Improving PTSD Treatment for Female Veterans When Gold Standard Fails

Female veterans who have experienced intimate partner violence (IPV) or military sexual trauma (MST) and co-occurring brain injury can develop post-traumatic stress disorder (PTSD) that can be difficult to treat. Effective interventions remain elusive, but a Mount Sinai-led team of researchers has identified a new approach that could be transformative.

In September 2024, the team launched the Multifaceted Intervention to Restore Resilience and Overcome Risk (MIRROR) study. Funded by the Department of Defense, this four-year, $2.5 million study will look at the potential of combining exposure therapy—the gold standard for PTSD—with an emotion regulation intervention designed by the Department of Veteran Affairs PTSD Center to achieve better outcomes.

There is great need for more effective treatments than just exposure therapy. “We have found approximately 24 percent to 40 percent drop out of PTSD treatment without reaping the benefits,” says Maria Kajankova, PhD, Assistant Professor of Rehabilitation and Human Performance at the Icahn School of Medicine at Mount Sinai.

The co-occurring brain injury is often undiagnosed in many female veterans with IPV or MST-related PTSD, which makes it hard for them to regulate their emotions and limits the effectiveness of standard therapy, says Dr. Kajankova.

“Our hypothesis is that giving patients an emotion regulation skill set before engaging them in exposure therapy can lead to better outcomes,” she notes.

Closing Treatment Gaps

The study, in partnership with the Baylor College of Medicine in Houston, Texas, will recruit 136 female veterans over the age of 18 who have MST and/or IPV, and have co-occurring brain injury, with sub-threshold PTSD and emotion dysregulation.

Participants will be randomized into two intervention groups: one cohort will undergo five weeks of emotion regulation skills training followed by five weeks of exposure therapy, and the other will undergo five weeks of psychoeducation followed by five weeks of exposure therapy. Follow-up assessments of both cohorts will be completed three months after treatment ends.

“One thing we are interested in is whether adding the emotion regulation intervention enables them to complete exposure therapy,” says Carrie Esopenko, PhD, Associate Professor of Rehabilitation and Human Performance. The primary objective of the study, however, is to see whether there are improvements in emotion regulation and in PTSD symptoms.

The emotion regulation skills training will be delivered through a web-based version of the evidence-based Skills Training in Affective and Interpersonal Regulation (webSTAIR) cognitive therapy program. The program is similar to an online emotion regulation intervention developed at Mount Sinai for patients with traumatic brain injury.

The Mount Sinai version of the emotion regulation intervention had been tested for effectiveness in a randomized controlled trial between 2017 and 2022. In that study, 58 of 102 participants completed the final post-treatment assessment. An interim analysis of results showed that the group that received the emotion regulation skills training had significant improvements in the Difficulty in Emotion Regulation Scores measure compared to the control group.

Additionally, Dr. Kajankova has been conducting an implementation study, which started in 2022, to assess whether clinicians in the community can be effectively trained to deliver the online intervention, with the goal of making the intervention more widely available to individuals with brain injury.

Recruitment for the MIRROR study will be underway soon. In addition to assessing the efficacy of a combined approach for PTSD, the team is interested in characterizing brain injury among female veterans, and whether there are different types or frequencies of symptoms.

“We are starting to see more understanding among care providers that IPV commonly results in brain injury, but many are unaware that brain injury can also occur with MST,” says Dr. Esopenko.

These insights will inform future studies to further characterize MST and brain injuries, and investigate the efficacy of combined emotional regulation and exposure therapy among larger, broader populations of veterans nationwide. “We want to get that message out because we believe it can have a dramatic and immediate benefit for individuals who have experienced this trauma,” Dr. Esopenko says.