Cognitive behavior therapy (CBT) is a well-established effective treatment for anxiety disorders in general (Olatunji, Cisler, & Deacon, 2010), and PTSD in particular (Kar, 2011). It has also been used as an early intervention for PTSD (Table 8.2). These studies show that brief early CBT both decreases initial symptoms levels, as well as prevents the long term development of PTSD. However, results are not entirely consistent. For example: in one study that compared CBT versus an assessment only control group, the CBT groups showed significantly lower PTSD symptoms at 1 week posttreatment, but by 4 months, this significant difference had disappeared (Sijbrandij et al., 2007).

Although the studies we have reviewed suggest that CBT offered close in time to a traumatic event may be effective at preventing PTSD, there remain several important questions:

First, optimal timing of early interventions remains unclear. These studies include interventions timed between several hours (Rothbaum, Meuli & Landolt 2012) or days (Zehnder et al., 2010) to a few months (Wagner et al., 2007) after the event. Knowledge of natural decline in symptoms indicates that interventions offered at 4 days and 10 weeks are dealing with different patient sets and needs.

Second, the interventions, while all falling under the umbrella of CBT, vary widely in the specific interventions included. Therefore, it is unclear which components are essential, and which may be less necessary.

Third, many of these studies have focused on patients with diagnoses of Acute Stress Disorder (ASD). A significant percentage of individuals with ASD subsequently develop PTSD, and therefore this is a vulnerable group. However, research shows that only between 30 (Creamer, O’Donnell, & Pattison, 2004) and 84 % (Bryant & Harvey, 1998) of individuals with ASD will develop PTSD, whereas between 10 (Schnyder, Moergeli, Klaghofer, & Buddeberg, 2001) and 72 % (Harvey & Bryant, 2000) of individuals with PTSD suffered from ASD. Therefore offering intervention only to those patients with ASD potentially neglects a large number of people who are at risk for PTSD.

Fourth, although it seems clear to clinicians that early interventions are important and essential, clients seem less accepting. Studies have shown that even when early interventions are readily available, a significant percentage of patients are reluctant to accept treatment (e.g., Hoge et al., 2004). Several explanations for this have been suggested, including stigma (Kim, Thomas, Wilk, Castro, & Hoge, 2010). However, a better understanding of these barriers to treatment is essential in planning acceptable, and not just effective, treatments.

The Jerusalem Trauma Outreach and Prevention Study (J-TOPS) project was designed in an attempt to answer some of the questions outlined above. It will be briefly described here (Shalev, Ankri, Peleg, Israeli-Shalev, & Freedman, 2011, gives more detailed information regarding its design), and the major results presented (Shalev et al., 2012).

J-TOPS consisted of two overlapping research methodologies: first, a longitudinal prospective outreach study and second, an embedded randomized controlled trial. Tracking all admissions to the Emergency Room of a large hospital in Israel, the outreach program identified, via computer, patients as suitable for the study (aged between 18 and 65, lived within the greater Jerusalem area, came to the ER as a result of a potentially traumatic event). These individuals were phoned within 2 weeks of their ER visit. This telephone interview (Telephone Interview I, or TI-1) identified whether the person had experienced a traumatic event, as per DSM (i.e., both objectively experienced an event as well as subjective responded to that event), as well as suffering from symptom levels of PTSD and depression. Figure 8.1 details the design of the study.

A second telephone interview was conducted 7 months post-trauma. At this point in time all subjects who had experienced a traumatic event were reinterviewed. In addition, 10 % of those subjects deemed not to have had experienced a traumatic event were randomly chosen and reinterviewed.

In the first telephone interview, 5,286 individuals were called, and 5,053 (94 %) agreed to participate. A large proportion of these people had not actually experienced a traumatic event, as defined in Criteria A1 and A2 of DSM IV. Of the 1996 that had experienced an event, 1,502 were considered to be sufficiently symptomatic as to warrant further investigation, and were invited to a clinical interview. Only 50 % actually attended. Of the 756 people interviewed at this stage, 397 exhibited PTSD symptoms, and were eligible for the randomized control trial. Of these, 296 (75 %) started treatment.

Participants who were invited to either the clinical interview, or to participate in the treatment trial, but did not attend, showed less symptom reduction over time. This difference between attendees and non-attendees remained significant, even when initial symptoms levels were taken into account. Thus, this study revealed that even when approached by a treatment team dedicated to outreach, the majority of recently traumatized individuals preferred not to meet with a mental health professional. However, acceptance of telephone contact was extremely high. As refusing an interview, or treatment, is clearly associated with poorer outcome, this represents a significant barrier to successful treatment.

The randomized controlled trial (Shalev et al., 2012) assessed effectiveness of three different treatment modalities. The first treatment, Prolonged Exposure (PE, Foa & Rothbaum, 1998), is a behavior based treatment that includes psychoeducation, breathing retraining, in vivo exposure, and imaginal exposure to the trauma narrative. Many studies, as described above, have demonstrated the effectiveness of PE as a treatment for both chronic PTSD as well as an early intervention. The latter, however, usually consisted of 4–5 sessions. In this study, the full protocol of 12 sessions was offered. The second treatment, cognitive therapy (CT, Marks, Lovell, Noshirvani, Livanou, & Thrasher, 1998), focuses on the negative interpretations that patients make about their trauma, themselves, and their reactions. It includes no elements of exposure, and therefore, can be compared with PE. CT been shown to be effective in treating chronic PTSD (Marks et al., 1998), although results as an early intervention were less positive (Bryant et al., 2008). In the third treatment group, patients received an SSRI in a double blind comparison with placebo. A fourth group of patients were a waitlist control. If they were symptomatic at the end of the waitlist condition, they received Prolonged Exposure. Thus, early and late interventions could be compared.

The results indicated that both PE and CT were successful in treating early symptoms. There were no significant differences between PE and CT in treatment acceptance, drop out from treatment, or its effectiveness. There were no significant difference between SSRI, placebo, and waitlist control, and all were significantly less effective than PE and CT.

This study allowed patients to refuse up to two treatment conditions within the randomization process: thus a patient could refuse PE, and then be re-randomized to one of the other conditions. This type of randomization better reflects real world clinical settings, where patients are able to choose their treatment. This study found that relatively few patients refused psychological treatments (CT: 8, 3.1 %; PE: 3, 1.2 %). However, a significantly higher number refused medication (103, 42.6 %).

The study found that early and late PE resulted in similar recovery rates.

While the majority of patients who entered the RCT presented with full PTSD or ASD symptoms, others met two out of the three necessary criteria and therefore could be said to have “partial PTSD.” When these patients with partial PTSD who received CT or PE were compared with waitlist control, no significant differences were found. This indicates that the effectiveness of PE and CT over natural recovery is only apparent in those presenting with all the symptoms of PTSD.