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Mental Health Matters Journal for Psychiatrists & GP's

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November 16, 2007 — Patients with posttraumatic stress disorder (PTSD) who received 8 weeks of Internet-delivered self-management cognitive behavior therapy had greater reductions in symptoms than patients in a comparison group who received Internet-delivered non–trauma-focused supportive counseling.
In this small pilot study, 25% of patients in the online self-management cognitive behavior therapy group no longer had a diagnosis of PTSD immediately after treatment or at 6 months; only 5% and 3% of patients in the comparison group had an absence of PTSD at these time periods.
These findings are published in the November issue of the American Journal of Psychiatry.
Not in the Cards
"If resources were unlimited, of course we would want everyone who was traumatized to be treated by an individual psychotherapist . . . in a face-to-face way, but that's just not in the cards," lead author Brett T. Litz, PhD, from VA Boston Healthcare System and Boston University School of Medicine, in Massachusetts, told Medscape Psychiatry. "We're encouraged that there are technologies that we might be able to use to get people the care they need when they are reluctant to get it or it's not available," he added.
The researchers conducted a randomized controlled proof-of-concept trial of therapist-assisted Internet-delivered self-management cognitive therapy vs Internet-delivered supportive non–trauma-focused counseling.
They recruited military service members from the Washington, DC area who had PTSD as a result of the September 11, 2001 attack on the Pentagon or combat in Iraq or Afghanistan. Of 141 individuals who responded to study recruitment ads, 96 were ineligible, did not consent, or could not be contacted, leaving 45 patients who were randomly assigned to receive 1 of the 2 treatments for 8 weeks. A total of 12 participants dropped out before or during treatment; this dropout rate (30%) was similar to regular cognitive behavior therapy and unrelated to treatment group.
All participants received an initial face-to-face meeting with a therapist. During the 8 weeks of treatment, participants were asked to log on daily to 1 of 2 different Web sites, depending on their treatment group. Each Web site had educational information about PTSD and provided homework assignments.
The self-management cognitive behavior therapy Web site, which was called "Delivery of self-training and education for stressful situations" (DE-STRESS), delivered therapy that was highly trauma focused. "The approach was to get people to learn ways of managing and coping with 'trauma triggers,' " said Dr. Litz.
The Internet-delivered supportive counseling was not trauma focused but rather was centered on problems in daily-living issues. "People would be prompted to think of ways they could tackle these situations differently," he said.
The DE-STRESS Web site was well received by the participants in the self-management cognitive behavior therapy group. Patients in this treatment group had a sharper decline in mean total PTSD symptom severity. One-third of patients who completed this program were considered to have high end-state functioning at 6 months, whereas none of the participants who completed the supportive counseling program were. Patients in both groups, however, were considered to have significant declines in PTSD symptoms and depression at 6 months.
Self-managed cognitive behavior therapy is a potential solution to meet the need for efficient, low-cost, and stigma-reducing interventions for traumatic stress, the authors conclude. They acknowledge that this was a small initial study and call for further research in self-management strategies.
"When you factor in disasters and veterans of war, the scale is pretty large in terms of need," Dr. Litz noted. "So we have no alternative in the mental healthcare field but to be creative and use technology such as the Internet, the telephone, or other telehealth approaches."
Extinguishing Conditioned Responses
The data from this study by Dr. Litz and colleagues are promising and provide "further evidence for the importance of the underlying mechanism of extinction in the treatment of PTSD," Ruth Lanius, MD, from the University of Western Ontario, in London, Ontario, writes in an accompanying editorial.
She notes that the rationale behind the self-management cognitive behavior therapy that was used is based on a fear-conditioning model, which is widely accepted in the PTSD literature. The study used graduated exposure to trauma triggers, with the goal of extinguishing the association between previously neutral stimuli and the conditioned response.
"However, insofar as exposure therapy failed to eliminate all PTSD symptoms, the inference is that there are probably additional mechanisms at work," she suggested.


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