reinforcement in their lives

• Many of the coping behaviors that people engage in may worsen the problem over time, via negative reinforcement

39Jacobson et al (2001); Martell et al (2001)

Behavior Therapy: Behavioral Activation

• Increase pleasurable and mastery activities• Increase social activities• Training in social skills, assertiveness, and problem solving• Relaxation training and visual imagery• Behavioral rehearsal and role playing• Military considerations

– Exercise may have at one time been pleasurable, but now may be seen as a mastery activity due to mandatory PT/fitness tests

– May have decreased activity level due to avoidance related to PTSD

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Interpersonal Psychotherapy (IPT)

• Goal: To change behavior by fostering adaptation to current interpersonal roles and situations

Klerman et al (1984)41

• Roots in psychodynamic therapy

• But also draws upon- Attachment Theory- Increased focus on interpersonal

relationship• More structured than dynamic

therapy, but less structured than CBT or BT

Therapies Effective in the Prevention of MDD Relapse/ Recurrence

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Cognitive Behavioral Therapy (CBT)

Mindfulness-Based Cognitive Therapy

Hollon & Ponniah (2010)

Mindfulness-Based CBT

Core AimTo prevent depression relapse/ recurrence

Goals1. Becoming more aware of bodily sensations, feelings and thoughts from moment to moment.2. Developing mindful acceptance of unwanted feelings and

thoughts, rather than habitual, automatic programmed routines.

3. Choosing the most skillful response to any unpleasant thoughts, feelings, or situations.

43Segal, Williams, & Teasdale (2013)

Mindfulness-Based CBT

Core Themes1. Preventing the establishment & consolidation of patterns of

negative thinking2. The 7 signs of driven-doing3. Core skill: How to exit and stay out of these self-

perpetuating cognitive routines4. Kindness plays an essential role5. Experiential learning6. Empowerment7. Skills to be learned

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Treatments for Suicidal Ideation and Behavior

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Empirically SupportedTreatments/ Interventions

• Dialectical Behavior Therapy (DBT)– Linehan (1993)

• Cognitive Therapy for Suicide– Brown et al (2005)

• Means Restriction (Public Health Approach)– Hawton (2002), Beuatrais (2007), Wiedenmann & Weyerer (1993), – Mott et al (2002), Ohberg et al (1995), Law et al (2009)

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Dialectical Behavior Therapy (DBT)

• Goals of DBT according to Linehan:– Increase the client’s behavioral capabilities– Improve motivation for skillful behavior through the use of

contingency management and reduction of interfering emotions and cognitions

– Assure generalization of gains to the client’s environment– Structure the treatment environment to reinforce functional

rather than dysfunctional behaviors– Enhance therapist capabilities and motivation to treat clients

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Means Restriction

• Toxic substances• Medications• Firearms

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Means Restriction

Possible mechanisms of effectiveness:1. Limiting access2. Reducing opportunity for habituation to

fear associated with means for suicide

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Cognitive Therapy for SuicideBrown et al (2005)

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Results of CT Study

– Significantly fewer suicide attempts in the CT group – Significantly lower rates of depression in the CT

group at 6, 12, and 18 month follow-up– Significantly lower hopelessness in the CT group at

the 6 month point but hopelessness improved overall

– Suicidal ideation went down across the follow-up period but no significant differences between the groups

51Brown et al (2005)

Session #: 1 2 3 4 5 6 7 8 9 10Early Sessions

• Informed consent• Treatment engagement• Assessing level of risk• Developing a safety plan• Instilling hope • Developing a cognitive case conceptualization• Treatment planning

52Wenzel et al (2009)

1 2 3

Safety Plan vs Safety Contract?

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SAFETY PLAN TO-GO

Warning Signs:

Coping Strategies:

Family/Friends:

Emergency Contacts:

– Modify negative suicide-relevant automatic thoughts & core beliefs

– Teach problem-solving skills– Help patients develop healthy behavioral coping

skills– Affective coping strategies

Wenzel et al (2009)54

Session #: 1 2 3 4 5 6 7 8 9 10Middle Sessions

4 5 6 7

– Identify Reasons for Living• Review advantages and

disadvantages of living

– Construct Survival Kit or Hope Box• Memory aid at time of

crisis– Photographs– Letters– Safety plan

Wenzel et al (2009)55

Session #: 1 2 3 4 5 6 7 8 9 10Middle Sessions

– Build Additional Coping Skills• Exercise Regimen, Hobbies

– Address Impulsivity – “Procrastinate” Suicide• Delay Tactics

– Increase Adaptive Use of Social Support

– Improve Compliance w/ Adjunctive Medical & Psychiatric Services

Wenzel et al (2009)56

Session #: 1 2 3 4 5 6 7 8 9 10Middle Sessions

– Relapse prevention task• Two guided imagery exercises involving past

suicidal crisis• One guided imagery exercise involving future

suicidal crisis– Debriefing and follow-up– Additional treatment planning

• Continuation of treatment• Appropriate referrals• Termination

Wenzel et al (2009)57

Session #: 1 2 3 4 5 6 7 8 9 10Later Sessions

8 9 10

CDP Website:Deploymentpsych.org

Features include:

• Descriptions and schedules of upcoming training events

• Blog updated daily with a range of relevant content

• Articles by subject matter experts related to deployment psychology, including PTSD, mTBI, depression, and insomnia

• Other resources and information for behavioral health providers

• Links to CDP’s Facebook page and Twitter feed 58

Online Learning

The following online courses are located on the CDP website at:http://www.deploymentpsych.org/content/online-courses

NOTE: All of these courses can be take for free or for CE Credits for a fee

• Cognitive Processing Therapy (CPT) for PTSD in Veterans and Military Personnel (1.25 CE Credits)• Prolonged Exposure Therapy for PTSD in Veterans and Military Personnel (1.25 CE Credits)• Epidemiology of PTSD in Veterans: Working with Service Members and Veterans with PTSD (1.5 CE Credits)• Provider Resiliency and Self-Care: An Ethical Issue (1 CE Credit)• Military Cultural Competence (1.25 CE Credits)• The Impact of Deployment and Combat Stress on Families and Children, Part 1 (2.25 CE Credits)• The Impact of Deployment and Combat Stress on Families and Children, Part 2 (1.75 CE Credits)• The Fundamentals of Traumatic Brain Injury (TBI) (1.5 CE Credits)• Identification, Prevention, & Treatment of Suicidal Behavior in Service Members & Veterans (2.25 CE Credits)• Depression in Service Members and Veterans (1.25 CE Credits)

All of these courses and several others are contained in the Serving Our Veterans Behavioral Health Certificate program, which also includes 20+ hours of Continuing Education Credits for $350.

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Provider SupportCDP’s “Provider Portal” is exclusively for individuals trained by

the CDP in evidence-based psychotherapies (e.g., CPT, PE, and CBT-I)

Features include:• Consultation message boards• Hosted consultation calls• Printable fact sheets, manuals,

handouts, and other materials• FAQs and one-on-one interaction

with answers from SMEs• Videos, webinars, and other

multimedia training aids

Participants in CDP’s evidence-based training will automatically receive an email instructing them how to activate their user name and access the “Provider Portal” section at Deploymentpsych.org.

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How to Contact Us

Center for Deployment PsychologyDepartment of Medical & Clinical Psychology

Uniformed Services University of the Health Sciences4301 Jones Bridge Road, Executive Office: Bldg. 11300-602

Bethesda, MD 20813-4768

Email: General@DeploymentPsych.orgWebsite: DeploymentPsych.orgFacebook: http://www.facebook.com/DeploymentPsychTwitter: @DeploymentPsych

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