SMART-CPT for veterans with comorbid post-traumatic stress disorder and history of traumatic brain injury: a randomised controlled trial

Correspondence to Dr Amy J Jak, Psychology Service, VA San Diego Healthcare System, San Diego, CA 92161, USA; [email protected]

Introduction

Post-traumatic stress disorder (PTSD) and history of traumatic brain injury (TBI) are highly comorbid in treatment-seeking Operation Iraqi Freedom/Enduring Freedom/New Dawn (OEF/OIF/OND) veterans.¹ Approximately 20% of deployed OEF/OIF/OND-era veterans have sustained a TBI,² the vast majority of which are characterised as mild.³ Approximately 23% of OEF/OIF/OND veterans are diagnosed with PTSD.⁴ Of those OEF/OIF/OND veterans with mild TBI (mTBI) seeking treatment, 73% carry a diagnosis of PTSD.⁵ PTSD and persistent postconcussive symptoms (PCS) are interconnected, with reciprocal influences of physical and psychological trauma on the development and/or persistence of symptoms in the postacute phase following mTBI.^{1 6}

Objective neuropsychological deficits are common acutely following mTBI and also affect many individuals with PTSD,^{7 8} particularly those seeking treatment.⁹ Following mTBI, symptoms typically resolve within 10 days.¹⁰ Nonetheless, 40%–72% of those with mTBI history reported PCS even after 1 year.¹¹ Although the aetiology of PCS is nebulous, persistent symptoms following mTBI are likely related to non-neurological aetiologies. Specifically, PTSD is thought to figure prominently into protracted recoveries from mTBI in this comorbid population.¹²

Neurocognitive functioning in veterans with PTSD and/or history of mTBI contributes notably to difficulties in social and occupational functioning.^{13 14} Worse cognitive performance in those with comorbid PTSD and mTBI history is related to worse psychiatric symptom severity, but not to mTBI injury characteristics.¹⁵ Nonetheless, cognitive complaints/deficits are more likely to be attributed to history of mTBI as opposed to PTSD or other behavioural health conditions in this comorbid population.^{16 17} The Veterans Affairs/Department of Defense (VA/DoD) guidelines state that co-occurring disorders should not prevent veterans from receiving empirically supported treatments for PTSD. Research also demonstrates that first-line psychotherapies for PTSD, such as cognitive processing therapy (CPT), are feasible and effective in individuals with comorbid PTSD and history of TBI.^{18 19} Nonetheless, concern remains about the ability of those with a history of TBI to participate in structured trauma-focused treatment. In a study of residential PTSD treatment facilities, the vast majority of VA providers surveyed noted TBI and cognitive limitations as factors dissuading them from using CPT in...