Effect of Written Exposure Therapy vs Cognitive Processing Therapy on Increasing Treatment Efficiency Among Military Service Members With Posttraumatic Stress Disorder

Abstract

IMPORTANCE Posttraumatic stress disorder (PTSD) occurs more commonly among military service members than among civilians; however, despite the availability of several evidence-based treatments, there is a need for more efficient evidence-based PTSD treatments to better address the needs of service members. Written exposure therapy is a brief PTSD intervention that consists of 5 sessions with no between-session assignments, has demonstrated efficacy, and is associated with low treatment dropout rates, but prior randomized clinical trials of this intervention have focused on civilian populations. OBJECTIVE To investigate whether the brief intervention, written exposure therapy, is noninferior in the treatment of PTSD vs the more time-intensive cognitive processing therapy among service members diagnosed with PTSD. DESIGN, SETTING, AND PARTICIPANTSThe study used a randomized, noninferiority design with a 1:1 randomization allocation. Recruitment for the study took place from August 2016 through October 2020. Participants were active-duty military service members diagnosed with posttraumatic stress disorder. The study was conducted in an outpatient setting for service members seeking PTSD treatment at military bases in San Antonio or Killeen, Texas.INTERVENTIONS Participants received either written exposure therapy, which consisted of 5 weekly sessions, or cognitive processing therapy, which consisted of 12 twice-weekly sessions. MAIN OUTCOMES AND MEASURESParticipants were assessed at baseline and at 10, 20, and 30 weeks after the first treatment session. The primary outcome measure was PTSD symptom severity assessed with the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5). Noninferiority was defined as the difference between the 2 groups being less than the upper bound of the 1-sided 95% CI-specified margin of 10 points on the CAPS-5. RESULTSOverall, 169 participants were included in the study. Participants were predominantly male (136 [80.5%]), serving in the Army (167 [98.8%]), with a mean (SD) age of 34 (8) years. Eightyfive participants were randomly assigned to written exposure therapy, with 65 (76.5%) completing all treatment sessions, and 84 to cognitive processing therapy, with 47 (54.8%) completing all treatment sessions. Findings indicated that written exposure therapy was noninferior to cognitive processing therapy, with the largest difference in change in outcome between the treatment conditions of 3.96 points on the outcome measure. The 1-sided 95% CI upper limit was less than 10 (continued) Key Points Question Is a 5-session, traumafocused written exposure therapy treatment noninferior to a more timeintensive, trauma-focused cognitive processing therapy treatment for activeduty service members diagnosed with posttraumatic stress disorder (PTSD)? Findings In this randomized noninferiority clinical trial that included 169 men and women activity-duty service members, written exposure therapy was found to be noninferior to cognitive processing therapy. Dropout rates for written exposure therapy were s...

Effect of the Memory Training for Recovery–Adolescent Intervention vs Treatment as Usual on Psychiatric Symptoms Among Adolescent Girls in Afghanistan

“…Module 2 was a modified form of written exposure therapy and writing for recovery . Session 1 included a brief outline of the purpose of module 2.…”

A review of the referral process for evidence-based psychotherapies for PTSD among veterans.

“…This shorter time investment may be especially important, as it can be difficult for veterans to engage in timeintensive treatment due to other time demands, including work, school, and childcare responsibilities. Indeed, one study found that dropout was lower for veterans assigned to WET than those assigned to CPT-and importantly that WET was as effective as CPT in reducing PTSD symptoms (Sloan et al, 2018(Sloan et al, , 2022. Patients may also prefer briefer versions of treatment when given the choice in a pilot study for a briefer version of PE, veterans reported higher preference for brief PE compared with referral to specialty mental health for longer term care (Cigrang et al, 2011;Rauch et al, 2017).…”

A multiverse approach to analyzing data from clinical trials

“…Third, treatment conditions within a study may call for conflicting analytic decisions by nature of differences between the treatments themselves. Treatments may differ in the number or length (e.g., Sloan et al, 2022) of sessions, which can complicate determination of how to optimally operationalize the passage of time to compare them. Operationalizing time as the end point of treatment may unfairly favor treatments with a higher numbers of sessions due to participants receiving more treatment.…”

“…Both situations may be problematic given treatments often show dose-response associations (Baldwin et al, 2009;Erekson et al, 2015). On the other hand, comparing treatments at some specified time since baseline disadvantages shorter-length or massed treatments whose main selling point may be speed of recovery (e.g., Foa et al, 2018;Sloan et al, 2022). When each option has benefits and drawbacks and no option is clearly superior, selecting just one may be problematic.…”