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PTSD

Library of Research Articles on Veterans and CIH Therapies

January 2021 Edition

PTSD

Arhin AO, Gallop K, Mann J, Cannon S, Tran K, Wang MC.  Acupuncture as a Treatment Option in Treating Posttraumatic Stress Disorder-Related Tinnitus in War Veterans: A Case Presentation.  J Holist Nurs. 2016

Although close associations between tinnitus and posttraumatic stress disorder (PTSD) among war veterans has been documented, there is limited research that explores evidence-based, efficacious interventions to treat the condition in this particular population. This article presents a case of three war veterans with PTSD symptoms who received a series of acupuncture treatments for tinnitus with positive outcomes. Even though the article presents cases of only three veterans and was based on self-reports, there were very clear trends on how veterans with tinnitus symptoms responded to acupuncture treatments. Information generated from this case presentation is a good starting place in exploring evidence-based approaches in treating tinnitus symptoms in war veterans with PTSD.

Avery T, Blasey C, Rosen C, Bayley P. Psychological Flexibility and Set-Shifting Among Veterans Participating in a Yoga Program: A Pilot Study. Mil Med. 2018 Nov 1;183(11-12):e359-e363. doi: 10.1093/milmed/usy045.

INTRODUCTION

Trauma-focused psychotherapies do not meet the needs of all veterans. Yoga shows some potential in reducing stress and perhaps even PTSD in veterans, although little is understood about the mechanisms of action. This study identifies preliminary correlates of change in PTSD and perceived stress for veterans participating in yoga.

MATERIALS AND METHODS

Nine veterans (seven males and two females) were recruited from an existing clinical yoga program and observed over 16 wk. Severity of PTSD symptoms (PCL-5) and perceived stress (PSS-10) were collected at baseline and weeks 4, 6, 8, and 16. Psychological flexibility (AAQ-II) and set-shifting (ratio of trail making test A to B) were collected at baseline and at week 6. Subjects attended yoga sessions freely, ranging from 1 to 23 classes over the 16 weeks. The Stanford University Institutional Review Board approved this research protocol.

RESULTS

Self-reported PTSD symptoms significantly reduced while perceived stress did not. Lower baseline set-shifting predicted greater improvements in PTSD between baseline and 4 weeks; early improvements in set-shifting predicted overall reduction in PTSD. Greater psychological flexibility was associated with lower PTSD and perceived stress; more yoga practice, before and during the study, was associated with greater psychological flexibility. Other predictors were not supported.

CONCLUSIONS

In a small uncontrolled sample, psychological flexibility and set-shifting predicted changes in PTSD symptoms in veterans participating in a clinical yoga program, which supports findings from prior research. Future research should include an active comparison group and record frequency of yoga practiced outside formal sessions.

Beck D, Cosco Holt L, Burkard J, Andrews T, Liu L, Heppner P, Bormann JE. Efficacy of the Mantram Repetition Program for Insomnia in Veterans With Posttraumatic Stress Disorder: A Naturalistic Study.  ANS Adv Nurs Sci. 2017 Apr/Jun;40(2):E1-E12. doi: 10.1097/ANS.0000000000000144.

Statistics show that more than 80% of Veterans mention posttraumatic stress disorder (PTSD)-related symptoms when seeking treatment. Sleep disturbances and nightmares are among the top 3 presenting problems. Current PTSD trauma-focused therapies generally do not improve sleep disturbances. The mantram repetition program (MRP), a mind-body-spiritual intervention, teaches a portable set of cognitive-spiritual skills for symptom management. The aim of this study was to evaluate the efficacy of the MRP on insomnia in Veterans with PTSD in a naturalistic, clinical setting. Results show that participation in the MRP significantly reduced insomnia, as well as decreased self-reported and clinician-assessed PTSD symptom burden.

Bergen-Cico D, Smith Y, Wolford K, Gooley C, Hannon K, Woodruff R, Spicer M, Gump B. Dog Ownership and Training Reduces Post-Traumatic Stress Symptoms and Increases Self-Compassion Among Veterans: Results of a Longitudinal Control Study. J Altern Complement Med. 2018 Sep 25. doi: 10.1089/acm.2018.0179.

OBJECTIVES

The aims of this study were to measure the potential impact of a therapeutic dog ownership and training program for Veterans with symptoms of post-traumatic stress.

SETTING

Clear Path for Veterans, a nonclinical, open recreation facility whose mission is to support Veterans and their families in the reintegration process after military service.

SUBJECTS

Participants (n = 48) were either enrolled in the veterans therapeutic dog owner-trainer program (Dogs2Vets) or were placed in the wait list control group.

INTERVENTION

Veterans were enrolled in the Dogs2Vets program, a 12-month structured dog owner-trainer program that engages veterans in the training and care of a dog that they ultimately adopt. The Dogs2Vets Program focuses on the healing aspects of the human-animal bond.

OUTCOME MEASURES

PTSD Checklist, Military Version (PCL-M), perceived stress scale, self-compassion scale (SCS) composite, and SCS subscales for isolation and self-judgment.

RESULTS

Veterans participating in the Dogs2Vets owner-trainer program experienced significant reductions in symptoms of post-traumatic stress, perceived stress, isolation, and self-judgment accompanied by significant increases in self-compassion. In contrast there were no significant improvements in these measures among veterans in the wait list control group. Qualitative data reinforced the statistical findings with themes of decreased isolation, unconditional acceptance and companionship, and a renewed sense of safety and purpose from their relationships with their dogs.

CONCLUSION

Veterans benefit significantly from dog ownership in combination with a structured dog training program. Not only do they experience significant decreases in stress and post-traumatic stress symptoms but also they experience less isolation and self-judgment while also experiencing significant improvements in self-compassion.

Bormann JE, Hurst S, Kelly A. Responses to Mantram Repetition Program from Veterans with posttraumatic stress disorder: a qualitative analysis. J Rehabil Res Dev. 2013

This study describes ways in which a Mantram Repetition Program (MRP) was used for managing posttraumatic stress disorder (PTSD) symptoms in 65 outpatient Veterans with PTSD. The MRP consisted of six weekly group sessions (90 min/wk) on how to (1) choose and use a mantram, (2) slow down thoughts and behaviors, and (3) develop one-pointed attention for emotional self-regulation. Critical incident research technique interviews were conducted at 3 mo postintervention as part of a larger randomized clinical trial. The setting was an academic-affiliated Department of Veterans Affairs hospital in southern California. Categorization and comparison of the types and frequency of incidents (i.e., triggering events) were collected. Participants reported a total of 268 triggering events. Content analysis of the outcomes resulted in 12 discreet categories, including relaxing and calming down, letting go of negative feelings, thinking clearly and rationally, diverting attention away from triggering events, focusing attention, refining mantram skills, dealing with sleep disturbances, coming back from flashbacks, slowing down, communicating thoughts and feelings more effectively, feeling in touch spiritually, and letting go of physical pain. The study shows that the MRP was helpful in managing a wide range of emotional reactions in Veterans with PTSD.

Bormann JE, Oman D, Walter KH, Johnson BD. Mindful attention increases and mediates psychological outcomes following mantram repetition practice in veterans with posttraumatic stress disorder. Med Care. 2014 Dec;52(12 Suppl 5):S13-8. doi: 10.1097/MLR.0000000000000200. PubMed PMID: 25397817.

BACKGROUND

Several evidence-based treatments are available to veterans diagnosed with posttraumatic stress disorder (PTSD). However, not all veterans benefit from these treatments or prefer to engage in them.

OBJECTIVES

The current study explored whether (1) a mantram repetition program (MRP) increased mindful attention among veterans with PTSD, (2) mindful attention mediated reduced PTSD symptom severity and enhanced psychological well-being, and (3) improvement in mindful attention was due to the frequency of mantram repetition practice.

RESEARCH DESIGN

Data from a randomized controlled trial comparing MRP plus treatment as usual (MRP+TAU) or TAU were analyzed using hierarchical linear models.

SUBJECTS

A total of 146 veterans with PTSD from military-related trauma were recruited from a Veterans Affairs outpatient PTSD clinic (71 MRP+TAU; 75 TAU).

MEASURES

The Clinician Administered PTSD Scale (CAPS), PTSD Checklist (PCL), the Brief Symptom Inventory-18 depression subscale, Health Survey SF-12v2, and Mindfulness Attention Awareness Scale (MAAS) were used. Frequency of mantram repetition practice was measured using wrist-worn counters and daily logs.

RESULTS

Intent-to-treat analyses indicated greater increases in mindful attention, as measured by the MAAS, for MRP+TAU as compared with TAU participants (P<0.01). Mindful attention gains mediated previously reported treatment effects on reduced PTSD symptoms (using both CAPS and PCL), reduced depression, and improved psychological well-being. Frequency of mantram repetition practice in turn mediated increased mindful attention.

CONCLUSIONS

The MRP intervention and specifically, mantram practice, improved mindful attention in veterans with PTSD, yielding improved overall psychological well-being. MRP may be a beneficial adjunct to usual care in veterans with PTSD

Bormann JE, Thorp SR, Smith E, Glickman M, Beck D, Plumb D, Zhao S, Ackland PE, Rodgers CS, Heppner P, Herz LR, Elwy AR. Individual Treatment of Posttraumatic Stress Disorder Using Mantram Repetition: A Randomized Clinical Trial. Am J Psychiatry. 2018 Oct 1;175(10):979-988. doi: 10.1176/appi.ajp.2018.17060611. Epub 2018 Jun 20. PubMed PMID: 29921143.

OBJECTIVE

Previous studies suggest that group "mantram" (sacred word) repetition therapy, a non-trauma-focused complementary therapy for posttraumatic stress disorder (PTSD), may be an effective treatment for veterans. The authors compared individually delivered mantram repetition therapy and another non-trauma-focused treatment for PTSD.

METHOD

The study was a two-site, open-allocation, blinded-assessment randomized trial involving 173 veterans diagnosed with military-related PTSD from two Veterans Affairs outpatient clinics (January 2012 to March 2014). The mantram group (N=89) learned skills for silent mantram repetition, slowing thoughts, and one-pointed attention. The comparison group (N=84) received present-centered therapy, focusing on currently stressful events and problem-solving skills. Both treatments were delivered individually in eight weekly 1-hour sessions. The primary outcome measure was change in PTSD symptom severity, as measured by the Clinician-Administered PTSD Scale (CAPS) and by self-report. Secondary outcome measures included insomnia, depression, anger, spiritual well-being, mindfulness, and quality of life. Intent-to-treat analysis was conducted using linear mixed models.

RESULTS

The mantram group had significantly greater improvements in CAPS score than the present-centered therapy group, both at the posttreatment assessment (between-group difference across time, -9.98, 95% CI=-3.63, -16.00; d=0.49) and at the 2-month follow-up (between-group difference, -9.34, 95% CI=-1.50, -17.18; d=0.46). Self-reported PTSD symptom severity was also lower in the mantram group compared with the present-centered therapy group at the posttreatment assessment, but there was no difference at the 2-month follow-up. Significantly more participants in the mantram group (59%) than in the present-centered therapy group (40%) who completed the 2-month follow-up no longer met criteria for PTSD (p<0.04). However, the percentage of participants in the mantram group (75%) compared with participants in the present-centered therapy group (61%) who experienced clinically meaningful changes (≥10-point improvements) in CAPS score did not differ significantly between groups. Reductions in insomnia were significantly greater for participants in the mantram group at both posttreatment assessment and 2-month follow-up.

CONCLUSIONS

In a sample of veterans with PTSD, individually delivered mantram repetition therapy was generally more effective than present-centered therapy for reducing PTSD symptom severity and insomnia.

Bremner JD, Mishra S, Campanella C, Shah M, Kasher N, Evans S, Fani N, Shah AJ, Reiff C, Davis LL, Vaccarino V, Carmody J. A Pilot Study of the Effects of Mindfulness-Based Stress Reduction on Post-traumatic Stress Disorder Symptoms and Brain Response to Traumatic Reminders of Combat in Operation Enduring Freedom/Operation Iraqi Freedom Combat Veterans with Post-traumatic Stress Disorder. Front Psychiatry. 2017 Aug 25;8:157.

OBJECTIVE

Brain imaging studies in patients with post-traumatic stress disorder (PTSD) have implicated a circuitry of brain regions including the medial prefrontal cortex, amygdala, hippocampus, parietal cortex, and insula. Pharmacological treatment studies have shown a reversal of medial prefrontal deficits in response to traumatic reminders. Mindfulness-based stress reduction (MBSR) is a promising non-pharmacologic approach to the treatment of anxiety and pain disorders. The purpose of this study was to assess the effects of MBSR on PTSD symptoms and brain response to traumatic reminders measured with positron-emission tomography (PET) in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) combat veterans with PTSD. We hypothesized that MBSR would show increased prefrontal response to stress and improved PTSD symptoms in veterans with PTSD.

METHOD

Twenty-six OEF/OIF combat veterans with PTSD who had recently returned from a combat zone were block randomized to receive eight sessions of MBSR or present-centered group therapy (PCGT). PTSD patients underwent assessment of PTSD symptoms with the Clinician-Administered PTSD Scale (CAPS), mindfulness with the Five Factor Mindfulness Questionnaire (FFMQ) and brain imaging using PET in conjunction with exposure to neutral and Iraq combat-related slides and sound before and after treatment. Nine patients in the MBSR group and 8 in the PCGT group completed all study procedures.

RESULTS

Post-traumatic stress disorder patients treated with MBSR (but not PCGT) had an improvement in PTSD symptoms measured with the CAPS that persisted for 6 months after treatment. MBSR also resulted in an increase in mindfulness measured with the FFMQ. MBSR-treated patients had increased anterior cingulate and inferior parietal lobule and decreased insula and precuneus function in response to traumatic reminders compared to the PCGT group.

CONCLUSION

This study shows that MBSR is a safe and effective treatment for PTSD. Furthermore, MBSR treatment is associated with changes in brain regions that have been implicated in PTSD and are involved in extinction of fear responses to traumatic memories as well as regulation of the stress response.

Chopin SM, Sheerin CM, Meyer BL. Yoga for warriors: An intervention for veterans with comorbid chronic pain and PTSD [published online ahead of print, 2020 Jul 23]. Psychol Trauma. 2020;10.1037/tra0000649.

OBJECTIVE

Comorbid chronic pain and posttraumatic stress disorder (PTSD) is common in veterans; this comorbidity is associated with increased severity and poorer prognosis when compared to each outcome alone. Yoga has been shown to be effective for chronic pain and promising for PTSD, but yoga for comorbid pain and PTSD has not been examined. This article offers empirical support for a yoga intervention for comorbid chronic pain and PTSD in a veteran population.

METHOD

Results are presented from a 4-year pilot yoga intervention for comorbid chronic pain and PTSD at a large, urban Veterans Affairs Medical Center. Based on the fear avoidance model of pain, the intervention used a cross-sectional, open-trial design with pre- and postmeasures. T test analyses were conducted on program completers (N = 49; out of 87 initially enrolled, 44% attrition rate), who were primarily African American (69%) and male (61%) and had a mean age of 51.41 years (SD = 11.32).

RESULTS

Results indicated trend-level reductions in overall PTSD symptoms, as measured by the PTSD Checklist for DSM-5 (p = .02, d = 0.38) and in symptom cluster scores of negative alterations of cognitions and mood (p = .03, d = 0.36) and arousal and reactivity (p = .03, d = 0.35). Veterans reported significant improvement in ability to participate in social activities (p < .001, d = 0.44) and significant reductions in kinesiophobia (fear of movement or physical activity; p < .001, d = 0.85). On a satisfaction measure with a range of 1 (quite dissatisfied) to 4 (extremely satisfied), the mean rating was 3.74 (SD = 0.33).

CONCLUSION

Yoga is a feasible and effective intervention for veterans with comorbid chronic pain and PTSD.

Coleman BC, Corcoran KL, DeRycke EC, Bastian LA, Brandt CA, Haskell SG, Heapy AA, Lisi AJ. Factors Associated With Posttraumatic Stress Disorder Among Veterans of Recent Wars Receiving Veterans Affairs Chiropractic Care. J Manipulative Physiol Ther. 2020 Oct;43(8):753-759.

OBJECTIVES

Post-traumatic stress disorder (PTSD) is thought to complicate pain management outcomes, which is consistent with the impact of other psychosocial factors in the biopsychosocial model of pain. This study aimed to identify patient sociodemographic and clinical characteristics associated with PTSD prevalence among veterans of Operations Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND) who received Veterans Affairs (VA) chiropractic care.

Methods

A cross-sectional analysis of electronic health record data from a national cohort study of OEF/OIF/OND veterans with at least 1 visit to a VA chiropractic clinic from 2001 to 2014 was performed. The primary outcome measure was a prior PTSD diagnosis. Variables including sex, race, age, body mass index, pain intensity, alcohol and substance use disorders, and smoking status were examined in association with PTSD diagnosis using logistic regression.

RESULTS

We identified 14,025 OEF/OIF/OND veterans with at least 1 VA chiropractic visit, with a mean age of 38 years and 54.2% having a diagnosis of PTSD. Male sex (adjusted odds ratio [OR] = 1.23, 95% CI = 1.11-1.37), younger age (OR = 0.99, CI = 0.98-0.99), moderate-to-severe pain intensity (numerical rating scale ≥ 4) (OR = 1.72, CI = 1.59-1.87), body mass index ≥ 30 (OR = 1.34, CI = 1.24-1.45), current smoking (OR = 1.32, CI = 1.20-1.44), and having an alcohol or substance use disorder (OR = 4.51, CI = 4.01-5.08) were significantly associated with a higher likelihood of PTSD diagnosis.

CONCLUSION

Post-traumatic stress disorder is a common comorbidity among OEF/OIF/OND veterans receiving VA chiropractic care and is significantly associated with several patient characteristics. Recognition of these factors is important for the appropriate diagnosis and management of veterans with PTSD seeking chiropractic treatment for pain conditions.

Crawford JN, Talkovsky AM, Bormann JE, Lang AJ.  Targeting hyperarousal: Mantram Repetition Program for PTSD in US veterans. Eur J Psychotraumatol. 2019 Sep 30;10(1):1665768. doi: 10.1080/20008198.2019.1665768.

BACKGROUND

Hyperarousal appears to play an important role in the development and maintenance of posttraumatic stress disorder (PTSD) symptoms, but current evidence-based treatments appear to address this symptom type less effectively than the other symptom clusters. The Mantram Repetition Program (MRP) is a meditation-based intervention that has previously been shown to improve symptoms of posttraumatic stress disorder (PTSD) and may be especially helpful for hyperarousal. If MRP is an effective tool for decreasing this often treatment-resistant symptom cluster, it may become an important clinical tool.

OBJECTIVE

The goal of this secondary analysis was to examine the effect of the MRP on hyperarousal and other PTSD symptom clusters and to examine hyperarousal as a mediator of treatment response.

METHOD

Secondary analyses were conducted on data from a randomized controlled trial in which Veterans with PTSD (n = 173) were assigned to the MRP or a non-specific psychotherapy control and assessed pre-treatment, post-treatment and 8 weeks after treatment completion. The impact of the interventions on PTSD symptom clusters was examined, and time-lagged hierarchical linear modelling was applied to examine alternative mediation models.

RESULTS

All PTSD symptom clusters improved in both treatments. MRP led to greater reductions in hyperarousal at post-treatment (Hedge's g = 0.57) and follow-up (Hedge's g = 0.52), and in numbing at post-treatment (Hedge's g = 0.47). Hyperarousal mediated reductions in the composite of the other PTSD symptom clusters. Although the reverse model was significant as well, the effect was weaker in this direction.

CONCLUSION

Interventions focused on the management of hyperarousal may play an important role in recovery from PTSD. The MRP appears efficacious in reducing hyperarousal, and thereby impacting other PTSD symptom clusters, as one pathway to facilitating recovery.

Cushing RE, Braun KL, Alden C-Iayt SW, Katz AR. Military-Tailored Yoga for Veterans with Post-traumatic Stress Disorder. Mil Med. 2018 May 1;183(5-6):e223-e231. doi: 10.1093/milmed/usx071. PubMed PMID: 29415222; PubMed Central PMCID: PMC6086130.

Among veterans of post-9/11 conflicts, estimates of post-traumatic stress disorder (PTSD) range from 9% shortly after returning from deployment to 31% a year after deployment. Clinical and pharmaceutically based treatments are underutilized. This could be due to concerns related to lost duty days, as well as PTSD patients' fears of stigma of having a mental health condition. Yoga has been shown to reduce PTSD symptoms in the civilian population, but few studies have tested the impact of yoga on veterans of post-9/11 conflicts. The purpose of this study is to test the impact of yoga on post-9/11 veterans diagnosed with PTSD.

Davis L, et al. A Multisite Randomized Controlled Trial of Mindfulness‐Based Stress Reduction in the Treatment of Posttraumatic Stress Disorder. Psychiatric research & clinical practice. 2018

OBJECTIVE

Posttraumatic stress disorder (PTSD) is often difficult to treat, and many patients do not achieve full remission. Complementary and integrative health approaches, such as mindfulness meditation, are intended to be integrated with evidence‐based treatment. This study examined the efficacy of mindfulness‐based stress reduction (MBSR) in the treatment of PTSD in U.S. military veterans.

Methods

Veterans with a diagnosis of PTSD (N=214) were randomly assigned to either 90‐minute group MBSR or present‐centered group therapy (PCGT) for eight weeks. Follow‐up assessments were obtained at baseline and weeks 3, 6, 9 (primary endpoint), and 16.

RESULTS

Both the MBSR and PCGT groups achieved significant improvement in PTSD as measured by the Clinician‐Administered PTSD Scale for DSM‐IV (CAPS‐IV), with no statistically significant differences between groups. However, compared with PCGT, the MBSR group showed a statistically significant improvement in PTSD on the self‐reported PTSD Checklist for DSM‐IV over the nine weeks. This difference was not maintained posttreatment, at week 16. Strengths of the study include its large sample size, multisite design, active control group, single‐blind outcome ratings, fidelity monitoring, large minority representation, and randomized approach. The study was limited by its high attrition rate and low representation of women.

CONCLUSIONS

Both MBSR and PCGT appear to have beneficial effects in treating PTSD in veterans, with greater improvement observed in self‐reported PTSD symptoms in the MBSR group. No differences between groups were observed on the CAPS‐IV scale.

Davis LW, Schmid AA, Daggy JK, Yang Z, O'Connor CE, Schalk N, Do AL, Maric D, Lazarick D, Knock H. Symptoms improve after a yoga program designed for PTSD in a randomized controlled trial with veterans and civilians. Psychol Trauma. 2020 Apr 20. doi: 10.1037/tra0000564.

OBJECTIVE

Although yoga shows promise as a treatment for posttraumatic stress disorder (PTSD), there are few randomized controlled trials that demonstrate significant benefits for individuals with PTSD. The present study addresses this need by comparing the effects of a holistic yoga program (HYP) to that of a wellness lifestyle program (WLP) on PTSD symptom severity with a randomized clinical trial.

METHOD

The sample consisted of 209 participants (91.4% veterans; 66% male; 61.7% White) who met diagnostic criteria for PTSD at baseline. Participants were randomly assigned to attend one of the 2 weekly interventions for 16 weeks. The HYP consisted of yoga instruction, while the WLP consisted of didactics, discussions, and walking. PTSD severity was measured using the Clinician Administered PTSD Scale (CAPS-5) and the PTSD Checklist (PCL-5).

RESULTS

Analyses revealed that the HYP reduced PTSD severity measured by the CAPS-5 significantly more than the WLP at treatment end (mean difference = -5.4, effect size = 0.46, p < .001), but not at 7-month follow up (mean difference = -0.9, p = .603). Similarly, the HYP reduced PTSD severity measured by the PCL-5 significantly more than the WLP at treatment end (difference = -6.0, p = .001), but not at 7-month follow up (mean difference = -1.0, p = .682).

CONCLUSION

Yoga may be an effective intervention for PTSD in addition to standard treatments. Future yoga trials should consider adding a social component to interventions or booster classes to maintain effects long term. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Duan-Porter W, Coeytaux RR, McDuffie JR, Goode AP, Sharma P, Mennella H, Nagi A, Williams JW Jr. Evidence Map of Yoga for Depression, Anxiety, and Posttraumatic Stress Disorder. J Phys Act Health. 2016 Mar;13(3):281-8. doi: 10.1123/jpah.2015-0027. PubMed PMID: 26181774.

BACKGROUND

This study describes evidence of yoga's effectiveness for depressive disorders, general anxiety disorder (GAD), panic disorder (PD), and posttraumatic stress disorder (PTSD) in adults. We also address adverse events associated with yoga.

METHODS

We searched multiple electronic databases for systematic reviews (SRs) published between 2008 and July 2014, randomized controlled trials (RCTs) not identified in eligible SRs, and ongoing RCTs registered with ClincalTrials.gov.

RESULTS

We identified 1 SR on depression, 1 for adverse events, and 3 addressing multiple conditions. The high-quality depression SR included 12 RCTs (n = 619) that showed improved short-term depressive symptoms (standardized mean difference, -0.69, 95% confidence interval, -0.99 to -0.39), but there was substantial variability (I2 = 86%) and a high risk of bias for 9 studies. Three SRs addressing multiple conditions identified 4 nonrandomized studies (n = 174) for GAD/PD and 1 RCT (n = 8) and 2 nonrandomized studies (n = 22) for PTSD. We separately found 1 RCT (n = 13) for GAD and 2 RCTs (n = 102) for PTSD. Collectively, these studies were inconclusive for the effectiveness of yoga in treating GAD/PD and PTSD. The high-quality SR for adverse events included 37 primary reports (n = 76) in which inversion postures were most often implicated. We found 5 ongoing trials (3 for PTSD).

CONCLUSIONS

Yoga may improve short-term depressive symptoms, but evidence for GAD, PD, and PTSD remain inconclusive.

Dunn AS, Passmore SR, Burke J, Chicoine D. A cross-sectional analysis of clinical outcomes following chiropractic care in veterans with and without post-traumatic stress disorder. Mil Med. 2009 Jun;174(6):578-83.

This study was a cross-sectional analysis of clinical outcomes for 130 veteran patients with neck or low back complaints completing a course of care within the chiropractic clinic at the VA of Western New York in 2006. Multivariate analysis of variance (MANOVA) was utilized, comparing baseline and discharge scores for both the neck and low back regions and for those patients with and without post-traumatic stress disorder (PTSD). Patients with PTSD (n = 21) experienced significantly lower levels of score improvement than those without PTSD (n = 119) on self-reported outcome measures of neck and low back disability. These findings, coupled with the theorized relationships between PTSD and chronic pain, suggest that the success of conservative forms of management for veteran patients with musculoskeletal disorders may be limited by the presence of PTSD. Further research is warranted to examine the potential contributions of PTSD on chiropractic clinical outcomes with this unique patient population.

Eads B, Wark DM. Alert Hypnotic Inductions: Use in Treating Combat Post-Traumatic Stress Disorder. Am J Clin Hypn. 2015 Oct;58(2):159-70. doi: 10.1080/00029157.2014.979276.

Alert hypnosis can be a valuable part of the treatment protocol for the resolution of post-traumatic stress disorder (PTSD). Research indicates that combat veterans with PTSD are more hypnotically susceptible than the general population. For that reason, it is hypothesized that they should be better able to use hypnosis in treatment. As opposed to the traditional modality, eyes-open alert hypnosis allows the patient to take advantage of hypnotic phenomena while participating responsibly in work, social life, and recreation. Three case studies are reported on combat veterans with PTSD who learned to overcome their symptoms using alert hypnosis.

Engel CC, Cordova EH, Benedek DM, Liu X, Gore KL, Goertz C, Freed MC, Crawford C, Jonas WB, Ursano RJ. Randomized effectiveness trial of a brief course of acupuncture for posttraumatic stress disorder. Med Care. 2014 Dec;52(12 Suppl 5):S57-64. doi: 10.1097/MLR.0000000000000237.

BACKGROUND

Initial posttraumatic stress disorder (PTSD) care is often delayed and many with PTSD go untreated. Acupuncture appears to be a safe, potentially nonstigmatizing treatment that reduces symptoms of anxiety, depression, and chronic pain, but little is known about its effect on PTSD.

METHODS

Fifty-five service members meeting research diagnostic criteria for PTSD were randomized to usual PTSD care (UPC) plus eight 60-minute sessions of acupuncture conducted twice weekly or to UPC alone. Outcomes were assessed at baseline and 4, 8, and 12 weeks postrandomization. The primary study outcomes were difference in PTSD symptom improvement on the PTSD Checklist (PCL) and the Clinician-administered PTSD Scale (CAPS) from baseline to 12-week follow-up between the 2 treatment groups. Secondary outcomes were depression, pain severity, and mental and physical health functioning. Mixed model regression and t test analyses were applied to the data.

RESULTS

Mean improvement in PTSD severity was significantly greater among those receiving acupuncture than in those receiving UPC (PCLΔ=19.8±13.3 vs. 9.7±12.9, P<0.001; CAPSΔ=35.0±20.26 vs. 10.9±20.8, P<0.0001). Acupuncture was also associated with significantly greater improvements in depression, pain, and physical and mental health functioning. Pre-post effect-sizes for these outcomes were large and robust.

CONCLUSIONS

Acupuncture was effective for reducing PTSD symptoms. Limitations included small sample size and inability to parse specific treatment mechanisms. Larger multisite trials with longer follow-up, comparisons to standard PTSD treatments, and assessments of treatment acceptability are needed. Acupuncture is a novel therapeutic option that may help to improve population reach of PTSD treatment.

Etingen, Bella PhD, Kathleen M Grubbs, PhD, Juliette M Harik, PhD. Drivers of Preference for Evidence-Based PTSD Treatment: A Qualitative Assessment. Military Medicine, Volume 185, Issue Supplement_1, January-February 2020, Pages 303–310

Introduction

Mental health treatment utilization among persons with posttraumatic stress disorder (PTSD) tends to be low but may be improved by aligning treatment with patient preferences. Our objective was to characterize the reasons that drive a person's selection of a specific evidence-based PTSD treatment.

Materials and Methods

Data were collected using an online survey of adults who screened positive for PTSD. Participants viewed descriptions of five evidence-based PTSD treatments (cognitive processing therapy, prolonged exposure, eye movement desensitization and reprocessing, stress inoculation training, antidepressant medication) and identified their most preferred treatment. Participants then explained why they selected their top choice. These free-text responses (n = 249) were analyzed using thematic coding and constant comparative methods.

Results

Identified themes included (1) perceived effectiveness, (2) perceived suitability, (3) requirements of participation, (4) familiarity with the modality, (5) perception of the option as 'better than alternatives,' (6) perception of the option as 'not harmful,' (7) accessibility, and (8) delivery format. Differences in themes were also examined by treatment modality.

Conclusions

By highlighting which pieces of information may be most important to detail when presenting different treatment options, these results can help guide treatment planning conversations, as well as the development of shared decision-making tools.

Evans APB, Mascaro JS, Kohn JN, Dobrusin A, Darcher A, Starr SD, Craighead LW, Negi LT.  Meditation Training for Emotional Numbing Symptoms Among Veterans with Post-Traumatic Stress Disorder. J Altern Complement Med. 2019

For the 8 million American adults suffering from post-traumatic stress disorder (PTSD), emotional numbing can impair the quality of interpersonal relationships that are themselves critical for the remediation of PTSD. Yet, although reducing emotional numbing and restoring interpersonal connectedness may improve response to treatment, few therapies specifically target the interpersonal deficits that accompany PTSD.

Fogger S, Moore R, Pickett L. Posttraumatic Stress Disorder and Veterans: Finding Hope and Supporting Healing. Journal for Nurse Practitioners, 2016-10-01, Volume 12, Issue 9, Pages 598-604, Copyright © 2016 Elsevier Inc.

Posttraumatic stress disorder (PTSD) frequently occurs among veterans and has multiple treatment options that are not entirely effective for all. Traditional evidence-based therapies for PTSD may not entirely eliminate symptoms or may not be acceptable or accessible to veterans. The most beneficial treatment may be a mix of traditional therapy and adjunctive nonpharmacologic treatments the veteran selects. Although PTSD is treated by mental health professionals, all practitioners can improve and support veteran care by ongoing assessment and education around the different types of treatment options for PTSD including integrative health therapies as viable strategies to improve patient outcomes.

Gallegos AM, Crean HF, Pigeon WR, Heffner KL. Meditation and yoga for posttraumatic stress disorder: A meta-analytic review of randomized controlled trials. Clin Psychol Rev. 2017 Dec;58:115-124. doi: 10.1016/j.cpr.2017.10.004. Review. PubMed PMID: 29100863; PubMed Central PMCID: PMC5939561.

Posttraumatic stress disorder (PTSD) is a chronic and debilitating disorder that affects the lives of 7-8% of adults in the U.S. Although several interventions demonstrate clinical effectiveness for treating PTSD, many patients continue to have residual symptoms and ask for a variety of treatment options. Complementary health approaches, such as meditation and yoga, hold promise for treating symptoms of PTSD. This meta-analysis evaluates the effect size (ES) of yoga and meditation on PTSD outcomes in adult patients. We also examined whether the intervention type, PTSD outcome measure, study population, sample size, or control condition moderated the effects of complementary approaches on PTSD outcomes. The studies included were 19 randomized control trials with data on 1173 participants. A random effects model yielded a statistically significant ES in the small to medium range (ES=-0.39, p<0.001, 95% CI [-0.57, -0.22]). There were no appreciable differences between intervention types, study population, outcome measures, or control condition. There was, however, a marginally significant higher ES for sample size≤30 (ES=-0.78, k=5). These findings suggest that meditation and yoga are promising complementary approaches in the treatment of PTSD among adults and warrant further study.

Goldstein LA, Mehling WE, Metzler TJ, Cohen BE, Barnes DE, Choucroun GJ, Silver A, Talbot LS, Maguen S, Hlavin JA, Chesney MA, Neylan TC. Veterans Group Exercise: A randomized pilot trial of an Integrative Exercise program for veterans with posttraumatic stress.  J Affect Disord. 2018 Feb;227:345-352.

BACKGROUND

Posttraumatic stress disorder (PTSD) is prevalent among military veterans and is associated with significant negative health outcomes. However, stigma and other barriers to care prevent many veterans from pursuing traditional mental health treatment. We developed a group-based Integrative Exercise (IE) program combining aerobic and resistance exercise, which is familiar to veterans, with mindfulness-based practices suited to veterans with PTSD. This study aimed to evaluate the effects of IE on PTSD symptom severity and quality of life, as well as assess the feasibility and acceptability of IE.

METHODS

Veterans (N = 47) were randomized to either IE or waitlist control (WL). Veterans in IE were asked to attend three 1-h group exercise sessions for 12 weeks.

RESULTS

Compared with WL, veterans randomized to IE demonstrated a greater reduction in PTSD symptom severity (d = -.90), a greater improvement in psychological quality of life (d = .53) and a smaller relative improvement in physical quality of life (d = .30) Veterans' ratings of IE indicated high feasibility and acceptability.

LIMITATIONS

The sample was relatively small and recruited from one site. The comparison condition was an inactive control.

CONCLUSIONS

This initial study suggests that IE is an innovative approach to treating veterans with symptoms of PTSD that reduces symptoms of posttraumatic stress and improves psychological quality of life. This approach to recovery may expand the reach of PTSD treatment into non-traditional settings and to veterans who may prefer a familiar activity, such as exercise, over medication or psychotherapy.

Heffner KL et al. Psychol Trauma. (2016)  Meditation programs for veterans with posttraumatic stress disorder: Aggregate findings from a multi-site evaluation. Psychol Trauma. 2016 May;8(3):365-74. doi: 10.1037/tra0000106. Epub 2016 Jan 11.

OBJECTIVE

Interest in meditation to manage posttraumatic stress disorder (PTSD) symptoms is increasing. Few studies have examined the effectiveness of meditation programs offered to Veterans within Department of Veterans Affairs (VA) mental health services. The current study addresses this gap using data from a multisite VA demonstration project.

METHOD

Evaluation data collected at 6 VA sites (N = 391 Veterans) before and after a meditation program, and a treatment-as-usual (TAU) program, were examined here using random effects meta-analyses. Site-specific and aggregate between group effect sizes comparing meditation programs to TAU were determined for PTSD severity measured by clinical interview and self-report. Additional outcomes included experiential avoidance and mindfulness.

RESULTS

In aggregate, analyses showed medium effect sizes for meditation programs compared to TAU for PTSD severity (clinical interview: effect size (ES) = -0.32; self-report: ES = -0.39). Similarly sized effects of meditation programs were found for overall mindfulness (ES = 0.41) and 1 specific aspect of mindfulness, nonreactivity to inner experience (ES = .37). Additional findings suggested meditation type and program completion differences each moderated program effects.

CONCLUSIONS

VA-sponsored meditation programs show promise for reducing PTSD severity in Veterans receiving mental health services. Where meditation training fits within mental health services, and for whom programs will be of interest and effective, require further clarification. (PsycINFO Database Record

Herron RE, Rees B. The Transcendental Meditation Program's Impact on the Symptoms of Post-traumatic StressDisorder of Veterans: An Uncontrolled Pilot Study. Mil Med. 2018 Jan 1;183(1-2):e144-e150. doi: 10.1093/milmed/usx059.

BACKGROUND

Current treatments for post-traumatic stress disorder (PTSD) are only partially effective. This study evaluated whether an extensively researched stress reduction method, the Transcendental Meditation (TM) technique, can reduce the PTSD symptoms of veterans. Previous research suggested that TM practice can decrease veterans' PTSD symptoms.

METHODS

A one-group pretest-posttest design was used to evaluate the impact of TM practice on reducing PTSD symptoms. A convenience sample of 89 veterans completed PTSD Checklist-Civilian (PCL-5) questionnaires. Among those, 46 scored above 33, the threshold for provisional diagnosis of PTSD, and were included in this evaluation. The PCL-5 measured PTSD symptoms at baseline and 30 and 90 d after intervention. Regularity of TM practice was recorded. Paired sample t-tests were used to assess within-group changes from baseline to post-intervention periods. Analysis of variance was used to compare full-dose (two 20-min TM sessions per day) and half-dose (one 20-min TM session per day) groups.

FINDINGS

After 1 mo of TM practice, all 46 veterans responded; their PCL-5 average decreased from 51.52 in the pre-intervention period to a post-intervention mean of 23.43, a decline of 28.09 points (-54.5%); standard deviation: 14.57; confidence interval: 23.76-32.41; and effect size: -1.93; p < 0.0001. The median PTSD scores declined from 52.5 to 22.5, a decrease of 30 points (-57%), while 40 veterans (87%) had clinically significant declines (>10 points) in PTSD symptoms, and 37 (80%) dropped below the clinical level (<33). At the 90 d posttest, 31 of the 46 responded and three more dropped below the 33 threshold. Intent-to-treat analyses revealed clinically and statistically significant effects. A dose-response effect suggested a causal relationship. The full-dose group exhibited larger mean declines in PTSD symptoms than the half-dose group. Averages of the 46 veterans' responses to 20 PCL-5 questions exhibited significant (p < 0.0001) declines from the pre-intervention period to the 30-d post-intervention assessment.

DISCUSSION

Results indicated that TM practice reduced PTSD symptoms without re-experiencing trauma. Because of the magnitude of these results and dose-response effect, regression to the mean, spontaneous remission of symptoms, and placebo effects are unlikely explanations for the results. Major limitations were absence of random assignment and lack of a control group. Participants chose to start and continue TM practice and to complete PCL-5 questionnaires. Those who self-selected to enter this study may not be representative of all veterans who have PTSD. Those who did not complete follow-up questionnaires at 90 d may or may not have had the same results as those who responded. The design and sampling method affect the generalizability of the results to wider populations. When taking into account these results and all previous research on the TM technique in reducing psychological and physiological stress, the convergence of evidence suggests that TM practice may offer a promising adjunct or alternative method for treating PTSD. Because of the widely recognized need to identify effective new approaches for treating PTSD, randomized research with control groups is warranted to further investigate the effectiveness of TM practice as a treatment for PTSD.

Hilton L, Maher AR, Colaiaco B, Apaydin E, Sorbero ME, Booth M, Shanman RM, Hempel S. Meditation for posttraumatic stress: Systematic review and meta-analysis.Psychol Trauma. 2017 Jul;9(4):453-460. doi: 10.1037/tra0000180. Epub 2016 Aug 18. Review. PubMed PMID: 27537781.

OBJECTIVE

We conducted a systematic review and meta-analysis that synthesized evidence from randomized controlled trials of meditation interventions to provide estimates of their efficacy and safety in treating adults diagnosed with posttraumatic stress disorder (PTSD). This review was based on an established protocol (PROSPERO: CRD42015025782) and is reported according to PRISMA guidelines. Outcomes of interest included PTSD symptoms, depression, anxiety, health-related quality of life, functional status, and adverse events.

METHOD

Meta-analyses were conducted using the Hartung-Knapp-Sidik-Jonkman method for random-effects models. Quality of evidence was assessed using the Grade of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

RESULTS

In total, 10 trials on meditation interventions for PTSD with 643 participants met inclusion criteria. Across interventions, adjunctive meditation interventions of mindfulness-based stress reduction, yoga, and the mantram repetition program improve PTSD and depression symptoms compared with control groups, but the findings are based on low and moderate quality of evidence. Effects were positive but not statistically significant for quality of life and anxiety, and no studies addressed functional status. The variety of meditation intervention types, the short follow-up times, and the quality of studies limited analyses. No adverse events were reported in the included studies; only half of the studies reported on safety.

CONCLUSIONS

Meditation appears to be effective for PTSD and depression symptoms, but in order to increase confidence in findings, more high-quality studies are needed on meditation as adjunctive treatment with PTSD-diagnosed participant samples large enough to detect statistical differences in outcomes. (PsycINFO Database Record

Hilton LG, Libretto S, Xenakis L, Elfenbaum P, Boyd C, Zhang W, Clark AA. Evaluation of an Integrative Post-Traumatic Stress Disorder Treatment Program. J Altern Complement Med. 2019

OBJECTIVES

Post-traumatic stress disorder (PTSD) and combat-related stress can be refractory, pervasive, and have a devastating impact on those affected, their families, and society at large. Challenges dealing with symptoms may in turn make a servicemember more susceptible to problems, including alcohol abuse, interpersonal conflict, and occupational problems. An effective treatment strategy will address multifactorial issues by using a holistic multimodal approach. Back on Track is an intensive outpatient program utilizing a holistic philosophy and multimodal treatments to provide a whole systems approach for the treatment of combat-related stress reactions and PTSD in active duty servicemembers.

Design/Setting/SUBJECTS

An explanatory, sequential, mixed-methods program evaluation was conducted to assess the effectiveness of a PTSD and combat stress treatment program. Quantitative outcomes were collected and analyzed on 595 participants at pre- and postinterventions and 6-week follow-up and qualitative data were gathered through participant interviews.

INTERVENTION

The manualized program uses a multimodal, psychoeducational group therapy format with a holistic approach for treating combat stress, increasing resiliency, and assisting with reintegration. Rotating providers visit from other programs and services to deliver content in bio–psycho–social–spiritual domains, including didactic lectures on mindfulness and the relaxation response and daily sessions of yoga nidra and meditation.

OUTCOME MEASURES

The primary outcome measure was PTSD symptom severity assessed with the PTSD Checklist-Military Version (PCL-M). Secondary outcomes included self-efficacy, knowledge, use, and satisfaction. Quantitative data were contextualized with interview data.

RESULTS

Results demonstrated a highly statistically significant effect of the program when comparing within-subject PCL-M scores before and after program participation, signed rank S (N= 595) = -47,367, p < 0.001. This translates to a moderate effect size, Cohen's d (N= 595) = -0.55, 95% confidence interval = -0.62 to -0.47, and a mean decrease of 7 points on the PCL-M at postintervention, demonstrating response to treatment. There were significant increases in knowledge and self-efficacy and high levels of satisfaction with the program overall, content, materials, and delivery.

CONCLUSIONS

The treatment program has served *800 servicemembers since inception and has since expanded to five installations. The provision of whole systems care where the approach is holistic, multimodal, and multidisciplinary may be a way forward for the successful treatment of PTSD and other debilitating behavioral health conditions in military contexts and beyond.

Huang W, Johnson TM, Kutner NG, Halpin SN, Weiss P, Griffiths PC, Bliwise DL. Acupuncture for Treatment of Persistent Disturbed Sleep: A Randomized Clinical Trial in VeteransWith Mild Traumatic Brain Injury and Posttraumatic Stress Disorder. J Clin Psychiatry. 2018 Dec

OBJECTIVE

To evaluate real, as compared with sham, acupuncture in improving persistent sleep disturbance in veterans with mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD).

METHODS

This sham-controlled randomized clinical trial at a US Department of Veterans Affairs Medical Center (2010-2015) included 60 veterans aged 24-55 years (mean of 40 years) with history of mTBI of at least 3 months and refractory sleep disturbance. Most of these participants (66.7%) carried a concurrent DSM-IV clinical diagnosis of PTSD. For the present study, they were randomized into 2 groups and stratified by PTSD status using the PTSD Checklist-Military Version. Each participant received up to 10 treatment sessions. The primary outcome measure was change in baseline-adjusted global Pittsburgh Sleep Quality Index (PSQI) score following intervention. Secondary outcomes were wrist-actigraphy-assessed objective sleep measurements. Comorbid PTSD was analyzed as a covariate.

RESULTS

Mean (SD) preintervention global PSQI score was 14.3 (3.2). Those receiving real acupuncture had a global PSQI score improvement of 4.4 points (relative to 2.4 points in sham, P = .04) and actigraphically measured sleep efficiency (absolute) improvement of 2.7% (relative to a decrement of 5.3% in sham, P = .0016). Effective blinding for active treatment was maintained in the study. PTSD participants presented with more clinically significant sleep difficulties at baseline; acupuncture was effective for both those with and without PTSD.

CONCLUSIONS

Real acupuncture, compared with a sham needling procedure, resulted in a significant improvement in sleep measures for veterans with mTBI and disturbed sleep, even in the presence of PTSD. These results indicate that an alternative-medicine treatment modality like acupuncture can provide clinically significant relief for a particularly recalcitrant problem affecting large segments of the veteran population.

Johnson RA, Albright DL, Marzolf JR, Bibbo JL, Yaglom HD, Crowder SM, Carlisle GK, Willard A, Russell CL, Grindler K, Osterlind S, Wassman M, Harms N. Effects of therapeutic horseback riding on post-traumatic stress disorder in military veterans. Mil Med Res. 2018

BACKGROUND

Large numbers of post-deployment U.S. veterans are diagnosed with post-traumatic stress disorder (PTSD) and/or traumatic brain injury (TBI), leading to an urgent need for effective interventions to reduce symptoms and increase veterans' coping. PTSD includes anxiety, flashbacks, and emotional numbing. The symptoms increase health care costs for stress-related illnesses and can make veterans' civilian life difficult.

METHODS

We used a randomized wait-list controlled design with repeated measures of U.S. military veterans to address our specific aim to test the efficacy of a 6-week therapeutic horseback riding (THR) program for decreasing PTSD symptoms and increasing coping self-efficacy, emotion regulation, social and emotional loneliness. Fifty-seven participants were recruited and 29 enrolled in the randomized trial. They were randomly assigned to either the horse riding group (n = 15) or a wait-list control group (n = 14). The wait-list control group experienced a 6-week waiting period, while the horse riding group began THR. The wait-list control group began riding after 6 weeks of participating in the control group. Demographic and health history information was obtained from all the participants. PTSD symptoms were measured using the standardized PTSD Checklist-Military Version (PCL-M). The PCL-M as well as other instruments including, The Coping Self Efficacy Scale (CSES), The Difficulties in Emotion Regulation Scale (DERS) and The Social and Emotional Loneliness Scale for Adults-short version (SELSA) were used to access different aspects of individual well-being and the PTSD symptoms.

RESULTS

Participants had a statistically significant decrease in PTSD scores after 3 weeks of THR (P ≤ 0.01) as well as a statistically and clinically significant decrease after 6 weeks of THR (P ≤ 0.01). Logistic regression showed that participants had a 66.7% likelihood of having lower PTSD scores at 3 weeks and 87.5% likelihood at 6 weeks. Under the generalized linear model(GLM), our ANOVA findings for the coping self-efficacy, emotion regulation, and social and emotional loneliness did not reach statistical significance. The results for coping self-efficacy and emotion regulation trended in the predicted direction. Results for emotional loneliness were opposite the predicted direction. Logistic regression provided validation that outcome effects were caused by riding longer.

CONCLUSION

The findings suggest that THR may be a clinically effective intervention for alleviating PTSD symptoms in military veterans.

Johnston JM, Minami T, Greenwald D, Li C, Reinhardt K, Khalsa SB. Yoga for military service personnel with PTSD: A single arm study. 2015

This study evaluated the effects of yoga on posttraumatic stress disorder (PTSD) symptoms, resilience, and mindfulness in military personnel. Participants completing the yoga intervention were 12 current or former military personnel who met the Diagnostic and Statistical Manual for Mental Disorders-Fourth Edition-Text Revision (DSM-IV-TR) diagnostic criteria for PTSD. Results were also benchmarked against other military intervention studies of PTSD using the Clinician Administered PTSD Scale (CAPS; Blake et al., 2000) as an outcome measure. Results of within-subject analyses supported the study's primary hypothesis that yoga would reduce PTSD symptoms (d = 0.768; t = 2.822; p = .009) but did not support the hypothesis that yoga would significantly increase mindfulness (d = 0.392; t = -0.9500; p = .181) and resilience (d = 0.270; t = -1.220; p = .124) in this population. Benchmarking results indicated that, as compared with the aggregated treatment benchmark (d = 1.074) obtained from published clinical trials, the current study's treatment effect (d = 0.768) was visibly lower, and compared with the waitlist control benchmark (d = 0.156), the treatment effect in the current study was visibly higher.

Justice L, Brems C. Bridging Body and Mind: Case Series of a 10-Week Trauma-Informed Yoga Protocol for Veterans. Int J Yoga Therap. 2019 Apr 8;. doi: 10.17761/D-17-2019-00029. [Epub ahead of print] PubMed PMID: 30958711.

This case series explored the feasibility and preliminary efficacy of therapeutic yoga as a complementary form of treatment for combat-related trauma. The series recruited for and implemented a 10-week Trauma-Informed Yoga protocol for veterans in an interprofessional community health treatment setting. Participants were enrolled in a series of 90-minute therapeutic yoga classes adapted to be trauma-informed. Feasibility was measured by recruitment, retention, and level of participation in the study. Preliminary efficacy was explored via the Posttraumatic Stress Disorder Checklist, Scale of Body Connection, PROMIS-29, P ROMIS Alcohol Use, PROMIS Substance Use, Difficulties in Emotional Regulation Scale, and Self-Compassion Scale-Short Form. All measures were administered at baseline, week 5, week 10, and at a 5-week follow-up. A qualitative Feasibility Questionnaire was administered weekly and at the 5-week follow-up to assess barriers and motivators for home practice and to collect feedback about session content. Recruitment challenges resulted in only seven interested individuals. Four participants (three males, one female) were successfully enrolled in the study after seven phone screenings and five in-person interviews. The four enrolled clients had a 100% follow-up retention rate, reported no adverse events, and on average participated in 85% of classes. Clinically significant enhancements were observed on trauma- and body connection-related scales for three participants from baseline to follow-up. Qualitative data revealed that motivators to practice include in-session philosophical discussions based on psychological themes; breathwork; mindfulness; and physical, social, work/academic, and mental health impact. Barriers included motivation, time, and location. Important themes emerged related to cultural considerations for veterans. Although this 10-week trauma-informed protocol faced challenges to recruitment, retention and participation were high. Efficacy measures yielded promising results for reducing reducing trauma-related symptoms.

Kang SS, Erbes CR, Lamberty GJ, Thuras P, Sponheim SR, Polusny MA, Moran AC, Van Voorhis AC, Lim KO. Transcendental meditation for veterans with post-traumatic stress disorder.  Psychol Trauma. 2018 Nov;10(6):675-680. doi: 10.1037/tra0000346. Epub 2018 Jul 19.

OBJECTIVE

Transcendental Meditation (TM) is a mental technique using a mantra to facilitate meditation. TM has a potential for treating symptoms of posttraumatic stress disorder (PTSD), but its clinical efficacy remains to be clarified. This pilot study evaluated the acceptability, preliminary effectiveness, and neurophysiology of TM for veterans with PTSD.

METHOD

Twenty-nine veterans (20.7% female) were recruited from a major medical center and enrolled in the study. TM instruction was provided by certified TM teachers from the Maharishi Foundation and consisted of 8 weeks of individual and group-based meditation instruction and practice. Outcomes were assessed at baseline, during treatment, posttreatment, and at 2-month follow-up, and included clinical interviews, self-report questionnaires, and electroencephalography (EEG) recorded during resting and meditation states.

RESULTS

From baseline to posttreatment, participants reported reductions in PTSD symptoms, experiential avoidance, and depressive and somatic symptoms, as well as increases on measures of mindfulness and quality of life. Gains were either maintained or continued to improve through the 2-month follow-up. Compared to baseline, EEG spectral power increased in low-frequency bands (1-7 Hz) at posttreatment and follow-up and only during meditation states suggesting TM-specific changes in brain state associated with the intervention.

CONCLUSIONS

TM appears to be an acceptable and effective treatment for veterans with PTSD that warrants further study regarding specific outcomes and beneficial changes in brain function. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Kearney DJ, Malte CA, McManus C, Martinez ME, Felleman B, Simpson TL. Loving-kindness meditation for posttraumatic stress disorder: a pilot study. J Trauma Stress. 2013

Loving-kindness meditation is a practice designed to enhance feelings of kindness and compassion for self and others. Loving-kindness meditation involves repetition of phrases of positive intention for self and others. We undertook an open pilot trial of loving-kindness meditation for veterans with posttraumatic stress disorder (PTSD). Measures of PTSD, depression, self-compassion, and mindfulness were obtained at baseline, after a 12-week loving-kindness meditation course, and 3 months later. Effect sizes were calculated from baseline to each follow-up point, and self-compassion was assessed as a mediator. Attendance was high; 74% attended 9-12 classes. Self-compassion increased with large effect sizes and mindfulness increased with medium to large effect sizes. A large effect size was found for PTSD symptoms at 3-month follow-up (d = -0.89), and a medium effect size was found for depression at 3-month follow-up (d = -0.49). There was evidence of mediation of reductions in PTSD symptoms and depression by enhanced self-compassion. Overall, loving-kindness meditation appeared safe and acceptable and was associated with reduced symptoms of PTSD and depression. Additional study of loving-kindness meditation for PTSD is warranted to determine whether the changes seen are due to the loving-kindness meditation intervention versus other influences, including concurrent receipt of other treatments.

Kearney DJ, McDermott K, Malte C, Martinez M, Simpson TL. Effects of participation in a mindfulness program for veterans with posttraumatic stress disorder: a randomized controlled pilot study. J Clin Psychol. 2013 Jan;69(1):14-27.

OBJECTIVE

To assess outcomes associated with Mindfulness-Based Stress Reduction (MBSR) for veterans with PTSD.

METHODS

Forty-seven veterans with posttraumatic stress disorder (PTSD; 37 male, 32 Caucasian) were randomized to treatment as usual (TAU; n = 22), or MBSR plus TAU (n = 25). PTSD, depression, and mental health-related quality of life (HRQOL) were assessed at baseline, posttreatment, and 4-month follow-up. Standardized effect sizes and the proportion with clinically meaningful changes in outcomes were calculated.

RESULTS

Intention-to-treat analyses found no reliable effects of MBSR on PTSD or depression. Mental HRQOL improved posttreatment but there was no reliable effect at 4 months. At 4-month follow-up, more veterans randomized to MBSR had clinically meaningful change in mental HRQOL, and in both mental HRQOL and PTSD symptoms. Completer analyses (≥ 4 classes attended) showed medium to large between group effect sizes for depression, mental HRQOL, and mindfulness skills.

CONCLUSIONS

Additional studies are warranted to assess MBSR for veterans with PTSD.

King AP, Erickson TM, Giardino ND, Favorite T, Rauch SA, Robinson E, Kulkarni M, Liberzon I. A pilot study of group mindfulness-based cognitive therapy (MBCT) for combat veterans with posttraumatic stress disorder (PTSD). Depress Anxiety. 2013 Jul;30(7):638-45. doi: 10.1002/da.22104. 

BACKGROUND

"Mindfulness-based" interventions show promise for stress reduction in general medical conditions, and initial evidence suggests that they are accepted in trauma-exposed individuals. Mindfulness-based cognitive therapy (MBCT) shows substantial efficacy for prevention of depression relapse, but it has been less studied in anxiety disorders. This study investigated the feasibility, acceptability, and clinical outcomes of an MBCT group intervention adapted for combat posttraumatic stress disorder (PTSD).

METHODS

Consecutive patients seeking treatment for chronic PTSD at a VA outpatient clinic were enrolled in 8-week MBCT groups, modified for PTSD (four groups, n = 20) or brief treatment-as-usual (TAU) comparison group interventions (three groups, n = 17). Pre and posttherapy psychological assessments with clinician administered PTSD scale (CAPS) were performed with all patients, and self-report measures (PTSD diagnostic scale, PDS, and posttraumatic cognitions inventory, PTCI) were administered in the MBCT group.

RESULTS

Intent to treat analyses showed significant improvement in PTSD (CAPS (t(19) = 4.8, P < .001)) in the MBCT condition but not the TAU conditions, and a significant Condition × Time interaction (F[1,35] = 16.4, P < .005). MBCT completers (n = 15, 75%) showed good compliance with assigned homework exercises, and significant and clinically meaningful improvement in PTSD symptom severity on posttreatment assessment in CAPS and PDS (particularly in avoidance/numbing symptoms), and reduced PTSD-relevant cognitions in PTCI (self blame).

CONCLUSIONS

These data suggest group MBCT as an acceptable brief intervention/adjunctive therapy for combat PTSD, with potential for reducing avoidance symptom cluster and PTSD cognitions. Further studies are needed to examine efficacy in a randomized controlled design and to identify factors influencing acceptability and efficacy.

King CH et al. J Holist Nurs. (2016). Exploring Self-Reported Benefits of Auricular Acupuncture Among Veterans With Posttraumatic Stress Disorder.

PURPOSE

Auricular acupuncture treatments are becoming increasingly available within military treatment facilities, resulting in an expansion of nonpharmacologic treatment options available to veterans with posttraumatic stress disorder (PTSD). This study aimed to explore the self-reported benefits of auricular acupuncture treatments for veterans living with PTSD.

DESIGN

A qualitative research methodology, thematic content analysis, was used to analyze data.

METHOD

Seventeen active duty veterans with PTSD provided written comments to describe their experiences and perceptions after receiving a standardized auricular acupuncture regimen for a 3-week period as part of a pilot feasibility study.

FINDINGS

A variety of symptoms experienced by veterans with PTSD were improved after receiving auricular acupuncture treatments. Additionally, veterans with PTSD were extremely receptive to auricular acupuncture treatments. Four themes emerged from the data: (1) improved sleep quality, (2) increased relaxation, (3) decreased pain, and (4) veterans liked/loved the auricular acupuncture treatments.

CONCLUSIONS

Veterans with PTSD reported numerous benefits following auricular acupuncture treatments. These treatments may facilitate healing and recovery for veterans with combat-related PTSD, although further investigations are warranted into the mechanisms of action for auricular acupuncture in this population.

Lang AJ, Malaktaris AL, Casmar P, Baca SA, Golshan S, Harrison T, Negi L. Compassion Meditation for Posttraumatic Stress Disorder in Veterans: A Randomized Proof of Concept Study. J Trauma Stress. 2019 Apr;32(2):299-309. doi: 10.1002/jts.22397. Epub 2019 Mar 31. PubMed PMID: 30929283.

There is considerable interest in developing complementary and integrative approaches for ameliorating posttraumatic stress disorder (PTSD). Compassion meditation (CM) and loving-kindness meditation appear to offer benefits to individuals with PTSD, including symptom reduction. The present study was a pilot randomized controlled trial of CM for PTSD in veterans. The CM condition, an adaptation of Cognitively-Based Compassion Training (CBCT®), consists of exercises to stabilize attention, develop present-moment awareness, and foster compassion. We compared CM to Veteran.calm (VC), which consists of psychoeducation about PTSD, rationale for relaxation, relaxation training, and sleep hygiene. Both conditions consist of 10 weekly 90-min group sessions with between-session practice assignments. A total of 28 veterans attended at least one session of the group intervention and completed pre- and posttreatment measures of PTSD severity and secondary outcomes as well as weekly measures of PTSD, depressive symptoms, and positive and negative emotions. Measures of treatment credibility, attendance, practice compliance, and satisfaction were administered to assess feasibility. A repeated measures analysis of variance revealed a more substantive reduction in PTSD symptoms in the CM condition than in the VC condition, between-group d = -0.85. Credibility, attendance, and satisfaction were similar across CM and VC conditions thus demonstrating the feasibility of CM and the appropriateness of VC as a comparison condition. The findings of this initial randomized pilot study provide rationale for future studies examining the efficacy and effectiveness of CM for veterans with PTSD.

Libby DJ1, Reddy F, Pilver CE, Desai RA. The use of yoga in specialized VA PTSD treatment programs.  Int J Yoga Therap. 2012;(22):79-87.

BACKGROUND

Posttraumatic stress disorder (PTSD) is a chronic, debilitating anxiety disorder that is highly prevalent among U.S. military veterans. Yoga, defined to include physical postures (asana) and mindfulness and meditation, is being increasingly used as an adjunctive treatment for PTSD and other psychological disorders. No research or administrative data have detailed the use of these services in Department of Veterans Affairs' (VA) 170 PTSD treatment programs.

METHODS

One hundred twenty-five program coordinators or designated staff completed an 81-item survey of their program's use of complementary and alternative medicine modalities in the past year. This report describes data from a subset of 30 questions used to assess the prevalence, nature, and context of the use of yoga, mindfulness, and meditation other than mindfulness practices.

RESULTS

Results revealed that these practices are widely offered in VA specialized PTSD treatment programs and that there is great variability in the context and nature of how they are delivered.

CONCLUSIONS

Understanding how yoga is used by these programs may inform ongoing efforts to define and distinguish yoga therapy as a respected therapeutic discipline and to create patient-centered care models that mindfully fulfill the unmet needs of individuals with mental health issues, including veterans with PTSD.

Luedtke, B., Davis, L. & Monson, C. Mindfulness-Based Cognitive-Behavioral Conjoint Therapy for Posttraumatic Stress Disorder: A Case Study. J Contemp Psychother 45, 227–234 (2015). https://doi.org/10.1007/s10879-015-9298-z

With as many as 1.9 million men and women deployed as part of the wars in Iraq and Afghanistan, increased recognition is being placed on the effect of returning Veterans' combat experiences on their adjustment and mental health, particularly those with symptoms of posttraumatic stress disorder (PTSD) and associated effects on families and relationships. Cognitive-behavioral conjoint therapy (CBCT) for PTSD is a manualized intervention with demonstrated efficacy in clinical trials with Veterans who have experienced trauma and their intimate partners. This case study involves the successful application of Mindfulness-based CBCT for PTSD to treat an operation Iraqi freedom male Veteran and his wife referred for PTSD and relationship dissatisfaction. In the current study, mindfulness interventions were integrated into the existing CBCT for PTSD protocol and treatment duration was shortened by including a weekend group retreat for couples. Baseline and post-treatment data from self- and partner-report measures demonstrates symptom reduction in posttraumatic stress symptoms as well as an increase in relationship satisfaction. The advantages of incorporating mindfulness strategies into this treatment protocol and recommendations for future work are discussed.

Maltz B, Hoyt T, Uomoto J, Herodes M. A case analysis of service-member trauma processing related to art therapy within a military-intensive outpatient program. J Clin Psychol. 2020 Jan 17.

OBJECTIVES

Art therapy has been widely used in clinical settings and has shown preliminary success in military trauma. This case study describes a mask-making art therapy directive facilitated by a board-certified art therapist as an adjunct to group posttraumatic stress disorder (PTSD) treatment in a military-intensive outpatient program.

METHODS

Described are clinical outcome measures, linguistic analysis of a personal journal, evaluation of this service-member's artwork, and experiences in the program.

RESULTS

Mask-making, as a trauma-focused group-art therapy directive, expanded the understanding of treatment progress reflected in journal notes, mask imagery, and by a change in linguistic indices of trauma processing, despite an overall increase in PTSD symptoms as he confronted his traumatic experiences. He reported improvement in coping and successfully returned to full military duty following treatment.

CONCLUSIONS

This case study suggests that art therapy and written narrative, combined with standardized self-report assessments, may more accurately indicate improvement in overall PTSD treatment.

Marchand WR, Yabko B, Herrmann T, Curtis H, Lackner R. Treatment Engagement and Outcomes of Mindfulness-Based Cognitive Therapy for Veterans with Psychiatric Disorders. J Altern Complement Med. 2019 Sep;25

OBJECTIVES

The aim of this study was to evaluate utilization and outcomes of mindfulness-based cognitive therapy (MBCT) provided to veterans with psychiatric disorders. Design: Retrospective chart review. Settings: Veterans Administration Medical Center (VAMC).

SUBJECTS

Ninety-eight veterans with psychiatric illness who were enrolled in an MBCT class between May of 2012 and January of 2016. Subjects were predominately white (95%), male (81%), and >50 years old (74%). The most common psychiatric conditions were any mood disorder (82%) and post-traumatic stress disorder (54%).

INTERVENTION

Eight-week MBCT class. OUTCOME MEASURES Session attendance and pre- to postintervention changes in numbers of emergency department (ED) visits and psychiatric hospitalizations. RESULTS The average number of sessions attended was 4.87 of 8 and only 16% were present for all sessions. Veteran demographic variables did not predict the number of MBCT sessions attended. However, both greater numbers of pre-MBCT ED visits (p = 0.004) and psychiatric admissions (p = 0.031) were associated with attending fewer sessions. Among patients who experienced at least one pre- or post-treatment psychiatric admission in the 2 years pre- or postintervention (N = 26, 27%), there was a significant reduction in psychiatric admissions from pre to post (p = 0.002). There was no significant change in ED visits (p = 0.535).

CONCLUSIONS

MBCT may be challenging to implement for veterans with psychiatric illness in, at least some, outpatient VAMC settings due to a high attrition rate. Possible mediation approaches include development of methods to screen for high dropout risk and/or development of shorter mindfulness-based interventions (MBIs) and/or coupling MBIs with pleasurable activities. The finding of a significant decrease in psychiatric hospitalizations from pre- to post-MBCT suggests that prospective studies are warranted utilizing MBCT for veterans at high risk for psychiatric hospitalization.

Martin EC, Dick AM, Scioli-Salter ER, Mitchell KS. Impact of a Yoga Intervention on Physical Activity, Self-Efficacy, and Motivation in Women with PTSD Symptoms. J Altern Complement Med. 2015 Jun;21(6):327-32. doi: 10.1089/acm.2014.0389. Epub 2015 May 14.

BACKGROUND

Studies using yoga have demonstrated initial efficacy for treating symptoms across anxiety disorders, including posttraumatic stress disorder.

OBJECTIVE

Understanding how interventions influence participants' physical activity and what determinants affect continued physical activity behavior change is important because maintenance of the behavior may be critical to continued mental health gains and symptom reduction.

METHODS

This study investigated change in physical activity and possible psychological mechanisms of physical activity behavior change, including self-efficacy and regulatory motivation, in a randomized controlled trial of yoga for women with post-traumatic stress disorder symptoms (n=38).

RESULTS

Growth curve modeling results showed no significant changes in physical activity or self-efficacy for either group, whereas external motivation decreased significantly in the yoga group but not in the control group.

CONCLUSIONS

Investigators of future yoga interventions may want to focus on increasing self-efficacy and internal regulatory motivation, so that physical activity and resultant symptom relief can be maintained.

Mathersul DC, Tang JS, Schulz-Heik RJ, Avery TJ, Seppälä EM, Bayley PJ. Study protocol for a non-inferiority randomised controlled trial of SKY breathing meditation versus cognitive processing therapy for PTSD among veterans. BMJ Open. 2019 Apr 3;9(4):e027150. doi: 10.1136/bmjopen-2018-027150.

INTRODUCTION

Post-traumatic stress disorder (PTSD) is a debilitating, highly prevalent condition. Current clinical practice guidelines recommend trauma-focused psychotherapy (eg, cognitive processing therapy; CPT) as the first-line treatment for PTSD. However, while these treatments show clinically meaningful symptom improvement, the majority of those who begin treatment retain a diagnosis of PTSD post-treatment. Perhaps for this reason, many individuals with PTSD have sought more holistic, mind-body, complementary and integrative health (CIH) interventions. However, there remains a paucity of high-quality, active controlled efficacy studies of CIH interventions for PTSD, which precludes their formal recommendation.

METHODS AND ANALYSES

We present the protocol for an ongoing non-inferiority parallel group randomised controlled trial (RCT) comparing the efficacy of a breathing meditation intervention (Sudarshan Kriya Yoga [SKY]) to a recommended evidence-based psychotherapy (CPT) for PTSD among veterans. Assessors are blinded to treatment group. The primary outcome measure is the PTSD Checklist-Civilian Version and a combination of clinical, self-report, experimental and physiological outcome measures assess treatment-related changes across each of the four PTSD symptom clusters (re-experiencing, avoidance, negative cognitions or mood and hyperarousal/reactivity). Once the RCT is completed, analyses will use both an intent-to-treat (using the 'last observation carried forward' for missing data) and a per-protocol or 'treatment completers' procedure, which is the most rigorous approach to non-inferiority designs.

ETHICS AND DISSEMINATION

To the best of our knowledge, this is this first non-inferiority RCT of SKY versus CPT for PTSD among veterans. The protocol is approved by the Stanford University Institutional Review Board. All participants provided written informed consent prior to participation. Results from this RCT will inform future studies including larger multi-site efficacy RCTs of SKY for PTSD and other mental health conditions, as well as exploration of cost-effectiveness and evaluation of implementation issues. Results will also inform evidence-based formal recommendations regarding CIH interventions for PTSD.

Mehling WE, Chesney MA, Metzler TJ, Goldstein LA, Maguen S, Geronimo C, Agcaoili G, Barnes DE, Hlavin JA, Neylan TC. A 12-week integrative exercise program improves self-reported mindfulness and interoceptive awareness in war veterans with posttraumatic stress symptoms. J Clin Psychol. 2018 Apr;74(4):554-565. doi: 10.1002/jclp.22549.

OBJECTIVE

Innovative approaches to the treatment of war-related posttraumatic stress disorder (PTSD) are needed. We report on secondary psychological outcomes of a randomized controlled trial of integrative exercise (IE) using aerobic and resistance exercise with mindfulness-based principles and yoga. We expected-in parallel to observed improvements in PTSD intensity and quality of life-improvements in mindfulness, interoceptive bodily awareness, and positive states of mind.

METHOD

A total of 47 war veterans with PTSD were randomized to 12-week IE versus waitlist. Changes in mindfulness, interoceptive awareness, and states of mind were assessed by self-report standard measures.

RESULTS

Large effect sizes for the intervention were observed on Five-Facet Mindfulness Questionnaire Non-Reactivity (d = .85), Multidimensional Assessment of Interoceptive Awareness Body Listening (d = .80), and Self-Regulation (d = 1.05).

CONCLUSION

In a randomized controlled trial of a 12-week IE program for war veterans with PTSD, we saw significant improvements in mindfulness, interoceptive bodily awareness, and positive states of mind compared to a waitlist.

Munro, S., Komelski, M., Lutgens, B., Lagoy, J., & Detweiler, M. (2019). Improving the Health of Veterans Though Moving Meditation Practices: A Mixed-Methods Pilot Study. Journal of Veterans Studies, 5(1), 16–23. DOI: http://doi.org/10.21061/jvs.v5i1.128

This study explores the use of low-to-moderate intensity mindfulness-based exercises ("moving meditation") to improve Veteran physical activity level and physiological health and psychological well-being including posttraumatic stress disorder (PTSD) symptomology. 12-week, pre- and post-test intervention, mixed methods pilot. Setting/SUBJECTS Veterans with a history of posttraumatic stress disorder receiving care at the Department of Veterans Affairs Medical Center in Salem, Virginia. All Veterans participated in bi-weekly classroom instruction prior to a 6-10 minute warm up period of Qigong exercises, followed by a 30 minute period of Taijiquan/Qigong or mindful-meditative walking, followed by a 6-10 minute cool down period of light movement. Overall physical activity was measured for a one-week period before and after the 12-week intervention period with an Actigraph accelerometer. Physiological health indices were measured pre- and post- 12-week intervention, including salivary cortisol, Hgb A1C, fasting glucose, gonadal panel (FSH, LH, testosterone), albumin, hs-CRP, and sex hormone-binding globulin. Veterans' mental well-being was measured by the Center for Epidemiological Studies-Depression Scale, the PTSD Checklist (PCL-C), the Cohen Perceived Stress scale, and the Beck Anxiety Inventory. Participants reported increased frequency and enjoyment of physical activity; improvement in Hgb A1C; improvement in balance and movement awareness; improvement in emotional regulation and focus; and reported reduced depression, stress and anxiety, and PTSD symptoms that benefitted social interactions. Moving meditation as part of a multifaceted treatment approach may increase physical activity, improve physiological health, and enhance mental well-being, particularly with respect to PTSD.

Nidich S, Mills PJ, Rainforth M, Heppner P, Schneider RH, Rosenthal NE, Salerno J, Gaylord-King C,.   Non-trauma-focused meditation versus exposure therapy in veterans with post-traumatic stress disorder: a randomised controlled trial. Lancet Psychiatry. 2018

BACKGROUND

Post-traumatic stress disorder (PTSD) is a complex and difficult-to-treat disorder, affecting 10-20% of military veterans. Previous research has raised the question of whether a non-trauma-focused treatment can be as effective as trauma exposure therapy in reducing PTSD symptoms. This study aimed to compare the non-trauma-focused practice of Transcendental Meditation (TM) with prolonged exposure therapy (PE) in a non-inferiority clinical trial, and to compare both therapies with a control of PTSD health education (HE).

METHODS

We did a randomised controlled trial at the Department of Veterans Affairs San Diego Healthcare System in CA, USA. We included 203 veterans with a current diagnosis of PTSD resulting from active military service randomly assigned to a TM or PE group, or an active control group of HE, using stratified block randomisation. Each treatment provided 12 sessions over 12 weeks, with daily home practice. TM and HE were mainly given in a group setting and PE was given individually. The primary outcome was change in PTSD symptom severity over 3 months, assessed by the Clinician-Administered PTSD Scale (CAPS). Analysis was by intention to treat. We hypothesised that TM would show non-inferiority to PE in improvement of CAPS score (Δ=10), with TM and PE superior to PTSD HE. This study is registered with ClinicalTrials.gov, number NCT01865123.

FINDINGS

Between June 10, 2013, and Oct 7, 2016, 203 veterans were randomly assigned to an intervention group (68 to the TM group, 68 to the PE group, and 67 to the PTSD HE group). TM was significantly non-inferior to PE on change in CAPS score from baseline to 3-month post-test (difference between groups in mean change -5·9, 95% CI -14·3 to 2·4, p=0·0002). In standard superiority comparisons, significant reductions in CAPS scores were found for TM versus PTSD HE (-14·6 95% CI, -23·3 to -5·9, p=0·0009), and PE versus PTSD HE (-8·7 95% CI, -17·0 to -0·32, p=0·041). 61% of those receiving TM, 42% of those receiving PE, and 32% of those receiving HE showed clinically significant improvements on the CAPS score.

INTERPRETATION

A non-trauma-focused-therapy, TM, might be a viable option for decreasing the severity of PTSD symptoms in veterans and represents an efficacious alternative for veterans who prefer not to receive or who do not respond to traditional exposure-based treatments of PTSD.

Niles BL, Mori DL, Polizzi CP, Pless Kaiser A, Ledoux AM, Wang C. Feasibility, qualitative findings and satisfaction of a brief Tai Chi mind-body programme for veterans with post-traumatic stress symptoms. BMJ Open. 2016 Nov 29;6(11):e012464. doi: 10.1136/bmjopen-2016-012464. PubMed PMID: 27899398; PubMed Central PMCID: PMC5168527.

OBJECTIVE

To examine feasibility, qualitative feedback and satisfaction associated with a 4-session introduction to Tai Chi for veterans with post-traumatic stress symptoms.

DESIGN

We observed and reported recruitment and retention rates, participant characteristics, adherence, and satisfaction across 2 cohorts. We also examined qualitative feedback provided by questionnaires, focus groups and individual interviews.

MAIN OUTCOME MEASURES

Rates of recruitment and retention, focus group and individual feedback interviews, self-reported satisfaction.

PARTICIPANTS

17 veterans with post-traumatic stress symptoms.

RESULTS

Almost 90% (17/19) of those eligible following the telephone screen enrolled in the programme. Three-quarters (76.4%) of the participants attended at least 3 of the 4 Tai Chi sessions. Qualitative data analysis revealed themes indicating favourable impressions of the Tai Chi sessions. In addition, participants reported feeling very engaged during the sessions, and found Tai Chi to be helpful for managing distressing symptoms (ie, intrusive thoughts, concentration difficulties, physiological arousal). Participants also reported high satisfaction: 93.8% endorsed being very or mostly satisfied with the programme. All participants (100%) indicated that they would like to participate in future Tai Chi programmes and would recommend it to a friend.

CONCLUSIONS

Tai Chi appears to be feasible and safe for veterans with symptoms of post-traumatic stress disorder (PTSD), is perceived to be beneficial and is associated with high rates of satisfaction. This study highlights the need for future investigation of Tai Chi as a novel intervention to address symptoms of PTSD

Nolan CR. Bending without breaking: A narrative review of trauma-sensitive yoga for women with PTSD. Complement Ther Clin Pract. 2016 Aug;24:32-40. doi: 10.1016/j.ctcp.2016.05.006. Epub 2016 May 8. Review.

OBJECTIVE

The purpose of this review is to evaluate the peer-reviewed empirical evidence on the use of Trauma-Sensitive Yoga (TSY) for the treatment of women with post-traumatic stress disorder (PTSD): specifically interpersonal trauma such as intimate partner violence. To date, no such review has been conducted.

METHODS

Articles meeting study inclusionary criteria were identified through electronic database searches. A total of five studies (N = 5) were selected and reviewed. These studies included two randomized controlled trials (RCT), one follow-up of an RCT, one quasi-experimental study, and one qualitative study.

RESULTS

There is tentative evidence to support the efficacy of TSY in reducing PTSD, depression, and anxiety symptomatology for women with PTSD; there is also tentative evidence confirming the feasibility of implementing TSY as an adjunctive mental health intervention, particularly for individuals who are non-responsive to cognitive-based psychotherapies. The qualitative findings speak to a number of benefits of yoga practice stimulated by TSY participation centering on the phenomenon of peaceful embodiment.

CONCLUSIONS

Replication of these results using larger and more diverse samples and rigorous study designs by independent researchers would add credibility to these findings and contribute to the growing body of knowledge on TSY. Additionally, there is a dearth of studies on this nascent form of therapeutic yoga. Therefore, further research is needed to explore the potential efficacy of TSY with other types of trauma, populations, and settings.

Pence PG, Katz LS, Huffman C, Cojucar G.  Delivering Integrative Restoration-Yoga Nidra Meditation (iRest®) to Women with Sexual Trauma at a Veteran's Medical Center: A Pilot Study. Int J Yoga Therap. 2014

OBJECTIVE

This pilot study examines iRest, a form of guided mindfulness meditation, and its ability to reduce symptoms associated with sexual trauma, including military sexual trauma (MST), in a sample of women seeking psychotherapy services at a Department of Veterans Affairs (VA) medical center.

METHODS

90-minute sessions were held 19 times, twice a week for 10 weeks, except for the week with a holiday. Participants completed self-report measures Brief Symptom Inventory-18 (BSI), Posttraumatic Cognitions Inventory (PTCI), and the Post-traumatic Stress Disorder Check List (PCL) pre- and post-treatment. Sixteen women were recruited: 15 enrolled, 5 dropped due to transportation issues, and 10 completed the protocol.

RESULTS

Completers reported significant decreases in symptoms of posttraumatic stress disorder (PCL, t (9) = 3.17, p < 0.01, d = 0.66), negative thoughts of self-blame (PTCI t (9) = 2.96, p < 0.05, d = 0.52), and depression (BSI, t (9) = 2.33, p < 0.05, d = 0.64). Participants also offered verbal reports of decreased body tension, improved quality of sleep, improved ability to handle intrusive thoughts, improved ability to manage stress, and an increased feeling of joy. Participants also enthusiastically endorsed the class and stated they would take it again and recommend it to others.

CONCLUSIONS

This small pilot study showed promising results for delivering iRest to women with sexual trauma in a VA medical center. Further research is warranted.

Pigeon W, Allen C, Possemato K, Bergen-Cico D, Treatman S. Feasibility and Acceptability of a Brief Mindfulness Program for Veterans in Primary Care with Posttraumatic Stress Disorder. Mindfulness, 2015, Volume 6, Number 5, Page 986

Mindfulness-based stress reduction programs have improved psychological health for clinical populations including veterans with posttraumatic stress disorder (PTSD). Veterans with PTSD who seek services in Department of Veterans Affairs primary care are especially in need of brief treatments that can alleviate PTSD symptoms. A clinical demonstration project was carried out to assess the feasibility and acceptability of a brief mindfulness program consisting of four weekly 1.5-h class sessions. Veterans enrolled in primary care with diagnostic or subthreshold PTSD were recruited. The brief mindfulness intervention was feasible to deliver, and veterans were generally satisfied with the program. Despite good retention once a class session was attended, a large number of veterans provided a variety of reasons for not attending the program at all. Veteran feedback that can be addressed to improve the brief mindfulness program is discussed, including enhancing initial attendance.

Polusny MA, Erbes CR, Thuras P, Moran A, Lamberty GJ, Collins RC, Rodman JL, Lim KO. Mindfulness-Based Stress Reduction for Posttraumatic Stress Disorder Among Veterans: A Randomized Clinical Trial. JAMA. 2015 Aug 4;314(5):456-65. doi: 10.1001/jama.2015.8361. PubMed PMID: 26241597.

OBJECTIVE

To compare mindfulness-based stress reduction with present-centered group therapy for treatment of PTSD.

Design: Randomized clinical trial of 116 veterans with PTSD recruited at the Minneapolis Veterans Affairs Medical Center from March 2012 to December 2013. Outcomes were assessed before, during, and after treatment and at 2-month follow-up. Data collection was completed on April 22, 2014.

Interventions: Participants were randomly assigned to receive mindfulness-based stress reduction therapy (n = 58), consisting of 9 sessions (8 weekly 2.5-hour group sessions and a daylong retreat) focused on teaching patients to attend to the present moment in a nonjudgmental, accepting manner; or present-centered group therapy (n = 58), an active-control condition consisting of 9 weekly 1.5-hour group sessions focused on current life problems.

OUTCOME MEASURES

The primary outcome, change in PTSD symptom severity over time, was assessed using the PTSD Checklist (range, 17-85; higher scores indicate greater severity; reduction of 10 or more considered a minimal clinically important difference) at baseline and weeks 3, 6, 9, and 17. Secondary outcomes included PTSD diagnosis and symptom severity assessed by independent evaluators using the Clinician-Administered PTSD Scale along with improvements in depressive symptoms, quality of life, and mindfulness.

RESULTS

Participants in the mindfulness-based stress reduction group demonstrated greater improvement in self-reported PTSD symptom severity during treatment (change in mean PTSD Checklist scores from 63.6 to 55.7 vs 58.8 to 55.8 with present-centered group therapy; between-group difference, 4.95; 95% CI, 1.92-7.99; P=.002) and at 2-month follow-up (change in mean scores from 63.6 to 54.4 vs 58.8 to 56.0, respectively; difference, 6.44; 95% CI, 3.34-9.53, P < .001). Although participants in the mindfulness-based stress reduction group were more likely to show clinically significant improvement in self-reported PTSD symptom severity (48.9% vs 28.1% with present-centered group therapy; difference, 20.9%; 95% CI, 2.2%-39.5%; P = .03) at 2-month follow-up, they were no more likely to have loss of PTSD diagnosis (53.3% vs 47.3%, respectively; difference, 6.0%; 95% CI, -14.1% to 26.2%; P = .55).

CONCLUSIONS

Among veterans with PTSD, mindfulness-based stress reduction therapy, compared with present-centered group therapy, resulted in a greater decrease in PTSD symptom severity. However, the magnitude of the average improvement suggests a modest effect.

Prisco MK, Jecmen MC, Bloeser KJ et al.  Group auricular acupuncture for PTSD-related insomnia in veterans: a randomized trial. 17 Dec 2013https://doi.org/10.1089/acu.2013.0989

OBJECTIVES

This study examined how group auricular acupuncture may influence sleep quality, sleep patterns, and hypnotic medication use associated with PTSD-related insomnia in Operation Enduring Freedom and Operation Iraqi Freedom veterans.

Design: This study was a randomized controlled trial with sham acupuncture and wait-list controls.

SETTING

This study took place at the Washington, DC, Department of Veterans Affairs (VA), Medical Center.

SUBJECTS

Thirty-five subjects were randomized to participate in the study, but only 25 subjects completed the study.

Interventions: Subjects were randomized to one of three groups: (1) true group auricular acupuncture; (2) sham auricular acupuncture; or (3) wait-list control.

OUTCOME MEASURES

The primary outcome measure was perceived sleep quality (as measured by Insomnia Severity Index (ISI) questionnaires and Morin Sleep Diaries [MSDs]). Secondary outcome measures were total sleep time (TST), sleep efficiency, sleep latency, naps (as measured by MSD and wrist actigraphs [WAs]), hypnotic medication use, veteran satisfaction, and attrition rates.

RESULTS

Subjects in the true auricular acupuncture group had a statistically significant improvement (p=0.0165) in sleep quality as measured by the ISI at time (t)=1 month. This group had a trend toward lower MSD TST at t=2 months (p=0.078), lower WA TST at t=1 month (p=0.0893), and toward higher MSD nap times than the other two groups post-treatment (p=0.0666). No statistically significant association between group assignment and hypnotic medication use and satisfaction scores were noted.

CONCLUSIONS

Acupuncturists should consider incorporating sleep hygiene education into their clinical practices and/or collaborate with insomnia health care professionals when working with individuals with insomnia. This study also supports the finding that perceived sleep quality and objective WA measurements are not significantly correlated.

Pyne JM, Constans JI, Nanney JT, Wiederhold MD, Gibson DP, Kimbrell T, Kramer TL, Pitcock JA, Han X, Williams DK, Chartrand D, Gevirtz RN, Spira J, Wiederhold BK, McCraty R, McCune TR.  Heart Rate Variability and Cognitive Bias Feedback Interventions to Prevent Post-deployment PTSD: Results from a Randomized Controlled Trial. Mil Med. 2019 Jan 1;184(1-2):e124-e132. doi: 10.1093/milmed/usy171.

INTRODUCTION

There is a long history of pre-deployment PTSD prevention efforts in the military and effective pre-deployment strategies to prevent post-deployment PTSD are still needed.

MATERIALS AND METHODS

This randomized controlled trial included three arms: heart rate variability biofeedback (HRVB), cognitive bias modification for interpretation (CBM-I), and control. The hypothesis was that pre-deployment resilience training would result in lower post-deployment PTSD symptoms compared with control. Army National Guard soldiers (n = 342) were enrolled in the Warriors Achieving Resilience (WAR) study and analyzed. The outcome was PTSD symptom severity using the PTSD Checklist - Military version (PCL) measured at pre-deployment, 3- and 12-month post-deployment. Due to the repeated measures for each participant and cluster randomization at the company level, generalized linear mixed models were used for the analysis. This study was approved by the Army Human Research Protection Office, Central Arkansas Veterans Healthcare System Institutional Review Board (IRB), and Southeast Louisiana Veterans Health Care System IRB.

RESULTS

Overall, there was no significant intervention effect. However, there were significant intervention effects for subgroups of soldiers. For example, at 3-months post-deployment, the HRVB arm had significantly lower PCL scores than the control arm for soldiers with no previous combat zone exposure who were age 30 and older and for soldiers with previous combat zone exposure who were 45 and older (unadjusted effect size -0.97 and -1.03, respectively). A significant difference between the CBM-I and control arms was found for soldiers without previous combat zone exposure between ages 23 and 42 (unadjusted effect size -0.41). Similarly, at 12-months post-deployment, the HRVB arm had significantly lower PCL scores in older soldiers.

CONCLUSION

Pre-deployment resilience training was acceptable and feasible and resulted in lower post-deployment PTSD symptom scores in subgroups of older soldiers compared with controls. Strengths of the study included cluster randomization at the company level, use of iPod device to deliver the resilience intervention throughout the deployment cycle, and minimal disruption of pre-deployment training by using self-paced resilience training. Weaknesses included self-report app use, study personnel not able to contact soldiers during deployment, and in general a low level of PTSD symptom severity throughout the study. In future studies, it would important for the study team and/or military personnel implementing the resilience training to be in frequent contact with participants to ensure proper use of the resilience training apps.

Rauch SAM, Yasinski CW, Post LM, et al. An intensive outpatient program with prolonged exposure for veterans with posttraumatic stress disorder: Retention, predictors, and patterns of change [published online ahead of print, 2020 Jul 13]. Psychol Serv.

High rates of drop-out from treatment of PTSD have challenged implementation. Care models that integrate PTSD focused psychotherapy and complementary interventions may provide benefit in retention and outcome. The first 80 veterans with chronic PTSD enrolled in a 2-week intensive outpatient program combining Prolonged Exposure (PE) and complementary interventions completed symptom and biological measures at baseline and posttreatment. We examined trajectories of symptom change, mediating and moderating effects of a range of patient characteristics. Of the 80 veterans, 77 completed (96.3%) treatment and pre- and posttreatment measures. Self-reported PTSD (p < .001), depression (p < .001) and neurological symptoms (p < .001) showed large reductions with treatment. For PTSD, 77% (n = 59) showed clinically significant reductions. Satisfaction with social function (p < .001) significantly increased. Black veterans and those with a primary military sexual trauma (MST) reported higher baseline severity than white or primary combat trauma veterans respectively but did not differ in their trajectories of treatment change. Greater cortisol response to the trauma potentiated startle paradigm at baseline predicted smaller reductions in PTSD over treatment while greater reductions in this response from baseline to post were associated with better outcomes. Intensive outpatient prolonged exposure combined with complementary interventions shows excellent retention and large, clinically significant reduction in PTSD and related symptoms in two weeks. This model of care is robust to complex presentations of patients with varying demographics and symptom presentations at baseline. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Reddy S, Dick AM, Gerber MR, Mitchell K. The effect of a yoga intervention on alcohol and drug abuse risk in veteran and civilian women with posttraumatic stress disorder. J Altern Complement Med. 2014 Oct;20(10):750-6. doi: 10.1089/acm.2014.0014. Epub 2014 Sep 11. PubMed PMID: 25211372; PubMed Central PMCID: PMC4195227

BACKGROUND

Individuals with posttraumatic stress disorder (PTSD) often exhibit high-risk substance use behaviors. Complementary and alternative therapies are increasingly used for mental health disorders, although evidence is sparse.

OBJECTIVES

Investigate the effect of a yoga intervention on alcohol and drug abuse behaviors in women with PTSD. Secondary outcomes include changes in PTSD symptom perception and management and initiation of evidence-based therapies.

MATERIALS AND METHODS

The current investigation analyzed data from a pilot randomized controlled trial comparing a 12-session yoga intervention with an assessment control for women age 18 to 65 years with PTSD. The Alcohol Use Disorder Identification Test (AUDIT) and Drug Use Disorder Identification Test (DUDIT) were administered at baseline, after the intervention, and a 1-month follow-up. Linear mixed models were used to test the significance of the change in AUDIT and DUDIT scores over time. Treatment-seeking questions were compared by using Fisher exact tests.

RESULTS

The mean AUDIT and DUDIT scores decreased in the yoga group; in the control group, mean AUDIT score increased while mean DUDIT score remained stable. In the linear mixed models, the change in AUDIT and DUDIT scores over time did not differ significantly by group. Most yoga group participants reported a reduction in symptoms and improved symptom management. All participants expressed interest in psychotherapy for PTSD, although only two participants, both in the yoga group, initiated therapy.

CONCLUSIONS

Results from this pilot study suggest that a specialized yoga therapy may play a role in attenuating the symptoms of PTSD, reducing risk of alcohol and drug use, and promoting interest in evidence-based psychotherapy. Further research is needed to confirm and evaluate the strength of these effects.

Reinhardt KM, Noggle Taylor JJ, Johnston J, Zameer A, Cheema S, Khalsa SBS. Kripalu Yoga for Military Veterans With PTSD: A Randomized Trial. J Clin Psychol. 2018 Jan;74(1):93-108. doi: 10.1002/jclp.22483.

OBJECTIVES

This randomized controlled trial of yoga for military veterans and active duty personnel with posttraumatic stress disorder (PTSD) evaluated the efficacy of a 10-week yoga intervention on PTSD.

METHOD

Fifty-one participants were randomized into yoga or no-treatment assessment-only control groups. Primary outcome measures included questionnaires and the Clinician Administered PTSD Scale.

RESULTS

Both yoga (n = 9) and control (n = 6) participants showed significant decreases in reexperiencing symptoms, with no significant between-group differences. Secondary within-group analyses of a self-selected wait-list yoga group (n = 7) showed significant reductions in PTSD symptoms after yoga participation, in contrast to their control group participation. Consistent with current literature regarding high rates of PTSD treatment dropout for veterans, this study faced challenges retaining participants across conditions.

CONCLUSION

These results are consistent with recent literature indicating that yoga may have potential as a PTSD therapy in a veteran or military population. However, additional larger sample size trials are necessary to confirm this conclusion.

Rosenthal JZ, Grosswald S, Ross R, Rosenthal N. Effects of transcendental meditation in veterans of Operation Enduring Freedom and Operation Iraqi Freedom with posttraumatic stress disorder: a pilot study. Mil Med. 2011 Jun;176(6):626-30.

We conducted an uncontrolled pilot study to determine whether transcendental meditation (TM) might be helpful in treating veterans from Operation Enduring Freedom or Operation Iraqi Freedom with combat-related posttraumatic stress disorder (PTSD). Five veterans were trained in the technique and followed for 12 weeks. All subjects improved on the primary outcome measure, the Clinician Administered PTSD Scale (mean change score, 31.4; p = 0.02; df = 4). Significant improvements were also observed for 3 secondary OUTCOME MEASURES Clinician's Global Inventory-Severity (mean change score, 1.60; p < 0.04; df = 4), Quality of Life Enjoyment and Satisfaction Questionnaire (mean change score, -13.00; p < 0.01; df = 4), and the PTSD Checklist-Military Version (mean change score, 24.00; p < 0.02; df = 4). TM may have helped to alleviate symptoms of PTSD and improve quality of life in this small group of veterans. Larger, placebo-controlled studies should be undertaken to further determine the efficacy of TM in this population.

Rutledge T, Nidich S, Schneider RH, Mills PJ, Salerno J, Heppner P, Gomez MA, Gaylord-King C, Rainforth M.  Design and rationale of a comparative effectiveness trial evaluating transcendental meditation against established therapies for PTSD. Contemp Clin Trials. 2014 Sep;39(1):50-6. doi: 10.1016/j.cct.2014.07.005. Epub 2014 Jul 25.

BACKGROUND

Although meditation therapies such as the Transcendental Meditation (TM) technique are commonly used to assist with stress and stress-related diseases, there remains a lack of rigorous clinical trial research establishing the relative efficacy of these treatments overall and for populations with psychiatric illness. This study uses a comparative effectiveness design to assess the relative benefits of TM to those obtained from a gold-standard cognitive behavioral therapy for posttraumatic stress disorder (PTSD) in a Veteran population.

METHODS AND DESIGN

This paper describes the rationale and design of an in progress randomized controlled trial comparing TM to an established cognitive behavioral treatment - Prolonged Exposure (PE) - and an active control condition (health education [HE]) for PTSD. This trial will recruit 210 Veterans meeting DSM-IV criteria for PTSD, with testing conducted at 0 and 3 months for PTSD symptoms, depression, mood disturbance, quality of life, behavioral factors, and physiological/biochemical and gene expression mechanisms using validated measures. The study hypothesis is that TM will be noninferior to PE and superior to HE on changes in PTSD symptoms, using the Clinician Administered PTSD Scale (CAPS).

DISCUSSION

The described study represents a methodologically rigorous protocol evaluating the benefits of TM for PTSD. The projected results will help to establish the overall efficacy of TM for PTSD among Veterans, identify bio-behavioral mechanisms through which TM and PE may improve PTSD symptoms, and will permit conclusions regarding the relative value of TM against currently established therapies for PTSD.

Schuman D.  Veterans' Experiences using Complementary and Alternative Medicine for Posttraumatic Stress: A Qualitative Interpretive Meta-Synthesis. Soc Work Public Health. 2016;31(2):83-97. doi: 10.1080/19371918.2015.1087915. Epub 2016 Jan 22.

Combat Veterans struggling with combat-related post(*)traumatic stress disorder and subthreshold symptoms often look outside the conventional behavioral health care system for treatment because standard care has not met their needs. This study utilized a qualitative interpretive metasynthesis to describe the lived experience of combat Veterans seeking complementary and alternative health therapies for posttraumatic stress symptoms. This research aimed to understand what attracts these Veterans to complementary and alternative medicine techniques and how they benefit from their experiences with nonconventional therapies. Findings suggest the need for further research into increasing access and eliminating disparities for Veterans seeking more integrative care.

Schuman DL, Killian MO. Pilot Study of a Single Session Heart Rate Variability Biofeedback Intervention on Veterans' Posttraumatic Stress Symptoms. Appl Psychophysiol Biofeedback. 2018 Sep 18. doi: 10.1007/s10484-018-9415-3. [Epub ahead of print] PubMed PMID: 30229543.

Veterans with posttraumatic stress symptoms exhibit reduced heart rate variability characteristic of autonomic nervous system dysregulation. Studies show heart rate variability biofeedback (HRVB) is effective in reducing posttraumatic stress symptoms by improving autonomic functioning. Participants in this pilot study were veterans of different war eras with military-related posttraumatic stress symptoms. The study aims were to examine the impact of a single session HRVB intervention on posttraumatic stress symptoms and heart rate variability, test persistence of effects, and determine if veterans would find the intervention acceptable. One group (n = 6) received training in diaphragmatic breathing and heart rate variability biofeedback, augmented by twice-daily practice using a smart phone and breath pacing app. A second group (n = 6) received only a single session of diaphragmatic breathing training. After 4 weeks, participants in the second group (n = 5) received the full intervention. HRVB significantly reduced global posttraumatic stress symptoms, whereas diaphragmatic breathing alone did not. Further, veterans found the approach acceptable, as demonstrated by a high degree of adherence with prescribed practice, low study attrition, and continued use over time. Results of this pilot study warrant further refinement of a protocol utilizing mHealth to treat posttraumatic stress symptoms in military populations.

Schure MB, Simpson TL, Martinez M, Sayre G, Kearney DJ.  Mindfulness-Based Processes of Healing for Veterans with Post-Traumatic Stress Disorder. J Altern Complement Med. 2018 Nov;24(11):1063-1068. doi: 10.1089/acm.2017.0404. Epub 2018 May 7.

OBJECTIVE

U.S. veterans are at increased risk of developing post-traumatic stress disorder (PTSD). Prior studies suggest a benefit of mindfulness-based stress reduction (MBSR) for PTSD, but the mechanisms through which MBSR reduces PTSD symptoms and improves functional status have received limited empirical inquiry. This study used a qualitative approach to better understand how training in mindfulness affects veterans with PTSD.

DESIGN

Qualitative study using semistructured in-depth interviews following participation in an MBSR intervention.

SETTING

Outpatient.

INTERVENTION

Eight-week MBSR program.

OUTCOME MEASURE

Participants' narratives of their experiences from participation in the program.

RESULTS

Interviews were completed with 15 veterans. Analyses identified six core aspects of participants' MBSR experience related to PTSD: dealing with the past, staying in the present, acceptance of adversity, breathing through stress, relaxation, and openness to self and others. Participants described specific aspects of a holistic mindfulness experience, which appeared to activate introspection and curiosity about their PTSD symptoms. Veterans with PTSD described a number of pathways by which mindfulness practice may help to ameliorate PTSD.

Seppälä EM, Nitschke JB, Tudorascu DL, Hayes A, Goldstein MR, Nguyen DT, Perlman D, Davidson RJ. Breathing-based meditation decreases posttraumatic stress disorder symptoms in U.S. military veterans: a randomized controlled longitudinal study. J Trauma Stress. 2014 Aug;27(4):397-405. doi: 10.1002/jts.21936.

Given the limited success of conventional treatments for veterans with posttraumatic stress disorder (PTSD), investigations of alternative approaches are warranted. We examined the effects of a breathing-based meditation intervention, Sudarshan Kriya yoga, on PTSD outcome variables in U.S. male veterans of the Iraq or Afghanistan war. We randomly assigned 21 veterans to an active (n = 11) or waitlist control (n = 10) group. Laboratory measures of eye-blink startle and respiration rate were obtained before and after the intervention, as were self-report symptom measures; the latter were also obtained 1 month and 1 year later. The active group showed reductions in PTSD scores, d = 1.16, 95% CI [0.20, 2.04], anxiety symptoms, and respiration rate, but the control group did not. Reductions in startle correlated with reductions in hyperarousal symptoms immediately postintervention (r = .93, p < .001) and at 1-year follow-up (r = .77, p = .025). This longitudinal intervention study suggests there may be clinical utility for Sudarshan Kriya yoga for PTSD.

Smeeding SJ, Bradshaw DH, Kumpfer K, Trevithick S, Stoddard GJ. Outcome evaluation of the Veterans Affairs Salt Lake City Integrative Health Clinic for chronic pain and stress-related depression, anxiety, and post-traumatic stress disorder. J Altern Complement Med. 2010 Aug;16(8):823-35. doi: 10.1089/acm.2009.0510. PubMed PMID: 20649442.

OBJECTIVES

The purpose of this longitudinal outcome research study was to determine the effectiveness of the Integrative Health Clinic and Program (IHCP) and to perform a subgroup analysis investigating patient benefit. The IHCP is an innovative clinical service within the Veterans Affairs Health Care System designed for nonpharmacologic biopsychosocial management of chronic nonmalignant pain and stress-related depression, anxiety, and symptoms of post-traumatic stress disorder (PTSD) utilizing complementary and alternative medicine and mind-body skills.

METHODS

A post-hoc quasi-experimental design was used and combined with subgroup analysis to determine who benefited the most from the program. Data were collected at intake and up to four follow-up visits over a 2-year time period. Hierarchical linear modeling was used for the statistical analysis. The outcome measures included: Health-Related Quality of Life (SF-36), the Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI). Subgroup comparisons included low anxiety (BAI < 19, n = 82), low depression (BDI < 19, n = 93), and absence of PTSD (n = 102) compared to veterans with high anxiety (BAI > or = 19, n = 77), high depression (BDI > 19, n = 67), and presence of PTSD (n = 63).

RESULTS

All of the comparison groups demonstrated an improvement in depression and anxiety scores, as well as in some SF-36 categories. The subgroups with the greatest improvement, seen at 6 months, were found in the high anxiety group (Cohen's d = 0.52), the high-depression group (Cohen's d = 0.46), and the PTSD group (Cohen's d = 0.41).

CONCLUSIONS

The results suggest IHCP is an effective program, improving chronic pain and stress-related depression, anxiety, and health-related quality of life. Of particular interest was a significant improvement in anxiety in the PTSD group. The IHCP model offers innovative treatment options that are low risk, low cost, and acceptable to patients and providers.

Staples JK, Hamilton MF, Uddo M. A yoga program for the symptoms of post-traumatic stress disorder in veterans. Mil Med. 2013 Aug;178(8):854-60. doi: 10.7205/MILMED-D-12-00536.

The purpose of this pilot study was to evaluate the feasibility and effectiveness of a yoga program as an adjunctive therapy for improving post-traumatic stress disorder (PTSD) symptoms in Veterans with military-related PTSD. Veterans (n = 12) participated in a 6 week yoga intervention held twice a week. There was significant improvement in PTSD hyperarousal symptoms and overall sleep quality as well as daytime dysfunction related to sleep. There were no significant improvements in the total PTSD, anger, or quality of life outcome scores. These results suggest that this yoga program may be an effective adjunctive therapy for improving hyperarousal symptoms of PTSD including sleep quality. This study demonstrates that the yoga program is acceptable, feasible, and that there is good adherence in a Veteran population.

Steele E, Wood DS, J Usadi E, Applegarth DM. TRR's Warrior Camp: An Intensive Treatment Program for Combat Trauma in Active Military and Veterans of All Eras. Mil Med. 2018 Mar 1;183(suppl_1):403-407.

Effective treatments for combat trauma in military service members exist, but barriers to care abound, including poor access, stigma, and dropout. Although the effects of post-traumatic stress disorder (PTSD) can be severe, recovery is possible when proper treatment is implemented. Trauma and Resiliency Resources, Inc.'s Warrior Camp (WC) program is designed to address the effects of combat trauma in military service members and veterans. This intensive, 7-d treatment incorporates eye movement desensitization and reprocessing therapy, equine-assisted psychotherapy, yoga, and narrative writing in context of community. This single-group pretest-posttest design included paired t-tests and effect size analyses for 85 participants of WC. Outcome measures included the Mississippi Scale for Combat-related PTSD, the Patient Health Questionnaire, the Revised Adult Attachment Scales, and the Moral Injury Events Scale. Clinician-administered measures included the Davidson Trauma Scale and the Dissociative Experiences Scale. All measures showed statistically significant reductions in distress. The effect sizes ranged from small to large. Results suggest that WC participants experienced significant improvement in PTSD, depression, moral injury, dissociation and adult attachment. Clinicians should consider the potential benefits of this short-term, intensive treatment when addressing combat-related PTSD among military service members and veterans.

Sylvia L, West E, Blackburn AM, Gupta C, Bui E, Mahoney T, Duncan G, Wright EC, Lejeune S, Spencer TJ. Acceptability of an adjunct equine-assisted activities and therapies program for veterans with posttraumatic stress disorder and/or traumatic brain injury. J Integr Med. 2020 Jan 21. pii: S2095-4964(20)30006-6. doi:

OBJECTIVE

Equine-assisted activities and therapies (EAATs) have been a growing adjunctive integrative health modality, as they allow participants to practice mindfulness, emotional regulation, and self-mastery or self-esteem building skills. Preliminary evidence suggests that these programs may be helpful in reducing posttraumatic stress disorder (PTSD), anxiety, and depressive symptoms. The current study examines the acceptability of integrating an EAAT program as part of a two-week, intensive clinical program for veterans with PTSD and/or traumatic brain injury (TBI).

METHODS

A family member or support person could accompany veterans and participate in the program. One hundred and six participants (veteran n = 62, family n = 44) left the urban environment in an intensive outpatient program (IOP) to attend a two-day, weekend EAAT in rural New Hampshire. Satisfaction surveys were conducted on the last day of the program and examined using thematic analysis.

RESULTS

The following themes were reported in the surveys: ability of horses to catalyze emotional rehabilitation, effectiveness of immersion in equine-assisted activities, program's ability to foster interpersonal relationships and necessity of education about PTSD for staff. Participants also reported enjoying the program as highlighted by qualitative feedback, a mean score of 9.76 (standard deviation [SD] = 0.61) as reported by veterans and a mean score of 9.91 (SD = 0.29) as reported by family members on a 10-point visual analog scale with higher scores indicating a greater overall experience.

CONCLUSION

These data offer preliminary evidence that an adjunct EAAT program is acceptable for veterans with PTSD and/or TBI participating in an IOP.

Wahbeh H, Goodrich E, Goy E, Oken BS.  Mechanistic Pathways of Mindfulness Meditation in Combat Veterans With Posttraumatic Stress Disorder.  J Clin Psychol. 2016

OBJECTIVE

This study's objective was to evaluate the effect of two common components of meditation (mindfulness and slow breathing) on potential mechanistic pathways.

METHODS

A total of 102 combat veterans with posttraumatic stress disorder (PTSD) were randomized to (a) the body scan mindfulness meditation (MM), (b) slow breathing (SB) with a biofeedback device, (c) mindful awareness of the breath with an intention to slow the breath (MM+SB), or (d) sitting quietly (SQ). Participants had 6 weekly one-on-one sessions with 20 minutes of daily home practice. The mechanistic pathways and measures were as follows: (a) autonomic nervous system (hyperarousal symptoms, heart rate [HR], and heart rate variability [HRV]); (b) frontal cortex activity (attentional network task [ANT] conflict effect and event-related negativity and intrusive thoughts); and (c) hypothalamic-pituitary-adrenal axis (awakening cortisol). PTSD measures were also evaluated.

RESULTS

Meditation participants had significant but modest within-group improvement in PTSD and related symptoms, although there were no effects between groups. Perceived impression of PTSD symptom improvement was greater in the meditation arms compared with controls. Resting respiration decreased in the meditation arms compared with SQ. For the mechanistic pathways, (a) subjective hyperarousal symptoms improved within-group (but not between groups) for MM, MM+SB, and SQ, while HR and HRV did not; (b) intrusive thoughts decreased in MM compared with MM+SB and SB, while the ANT measures did not change; and (c) MM had lower awakening cortisol within-group (but not between groups).

CONCLUSION

Treatment effects were mostly specific to self-report rather than physiological measures. Continued research is needed to further evaluate mindfulness meditation's mechanism in people with PTSD.

Walker J 3rd, Pacik D.  Controlled Rhythmic Yogic Breathing as Complementary Treatment for Post-Traumatic Stress Disorder in Military Veterans: A Case Series. Med Acupunct. 2017 Aug 1;29(4):232-238. doi: 10.1089/acu.2017.1215.

BACKGROUND

Post-traumatic stress disorder (PTSD) is a cluster of symptoms in which a person persistently relives a traumatic event, through recurring thoughts, nightmares, and flashbacks for at least 1 month or more. There are various behavioral and medical treatment options for PTSD. Mind-body techniques, such as biofeedback and breathing-based stress reduction, have shown some promise in the treatment of PTSD symptoms. The purpose of this case series was to examine controlled yogic breathing as a complementary treatment of PTSD in military veterans. A retrospective review was performed from 2012 to 2016 in 3 cases, and participant demographics, member statements, and PTSD Checklist-Military Version (PCL-M) scores, pre-and-post course, were extracted. Cases: Three military veterans with PTSD participated in a standardized 5-day course designed to teach them controlled rhythmic yogic breathing exercises.

RESULTS

Subjectively, all 3 participants reported a decrease in PTSD symptoms after the course. Objectively, all 3 participants had a reduction in their overall PCL-M scores after the course. Among all 3 participants, there were score decreases in the Avoidance and Increased Arousal categories. The most dramatic improvement occurred in the participant with the most severe symptoms.

CONCLUSIONS

Controlled yogic breathing, specifically Sudarshan Kriya (SKY), appeared to reduce the symptoms of PTSD in 3 veterans of the Armed Services.

Willing AE, Girling SA, Deichert R, Wood-Deichert R, Gonzalez J, Hernandez D, Foran E, Sanberg PR, Kip KE. Brazilian Jiu Jitsu Training for US Service Members and Veterans with Symptoms of PTSD. Mil Med. 2019 Dec 1;184(11-12):e626-e631. doi:

INTRODUCTION

The United States has been actively involved in major armed conflicts over the last 15 years. As a result, a significant proportion of active duty service personnel and returning veterans have endured combat, putting them at risk for developing post-traumatic stress disorder (PTSD), a disabling disorder that may occur after exposure to a traumatic event. Current therapies often require long-term, time-intensive and costly commitment from the patient and have variable degrees of success. There remains an ongoing need for better therapies, including complementary medicine approaches that can effectively reduce PTSD symptoms. While anecdotal evidence suggests that routine practice of Brazilian Jiu Jitsu (BJJ) can reduce symptoms of PTSD, there have been no formal studies to address this.

METHODS

This study was approved by the University of South Florida Institutional Review Board (#PRO00019430). Male US active duty service members and veterans from the Tampa area participated in a 5-month (40 sessions) BJJ training program. Before beginning and again midway through and upon completion of training the participants completed several validated self-report measures that addressed symptoms of PTSD and other co-morbid conditions. Effect size and 95% confidence intervals were determined using a within-person single-group pretest-posttest design.

RESULTS

Study participants demonstrated clinically meaningful improvements in their PTSD symptoms as well as decreased symptoms of major depressive disorder, generalized anxiety and decreased alcohol use; effect sizes varied from 0.80 to 1.85.

CONCLUSIONS

The results from this first-of-kind pilot study suggest that including BJJ as a complementary treatment to standard therapy for PTSD may be of value. It will be necessary to validate these promising results with a larger subject cohort and a more rigorous experimental design before routinely recommending this complementary therapy.

Zalta AK, Held P, Smith DL, Klassen BJ, Lofgreen AM, Normand PS, Brennan MB, Rydberg TS, Boley RA, Pollack MH, Karnik NS.  Evaluating patterns and predictors of symptom change during a three-week intensive outpatient treatment for veterans with PTSD. BMC Psychiatry. 2018 Jul 27;18(1):242. doi: 10.1186/s12888-018-1816-6.

BACKGROUND

Intensive delivery of evidence-based treatment for posttraumatic stress disorder (PTSD) is becoming increasingly popular for overcoming barriers to treatment for veterans. Understanding how and for whom these intensive treatments work is critical for optimizing their dissemination. The goals of the current study were to evaluate patterns of PTSD and depression symptom change over the course of a 3-week cohort-based intensive outpatient program (IOP) for veterans with PTSD, examine changes in posttraumatic cognitions as a predictor of treatment response, and determine whether patterns of treatment outcome or predictors of treatment outcome differed by sex and cohort type (combat versus military sexual trauma [MST]).

METHOD

One-hundred ninety-one veterans (19 cohorts: 12 combat-PTSD cohorts, 7 MST-PTSD cohorts) completed a 3-week intensive outpatient program for PTSD comprised of daily group and individual Cognitive Processing Therapy (CPT), mindfulness, yoga, and psychoeducation. Measures of PTSD symptoms, depression symptoms, and posttraumatic cognitions were collected before the intervention, after the intervention, and approximately every other day during the intervention.

RESULTS

Pre-post analyses for completers (N = 176; 92.1% of sample) revealed large reductions in PTSD (d = 1.12 for past month symptoms and d = 1.40 for past week symptoms) and depression symptoms (d = 1.04 for past 2 weeks). Combat cohorts saw a greater reduction in PTSD symptoms over time relative to MST cohorts. Reduction in posttraumatic cognitions over time significantly predicted decreases in PTSD and depression symptom scores, which remained robust to adjustment for autocorrelation.

CONCLUSION

Intensive treatment programs are a promising approach for delivering evidence-based interventions to produce rapid treatment response and high rates of retention. Reductions in posttraumatic cognitions appear to be an important predictor of response to intensive treatment. Further research is needed to explore differences in intensive treatment response for veterans with combat exposure versus MST.