Post Traumatic Stress DisorderWe can offer better help … if we know how

Reg NixonAssociate Professor, School of Psychology

Flinders University

18 February 2014

‘My heart’s desire had been that I alone should perish…here at Troy; that you should sail…[home].’

– Achilles, standing above Patroklos’s corpse

(The Illiad, Homer; translation cited in Shay, 1991).

• It wasn't so bad because I wasn't physically injured • I should have said ‘no’ more• People are dangerous• People can't be trusted • Something terrible will happen again • I can't protect myself • I am damaged

Sexual assault victim, 2013

• Trauma exposure 75% (Australia)

• PTSD prevalence 6.4% (12-month, Australia)

• 79-85% have a comorbid disorder

• PTSD individuals have 1.5-2 times the health costs of those without PTSD

• At best, only 50% have received treatment, could be as low as 8%

• Relative to other anxiety disorders, sufferers:

– Have higher health costs

– Lower quality of life

– Are 2nd only to Agoraphobia in work loss days

– Have more suicidal ideation and attempts, even after prior mood disorder is controlled

• TF-CBT ✔• EMDR ✔

• Cochrane Review / Bisson (2005, 2013)

• ISTSS / Foa et al., (2009)

• ACPMH Guidelines (2007)

• NICE (2005)Released August 2013

Effective Treatments Are Not Always Used for PTSD

Becker, Zayfert, & Anderson, 2004

Rosen et al., 2004; Russell & Silver, 2007.

van Minnen et al., 2010

Not at all

Always

Some critical factors for successful dissemination, implementation and

sustained practice change

• Practitioner• Pre-existing skills• Beliefs, esp. re: evidence-based practice, and

beliefs specific to trauma-focussed therapy

Cook et al. 2004; Couineau & Forbes, 2011; Ruzek & Rosen, 2009.

• Training• Accessibility, cost• Stand alone versus ongoing consult/support,

format of training• Availability of supervisors etc.

Cook et al. 2004; Couineau & Forbes, 2011; Ruzek & Rosen, 2009.

• System• Trauma-informed (including screening and

assessment)• Group cohesiveness• Leadership• Practical – staffing levels, resources, waiting lists

Cook et al. 2004; Couineau & Forbes, 2011; Ruzek & Rosen, 2009.

Recent Initiatives in Australia

Step 1 – Does TF-CBT actually work in routine clinical settings?•Yarrow Place – effectiveness trial•Veterans and Veterans Families Counselling Service (VVCS) – effectiveness trial

Step 2 – If so, how to make it routine practice (sustainability)

• VVCS – dissemination project• Australian Defence Force – dissemination project

Yarrow Place - Recent Sexual Assault Survivors

• Cognitive Processing Therapy (CPT) compared to Treatment as Usual (TAU)

• CPT clinicians – 3 day workshop, then weekly consultation

• CPT = 6 x 90min sessions• TAU = TAU

• N.B. No significant differences between groups in terms of therapeutic alliance.

PTSD Checklist (PCL)

Cut-offd = 0.16 d = 0.32

d = -0.10

d = 0.30 d = 0.13

8-11 TAU continue to have further sessions versus 1 CPT between post-3mths

Intent-to-treat sample

Results – % achieving good end-state functioning1

1Good end-state functioning defined as < 20 on the Clinician-Administered PTSD Scale

VVCS Effectiveness Trial

• Cognitive Processing Therapy (CPT) compared to Treatment as Usual (TAU)

• CPT clinicians – workshop, then weekly consultation

• CPT = 12 sessions• TAU = TAU

• N.B. No significant differences between groups in therapeutic working alliance

Forbes, Lloyd, Nixon et al., 2012, J Anxiety Disorders.

Treatment Outcomes - PTSD(3 months follow-up)

CPT:• 67% had clinically significant improvements• 38% no longer met DSM criterion for PTSD• 27% achieved good end-state functioning (remission)

TAU: • 35% had clinically significant improvements• 13% no longer met DSM criterion for PTSD• 3% achieved good end-state functioning

VVCS Dissemination

• A focus on sustainability• Organizational readiness to implement the intervention

– e.g., reducing case loads to allow CPT preparation time: short-term service pain for long-term client and service gain

• Monitoring– e.g., embedding PCL into electronic clinical records

• Supervisors and deputy directors took part in workshop and consultation

• [Less consult than RCT– fortnightly for 6-month period]• Two booster workshops following consultation process

Preliminary findings:•Large effect of treatment•Clinician adherence to CPT protocol good (~80%)•CPT Competence – 88% of sessions rated satisfactory or better (i.e., good/very good/excellent)•47% of clients fell below cut-off in an average of 8 sessions.

d = 1.02

Australian Defence Force

Ongoing Dissemination Project:•Clients are active duty personnel•Mixture of military and non-military trauma presentations•Training - workshop, 3-months weekly consultation, 3-months fortnightly consultation

Preliminary findings

Where to from here?

Where to from here?

• Research, training and treatment– Optimal but most cost-efficient training methods– How to overcome barriers to dissemination (individual,

organisational etc.)– TF-CBT supervisors – how to retain the knowledge– Long-term assessment of implementation required (skills

and quality of treatment maintained?)

• Policy– Emphasis on cost-benefit analysis of improved treatment

methods

And if we get research, training, and policy right

Ok, maybe we can’t help Achilles…

And if we get research, training, and policy right

Before therapy:•I should have fought back more•People are dangerous•People will hurt you if you let your guard down•People can't be trusted •Something terrible will happen again •I can't protect myself •I am damaged•[PCL = 64]

After therapy:•I did nothing to deserve this •I did not bring about this event - he did it•I did everything I could do •This was a significant event but I can cope with it•I am a good person and a good mother •I am brave and strong•Most people are good•[PCL = 17]

Therapist: Samantha Angelakis

Acknowledgments

Clients and staff:• Yarrow Place • VVCS• ADF• Victim Support Service

Flinders staff and students•Talitha Best, Lisa Beatty, Sarah Wilksch, Samantha Angelakis, Nathan Weber

CollaboratorsDavid Forbes, Delyth Lloyd, Dzenana Kartal, Anne-Laure Couineau, Meaghan O’Donnell, Richard Bryant

Funding agenciesAustralian Rotary Health Research Foundation,

Department of Veterans’ Affairs,

Flinders University

Questions?