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STAT

An MUSC blog
Keyword: veterans

Photograph of veteran on tranIn an article published in the March 2016 issue of the Journal of Anxiety Disorders, investigators in the Department of Psychiatry and Behavioral Sciences at the Medical University of South Carolina (MUSC) report that veterans who fall just below the threshold for a diagnosis of post-traumatic stress disorder (PTSD) respond to a psychotherapy regimen better than those with full PTSD. The study highlights the need to recognize veterans suffering from an overlooked condition called subclinical PTSD. “The study shows not only that we can treat those experiencing subclinical presentations of PTSD, but also that those with subclinical PTSD may actually respond better to treatment than those with more severe forms of the disease,” says MUSC investigator Kristina Korte, Ph.D., who is the first author on the article. MUSC co-authors include Ron Acierno, Ph.D., Daniel F. Gros, Ph.D., and Nicholas P. Allan, MS.

Just like patients with full PTSD, those with subclinical PTSD have experienced a traumatic event and are regularly re-experiencing it, often in nightmares or flashbacks. Patients with full PTSD also experience hyperarousal (i.e., they are easily startled) and avoid reminders of the event, for example by withdrawing from social interaction or turning to substance abuse. In addition re-experiencing the event, patients with subclinical PTSD may exhibit either hyperarousal or avoidance, but not both.

Psychologists began noticing this pattern more frequently in the nineties in veterans returning from the first Iraq War, and even more frequently in veterans returning from Iraq and Afghanistan in the last decade. As researchers have learned more about these patients over time, varying and sometimes conflicting symptoms have provided an incomplete picture of the disorder and how to treat it. Further confounding the issue is that those with subclinical PTSD are often excluded from clinical trials testing treatments for PTSD—patients with only some symptoms of PTSD commonly aren’t included in the healthy control group or in the group with full PTSD. As a result, there is still no standard psychotherapy for treating subclinical PTSD as there is for full PTSD.

The researchers devised an intuitive approach—Why not treat subclinical PTSD patients with one of the standard evidence-based psychotherapy tools already being used in PTSD patients? They enrolled 200 patients with combat-related PTSD symptoms from the Ralph H. Johnson VA Medical Center located adjacent to MUSC, identifying those with either subclinical or full PTSD. For eight weeks, patients received intensive weekly sessions of behavioral activation and therapeutic exposure therapy, designed to lessen their PTSD symptoms by helping them safely re-experience and resolve elements of the original trauma. Psychologists rated the patients’ PTSD symptoms and had patients rate their own symptoms before, during, and after the eight weeks.

The results were encouraging. Those with subclinical or full PTSD each experienced a real drop in PTSD symptoms after treatment. The striking result was in how much those symptoms dropped: 29% in those with subclinical PTSD as compared to 14% with full PTSD.

It may seem obvious that patients with a less severe form of PTSD would respond better to standard psychotherapy, but the implications for treatment extend beyond that. PTSD symptoms often worsen over time; as they do, treatments become less effective at reducing symptoms. In this context, subclinical PTSD could be seen as “early-stage” PTSD, in that treatment might be more effective when the disorder is caught early.

Gros’ group hopes these early studies can move beyond men in combat to civilians of both sexes.

“It is our hope that providing treatment for subclinical PTSD could have a significant impact on the cost-effectiveness of treating this common disorder,” says Korte. “It could lead to the prevention of more intractable forms of PTSD that can occur when subclinical PTSD goes untreated.”

Image Caption:  Licensed from iStock. Copyright: Mie Ahmt.

Photo of veteranA study among military veterans needing psychotherapy for depression has demonstrated that such therapy delivered via telemedicine in patients’ homes achieves outcomes that are not significantly inferior to those of traditional in-person clinical encounters.1 In their editorial in the August 2015 The Lancet Psychiatry, Hoge and Rye describe this study as the kind of rigorous clinical trial that is necessary to establish acceptable standards of care, calling it “a vanguard of demonstration of safety and efficacy of in-home telemental health.”  All research team members were affiliated with the Medical University of South Carolina (MUSC) or the Ralph H. Johnson Veterans Affairs Medical Center in Charleston, SC. The Principal Investigator was Leonard E. Egede, M.D., Professor of Medicine at MUSC, Director of the MUSC Center for Health Disparities Research, and the Director of the Charleston VA HSR&D Health Equity and Rural Outreach Innovation Center. In the 2007 - 2011 study (NCT00324701), 204 veterans aged 58 years and older were treated via either telemedicine or same-room treatment. Their response to the treatments did not differ significantly. The researchers’ interpretation of this data, which is in the same issue of The Lancet Psychiatry2, is that evidence-based psychotherapy delivered to patients in their homes is not only not inferior, it is advantageous because it overcomes distance, attendance, and stigma barriers faced by some veterans. "This is the first study in the elderly that shows that in-home telemedicine works as well as face-to-face sessions for the treatment of depression,” says Egede. “It provides strong evidence for using in-home telemedicine to treat depression and possibly other mental health conditions in those with stigma or mobility challenges, the home-bound, or those who are geographically isolated and cannot get to care easily. In addition, there were no adverse events, which have always been a concern for mental health treatment delivery via telemedicine.”

1 Egede LE, Acierno R, Knapp RG, et al. Psychotherapy for depression in older veterans via telemedicine: a randomized, controlled, open-label, non-inferiority trial. The Lancet Psychiatry 2015; 2(8): 693-701.

2 Hoge, CW, Rye, CB. Efficacy and challenges of in-home telepsychotherapy. The Lancet Psychiatry 2015; 2(8): 668-669.

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