Treatment of Older Veterans With Chronic Posttraumatic Stress Disorder

PTSD is associated with high rates of mortality from suicide and health complications, high
healthcare costs, and diminished health and quality of life. Many military veterans have
PTSD due to combat, and many veterans continue to carry the symptoms of PTSD into late life.
The percentage of older veterans is expected to increase substantially in coming years
(especially as Vietnam-era veterans become older adults). The psychosocial intervention with
the most rigorous empirical support for treating PTSD in the general population is a
cognitive-behavioral treatment known as exposure therapy (which involves helping patients
face feared memories and situations), yet there have been no controlled studies of any
psychosocial interventions for PTSD in samples of older adults. Some have argued that older
adults will not respond well to exposure because of their cognitive limitations. However,
several empirical studies have shown exposure therapy to be safe and effective with older
adults with anxiety disorders other than PTSD.

The current project represents the first randomized clinical trial of psychotherapy for
older veterans with posttraumatic stress disorder (PTSD). It will compare relaxation
training (RT) to prolonged exposure therapy (PE). The project will also examine whether
cognitive impairment influences psychotherapy outcome. The five-year Research Plan is
divided into three phases. Phase 1 (Year 1) involves the development of procedures for
assessment and preparation for the clinical trial. Phase 2 (Years 2-4) will entail the first
randomized clinical trial of psychosocial treatments for PTSD in late life. One hundred
veterans aged 60 years or older, with chronic PTSD, will be recruited from the San Diego VA
PTSD Clinical Team and randomly assigned to 12 sessions of PE or 12 sessions of RT. Phase 3
(Year 5) will be comprised of final data collection, scoring and interpretation of all
neuropsychological tests, data cleaning and analysis, and writing for publication of
results. Primary hypotheses: (1) Subjects in the PE condition will have significantly less
severe PTSD symptoms, depressive symptoms, and functional impairment than subjects in the RT
condition at posttest; (2) Executive functioning will modify the response to both
treatments, such that those with impaired executive functioning will demonstrate a smaller
reduction in PTSD symptoms (representing less clinically significant change).

Inclusion Criteria:

- Veterans with primary diagnosis of chronic PTSD due to combat or non-sexual military
trauma; comorbid mood and anxiety disorders are expected, and will be permitted (to
maximize generalizability) if PTSD symptoms are judged to be predominant based on
primacy and severity of symptoms

- Male

- Age 60 or older; and

- English literacy.

Exclusion Criteria:

- Unmanaged psychosis or manic episodes in past year

- Substance dependence or alcohol dependence in past 3 months

- Concurrent psychotherapies targeting PTSD or exposure therapy for other anxiety
symptoms [veterans who are engaged in treatment for non-PTSD symptoms (e.g., 12-step
programs for substance problems) will be eligible]

- Severe cardiovascular or respiratory disease that would make it difficult to ensure
regular attendance at psychotherapy sessions

- Probable dementia (based on chart diagnosis); or

- Head trauma resulting in loss of consciousness longer than 20 minutes.