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David Baxter

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Internet-based therapy for PTSD shows potential
November 2, 2007

Rapid delivery of effective PTSD treatment may overcome barriers to care following traumatic events

An eight-week program of self-managed cognitive behavior therapy (CBT) delivered over the Internet to U.S. military service members produced greater reductions in posttraumatic stress disorder (PTSD) and depression than did Internet-based supportive counseling.

The patients were Department of Defense service members in the Washington, D.C., area who had PTSD as a result of the 9/11 Pentagon attack or combat in Iraq or Afghanistan. Each patient had an initial face-to-face interview with a therapist. Periodic contact during treatment was made through scheduled e-mail and telephone calls, however, patients could also call or e-mail as needed.

Two highly specialized web applications were developed for the pilot study to provide the online self-management CBT and supportive counseling, collect data, and monitor patient participation.

One treatment used strategies from CBT, which previous research has shown to be effective in relieving symptoms of PTSD. This CBT-based therapy aimed to first help participants identify situations that triggered their PTSD symptoms by working with a therapist and then improve their ability to manage those symptoms through on-line homework assignments. In order to reduce stigma and to emphasize the self-care aspects of the CBT program, it was named DE-STRESS, for Delivery of Self-TRraining and Education for Stressful Situations. The DE-STRESS acronym was particularly well received in the military context and by patients.

The other therapy, called supportive counseling, asked participants to monitor their own current, non-trauma-related problems, and then write about those experiences online. These participants also received periodic phone calls or emails from their therapist, who provided supportive but non-directed counseling.

Both web programs included symptom ratings, therapeutic and educational content, and homework assignments. Participants were asked to log on daily to a Web site specific to their assigned treatment. After rating their PTSD and depression symptoms using a checklist, participants were allowed access to the Web site where they could find information about PTSD, stress, trauma, and other related health topics; communicate with their therapist; or complete treatment-specific activities.

After eight weeks of treatment, participants in both groups had fewer or less severe PTSD and depression symptoms, but those in CBT-based therapy showed greater improvements than those in supportive counseling therapy. Six months after their first meeting with a study therapist, participants who received CBT-based therapy showed continued improvements, while those in the supportive therapy group experienced an increase in PTSD and depression symptoms.

The researchers noted that fewer people completed the CBT-based therapy than the supportive counseling therapy. However, regardless of therapy group, the discontinuation rate among study participants was similar to the 30 percent discontinuation rate reported in studies of face-to-face treatment.

Commentating on the study, AJP editor-in-chief Robert Freedman stated, "We felt that this web-based treatment was highly innovative and particularly well-suited for groups of people who have experienced a single highly traumatic event and want to resume their normal life as quickly as possible."

Cognitive-Behavior Therapy helps patients process traumatic memories therapeutically, understand and manage symptoms, and correct maladaptive thoughts and behavior. It has been shown to be effective, but requires substantial training and expertise to administer. It is also not widely available within the VA system of care. In addition, many military and emergency service personnel with PTSD do not receive evidence-based treatment.

These initial results for online self-management CBT point to a possible means to deliver rapid and effective PTSD treatment to a large population. One-third of the patients who completed the program were considered to have high end-state functioning six months after treatment, compared to none of those who completed counseling. However, patients in both groups showed significant declines in symptom ratings for both PTSD and depression at the end of treatment and at six months. In addition to extending treatment much more widely, online self-management CBT costs less than in-person treatment and may reduce the stigma of treatment perceived by some patients.

"We are very encouraged by the results, especially because we demonstrated that service members with PTSD, who may not have the time or inclination to seek formal therapy, can get the help they need. Because self-management CBT respects the ability of service members to help themselves with structure and encouragement, and because the program is private and framed as training, it has the promise for overcoming some of the barriers that prevent many service members from seeking and receiving mental health services," said lead author Brett Litz, Ph.D. of the National Center for PTSD at the VA Boston Healthcare System and Boston University School of Medicine.

Source: Litz BT, Engel CC, Bryant RA, Papa A. A Randomized, Controlled Proof-of-Concept Trial of an Internet-Based, Therapist-Assisted Self-Management Treatment for Posttraumatic Stress Disorder Am J Psychiatry 2007 Nov;164:1676-1684 [Abstract]
 

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