Suicide Risk Lower for Veterans With PTSD Who Start Evidence-Based Therapy

Initiating cognitive processing therapy or prolonged exposure (CPT/PE) sessions for post-traumatic stress disorder (PTSD) was associated with lower suicide risk in military veterans in an observational study, but completing an adequate course of CPT/PE sessions was not.

Among nearly 850,000 veterans newly diagnosed with PTSD, starting CPT/PE treatment was linked with a 23% lower suicide risk compared with not starting treatment (HR 0.77, 95% CI 0.59-0.99, P=0.05), reported Rebecca Sripada, PhD, of the Department of Veterans Affairs (VA) in Ann Arbor, Michigan, and co-authors.

For those who initiated CPT/PE, however, receiving eight or more sessions — considered an adequate course of therapy — was not associated with benefit (HR 0.80, 95% CI 0.55-1.18, P=0.26), the researchers said in JAMA Network Open.

“Although receipt of eight or more CPT/PE encounters was associated with lower suicide risk in unadjusted analyses, this finding was not significant in adjusted analyses,” Sripada and colleagues wrote.

“However, the parameter estimates for adequate therapy (HR 0.80) and initiation (HR 0.77) were similar, and it is notable that CPT/PE initiators who received fewer than eight sessions were included as controls in the analysis of adequate treatment analyses,” they pointed out. “Thus, differences in significance between the two analyses should be interpreted with caution.”

While the study could not directly test whether starting CPT/PE reduced suicide risk, “the findings nevertheless point to some important clinical implications,” noted Shannon Wiltsey Stirman, PhD, of the VA Palo Alto Healthcare System in Menlo Park, California.

“Contrary to expectations, an adequate course (≥eight sessions) of trauma-focused therapy, as opposed to simply initiating CPT/PE, was no longer associated with suicide risk after controlling for covariates,” Wiltsey Stirman wrote in an accompanying editorial.

“However, given the rates of dropout from trauma-focused therapy and therapy in general, it is reassuring that the potential for reduced suicide risk exists even among veterans who do not complete a full course of CPT/PE,” she added.

CPT and PE are evidence-based treatments included in VA guidelines for managing PTSD. The therapies target avoidance and isolation, and have reduced negative cognition associated with traumatic memories. Prior studies have also reported that CPT can improve emotion regulation and reduce perceived burdensomeness.

CPT/PE treatment is designed to be delivered in a time-limited fashion. A full course of CPT/PE generally requires eight or nine sessions, and many patients report significant improvements after eight sessions.

The researchers studied 847,217 veterans diagnosed with PTSD from 2016 to 2019, using Veteran’s Health Administration (VHA) Corporate Data Warehouse records to obtain demographic, clinical, and treatment records. The cohort was 86.9% men; 68.4% were white, and the mean age was 50 years.

In total, 8.7% of participants initiated CPT/PE. Of those, 46.2% were classified as having eight or more sessions.

From initial PTSD diagnosis through 2020, there were 1,552 suicide deaths (0.2% of the overall cohort). Results were adjusted for multiple covariates including age, sex, service connection, distance to the nearest VHA facility, period of military service, presence of military sexual trauma, and comorbidities.

When limiting analyses to those who received any psychotherapy (552,742 participants), outcomes for suicide risk were similar. Starting CPT/PE led to an HR of 0.73 (95% CI 0.56-0.95, P=0.02), and completing an adequate course led to an HR of 0.77 (95% CI 0.52-1.12, P=0.17).

Although 65.2% received some psychotherapy, only 8.7% of the study cohort started CPT/PE, Sripada and colleagues observed.

“Given that CPT/PE initiation was associated with a lower suicide risk among veterans who initiated any form of psychotherapy, it is important to discuss CPT and/or PE as part of shared treatment decision-making for all veterans with new PTSD diagnoses and understand barriers to initiating CPT/PE,” they wrote.

Wiltsey Stirman echoed the concern that few veterans started CPT/PE. “This low level of reach may stem in part from challenges related to therapist availability and capacity in some treatment settings, which have been well documented in research and pragmatic implementation studies,” she noted.

Although the study adjusted for propensity of veterans to begin trauma-focused psychotherapy, it did not address how many were ineligible based on established contraindications like primary substance use disorder or unmanaged psychosis, Wiltsey Stirman added.

The analysis was unable to differentiate between veterans who were offered CPT/PE but declined from those who were not offered the treatments. Findings may have been influenced by residual confounding, the researchers acknowledged.

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