Cognitive-behavioural conjoint therapy versus prolonged exposure for PTSD in military service members and veterans: results and lessons from a randomized controlled trial

Background:Military personnel and veterans are at heightened risk for exposure to traumatic events and posttraumatic stress disorder (PTSD), as well as intimate relationship problems associated with PTSD.Objective:The purpose of this study was to evaluate the relative efficacy of CBCT and PE in improving intimate relationship functioning in active duty military personnel or veterans and their intimate partners; both conditions were hypothesized to significantly improve PTSD. Method: In this study, 32 military service members or veterans with PTSD and their intimate partners were randomized to receive either Cognitive-Behavioral Conjoint Therapy for PTSD (n = 15; CBCT; [Monson, C. M., & Fredman, S. J. (2012). Cognitive-behavioral conjoint therapy for posttraumatic stress disorder: Harnessing the healing power of relationships. Guilford]), a trauma-focused couple therapy, or Prolonged Exposure (n = 17; PE; [Foa, E. B., Hembree, E. A., Dancu, C. V., Peterson, A. L., Cigrang, J. A., & Riggs, D. S. (2008). Prolonged exposure treatment for combat-related stress disorders - provider's treatment manual [unpublished]. Department of Psychiatry, University of Pennsylvania]), a front-line evidence-based individual treatment for PTSD.Results:There were significant challenges with recruitment and a significant difference in dropout from treatment for the two therapies (65% for PE; 27% for CBCT). Treatment dropout was differentially related to pre-treatment relationship functioning; those with below average relationship functioning had higher dropout in PE compared with CBCT, whereas those with above average relationship functioning did not show differential dropout. In general, CBCT led to relational improvements, but this was not consistently found in PE. Clinician- and self-reported PTSD symptoms improved with both treatments.Conclusions:This study is the first to test a couple or family therapy against a well-established, front-line recommended treatment for PTSD, with expected superiority of CBCT over PE on relationship outcomes. Lessons learned in trial design, including considerations of equipoise, and the effects of differential dropout on trial analyses are discussed. This trial provides further support for the efficacy of CBCT in the treatment of PTSD and enhancement of intimate relationships. Differential dropout from trial of couple versus individual therapy for PTSD.General pattern of improvements in relationship outcomes in couple therapy for PTSD.PTSD symptoms improved in the individual and couple therapy for PTSD.Lessons learned in trial design, including considerations of equipoise, and the effects of differential dropout by condition on trial analyses are discussed. Antecedentes: El personal militar y los veteranos estan en mayor riesgo de exposicion a eventos traumaticos y el trastorno de estres postraumatico (TEPT), asi como tambien a problemas de relaciones intimas asociadas con el TEPT.Objetivo: El proposito de este estudio fue evaluar la eficacia relativa de la Terapia Conjunta Cognitiva-Conductual (CBCT, en su sigla en ingles) y Exposicion Prolongada (PE, en su sigla en ingles) en mejorar el funcionamiento de la relacion intima en el personal militar en servicio activo o los veteranos y sus parejas intimas; se hipotetizo que ambas condiciones mejorarian significativamente del TEPT.Metodo: En este estudio, 32 miembros del servicio militar o veteranos con TEPT y sus parejas intimas fueron asignados de forma aleatoria para recibir ya sea CBCT para TEPT (n = 15; CBCT; Monson & Fredman, 2012), una terapia de pareja centrado en el trauma, o PE (n = 17; PE; Foa et al., 2008), un tratamiento individual basado en la evidencia de primera linea para el TEPT.Resultados: Hubo desafios significativos con el reclutamiento y una diferencia significativa en el abandono al tratamiento para las dos terapias (65% para PE; 27% para CBCT). El abandono del tratamiento se relaciono diferencialmente con el funcionamiento de la relacion antes del tratamiento; aquellos que tenian un funcionamiento de la relacion bajo el promedio tuvieron un abandono mas alto en PE comparado con CBCT, mientras que aquellos con un funcionamiento sobre el promedio no mostraron abandono diferencial. En general, CBCT resulto en mejoras relacionales, pero esto no fue encontrado en PE. Los sintomas TEPT clinicos y de autoinforme mejoraron en ambos tratamientos.Conclusiones: Este estudio es el primero en evaluar la terapia de parejas o familias contra un tratamiento recomendado de primera linea, bien establecido para el tratamiento del TEPT, con superioridad esperada del CBCT por sobre el PE en los resultados de las relaciones. Se discutieron las lecciones aprendidas en el diseno de ensayos, incluyendo consideraciones de equilibrio, y los efectos del abandono diferencial en los analisis de ensayos. Este ensayo provee mayor apoyo para la eficacia del CBCT en el tratamiento del TEPT y la mejora de las relaciones intimas.