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A Randomized Controlled Trial of 7-Day Intensive and Standard Weekly Cognitive Therapy for PTSD and Emotion-Focused Supportive Therapy
Anke Ehlers, Ph.D.; Ann Hackmann, D.Clin.Psy.; Nick Grey, D.Clin.Psy.; Jennifer Wild, D.Clin.Psy.; Sheena Liness, M.A.; Idit Albert, D.Clin.Psy.; Alicia Deale, Ph.D.; Richard Stott, D.Clin.Psy.; David M. Clark, D.Phil.
Am J Psychiatry 2014;171:294-304. doi:10.1176/appi.ajp.2013.13040552
View Author and Article Information

The authors report no financial relationships with commercial interests.

Supported by Wellcome Trust (grant 069777 to Anke Ehlers and David Clark).

The authors thank Kelly Archer, Anna Bevan, Francesca Brady, Ruth Collins, Linda Horrell, Judith Kalthoff, and Catherine Seaman for their help with trial administration, data collection, entry, and analysis; Margaret Dakin, Sue Helen, and Julie Twomey for administrative support; Dirk Hillebrandt for statistical consultation; Sue Clohessy, Martina Mueller, Antje Horsch, Hannah Murray, Anna Sandall, Sandra Ewing, and Olivia Bolt for assessments; Louise Waddington and Ruth Collins for ratings of treatment sessions; and Michelle Moulds for therapist training.

The trial was registered as ISRCTN 48524925.

From the Department of Experimental Psychology, University of Oxford, U.K., and National Institute for Health (NIHR) Research Oxford Cognitive Health Clinical Research Facility; the NIHR Biomedical Research Centre for Mental Health, South London and Maudsley NHS Foundation Trust, King’s College London; and the Department of Psychiatry, University of Oxford, U.K.

Address correspondence to Dr. Ehlers (anke.ehlers@psy.ox.ac.uk).

Copyright © 2014 by the American Psychiatric Association

Received April 25, 2013; Revised July 16, 2013; Revised August 27, 2013; Accepted September 06, 2013.

Abstract

Objective  Psychological treatments for posttraumatic stress disorder (PTSD) are usually delivered once or twice a week over several months. It is unclear whether they can be successfully delivered over a shorter period of time. This clinical trial had two goals: to investigate the acceptability and efficacy of a 7-day intensive version of cognitive therapy for PTSD and to investigate whether cognitive therapy has specific treatment effects by comparing intensive and standard weekly cognitive therapy with an equally credible alternative treatment.

Method  Patients with chronic PTSD (N=121) were randomly allocated to 7-day intensive cognitive therapy for PTSD, 3 months of standard weekly cognitive therapy, 3 months of weekly emotion-focused supportive therapy, or a 14-week waiting list condition. The primary outcomes were change in PTSD symptoms and diagnosis as measured by independent assessor ratings and self-report. The secondary outcomes were change in disability, anxiety, depression, and quality of life. Evaluations were conducted at the baseline assessment and at 6 and 14 weeks (the posttreatment/wait assessment). For groups receiving treatment, evaluations were also conducted at 3 weeks and follow-up assessments at 27 and 40 weeks after randomization. All analyses were intent-to-treat.

Results  At the posttreatment/wait assessment, 73% of the intensive cognitive therapy group, 77% of the standard cognitive therapy group, 43% of the supportive therapy group, and 7% of the waiting list group had recovered from PTSD. All treatments were well tolerated and were superior to waiting list on nearly all outcome measures; no difference was observed between supportive therapy and waiting list on quality of life. For primary outcomes, disability, and general anxiety, intensive and standard cognitive therapy were superior to supportive therapy. Intensive cognitive therapy achieved faster symptom reduction and comparable overall outcomes to standard cognitive therapy.

Conclusions  Cognitive therapy for PTSD delivered intensively over little more than a week was as effective as cognitive therapy delivered over 3 months. Both had specific effects and were superior to supportive therapy. Intensive cognitive therapy for PTSD is a feasible and promising alternative to traditional weekly treatment.

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FIGURE 1. Flow Diagram of Patient Recruitment and Trial Progress in a Study of Cognitive and Supportive Therapies for PTSD

FIGURE 2. Changes in PTSD Symptoms in a Randomized Controlled Trial of Cognitive and Supportive Therapies for PTSDa

a Scores were measured with the Posttraumatic Diagnostic Scale for 7-day intensive cognitive therapy (iCT, all patients), standard weekly cognitive therapy (sCT, all patients), weekly emotion-focused supportive therapy (EST), and waiting list. All patients completed the scale at baseline, 6 weeks, and 14 weeks (posttreatment/wait). Patients receiving therapy also completed the scale at 3 weeks, 27 weeks (follow-up 1, FU1), and 40 weeks (follow-up 2, FU2).

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TABLE 1.Sample, Trauma, and Treatment Characteristics by Treatment Condition in a Study of Cognitive and Supportive Therapies for PTSD
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TABLE 2.Dichotomous Measures of Response to Treatment in a Study of Cognitive and Supportive Therapies for PTSD
Table Footer Note

a CAPS=Clinician-Administered PTSD Scale; PDS=Posttraumatic Diagnostic Scale.

Table Footer Note

* p<0.05. **p<0.01. ***p<0.001.

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TABLE 3.Intent-to-Treat Results for Continuous Primary and Secondary Outcome Measures
Table Footer Note

a CAPS=Clinician-Administered PTSD Scale; PDS=Posttraumatic Diagnostic Scale; SDS=Sheehan Disability Scale; BDI=Beck Depression Inventory; BAI=Beck Anxiety Inventory.

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TABLE 4.Within- and Between-Group Cohen’s d Effect Sizes at the 14-Week Assessment (Posttreatment/Wait) and Adjusted Intent-to-Treat Group Differences
Table Footer Note

a CAPS=Clinician-Administered PTSD Scale; PDS=Posttraumatic Diagnostic Scale.

Table Footer Note

* p<0.05. **p<0.01. ***p<0.001.

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