Clinical Effectiveness Trial of In-Home Cognitive Processing Therapy for Combat-Related PTSD
- Conditions
- Posttraumatic Stress DisorderPTSD
- Interventions
- Behavioral: Cognitive Processing Therapy (cognitive only version; CPT-C)
- Registration Number
- NCT02290847
- Brief Summary
The primary objective of this study is to evaluate the effectiveness of Cognitive Processing Therapy (cognitive only version; CPT-C) delivered using two different formats in the home setting for the treatment of combat-related PTSD as compared to conventional face-to-face CPT-C delivered in a mental health clinic. The study will include two different formats of in-home therapy: face-to-face in-home CPT-C and tele-behavioral health in-home CPT-C.
- Detailed Description
The study will use a 3-arm equipoise-stratified randomization design (Lavori et al., 2001; Shalev et al., 2011) to evaluate the clinical effectiveness of CPT-C delivered in three formats: Face-to-Face In-Office (F2F-O), Face-to-Face In -Home (F2F-H), and Telebehavioral Health In -Home (TBH-H). The equipoise stratified design was specifically developed for clinical effectiveness trials involving multiple treatments that may not be appropriate for all research participants. The design will allow for complete randomization of those participants who are interested and eligible for all three treatment arms. It will also allow participants to opt out of one treatment arm if they are not interested or eligible for one of the arms. Without this provision a large proportion of the potential participants would be excluded from the study, seriously compromising external validity. Participants who elect to opt out of one arm will be randomized to one of the two remaining treatment arms. For example, the F2F-O treatment could be eliminated by those who are severely injured, home-bound, or seriously concerned about stigma, and they then would be randomized to receive one of the home-based CPT-C formats. The F2F-H treatment could be eliminated for participants who are uncomfortable with the idea of a mental health provider coming into their home. The telehealth arm could be opted out by veterans who are unable to use a computer, or cannot situate it in a private area.
The equipoise design will be used because a significant confound exists with the use of a completely randomized three-arm research design when all participants cannot be randomized to all arms. With a completely randomized design, participants must be willing to be randomized to all treatment arms or else they must be excluded. All participants willing to be randomized to all arms will occupy a universal donor stratum. The universal donor participants are randomized as in a completely randomized design, and they are able to participate in all statistical analyses. Participants that elect to opt out of one arm will enter a stratum comprising the remaining two arms, and they will be assigned at random to one of the two remaining arms. These participants may participate (along with those in the universal donor stratum) only in statistical analyses that compare arms to which they could have been randomized. By making a choice, each participant assigns himself or herself to a stratum, which consists of all the options that he or she finds equally acceptable. In this design, those who are unable to attend clinic will be randomized to one of the in-home arms. Those who are able to attend clinic will be given the option to reject any one of the three treatments. The randomization plan defines four strata (i.e., those who accept randomization to all three arms and those who reject one of the three treatments). Analyses will be done pairwise using only participants who accepted randomization to two or three treatments, and it will include stratum and the stratum-by-treatment interaction as design effects. Note that this design is the only way to include an in-clinic arm and a sample of participants who are unwilling or unable to be randomized to in-clinic treatment.
Specific Aims. The overall aim of the project is to conduct a 3-group randomized clinical trial to evaluate the clinical effectiveness of CPT-C delivered in three formats: (1) Face-to-Face In-Home CPT-C; (2) Face-to-Face In-Office CPT-C; and (3) Tele-Behavioral Health In-Home CPT-C.
Objective 1: Conduct a randomized clinical trial to evaluate the effectiveness of CPT-C delivered in three formats: (1) Face-to-Face In-Home CPT-C (F2F-H); (2) Face-to-Face In-Office CPT-C (F2F-O); and (3) Tele-Behavioral Health In-Home CPT-C (TBH-H) employing equipoise-stratified randomization.
Hypothesis 1: CPT-C delivered in F2F-H format will be more effective for the treatment of PTSD (symptom reduction below diagnostic threshold on the CAPS-5) than F2F-O \& TBH-H.
Hypothesis 2: CPT-C delivered in F2F-H format will result in greater improvement in secondary outcomes (depression, alcohol consumption, marital and family functioning) than F2F-O \& TBH-H.
Objective 2: Determine if standard F2F-O CPT-C can be enhanced and delivered to special populations (seriously injured, home-based rehab, rural living, severe avoidance) with in-home therapies.
Hypothesis 3: In-home therapies (F2F-H and TBH-H) will result in lower perceived stigma of seeking mental health care and higher treatment adherence (session attendance; out-of-session assignment completion; dose of therapy) compared to mental health clinic-based therapy.
Hypothesis 4: Participants who opt to participate in the in-home therapies (i.e., decline F2F-O) will have higher levels of treatment satisfaction than those in the F2F-O treatment arm.
Recruitment & Eligibility
- Status
- COMPLETED
- Sex
- All
- Target Recruitment
- 172
Not provided
Not provided
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description In-Home Therapy Cognitive Processing Therapy (cognitive only version; CPT-C) Cognitive Processing Therapy (CPT-C) will be delivered to participants face to face in their homes by a certified therapist. In-Office Therapy Cognitive Processing Therapy (cognitive only version; CPT-C) Cognitive Processing Therapy (CPT-C) will be delivered to participants face to face in a mental health clinic office setting by a certified therapist. Telebehavioral Health Cognitive Processing Therapy (cognitive only version; CPT-C) Cognitive Processing Therapy (CPT-C) will be delivered to participants over the internet using video conferencing software by a certified therapist.
- Primary Outcome Measures
Name Time Method PTSD Check List - DSM-5 (PCL-5), to assess change in PTSD symptomatology from baseline throughout treatment and at multiple follow up points Baseline, Weekly during therapy (6 time points), 1 month Post-tx follow up, 2 Month Follow-Up, 3 Month Follow-Up, 4 Month Follow-Up, 5 Month Follow-Up, 6 Month Follow-Up The PCL-5 is a 20-item self-report measure based upon the DSM-5 criteria for PTSD that evaluates how much participants have been bothered by PTSD symptoms in the past month as a result of a specific life event. Each item of the PCL-5 is scored on a five point scale ranging from 0 "not at all") to 4 ("extremely).
Clinician-Administered PTSD Scale - 5 (CAPS-5); to assess change in PTSD symptomatology and/or diagnosis from baseline to multiple follow up points Baseline, 1-month Post-tx Follow-Up, 3-month Follow-Up, 6-month Follow-Up The CAPS-5 is a structured interview that assesses the DSM-5 criteria for PTSD (Weathers et al., 2013). Each item is rated on a severity scale ranging from 0 (Absent) to 4 (Extreme) and combines information about frequency and intensity for each symptom. Validation studies are nearly complete to establish the psychometric properties of the CAPS-5. This interview is very similar to its predecessor, the CAPS for DSM-IV, which has been considered the gold standard for evaluating PTSD (Weathers, Keane, \& Davidson, 2001). In addition to reflecting diagnostic changes for PTSD in DSM-5, the CAPS-5 differs from the CAPS in that frequency and intensity ratings for each symptom are no longer scored separately, so the severity rating for each item determines whether a symptom is present or not. Subscale scores are calculated by summing severity scores for items in the following PTSD symptom clusters: re-experiencing, avoidance, negative alterations in cognitions and mood, and hyperarousal.
- Secondary Outcome Measures
Name Time Method
Trial Locations
- Locations (1)
Strong Star
🇺🇸San Antonio, Texas, United States