Quality of Research
Review Date: December 2007
Documents Reviewed
The documents below were reviewed for Quality of Research. The research point of
contact can provide information regarding the studies reviewed and the availability
of additional materials, including those from more recent studies that may have been conducted.
Study 1Foa, E. B., Dancu, C. V., Hembree, E. A., Jaycox, L. H., Meadows, E. A., & Street, G. P. (1999). A comparison of exposure therapy, stress inoculation training, and their combination for reducing posttraumatic stress disorder in female assault victims. Journal of Consulting and Clinical Psychology, 67(2), 194-200.  Study 2Resick, P. A., Nishith, P., Weaver, T. L., Astin, M. C., & Feuer, C. A. (2002). A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. Journal of Consulting and Clinical Psychology, 70(4), 867-879. Study 3Foa, E. B., Hembree, E. A., Cahill, S. P., Rauch, S. A., Riggs, D. S., Feeny, N. C., et al. (2005). Randomized trial of prolonged exposure for posttraumatic stress disorder with and without cognitive restructuring: Outcome at academic and community clinics. Journal of Consulting and Clinical Psychology, 73(5), 953-964. Study 4Bryant, R. A., Sackville, T., Dang, S. T., Moulds, M., & Guthrie, R. (1999). Treating acute stress disorder: An evaluation of cognitive behavior therapy and supportive counseling techniques. American Journal of Psychiatry, 156(11), 1780-1786.
Supplementary Materials Cahill, S. P., Foa, E. B., Hembree, E. A., Marshall, R. D., & Nacash, N. (2006). Dissemination of exposure therapy in the treatment of posttraumatic stress disorder. Journal of Traumatic Stress, 19(5), 597-610.
Cahill, S. P., Hembree, E. A., & Foa, E. B. (2006). Dissemination of prolonged exposure therapy for posttraumatic stress disorder: Success and challenges. In Y. Neria, R. Gross, R. D. Marshall, & E. S. Susser (Eds.), 9/11: Public health in the wake of terrorists attacks. Cambridge, United Kingdom: Cambridge University Press.
Foa, E. B., Hearst-Ikeda, D., & Perry, K. J. (1995). Evaluation of a brief cognitive-behavioral program for the prevention of chronic PTSD in recent assault victims. Journal of Consulting and Clinical Psychology, 63(6), 948-955.
Foa, E. B., Rothbaum, R. O., Riggs, D. S., & Murdock, T. B. (1991). Treatment of posttraumatic stress disorder in rape victims: A comparison between cognitive-behavioral procedures and counseling. Journal of Consulting and Clinical Psychology, 59(5), 715-723.
Outcomes
| Outcome 1: Severity of PTSD symptoms |
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Description of Measures
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Severity of PTSD symptoms was measured using three instruments:
- The PTSD Symptom Scale--Interview (PSS-I), a 17-item interview, assesses the severity of each of the DSM-IV PTSD symptoms during the past 2 weeks and ascertains PTSD diagnostic status. Each symptom is rated on a 4-point scale from 0 (not at all) to 3 (very much; 5 or more times per week). Subscale scores are calculated by summing items in each of the PTSD symptom clusters: reexperiencing, avoidance, and arousal.
- The PTSD Symptom Scale--Self-Report (PSS-SR) is a self-report version of the PSS-I. Symptoms are rated for frequency and severity in the past week.
- The Clinician Administered PTSD Scale (CAPS) is an interviewer-administered diagnostic instrument that measures PTSD. A clinician rates the frequency and intensity of each symptom on a scale ranging from 0 to 4. For a symptom to be considered clinically significant, it must score at least 1 on frequency and at least 2 on intensity.
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Key Findings
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In a study that compared four treatment conditions--PE, stress inoculation training (SIT), PE plus SIT, and a wait-list control condition--all three active treatments significantly reduced the severity of PTSD symptoms compared with the wait-list condition (p < .05). Effect sizes were large for all the active treatment conditions, with PE having the largest effect size (Cohen's d = 1.46 for PE, 0.85 for SIT, and 0.82 for PE plus SIT).
Another study compared PE, cognitive processing therapy (CPT), and a minimal attention condition. Participants in the PE and CPT groups showed significantly reduced severity of PTSD symptoms compared with participants who received minimal attention (p < .001). The PE and CPT groups did not differ significantly from each other on severity of PTSD symptoms.
A third study compared PE, PE plus cognitive restructuring (CR), and a wait-list control condition. Participants in the PE and PE plus CR groups showed significantly reduced severity of PTSD symptoms compared with participants in the wait-list group (p < .001). The PE and PE plus CR groups did not differ significantly from each other on severity of PTSD symptoms.
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Studies Measuring Outcome
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Study 1, Study 2, Study 3
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Study Designs
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Experimental
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Quality of Research Rating
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3.7
(0.0-4.0 scale)
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| Outcome 2: Depression symptoms |
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Description of Measures
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Depression symptoms were assessed using two instruments:
- The Beck Depression Inventory is a 21-item self-report instrument used to assess symptoms of depression, each rated on a scale from 0 (e.g., I do not feel sad) to 3 (e.g., I am so sad or unhappy that I can't stand it).
- The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) is a diagnostic instrument used to assess current and lifetime diagnosis of depression, alcohol dependence, substance dependence, and other Axis I DSM-IV disorders.
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Key Findings
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In a study that compared four treatment conditions--PE, SIT, PE plus SIT, and a wait-list control condition--all three active treatments significantly reduced the symptoms of depression compared with the wait-list condition (p < .001). The effect size was large for PE (Cohen's d = 1.42) and medium for SIT (Cohen's d = 0.73) and PE plus SIT (Cohen's d = 0.57).
Another study compared PE, CPT, and a minimal attention condition. Participants in the PE and CPT groups showed significantly reduced symptoms of depression compared with participants who received minimal attention (p < .001). The PE and CPT groups did not differ from each other on depression symptoms.
A third study compared PE, PE plus CR, and a wait-list control condition. Participants in the PE and PE plus CR groups showed significantly reduced symptoms of depression compared with participants in the wait-list group (p < .05). The PE and PE plus CR groups did not differ significantly from each other on depression symptoms.
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Studies Measuring Outcome
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Study 1, Study 2, Study 3
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Study Designs
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Experimental
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Quality of Research Rating
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3.7
(0.0-4.0 scale)
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| Outcome 3: Social adjustment |
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Description of Measures
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Social adjustment was measured using the Social Adjustment Scale (SAS), a semistructured interview that assesses an individual's functioning in eight areas. The study used the Social and Work scales of the SAS, which were rated on a 7-point scale, with higher scores indicating more severe maladjustment.
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Key Findings
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In a study that compared four treatment conditions--PE, SIT, PE plus SIT, and a wait-list control condition--PE participants had significantly improved social adjustment compared with participants in SIT, PE plus SIT, and the wait-list condition (p < .05). When the wait-list condition was compared with SIT and with PE plus SIT, no differences were detected.
Another study compared PE, PE plus CR, and a wait-list control condition. Participants in the PE and PE plus CR groups showed significantly improved social adjustment compared with participants in the wait-list group (p < .01). The PE and PE plus CR groups did not differ significantly from each other on social adjustment.
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Studies Measuring Outcome
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Study 1, Study 3
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Study Designs
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Experimental
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Quality of Research Rating
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3.3
(0.0-4.0 scale)
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| Outcome 4: Anxiety symptoms |
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Description of Measures
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Anxiety symptoms were assessed using the State subscale of the State-Trait Anxiety Inventory (STAI). The STAI is a 40-item questionnaire that evaluates anxiety at the immediate moment (state anxiety) and the enduring tendency to experience anxiety (trait anxiety).
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Key Findings
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In a study that compared four treatment conditions--PE, SIT, PE plus SIT, and a wait-list control condition--all three active treatments significantly reduced the symptoms of anxiety compared with the wait-list condition (p < .05). The effect size was large for PE (Cohen's d = 1.32) and small for SIT (Cohen's d = 0.37) and PE plus SIT (Cohen's d = 0.45).
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Studies Measuring Outcome
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Study 1
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Study Designs
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Experimental
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Quality of Research Rating
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3.7
(0.0-4.0 scale)
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| Outcome 5: PTSD diagnostic status |
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Description of Measures
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PTSD diagnostic status was assessed using the Clinician Administered PTSD Scale, Form 2, which assesses the frequency and severity of each PTSD symptom in the past week. This instrument was used at posttreatment and follow-up diagnostic assessments only, as the timing of those interviews (at least 30 days after baseline) made it possible to differentiate diagnoses of PTSD from acute stress disorder (in which severe symptoms typically do not persist after 30 days).
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Key Findings
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In a study that compared PE, PE plus anxiety management, and supportive counseling, patients in both the PE plus anxiety management group and the PE group were less likely to meet the criteria for PTSD diagnosis at posttest than those in the supportive counseling group (p < .05). Similar results were observed at 6-month follow-up (p < .01).
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Studies Measuring Outcome
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Study 4
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Study Designs
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Experimental
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Quality of Research Rating
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2.9
(0.0-4.0 scale)
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Study Populations
The following populations were identified in the studies reviewed for Quality of
Research.
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Study
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Age
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Gender
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Race/Ethnicity
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Study 1
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18-25 (Young adult)
26-55 (Adult)
55+ (Older adult)
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100% Female
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63% White
36% Black or African American
1% Race/ethnicity unspecified
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Study 2
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18-25 (Young adult)
26-55 (Adult)
55+ (Older adult)
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100% Female
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71% White
25% Black or African American
4% Race/ethnicity unspecified
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Study 3
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18-25 (Young adult)
26-55 (Adult)
55+ (Older adult)
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100% Female
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49% White
44% Black or African American
7% Race/ethnicity unspecified
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Study 4
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18-25 (Young adult)
26-55 (Adult)
55+ (Older adult)
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51% Female
49% Male
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100% Non-U.S. population
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Quality of Research Ratings by Criteria (0.0-4.0 scale)
External reviewers independently evaluate the Quality of Research for an intervention's
reported results using six criteria:
For more information about these criteria and the meaning of the ratings, see Quality of Research.
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Outcome
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Reliability
of Measures
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Validity
of Measures
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Fidelity
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Missing
Data/Attrition
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Confounding
Variables
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Data
Analysis
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Overall
Rating
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1: Severity of PTSD symptoms
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4.0
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4.0
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3.9
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3.5
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3.3
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3.5
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3.7
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2: Depression symptoms
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4.0
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4.0
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3.9
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3.5
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3.3
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3.5
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3.7
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3: Social adjustment
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2.8
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2.8
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3.9
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3.5
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3.1
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3.8
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3.3
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4: Anxiety symptoms
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4.0
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4.0
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3.8
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4.0
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3.0
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3.5
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3.7
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5: PTSD diagnostic status
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4.0
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4.0
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3.0
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1.8
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2.0
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2.5
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2.9
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Study Strengths The studies used standardized instruments with good to excellent psychometric properties. Adequate attention was given to intervention fidelity and process monitoring and assessment. The data analysis strategies (i.e., intent-to-treat samples, analyses of completers versus noncompleters) were thorough and attended to the potential threats posed by differential attrition and missing data.
Study Weaknesses The studies had moderate levels of attrition and, in some cases, differential attrition by treatment condition.
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Readiness for Dissemination
Review Date: December 2007
Materials Reviewed
The materials below were reviewed for Readiness for Dissemination. The implementation
point of contact can provide information regarding implementation of the intervention
and the availability of additional, updated, or new materials.
Cahill, S. P., Foa, E. B., Hembree, E. A., Marshall, R. D., & Nacash, N. (2006). Dissemination of exposure therapy in the treatment of posttraumatic stress disorder. Journal of Traumatic Stress, 19(5), 597-610.
Center for the Treatment and Study of Anxiety, University of Pennsylvania. (n.d.). PTSD Symptom Scale--Interview (PSSI).
Center for the Treatment and Study of Anxiety, University of Pennsylvania. (n.d.). PTSD Symptom Scale--Self-Report (PSS-SR).
Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged Exposure Therapy for PTSD: Therapist guide. New York: Oxford University Press.
PE Treatment Checklist
Rothbaum, R. O., Foa, E. B., & Hembree, E. A. (2007). Reclaiming your life from a traumatic experience: Workbook. New York: Oxford University Press.
Training documents:
- Four-day training workshop agenda
- PTSD reading list
- Resources for training and implementation
Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)
External reviewers independently evaluate the intervention's Readiness for Dissemination
using three criteria:
- Availability of implementation materials
- Availability of training and support resources
- Availability of quality assurance procedures
For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.
Implementation
Materials
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Training and Support
Resources
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Quality Assurance
Procedures
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Overall
Rating
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3.0
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3.5
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2.8
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3.1
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Dissemination Strengths The treatment manual includes session-by-session strategies and case examples. A comprehensive training provides opportunities for implementers to observe and practice the application of intervention concepts. Several tools, including client outcome measures and session checklists, are available to support quality assurance.
Dissemination Weaknesses No resources or training is provided for program administrators or clinical supervisors. The intervention requires a high degree of clinical skill. Little guidance is available for using quality assurance measures and interpreting results.
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Costs
The cost information below was provided by the developer. Although this cost information
may have been updated by the developer since the time of review, it may not reflect
the current costs or availability of items (including newly developed or discontinued
items). The implementation point of contact can provide current information and
discuss implementation requirements.
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Item Description
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Cost
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Required by Developer
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4-day, on-site clinical training (includes intervention therapist guide, client workbook, educational DVD, assessment measures, and adherence manual)
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$1,100 per participant
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Yes
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Replications
Selected citations are presented below. An asterisk indicates that the document
was reviewed for Quality of Research.
Bryant, R. A., Harvey, A. G., Dang, S. T., Sackville, T., & Basten, C. (1998). Treatment of acute stress disorder: A comparison of cognitive-behavioral therapy and supportive counseling. Journal of Consulting and Clinical Psychology, 66(5), 862-866.
* Bryant, R. A., Sackville, T., Dang, S. T., Moulds, M., & Guthrie, R. (1999). Treating acute stress disorder: An evaluation of cognitive behavior therapy and supportive counseling techniques. American Journal of Psychiatry, 156(11), 1780-1786.
Foa, E. B., Zoellner, L. A., & Feeny, N. C. (2006). An evaluation of three brief programs for facilitating recovery after assault. Journal of Traumatic Stress, 19(1), 29-43.
Paunovic, N., & Ost, L.-G. (2001). Cognitive-behavior therapy vs exposure therapy in the treatment of PTSD in refugees. Behaviour Research and Therapy, 39(10), 1183-1197.
Rothbaum, B. O., Astin, M. C., & Marsteller, F. (2005). Prolonged exposure versus eye movement desensitization and reprocessing (EMDR) for PTSD rape victims. Journal of Traumatic Stress, 18(6), 607-616.
Rothbaum, B. O., Cahill, S. P., Foa, E. B., Davidson, J. R. T., Compton, J., Connor, K. M., et al. (2006). Augmentation of sertraline with prolonged exposure in the treatment of posttraumatic stress disorder. Journal of Traumatic Stress, 19(5), 625-638.
Schnurr, P. P., Friedman, M. J., Engel, C. C., Foa, E. B., Shea, M. T., Chow, B. K., et al. (2007). Cognitive behavioral therapy for posttraumatic stress disorder in women: A randomized controlled trial. Journal of the American Medical Association, 297(8), 820-830.
Taylor, S., Thordarson, D. S., Maxfield, L., Fedoroff, I. C., Lovell, K. & Ogrodniczuk, J. (2003). Comparative efficacy, speed, and adverse effects of three PTSD treatments: Exposure therapy, EMDR, and relaxation training. Journal of Consulting and Clinical Psychology, 71(2), 330-338.
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