A Brief Exposure-Based Treatment vs Cognitive Processing Therapy for Posttraumatic Stress Disorder: A Randomized Noninferiority Clinical Trial

Abstract

IMPORTANCE Written exposure therapy (WET), a 5-session intervention, has been shown to efficaciously treat posttraumatic stress disorder (PTSD). However, this treatment has not yet been directly compared with a first-line PTSD treatment such as cognitive processing therapy (CPT). OBJECTIVE To determine if WET is noninferior to CPT in patients with PTSD. DESIGN, SETTING, AND PARTICIPANTS In this randomized clinical trial conducted at a Veterans Affairs medical facility between February 28, 2013, and November 6, 2016, 126 veteran and nonveteran adults were randomized to either WET or CPT. Inclusion criteria were a primary diagnosis of PTSD and stable medication therapy. Exclusion criteria included current psychotherapy for PTSD, high risk of suicide, diagnosis of psychosis, and unstable bipolar illness. Analysis was performed on an intent-to-treat basis. INTERVENTIONS Participants assigned to CPT (n = 63) received 12 sessions and participants assigned to WET (n = 63) received 5 sessions. The CPT protocol that includes written accounts was delivered individually in 60-minute weekly sessions. The first WET session requires 60 minutes while the remaining 4 sessions require 40 minutes. MAIN OUTCOMES AND MEASURES The primary outcome was the total score on the Clinician-Administered PTSD Scale for DSM-5; noninferiority was defined by a score of 10 points. Blinded evaluations were conducted at baseline and 6, 12, 24, and 36 weeks after the first treatment session. Treatment dropout was also examined. RESULTS For the 126 participants (66 men and 60 women; mean [SD] age, 43.9 [14.6] years), improvements in PTSD symptoms in the WET condition were noninferior to improvements in the CPT condition at each of the assessment periods. The largest difference between treatments was observed at the 24-week assessment (mean difference, 4.31 points; 95%CI, – 1.37 to 9.99). There were significantly fewer dropouts in the WET vs CPT condition (4 [6.4%] vs 25 [39.7%]; χ12=12.84, Cramer V = 0.40). CONCLUSIONS AND RELEVANCE Although WET involves fewer sessions, it was noninferior to CPT in reducing symptoms of PTSD. The findings suggest that WET is an efficacious and efficient PTSD treatment that may reduce attrition and transcend previously observed barriers to PTSD treatment for both patients and providers. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01800773

Long-term treatment gains of a brief exposure-based treatment for PTSD

“…The demographics of the sample and the study methodology have been described elsewhere (Sloan et al, 2018; Sloan et al, 2016). Briefly, participants were 126 adults (52% male, 54.8% Caucasian) who sought treatment for PTSD.…”

“…Thus, assessments were conducted at baseline and 6-, 12-, 24-, 36-, and 60-weeks following the first treatment session for both treatment conditions (see Sloan et al, 2016 for additional information); outcomes through the 36-week assessment are reported in Sloan et al (2018). Clinical interviews were administered by masters-level evaluators who were blinded to treatment assignment.…”

“…1 Both treatments were delivered as individual sessions, and both followed a manualized protocol. Adherence and competence of treatment delivery was rated as good to excellent for both WET and CPT, and therapists were supervised by the developers of both treatments throughout the trial (further information can be found in the supplemental material for Sloan et al, 2018). The WET protocol consists of five weekly sessions during which participants wrote for 30 minutes in detail about a single traumatic event associated with their PTSD diagnosis.…”

“…A recent study found outcomes for WET were non-inferior to outcomes from Cognitive Processing Therapy (CPT) through 36 weeks from first treatment session (Sloan, Marx, Lee, & Resick, 2018); the current study examined whether treatment gains were maintained through 60 weeks from first session, and also evaluated both treatments’ effect on depressive symptoms. …”

“…From the provider perspective, WET requires less time to learn how to implement than other trauma-focused treatments. A recently published randomized controlled trial found that WET was non-inferior compared with Cognitive Processing Therapy (CPT), a 12-session, first line psychotherapy for PTSD (Sloan et al, 2018). Specifically, results showed that WET was non-inferior to CPT in terms of PTSD symptom severity outcome at assessments conducted out to 36 weeks post-first treatment session, and there were no significant condition differences in the percentage of participants who no longer met diagnostic criteria for PTSD.…”