Accelerated Resolution Therapy (ART)

Transcription

1 Accelerated Resolution Therapy (ART) An Innovative Mental Health Intervention to Treat PTSD Presented by: Kevin E. Kip, Ph.D. July 20, 2017

2 Workshop Outline Part I: Review of Trauma-Focused Therapies and ART Evidence Base Part II: Review of the ART Clinical Protocol Part III: Theoretical Basis of Memory Reconsolidation and Eye Movements (i.e. how ART may work)

3 Sir Peter Medawar (1979) I cannot give any scientist of any age better advice than this: the intensity of the conviction that a hypothesis is true has no bearing on whether it is true or not. The importance of the strength of our conviction is only to provide a proportionately strong incentive to find out if the hypothesis will stand up to critical evaluation.

4 Post-Traumatic Stress Disorder (PTSD) DSM-V symptom clusters (all 4): (APA, 2013) 1) Re-experiencing memories of traumatic event, recurrent dreams related to it, flashbacks, or other intense or prolonged psychological distress 2) Avoidance of distressing memories, thoughts, feelings or external reminders of the event 3) Negative cognitions and mood --- distorted sense of blame of self or others --- estrangement from others or markedly diminished interest in activities --- inability to remember key aspects of event 4) Arousal aggressive, reckless, or self-destructive behavior, hyper-vigilance, or related problems

5 Prevalence of PTSD in United States Lifetime prevalence of PTSD 6 to 9% among persons in US (Kessler, 2005) Prevalence of PTSD ~2-fold higher in women Since September 11, 2001, >2.6M American military personnel deployed to Iraq, Afghanistan, or both. 900,000 deployed more than once. From OIF/OEF/OND conflicts, prevalence estimates of PTSD range from 2%-31% (different sampling and study methodologies) (Ramchand et al., 2010) IOM Report 2012: 20% OIF/OEF/OND veterans (~520,000) suffer from PTSD (Institute of Medicine, 2012)

6 Prevalence of PTSD in UK Service Personnel

7 Prevalence of PTSD in UK Service Personnel No change in prevalence of PTSD and alcohol misuse since time from end of deployment US studies have shown an increase in the prevalence of PTSD in relation to post-deployment time (Milken, 2007)

8 First Line Trauma Therapies Institute of Medicine (IOM), (Institute of Medicine, 2012) Trauma-focused cognitive behavioral therapy (CBT) is rated as the only first-level treatment for PTSD. Pharmacotherapy has accumulated some empirical support. Core Components of Trauma Focused Therapy: Narration Cognitive restructuring In vivo exposure Stress inoculation (e.g. relaxation) skills Psycho-education

9 Current Evidence Based Treatments Cognitive Processing Therapy (CPT) Focuses on modifying dysfunctional thoughts, beliefs, and expectations by identifying, challenging, and replacing maladaptive cognitions. Prolonged Exposure Therapy (PE) Repeated exposure to feared, yet safe, stimuli and memories surrounding the trauma. Aims for patient to experience decrease in fear and an increase in mastery. Eye Movement Desensitization Reprocessing (EMDR) Involves exposure and cognitive therapy, but with additional bilateral stimulation, usually in the form of eye movements. Stress Inoculation Training (SIT) Teaches anxiety-management skills including relaxation training, breathing retraining, positive thinking and self-talk, assertiveness training, and thought stopping.

10 First Line Trauma Therapies

11 NICE Guidelines for Treatment of PTSD For Treatment of PTSD >3 Months After Trauma: Offer course of trauma-focused psychological treatment (TF-CBT) or eye movement desensitisation and reprocessing (EMDR) Provide treatment on individual outpatient basis Non-trauma-focused interventions, such as non-directive therapy or relaxation, should not be routinely offered Pharmacological treatments should not be used as routine first-line treatment for adults Pharmacological treatments can be considered as an adjunct to psychological treatment

12 Reality of Evidence Based Treatments Review of treatment dropout and non-response rates in 55 studies of empirically supported treatments for PTSD: A careful review of empirically supported psychotherapies for PTSD indicates that these therapies have relatively large dropout or non-response rates.

13 Reality of Evidence Based Treatments Interventions for War-Related Posttraumatic Stress Disorder Meeting Veterans Where They Are Charles W. Hoge, MD JAMA, August Vol 306, No 5 Among veterans who begin treatment for PTSD with psychotherapy or medication: A high percentage of veterans drop out. Rate of recovery of 60% to 80% among treatment completers declines to about 40% when non-completers are taken into account.

14 Reality of Evidence Based Treatments The term gold-standard evidence-based treatments should be reserved for treatments that evidence both positive results in RCTs, but also feasibility and strong retention in real-world settings

15 Initial ART Testimonial re=share&list=uuzzzlgbyx9ohlcjn5ttsv4w&index=1

16 Hierarchy for Evidence of a New Psychotherapy RCT: Randomized Controlled Trial; EBP: Evidence-Based Practice

17 Federal Classification Accelerated Resolution Therapy. Classified as evidence-based by the Substance Abuse and Mental Health Services Administration (SAMHSA), National Registry of Evidence Based Programs and Practices (NREPP), November, 2015;

18 Study 1: Title: Design: Sample: ART for Civilian Psychological Trauma Prospective Cohort Study 80 adults Assessments: --- Before ART --- After ART month follow-up month follow-up Primary Publications: Kip KE, Elk CA, Sullivan KL, Kadel R, Lengacher CA, Long CJ, Rosenzweig L, Shuman A, Hernandez DF, Street JD, Girling SA, Diamond DM. Brief treatment of symptoms of posttraumatic stress disorder (PTSD) by use of Accelerated Resolution Therapy (ART). Behavioral Sciences 2012; 2(2): PMID: Kip KE, Sullivan KL, Lengacher CA, Rosenzweig L, Hernandez DF, Kadel R, Kozel FA, Shuman A, Girling SA, Hardwick MJ, Diamond DM. Brief treatment of co-occurring posttraumatic stress and depressive symptoms by use of accelerated resolution therapy. Frontiers in Psychiatry 2013; 4 (article 11):1-12. doi: /fpsyt PMID:

19 Demographic and Presenting Characteristics Characteristic All (n = 80) Male (n = 18) Female (n = 62) Age in years (mean ± SD) 40.0 ± ± ± 9.8 Race (%) Black or African American White Other Hispanic (%) PCL-C score (mean ± SD) 54.5 ± ± ± 12.6 Less than 40 (%) to 60 (%) More than 60 (%) Traumatic memories still impacting life (%) 1 to to or more Previous tx for PTSD/other MH condition (%) Time lived with traumatic memory(ies) (%) Less than 1 year to 6 years years or more PCL-C: 17-item PTSD Checklist; MH: Mental Health

20 Mean of 3.5 ART Sessions

21 Self-Report Changes in Symptoms Before and After Treatment with ART Pre-Treatment Versus 2-Month Follow-Up Symptom Measure N Pre a 2-Mo. a Diff ab ES P PTSD Checklist (PCL-C) (12.2) 29.5 (12.0) 24.5 (12.2) 2.01 < Brief Symptom Inventory (14.2) 9.6 (11.9) 20.5 (13.3) 1.54 < CES-D (Depression) (10.7) 13.3 (12.1) 15.5 (11.0) 1.41 < Pittsburgh Sleep Quality (4.6) 6.2 (4.2) 3.6 (4.0) 0.89 < Trauma Related Growth Global Guilt (2.4) 1.9 (2.0) 2.7 (2.8) 0.98 < Distress (4.0) 8.0 (5.9) 10.7 (5.6) 1.89 < Guilt Cognition (18.3) 24.4 (14.9) 19.9 (19.2) 1.04 < Self-Compassion Scale (16.8) 82.0 (21.1) 14.8 (17.8) 0.83 < Alcohol Use (AUDIT) (3.3) 1.8 (2.1) 1.2 (2.2) a Presented as mean (standard deviation). b All mean differences are coded with positive numbers reflecting improvements in symptoms. ES: effect size.

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23 80 70 PCL-C (PTSD) CES-D (Depression) (n=28) (n=28) (n=28) (n=19) (n=28) (n=28) (n=28) (n=19) 0 Pre-ART Post-ART 2-Month 4-Month Pre-ART Post-ART 2-Month 4-Month

24 Study 2: Title: Design: Sample: ART for Military Psychological Trauma Randomized Controlled Trial 57 U.S. veterans/service members Assessments: --- Before ART --- After ART month follow-up Primary Publications: Kip, KE, Rosenzweig L, Hernandez DF, Shuman A, Sullivan KL., Long CJ, Taylor J, McGhee S, Girling SA, Wittenberg, T, Sahebzamani, FM, Lengacher CA, Kadel R, Diamond DM. Randomized controlled trial of accelerated resolution therapy (ART) for symptoms of combat-related post-traumatic stress disorder (PTSD). Military Medicine 2013; 178: PMID: Kip KE, Shuman A, Hernandez DF, Diamond DM, Rosenzweig L. Case report and theoretical description of Accelerated Resolution Therapy (ART) for military-related post-traumatic stress disorder. Military Medicine 2014; 179: PMID: Kip KE, Rosenzweig L, Hernandez DF, Shuman A, Diamond DM, Girling SA, Sullivan KL, Wittenberg T, Witt AM, Lengacher CA, Anderson B, McMillan SC. Accelerated Resolution Therapy for treatment of pain secondary to symptoms of combat-related posttraumatic stress disorder. European Journal of Psychotraumatology 2014, 5: PMID: Kip KE, Hernandez DF, Shuman A, Witt A, Diamond DM, Davis SE, Kip R, Abhayakumar A, Wittenberg T, Girling SA, Witt S, Rosenzweig L. Comparison of Accelerated Resolution Therapy (ART) for treatment of symptoms of PTSD and sexual trauma between civilian and military adults. Military Medicine, 180: PMID:

25 Demographic, Military, and Clinical Characteristics by Random Assignment. Characteristic All (n = 57) ART (n = 29) AC (n = 28) p- value Age in years (mean ± SD) 41.4 ± ± ± Female gender (%) Current military status (%) 1.0 Active duty Reservist Discharged/veteran Primary branch of military service 0.09 Army Navy Air Force Marines Principal location of deployment(s)(%) 0.52 Iraq Afghanistan Vietnam Other History of head trauma (%) On disability for PTSD/other MH (%) Previous treatment for PTSD (%) Individual therapy Group therapy Pharmacotherapy PCL-M score (mean ± SD) 56.9 ± ± ± Any PTSD screening criteria (%) \

26 Change in PCL-M Score Mean of 3.6 ART Sessions

27 Treatment Effect of ART versus Attention Control for Comorbidities of PTSD Measure of Comorbidity Attention Control (n=24) ART (n=26) Effect Size p-value a Pre Post Diff 95% C.I. Pre Post Diff 95% C.I. Obs ITT Obs. a ITT b CES-D (Depression) , , < < Brief Symptom Inventory , , STICSA (Somatic) , , STICSA (Cognitive) , , Pittsburgh Sleep Quality , , Trauma Related Growth Global Guilt , , Distress , , Guilt Cognition , , Self-Compassion Scale , , Aggression Questionnaire , , a p-value adjusted for baseline measurement. b Based on student t test and Intention to Treat assuming mean difference of zero from baseline to post-intervention assessment and standard error from completers with non-missing data.

28 ART for Pain Secondary to PTSD

29 ART for Pain Secondary to PTSD

30 Pooled Data Primary Trauma Exposure

31 PTSD treatment response with ART is similar between civilians and military

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33 Study 3: Title: Design: Sample: ART for Military Combat-Related Trauma and Military Sexual Trauma Prospective Cohort Study 140 U.S. veterans/service members Assessments: --- Before ART --- After ART month follow-up Primary Publication: Kip KE, D'Aoust RF, Hernandez DF, Girling SA, Cuttino B, Long MK, Rojas P, Wittenberg T, Abhayakumar A, Rosenzweig L. Evaluation of brief treatment of symptoms of psychological trauma among veterans residing in a homeless shelter by use of Accelerated Resolution Therapy (ART), Nursing Outlook 2016;64:

34 Characteristics of Study Participants by Residential Status (Quasi Diagnosis of PTSD) Characteristic All (n=89) Homeless (n=12) Community (n=77) p- value Age in years, mean + SD Male gender, % Combat Exposure Scale, mean + SD Experienced combat-related activity, % PCL-M (PTSD checklist), mean + SD On disability for PTSD/MH disorder, % Screen positive for mild TBI, % Five or more traumas impacting life, % Guilt associated with trauma(s), % Trauma for 11 or more years, % Prior psychotherapy Treatment Provided, mean + SD Total sessions of ART ART sessions for non-trauma Among participants with quasi-diagnosis of PTSD and who completed treatment.

35 ART for Homeless Veterans

36 Mobile ART Clinical/Research Team Eagles Healing Nest, Sauk Centre, MN 10 0 Change in PCL-M Score (n=10) Mean: p = Mean of 2.7 (± 1.0) treatment sessions

37 Study 4: Title: Design: Sample: Pilot Study of ART for Chronic Neuropathic Pain Prospective Cohort Study 10 Adults with chronic pain Assessments: --- Before ART --- After ART month follow-up Primary Publication: Kip KE, Tofthagen C, D'Aoust R, Girling SA, Harper Y, Rosenzweig L. Pilot study of Accelerated Resolution Therapy for treatment of chronic refractory neuropathic pain. Alternative and Complementary Therapies. December 2016, 22(6): doi: /act kek.

38 ART for Chronic Neuropathic Pain Pain Outcomes Questionnaire SF-36 Bodily Pain Scale

39 Study 5: Title: Design: Sample: ART Sleep EEG Study Case Series 9 veterans with symptoms of PTSD 9 control subjects without PTSD Assessments: --- Before ART --- After ART

40 ART Sleep EEG Study PTSD patients studied before and after treatment with ART Test protocol consisted of multi-channel surface EEG during a 30-minute daytime nap. Surface EEG electrodes attached to frontal, central, and parietal sites-both hemispheres. Measures of brain wave coherence evaluated between adjacent segments.

41 ART Sleep EEG Study

42 References American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC, American Psychiatric Publishing Inc. Hoge, C. W. (2011). "Interventions for war-related posttraumatic stress disorder: Meeting veterans where they are." JAMA 306: Institute of Medicine Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial Assessment. Washington, DC: The National Academies Press. Kessler RC, Berglund PA, Demler O, Jin R, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry Jun;62(6): Najavitis, L.M. The problem of dropout from gold standard PTSD therapies. F1000Prime Rep. 2015; 7: 43. Milliken CS, Auchterlonie JL, Hoge CW. Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. JAMA. 2007;298(18): National Institute for Health and Care Excellence. Evidence Update 49 Post-traumatic stress disorder (PTSD) (December 2013). Ramchand, R., Schell, T.L., Karney, B.R., Osilla, K.C., Bruns, R.M., Caldarone, L.B. Disparate prevalence estimates of PTSD among service members who served in Iraq and Afghanistan: Possible explanations. Journal of Traumatic Stress 2010; 23(1); Rona, R.J., Burdett. H., Bull, S., Jones, M., Jones, N., Greenberg, N., Wessely, S., Fear, N.T. Prevalence of PTSD and other mental disorders in UK service personnel by time since end of deployment: a meta-analysis. BMC Psychiatry 2016; 16: 333. Schottenbauer, M. A., et al. (2008). "Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations." Psychiatry 71:

43 ART Bibliography Peer-Reviewed Publications 1. Kip KE, Elk CA, Sullivan KL, Kadel R, Lengacher CA, Long CJ, Rosenzweig L, Shuman A, Hernandez DF, Street JD, Girling SA, Diamond DM. Brief treatment of symptoms of post-traumatic stress disorder (PTSD) by use of Accelerated Resolution Therapy (ART). Behavioral Sciences 2012; 2(2): PMID: Kip KE, Sullivan KL, Lengacher CA, Rosenzweig L, Hernandez DF, Kadel R, Kozel FA, Shuman A, Girling SA, Hardwick MJ, Diamond DM. Brief treatment of co-occurring post-traumatic stress and depressive symptoms by use of accelerated resolution therapy. Frontiers in Psychiatry 2013; 4 (article 11):1-12. doi: /fpsyt PMID: Kip, KE, Rosenzweig L, Hernandez DF, Shuman A, Sullivan KL., Long CJ, Taylor J, McGhee S, Girling SA, Wittenberg, T, Sahebzamani, FM, Lengacher CA, Kadel R, Diamond DM. Randomized controlled trial of accelerated resolution therapy (ART) for symptoms of combat-related post-traumatic stress disorder (PTSD). Military Medicine 2013; 178: PMID: , Kip KE, Shuman A, Hernandez DF, Diamond DM, Rosenzweig L. Case report and theoretical description of Accelerated Resolution Therapy (ART) for military-related post-traumatic stress disorder. Military Medicine 2014; 179: PMID: Kip KE, Rosenzweig L, Hernandez DF, Shuman A, Diamond DM, Girling SA, Sullivan KL, Wittenberg T, Witt AM, Lengacher CA, Anderson B, McMillan SC. Accelerated Resolution Therapy for treatment of pain secondary to symptoms of combat-related posttraumatic stress disorder. European Journal of Psychotraumatology 2014, 5: PMID: Kip KE, Hernandez DF, Shuman A, Witt A, Diamond DM, Davis SE, Kip R, Abhayakumar A, Wittenberg T, Girling SA, Witt S, Rosenzweig L. Comparison of Accelerated Resolution Therapy (ART) for treatment of symptoms of PTSD and sexual trauma between civilian and military adults. Military Medicine 2015; 180: PMID: Finnegan A, Kip K, Hernandez D, McGhee S, Rosenzweig L, Hynes C, Thomas M. Accelerated resolution therapy: an innovative mental health intervention to treat post-traumatic stress disorder. Journal of the Royal Army Medical Corps 2016; 162: PMID Kip KE, D'Aoust RF, Hernandez DF, Girling SA, Cuttino B, Long MK, Rojas P, Wittenberg T, Abhayakumar A, Rosenzweig L. Evaluation of brief treatment of symptoms of psychological trauma among veterans residing in a homeless shelter by use of Accelerated Resolution Therapy (ART), Nursing Outlook 2016;64: Kip KE, Tofthagen C, D'Aoust R, Girling SA, Harper Y, Rosenzweig L. Pilot study of Accelerated Resolution Therapy for treatment of chronic refractory neuropathic pain Alternative and Complementary Therapies. December 2016, 22(6): doi: /act kek. 10. Hernandez DF, Waits W, Calvio L, Byrne M. Practice comparisons between accelerated resolution therapy, eye movement desensitization and reprocessing and cognitive processing therapy with case examples. Nurse Education Today 2016; 47: Waits W, Marumoto M, Weaver J. Accelerated resolution therapy (ART): a review and research to date. Current Psychiatry Reports 2017; 19:18. Published at: doi: /s y

44 ART Bibliography Book Chapters Waits WM, Kip KE, Hernandez DF. Accelerated Resolution Therapy. In Ritchie EC (ed): Posttraumatic Stress Disorder and Related Diseases in Combat Veterans. Springer International Publishing, Switzerland, 2015; pp Kip KE, Rosenzweig L, Hernandez DF, Shuman A, Witt A, Keller E, Diamond DM. Accelerated Resolution Therapy: A Brief, Emerging Evidence-Based Treatment for PTSD. In Martin C, Preedy V, and Patel VB (eds): Comprehensive Guide to Post-Traumatic Stress Disorders. Springer International Publishing, Switzerland, 2016; Related/Referenced Publications Interview with Dr. Charles Hoge on PTSD Treatments and a Novel Treatment, Accelerated Resolution Therapy. Australasian Society for Traumatic Stress Studies (ASTSS). August 2015: 5-9. Hoge CW, Lies J. Posttraumatic stress disorder: developments in assessment and treatment. Federal Practitioner 2015 (April); 16S-20S. Federal Classification Accelerated Resolution Therapy. Classified as evidence-based by the Substance Abuse and Mental Health Services Administration (SAMHSA), National Registry of Evidence Based Programs and Practices (NREPP), November, 2015;