January 18, 2018
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Written exposure therapy noninferior to cognitive processing therapy for PTSD

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Denise M. Sloan

Written exposure therapy showed noninferiority to the more time-intensive cognitive processing therapy in reducing PTSD symptoms, according to findings published in JAMA Psychiatry.

“Prior research has shown [written exposure therapy] to significantly reduce the severity of PTSD symptoms in a variety of trauma survivors, with effect sizes similar to those associated with [cognitive processing therapy] and prolonged exposure, and to have substantially fewer treatment dropouts than these other treatments,” Denise M. Sloan, PhD, National Center for PTSD, Veterans Affairs Boston Health Care System, and Boston University School of Medicine, and colleagues wrote. “However, [written exposure therapy] has not yet been directly compared with either of these treatments in the same study.”

To examine whether written exposure therapy was noninferior to cognitive processing therapy in patients with PTSD, researchers conducted a randomized clinical trial of 126 veterans and nonveterans with PTSD at a VA medical facility between February 28, 2013, and Nov. 6, 2016.

They randomly assigned participants to receive either five sessions of written exposure therapy (n = 63) or 12 sessions of cognitive processing therapy (n = 63). In written exposure therapy, participants wrote about a specific traumatic event, focusing on details of the event and thoughts and feelings during the event, for 30 minutes each session. In cognitive processing therapy, patients learn to identify and challenge dysfunctional cognitions about their traumatic event and current thoughts about themselves, others and the world, and write about two trauma accounts, for 60 minutes each session.

Researchers evaluated total score on the Clinician-Administered PTSD Scale for DSM-5 at baseline and at weeks 6, 12, 24 and 36 after the first treatment session to determine noninferiority (defined by a score of 10 points).

Analysis indicated that the PTSD severity scores for participants receiving written exposure therapy were noninferior to those for participants receiving cognitive processing therapy at each assessment period. PTSD total scores in both treatment groups demonstrated significant effects of linear change over time (P < .001). Notably, patients assigned to cognitive processing therapy were more likely to drop out of treatment, with 20 dropping out within the first five sessions compared with four assigned to written exposure therapy.

“The findings suggest that written exposure therapy results in comparable outcome relative to the more intensive cognitive processing therapy. In addition, the treatment was better tolerated with only 6% dropping out prematurely relative to 39% assigned to [cognitive processing therapy],” Sloan told Healio Psychiatry. “These findings are important, as it indicates that there is a more efficient and tolerable treatment option for PTSD.”

Treatment expectations did not significantly differ between the two therapies, with high expectations indicated by participants in both treatment groups; patients in both groups also reported high levels of satisfaction with their therapy. Researchers observed the largest difference between treatment effect at week 24 (mean difference, 4.31 points; 95% CI, –1.37 to 9.99), but this difference was not maintained in the next assessment at 36 weeks.

“Our findings have important implications for treating individuals with PTSD, especially given the high clinical demand for PTSD treatment among veterans and military service members,” Sloan and colleagues wrote. “Written exposure therapy should be considered by clinicians to be a viable treatment option that can address some of the barriers to receiving and implementing [cognitive processing therapy] and prolonged exposure that have been noted in health care settings.” – by Savannah Demko

Disclosures: The authors report no relevant financial disclosures.