# Study of the 12-month follow-up of intensive outpatient treatment for PTSD combining prolonged exposure therapy, EMDR and physical activity

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# Study of the 12-month follow-up of intensive outpatient treatment for PTSD combining prolonged exposure therapy, EMDR and physical activity

April 16, 2024Recent Articles

**12-month follow-up of intensive outpatient treatment for PTSD combining prolonged exposure therapy, EMDR and physical activity**

***(12-month follow-up of intensive outpatient treatment for PTSD combining prolonged exposure therapy, EMDR and physical activity)***

**Link:**[https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-024-05656-9](https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-024-05656-9)

**Publication Date:**26 March 2024

**Authors:**Julie Rendum Klaeth, Andreas Gjerde Jensen, Trude Julie Brynhildsvoll Auren and Stian Solem

**Translated by:**Specialist Psychologist Gizem Pozam

**Abstract**

**Background:** Preliminary evidence shows promising treatment outcomes at short-term follow-up for intensive treatment of posttraumatic stress disorder (PTSD), but long-term follow-up studies are scarce. This study is a continuation of a previous pilot study and open trial, setting out to investigate treatment outcomes at 12-month follow-up for outpatients who completed an 8-day intensive treatment for PTSD.

**Method:** All patients had been diagnosed with PTSD and had undergone multiple previous attempts at psychotherapy (M=3.1). Patients were assessed before treatment, after treatment, and at 3- and 12-month follow-ups. Of the 35 patients treated, 32 (91.4%) participated in the long-term follow-up assessment. The treatment program combined prolonged exposure therapy, eye movement desensitization and reprocessing, and physical activity.

**Results:** Effect sizes indicated large reductions in symptoms of PTSD, depression, anxiety, interpersonal problems, and difficulties with well-being. Changes in functioning showed a small-to-moderate effect. Results remained stable throughout the follow-up period. Treatment response rates indicated that 46–60% of patients achieved recovery in terms of PTSD symptoms and 44–48% no longer met the diagnostic criteria for PTSD.

**Conclusions:** Time-limited and intensive outpatient treatment for PTSD can yield large and lasting positive outcomes. Controlled studies are needed to determine relative efficacy. Trial registration The study was registered in the Current Research Information System in Norway (Cristin).
Cristinproject-ID: 654,790. Registration date: 18.03.2019.

**Keywords:** Brief, Concentrated, EMDR, Intensive, Long-Term Follow-Up, Massed, PE, Physical Activity, PTSD, Trauma

**Background**

Intensified session frequency in the treatment of posttraumatic stress disorder (PTSD) has been associated with increased engagement and motivation through experiencing early gains, fewer distractions from the therapeutic process, and less avoidance [1, 2]. High session frequency in outpatient treatment for PTSD has also been associated with greater symptom reduction. A study investigating the effect of session frequency on treatment outcome (with the average number of days between sessions ranging from 2 to 32) found that a higher average number of days between sessions was associated with less reduction in PTSD symptoms . Intensive outpatient programs (IOPs) show equivalent treatment effects and lower dropout rates compared with standard outpatient treatment (usually defined as a maximum of 2 sessions per week) [4, 5]. However, the evidence for both intensive and traditional weekly therapy for PTSD is largely based on short-term outcomes, as research on long-term follow-up (LTFU) is lacking. A meta-analysis of randomized controlled trials of non-intensive psychological treatments for PTSD with LTFU (i.e., at least 12 months after treatment completion) identified 22 eligible studies . They concluded that robust research on LTFU was available only for cognitive behavioral therapies (CBT) for PTSD, with an effect size of 1.36. One of the studies included in the meta-analysis examined LTFU up to 10 years after treatment . At the 9-month follow-up, 50–55% no longer met the criteria for PTSD, and the sample improved further during LTFU (5–10 years), with 78–82% no longer suffering from PTSD . Improvement at LTFU was not explained by further treatment during the follow-up period. In fact, additional treatment was associated with poorer outcomes at LTFU

There is less research on LTFU for IOPs. A study of 3-week cognitive processing therapy reported large changes from pretreatment to 12-month follow-up (PTSD; d=1.28 and depression; d=1.18) . Another study of two-week PE (prolonged exposure therapy) showed large reductions in PTSD (d=0.88) and depression (d=0.81) at 12-month follow-up . A third study of 10-day EMDR (eye movement desensitization and reprocessing) treatment reported significant symptom reduction and large effect sizes at 12-month follow-up . These studies indicate that gains from IOPs for PTSD are maintained. However, response rates were low in the first two studies (37% and 52%) [9, 10], and the sample size of the third study was only 15 .

At our public PTSD clinic in Trondheim, Norway, we implemented an IOP based on an inpatient treatment program in the Netherlands . The Dutch program consisted of an 8-day intensive treatment combining individual PE and EMDR, psychoeducation, physical activity (PA), and therapist rotation. The Dutch study reported large effect sizes for reductions in PTSD symptoms from pretreatment to posttreatment. From posttreatment to 6-month follow-up, results indicated a small but significant increase in PTSD symptoms (based on a clinical interview). This increase was not apparent in patients' self-reported symptoms. Effect sizes remained large from pretreatment to 6-month follow-up (d=1.70–1.99). Furthermore, 91.7% of patients showed a clinically significant treatment response, with a reduction of at least 10 points on the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), and 67% no longer met the criteria for a PTSD diagnosis. LTFU data were not reported. When we implemented the Dutch program as an outpatient program, all treatment components were retained, but the time allocated to group physical activity and psychoeducation was reduced. The program produced significant improvements in PTSD symptoms at posttreatment and 3-month follow-up (d=1.38–1.52) . Patients also reported significant improvements in scores for depression, anxiety, well-being, and interpersonal functioning. There were no treatment dropouts, and treatment satisfaction was high .

Given the lack of long-term follow-up studies on the efficacy of intensive treatment for PTSD, this study reports 12-month follow-up outcomes for patients included in a previous pilot study and an open trial . The current study aimed to investigate the maintenance of gains 12 months after an 8-day IOP in a sample that had not responded to previous treatment. Based on the large effect sizes at 3-month follow-up in the pilot study and open trial, as well as the large effects observed at 6-month follow-up in the Dutch study, we hypothesized that gains would be maintained at 12-month follow-up.

**Methods**

**Participants and procedure**

This 12-month follow-up study consisted of data collected from patients who participated in a pilot study and an open trial of an 8-day intensive treatment program for PTSD . All applicants were required to be aged 18 or older, to have previously been diagnosed with PTSD, and to have undergone at least one previous treatment attempt for PTSD. Exclusion criteria included acute suicidality, psychosis, severe drug dependence, and insufficient fluency in Norwegian. Before inclusion in the study, patients underwent a diagnostic assessment that included their medical and mental health history and completed relevant self-report questionnaires. Diagnosis was established using diagnostic interviews such as the MINI Plus 5.0 interview or ADIS-IV, in addition to the PTSD Symptom Scale Interview (PSS-I) . Of the patients referred to the clinic between August 2018 and March 2021, 31.8% chose intensive treatment rather than traditional outpatient treatment. Five of these were ineligible for study participation because they did not consent to participate in the research, did not attend at the start of treatment, or because treatment deviated from the protocol (i.e., a group size of fewer than three). This left 35 eligible participants for analysis.

Between the assessment and the 8-day intensive program, patients attended 3.2 (SD=0.9) preparatory sessions. Preparation involved identifying targets for imaginal exposure, developing in vivo exposure tasks, and receiving further information about the program. The eight days followed a similar structure. Each day consisted, in order, of 90 minutes of individual PE, 45 minutes of group physical activity (PA), 90 minutes of individual EMDR, and 45 minutes of group psychoeducation. PE sessions followed the PE protocol, including imaginal exposure, processing, and homework assignments . Participants listened to audio recordings of imaginal exposure and completed in vivo exercises at home daily. EMDR sessions focused on desensitization, installation, body scan, and closure, targeting traumatic memories, triggers, and future templates in accordance with the EMDR protocol .

To prevent therapist drift and underuse of exposure interventions, therapists rotated among patients from session to session. Patients saw four to seven different therapists throughout the program, depending on the size of the patient group. Psychoeducation was delivered in a group setting (three to six patients) and focused on themes from the PE manual: posttraumatic symptoms as normal responses to trauma, the rationale for exposure treatment, avoidance, negative thoughts, emotions, self-esteem, and relapse prevention. PA, led by a physiotherapist, was also group-based. The purpose of PA was to provide patients with moderate-intensity exercises requiring attention and whole-body activation, and to give them experiences of mastery and strength. All participants were offered an individual follow-up session two weeks, three months, and 12 months after the intensive program.

The mean age of the sample was 38.5 years, and most participants were women (91.4%). Twenty-nine patients were native Norwegian speakers, and all participants spoke Norwegian adequately. The sample had received 3.1 previous courses of psychotherapy (SD=1.6, range 1–6), defined as attendance at an equivalent number of sessions over at least three months. Reported traumas included domestic violence, childhood sexual and physical abuse, rape, terrorist attacks, witnessing murder, and war. Most patients had experienced multiple traumas (n=31, 88.6%), and 25 (71.4%) reported sexual trauma. The mean time since the first onset of PTSD symptoms was 15.8 years (SD=10.8). Fifty-one percent of patients (n=18) were currently taking psychotropic medication, including benzodiazepines (n=9), antidepressants (n=7), antipsychotics (n=4), and stimulants (n=1). The nine patients taking prescribed benzodiazepines were encouraged to refrain from using them during treatment and complied. Other medications remained stable during treatment, and no medication changes were reported during follow-up. Twelve patients had one comorbid disorder, one patient had two comorbid disorders, and two patients had three comorbid disorders, while 19 patients were not diagnosed with a comorbid disorder. Comorbid disorders included attention-deficit/hyperactivity disorder (n=2), social anxiety disorder (n=2), depression (n=11), personality disorder (n=3), obsessive-compulsive disorder (n=1), alcohol abuse (n=1), and unspecified eating disorder (n=1). A summary of the group's background information is shown in Table 1.

**Measures**

A range of self-report questionnaires and a structured diagnostic interview for PTSD were used to measure symptoms before treatment, two weeks after treatment, and at 3- and 12-month follow-ups. Independent assessors conducted the diagnostic interviews after treatment.

Diagnostic status was assessed using the PSS-I at pretreatment, posttreatment, and 3- and 12-month follow-ups . The PSS-I is a diagnostic interview corresponding to the DSM-IV criteria for PTSD. It consists of 17 items rated from 0 to 3, with a total score ranging from 0 to 51. According to the PSS-I, to meet diagnostic criteria, a patient must have at least one endorsed symptom (a score of 1 or more) for "re-experiencing" (items 1–5), at least three for "avoidance" (items 6–12), and at least two for "arousal" (items 13–17). This study defined a cutoff score of 20 and a reliable change index (RCI) of 8 points. Cronbach's alpha was 0.75. The updated PSS-I-5 was not available in Norwegian at the start of the study.

Self-reported PTSD symptoms were assessed using the PTSD Checklist for DSM-5 (PCL-5) . The PCL-5 consists of 20 items rated on a scale from 0 to 4 (not at all to extremely), with a total score ranging from 0 to 80. To meet diagnostic criteria using the PCL-5, at least one endorsed symptom (a score of 2 or more) is required for "intrusion" (items 1–5) and "avoidance" (items 6–7), and two symptoms for "cognitions and mood" (items 8–14) and "arousal" (items 15–20). As in the Improving Access to Psychological Therapies program, this study used a cutoff of 32 and set the RCI at 10 points. Cronbach's alpha was 0.84.

To assess the severity of depression and anxiety, this study used the Beck Depression Inventory (BDI-II) and the Beck Anxiety Inventory (BAI) . Both scales consist of 21 items scored from 0 to 3. Severity levels are typically classified as mild (14–19), moderate (20–28), and severe (29–63) for the BDI-II, and minimal (0–7), mild (8–15), moderate (16–25), and severe (26–63) for the BAI. In this study, the cutoff was set at 11 with an RCI of 12 points for the BAI, and at 15 with an RCI of 9 points for the BDI-II. Cronbach's alpha was 0.86 for the BDI and 0.91 for the BAI.

To assess the impact of patients' mental health on their functional capacity at home, in social activities, in personal relationships, and at work, this study used the Work and Social Adjustment Scale (WSAS) . The WSAS consists of five items rated from 0 to 8 (not at all to very severely). Higher scores indicate poorer functioning (<15 mild, 15–30 moderate, and >30 severe). In this study, the cutoff was set at 17 and the RCI at 8 points. Cronbach's alpha was 0.77.

Patients' subjective psychological well-being was assessed using the five-item World Health Organization Well-Being Index (WHO-5) . The five positively worded items were rated from 0 to 5 (at no time to all of the time). Scores are multiplied to yield a total range of 0 to 100. In this study, the cutoff was set at 29 and the RCI at 10 points, as in a previous study on depression . Cronbach's alpha was 0.83.

Interpersonal distress was assessed using the Inventory of Interpersonal Problems (IIP-64), which consists of 64 items rated from 0 to 4 . These results were presented as mean item scores. Higher levels of interpersonal problems result in higher scores. A cutoff of 1.03 and an RCI of at least 0.38 were used, as is common in studies with Norwegian samples. Cronbach's alpha was 0.89.

**Statistical analyses**

Missing data were imputed using the expectation-maximization method . Little's missing completely at random test indicated that the data were missing completely at random (x2=191.79, p=.85). Repeated-measures ANOVA was used to test changes in symptoms, functioning, interpersonal problems, and well-being. The analyses used data from four assessments (pretreatment, posttreatment, and 3- and 12-month follow-ups). Effect sizes were reported using partial eta squared (η2 ) and Cohen's d (using the pooled SD). Typical benchmarks for η2 are small (0.01), medium (0.06), and large (0.14), while the most common cutoffs for Cohen's d are small (0.2), medium (0.5), and large (0.8). Treatment response rates were also calculated using the percentages scoring below the clinical cutoff, achieving reliable change, and achieving clinically significant change (recovery), which combines the first two criteria .

**Results**

At the 12-month follow-up, 31 of the 35 participants included in our study completed the self-report inventories (88.6%), and 32 attended reassessment with the PSS-I (91.4%). Repeated-measures ANOVA analyses revealed significant improvements in treatment outcomes over time for all measures. Effect sizes using partial eta squared indicated large effects for all treatment outcomes at 12-month follow-up except the WSAS, which showed a medium-to-large effect. Using Cohen's d, large effects were observed at 12-month follow-up, particularly for PTSD symptoms, while medium-to-large effects were observed for depression, anxiety, interpersonal problems, and well-being. A small-to-medium effect was observed for the WSAS. Effects at 12-month follow-up were very similar to those observed at posttreatment. The only exception was PTSD symptoms, for which further improvement was observed after treatment. When posttreatment scores were compared with 12-month follow-up, the improvement corresponded to a small effect size (PSS-I: dPost-12mFU = 0.33, PCL-5: dPost-12mFU = 0.21). There was no notable change when 3-month scores were compared with 12-month follow-up (PSS-I: d3mFU-12mFU = -0.03, PCL-5: d3mFU-12mFU = -0.09). Thus, further improvement in posttraumatic symptoms occurred mainly within the first three months, then stabilized between the 3- and 12-month follow-ups. Table 2 summarizes changes in outcome measures across all four assessment points.

Treatment response rates indicated that 60% of patients achieved recovery in terms of PTSD symptoms measured by the PSS-I at 12-month follow-up. Using the PCL-5, this rate was 45.7%. Recovery rates were lower for secondary outcome measures such as depression (26%), anxiety (23%), work and social functioning (20%), and interpersonal problems (20%). For well-being, 49% were classified as recovered. Table 3 summarizes treatment response rates.

Note. Pre=pretreatment, Post=posttreatment, 3 m FU=3-month follow-up, 12 m FU=12-month follow-up, PSS-I=PTSD Symptom Scale Interview, PCL-5=PTSD Checklist for DSM-5, BAI=Beck Anxiety Inventory, BDI-II=Beck Depression Inventory II, WSAS=Work and Social Adjustment Scale, IIP-64=Inventory of Interpersonal Problems, WHO-5=World Health Organization Well-Being Index. N=35. Cohen's d was calculated using pooled standard deviations

Note. CSC=clinically significant change (scoring below the clinical cutoff and achieving reliable change). PSS-I=PTSD Symptom Scale – Interview for DSM-IV, PCL-5=PTSD Checklist for DSM-5, BDI-II=Beck Depression Inventory, BAI=Beck Anxiety Inventory, WSAS=Work and Social Adjustment Scale, WHO-5=World Health Organization–Five Well-Being Index, IIP-64=Inventory of Interpersonal Problems. CSC/recovery involves both scoring below the cutoff and achieving reliable change

According to the PCL-5, 48.4% of patients (n=15) did not meet the diagnostic criteria for PTSD at 12-month follow-up. In comparison, this rate was 51.7% at posttreatment and 62.1% at 3-month follow-up. According to the PSS-I, 43.8% (n=14) did not meet the diagnostic criteria for PTSD at 12-month follow-up. In comparison, this rate was 44.8% at posttreatment and 51.7% at 3-month follow-up.

Eighteen participants received no additional treatment during the 12-month follow-up period, while 17 received additional sessions (M=12.3, range=1–26). Of these additional sessions, 44% targeted relational or self-esteem issues, 34% further PTSD treatment, 9% depressive symptoms, 8% other anxiety symptoms, 3% various crises, and 2% discussions of further treatment. Three patients were referred for treatment for other existing problems. When the number of sessions delivered during the follow-up period was added as a covariate to the repeated-measures analysis of the PSS-I, a significant interaction emerged (p=.003, η2 =0.137), indicating more symptoms in the group receiving additional sessions. Repeating the covariate analyses using secondary outcome measures showed a significant interaction for the PCL-5 and WSAS, but not for the BAI, BDI-II, IIP-64, or WHO-5.

**Discussion**

The results supported the hypothesis: patients who received intensive treatment maintained symptom reductions at 12-month follow-up. Gains were maintained on both the primary PTSD outcome measures and the secondary outcome measures. Improvement in posttraumatic symptoms occurred from pretreatment to 3-month follow-up and then stabilized. This study showed effect sizes of d=1.44 for the PCL-5 and d=1.86 for the PSS-I from pretreatment to 12-month follow-up. In comparison, the meta-analysis of 22 studies on LTFU of CBT for PTSD found an effect size of 1.36 . Other studies on long-term follow-up of three-week intensive CBT and two-week PE found effect sizes of 1.28 and 0.88. In addition, this study had a high response rate at 12-month follow-up.

It should be noted that our effect sizes were obtained in a sample of patients with previous unsuccessful treatment experiences or relapses. The large effect sizes in this study may be attributable to the limited sample size and the uncontrolled, nonrandomized study design. Furthermore, features of the treatment program, such as therapist rotation, may have contributed to greater protocol adherence.

This study also showed large effect sizes reflecting positive changes in levels of depressive symptoms, anxiety, well-being, and interpersonal problems. This is consistent with studies by Held and colleagues and Yasinski and colleagues, which reported large effect sizes for depression, and supports the idea that intensive treatment for PTSD may also have a positive effect on depressive symptoms. The effect size for work and social functioning (WSAS) was lower (d=0.38).

Given that the results showed a large effect on interpersonal functioning (IIP-64; d=0.75), the smaller effect on the WSAS may be more closely related to work capacity. The majority of the sample (n=26, 74.3%) were receiving long-term disability benefits or were on sick leave at the start of treatment, and only three of these patients had part-time or full-time employment at 12-month follow-up. Although intensive treatment affected a broad range of symptoms, it did not appear to improve their occupational status after treatment. To achieve larger effects on the WSAS, treatment would likely need to focus more on functioning and work-related skills.

In the current study, 44–48% of patients (PSS-I and PCL-5, respectively) no longer met the criteria for PTSD based on diagnostic status at 12-month follow-up. Of all patients, 66–83% (PCL-5 and PSS-I, respectively) reported reliable change. In the aforementioned 5–10-year LTFU study of patients receiving individual CBT for PTSD, 78–82% did not meet the diagnostic criteria as measured by the Clinician-Administered PTSD Scale . At 9-month follow-up, the same study population showed results similar to the current study, with 50–55% no longer meeting the criteria for PTSD . Therefore, longer-term follow-up studies of intensive treatment for PTSD with control groups are needed to investigate whether similar delayed effects can be observed.

Similar to the current study, Resick and colleagues found that additional treatment sessions during the follow-up period were associated with poorer treatment outcomes . This suggests that patients who respond well to an IOP do not need further treatment to maintain gains. Conversely, patients who initially responded poorly to treatment continued to show limited improvement even after receiving additional sessions. More research is needed to understand why some patients respond poorly to treatment and how treatment can be adapted for this group of patients.

Several strengths and limitations should be considered when interpreting the results. The study population consisted of a clinical population who had previously received psychotherapy for PTSD but had not responded adequately. The high participation rate at the study's 12-month follow-up enhances generalizability. However, the sample size was small, and the absence of a control group and lack of randomization limit the ability to infer causality from the findings. In addition, the study used the PSS-I as its clinical interview, making comparison with studies using the CAPS-5 difficult.

**Conclusion**

An IOP for PTSD delivered to individuals who have not responded to previous treatment produces large positive outcomes that persist for up to 12 months after treatment completion. Controlled studies are needed to establish relative efficacy. IOPs offer an additional treatment option for patients with PTSD, potentially facilitating faster recovery, greater protocol adherence, and the prevention of disruptions to session frequency. Furthermore, IOPs may improve the accessibility of treatment for PTSD by providing a concentrated treatment approach suited to patients who live far from treatment providers or who have difficulty attending traditional weekly therapy sessions.

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