SMART: SUMMARY OF DUKE GUIDED IMAGERY STUDIES TO DATE

Jennifer Strauss PhD and her team at Duke Medical Center & the Durham V.A.M.C. have conducted one survey and 3 studies assessing SMART (Self-Management Audio for Recovery from Trauma) on soldiers and veterans with posttraumatic stress. The results have exceeded expectations, and compare with far more expensive, time-consuming, and hard-to-implement best practices currently in use for PTSD. Journal write-ups to come at completion of data collection and analysis. Chapter article and presentations at national meetings listed below*.

1. The 1^st study was a survey of VA clinic users, showing that over 70% of active military & vets prefer help via audio downloads. (Similar findings @ Phoenix V.A.)
   
   
2. The 2^nd study was a small pilot (no controls) that looked at imagery's impact on 15 women with PTSD from Military Sexual Trauma, mostly from the Vietnam era, to see if it worked, if subjects liked it and would stay with it. They listened 5x/wk for 12 weeks.There were large, significant effect sizes - steep drops in symptoms, as measured by 2 gold-standard measures: the CAPS (Clinician Administered PTSD Scale) and the PCL (PTSD Check List), as well as the Well-Being Scale - scores comparable to individual therapy and to CBT/prolonged exposure therapy.
   
   
3. The 3^rd study is an ongoing randomized controlled trial funded by the Dept. of Defense through Samueli, with 28 women enrolled to date, 14 in each group (the intervention group receives SMART; controls get music only). The population is mostly older but 25% are OIF/OEF. Study yields the same results: large, significant effect sizes, consistent with best outcomes from individual with prolonged exposure. (Thanks to an NIH grant, this study will be over-enrolled to 50 subjects.) From this study, we found that 80% of change occurs by week #6 and that by week #8, subjects drop out due to feeling better. In addition to drops in PTSD, Well- Being Scale data reveals improved social efficacy & relationships and better positive self-regard. This study will finish by June, then rolled out on a larger scale.
   
   
4. The 4^th study is an open trial with male vets - to date, 14 with combat-related PTSD (14% OIF/OEF) - aiming for 20 to complete the pilot. The intervention is framed as "skills training", not "therapy"; the program was shortened to 8 weeks; and changes were made to the audio content, based on previous feedback. There is unusually high retention (only one dropout so far), very positive feedback and the same outcomes: large effect sizes on all clusters, comparable to individual therapy. The team is now proposing a randomized controlled trial with 162 soldiers, to begin next year.
   
   

Implications:Although the numbers are small, they are compelling & consistent. We feel it is likely that SMART can reduce mild or moderate PTS symptoms on its own; or it may be a useful adjunct to prolonged exposure therapy, to help manage or reduce the distress this protocol can generate; and it might be helpful in inoculating against the later acquisition of PTS symptoms or reducing their severity, by being part of early training. Highly practical, it is cost-effective, self-administered, user-friendly, non-threatening and portable.

* Citations

Chapter:
STRAUSS JL, Marx CE, Calhoun PS. Guided imagery as a therapeutic tool in PTSD. Chapter in: Neurobiology of PTSD. Shiromani P, Keane T, LeDoux J, eds. Humana Press, Inc; Totowa, NJ 2008: In press.

Presentations at National Meetings:
Strauss JL, Roland JE, Marx C, Coffman C, O'Loughlin S, Butterfield MI. Effects of guided imagery for military sexual trauma-related PTSD. Poster presented at the 21st Annual Meeting of the International Society for Traumatic Stress Studies, Toronto CN, November 2005.

Strauss JL, Marx CE, Oddone EZ, O'Loughlin SH, Butterfield MI. A transportable PTSD intervention shows promise for women veterans with military sexual trauma. Poster presented at the 2006 American Psychiatric Association Annual Meeting. Toronto, Canada, May 2006.

STRAUSS JL, Coffman CJ, Olsen MK, Marx CE, Oddone EZ, O'Loughlin SH, Butterfield MI. A self-management intervention to improve outcomes of PTSD related to military sexual trauma. Paper presented at the National Conference on Health and Domestic Violence, San Francisco, CA, March, 2007.

STRAUSS JL, Marx CE, Morey RA, Jeffreys, A., Almirall D, Olsen MK, Coffman CJ, O'Loughlin SH, Oddone, EZ, Butterfield, MI. A Brief, Transportable Intervention for Women Veterans with PTSD Related to Military Sexual Trauma. Paper presented at the 10th Annual Force Health Protection Conference, Louisville, KY, August 2007.

STRAUSS JL, Marx CE, Morey RA, Jeffreys, A, Almirall D, O'Loughlin SH, Close JE, Chaudhry N, Oddone, EZ. A Novel Self-Management Intervention for PTSD Related to Military Sexual Trauma; Early RCT Findings. Paper presented at the International Society of Traumatic Stress Studies, Chicago, IL, November 2008.