Soldiers stand as a performance of the National Anthem plays. Photo by Scott Ball.
San Antonio is home to one of the nation’s largest active-duty and retired military populations. Credit: Scott Ball / San Antonio Report

A cognitive behavioral therapy used to treat post-traumatic stress disorder led to significant symptom reduction in nearly half of the subjects in the largest PTSD clinical trial conducted with an active-duty military population in the history of combat defense.

The study, published Tuesday in the Journal of the American Medical Association, by 23 researchers with UT Health San Antonio, the University of Pennsylvania, and other institutions, included 370 active-duty service members seeking PTSD treatment.

The positive results held up whether the treatment was delivered in its traditional format over the course of eight weeks or in a newly tested, intensive format of daily treatment for two weeks.

“The shorter treatment [is] an optimal intervention for military personnel with PTSD, as it minimizes the time and inconvenience entailed by a longer treatment before continuing their military,” said Edna Foa, the study’s principle investigator, who developed the Prolonged Exposure treatment used in the study.

Prolonged Exposure targets the details of patients’ memory of a traumatic event and repeatedly confronts them with it, which helps reduce symptoms of PTSD, such as hypervigilance, flashbacks, nightmares, and extreme anxiety.

“In the last two decades, the number of individuals suffering from trauma and resulting PTSD has increased dramatically in the U.S. and around the world [due to] massive natural disasters, increased terror attacks, and the wars in Iraq and Afghanistan,” Foa said. “This increase has resulted in urgent need to disseminate evidence-based treatments to mental health professionals around the world.”

San Antonio is home to one of the nation’s largest active-duty and retired military populations as well as the Department of Defense’s largest medical center at Joint Base San Antonio Fort Sam Houston. Sixty-four percent of Texas’ total military population resides in Bexar County.

Up to 20 percent of military personnel returning from deployments to Iraq and Afghanistan suffer from PTSD that can be chronic and debilitating, according to the study.

“PTSD can be treated into remission – it can be cured,” said Alan Peterson, professor of psychiatry at UT Health San Antonio. “It is a misperception that this is a chronic disorder that needs lifelong care.”

Peterson is the director of the Strong Star consortium, a multi-institutional research network funded by the Department of Defense to find the most effective methods to prevent and treat combat-related PTSD and related conditions, under the leadership of the UT Health San Antonio.

Don Gagliano was a medical forces commander during the invasion of Iraq in 2003, designing and implementing health care services for the military. Following his deployment, he found it difficult to cope with memories of his wartime experiences and everyday events and experienced emotional outbursts for years before seeking treatment and being referred to Strong Star in 2017.

“Because I was a senior military officer, I didn’t want to acknowledge that I had any issues,” Gagliano said. “I feared it might impact my career, or that I might be perceived as weak or unstable.”

Gagliano did not participate in the case study, but received the same treatment. For two weeks, he partook in daily Prolonged Exposure sessions where he “relived in great detail the memories [he] didn’t want to recall,” which, through therapy, were found to be the underlying components that influenced his emotional responses.

“I had never spoken about these events before,” Gagliano said. “I had never even told my wife, so it was very hard to delve into those memories repeatedly, time and time again.”

While difficult, the treatment was effective for Gagliano, who said he is now free from PTSD symptoms.

The Strong Star study, which was conducted at Fort Hood in Killeen in collaboration with the Carl. R. Darnall Army Medical Center, analyzed outcomes with two delivery methods of Prolonged Exposure: 10 therapy sessions over two weeks; and the more traditional treatment administered in 10 sessions over eight weeks. It then compared outcomes with the longer treatment to those who participated in Present-Centered Therapy (PCT), a non-trauma-focused therapy that emphasizes identifying and managing daily stressors, similarly delivered in 10 sessions over eight weeks.

Researchers found that all three therapies were equally effective in significantly reducing combat PTSD symptoms and leading to loss of PTSD diagnosis. For all participants, treatment gains were largely maintained over time, continuing through the six-month followup with nearly 40 percent of patients in all three treatment conditions.

“Findings show that Prolonged Exposure is effective for PTSD in military personnel. In addition, the shorter, two-week treatment with Prolonged Exposure is as effective as the longer treatment,” Foa said.

Gagliano participated in the shorter treatment and continued to work on emotion regulation and behavioral change outside of therapy, through homework assignments and actively practicing coping skills. As his symptoms lessened, he said his fear of participating in therapy diminished. Instead of believing it was a sign of weakness, he concluded that it “made [him] stronger.”

Peterson explained that revisiting traumatic experiences can feel dangerous and uncomfortable for the person reliving them, and that while researchers initially thought that Prolonged Exposure may be overwhelming for those who have experienced combat trauma, they are pleased with the results of its effectiveness.

“When something really, really bad happens … when you first talk about it, it can be very upsetting,” Peterson said. “The more you talk about it, the easier it gets over time. That’s part of what makes people feel better.”

For more information on all Strong Star studies and to participate in ongoing treatment programs for veterans, click here.

Roseanna Garza reports on health and bioscience for the San Antonio Report.