Less Burdensome PTSD Therapy Proves Viable

A shorter type of exposure therapy worked just as well as a more involved one for post-traumatic stress disorder (PTSD), according to a non-inferiority trial involving military veterans.

Written exposure therapy, given over five to seven sessions, was non-inferior to eight to 15 sessions of prolonged exposure therapy for reducing PTSD symptoms, as measured by the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), reported researchers led by Denise Sloan, PhD, of the National Center for PTSD and VA Boston Health Care System.

At the primary endpoint follow-up of 20 weeks, participants assigned to the written exposure group had similar mean total scores on CAPS-5 compared with prolonged exposure participants (26.17 vs 24.78), with that 1.38-point difference (95% CI -2.38 to 5.15) falling within prespecified noninferiority criteria, they detailed in JAMA Psychiatry.

Higher scores on the 0-80 scale indicate more severe PTSD. In the 178-patient trial, the largest numerical difference in scores between groups was observed at 10 weeks (favoring written exposure therapy), and scores were non-inferior at the last follow-up point of 30 weeks as well:

• 10 weeks: 27.69 with written exposure vs 30.10 with prolonged exposure
• 30 weeks: 26.58 vs 26.33, respectively

While both programs seemed equally effective for treating PTSD, patients were significantly more likely to stick with written exposure therapy, with premature dropout rates of only 12.5% versus 35.6% in the prolonged exposure group, likely owing to the fewer but also shorter sessions (45 to 60 minutes rather than 90 minutes), according to the researchers.

However, Sloan’s group pointed out that the percentage of dropouts in the written exposure group was lower than the 25% rate seen in the only other effectiveness study of the therapy for veterans.

“The greater percentage of participants receiving treatment remotely through a secure video teleconference platform may account for the better retention observed in this study relative to the prior study with veterans,” the researchers suggested. Likewise, the prolonged exposure dropout rate was lower than other comparable studies.

Sloan’s group said their findings “add to the evidence that good PTSD treatment outcomes can be achieved with fewer sessions and less exposure to trauma-related stimuli than previously assumed.” They added that the structure of these shorter in-person or virtual written exposure sessions bolstered its accessibility, seeing as how the typical 90-minute prolonged exposure protocol “is not usually feasible in most clinical settings.”

In an accompanying editorial, Charles Taylor, PhD, and Murray Stein, MD, MPH, both of the University of California San Diego in La Jolla, said that written exposure therapy “is poised to slide into place among those extensively studied and highly regarded treatments for PTSD.”

Based on the study findings, they suggested that patients could start on the “least burdensome” option (written exposure), and if needed progress to more intensive treatments: prolonged exposure, cognitive processing therapy, or eye movement desensitization and reprocessing.

The randomized trial assigned 178 military veterans with a primary diagnosis of PTSD who presented to one of three VA medical centers from September 2019 to April 2022 to either written exposure (n=88) or prolonged exposure (n=90) therapy.

Written exposure sessions involved 30 minutes where participants had to write about a specific index trauma, focusing on the details and feelings surrounding this event. This writing session was then followed by a discussion of the experience with a therapist. There was no homework between sessions.

As for the classic prolonged exposure sessions, these involved 40 minutes of in-session imaginal exposure where participants focused on their most distressing traumatic memory. Between sessions, individuals were instructed to conduct in vivo exposures to people, places, and situations that they have been avoiding, related to their index trauma.

For the primary endpoint, noninferiority was defined as a less-than 10-point difference between the written exposure and prolonged exposure therapy groups. Baseline CAPS-5 total scores were 34.51 and 35.20, respectively.

Participants had an average age of 45, and three-fourths were men. Nearly two-thirds were white and 21% were Black. More than half had a combat-related index trauma, another 15% experienced a military sexual assault, 6% experienced a sudden violent death, and 27% had another type of index trauma.

A majority of patients also had major depressive disorder, 20% had generalized anxiety, and 19% had alcohol use disorders. Participants were excluded if they were at high risk for suicide, had active psychosis or unstable bipolar disorder, or if they had severe cognitive impairment.

Study limitations included the fact that most of the participants were male military vets. Also, the research took place during the pandemic, so participants “encountered a variety of stressors,” which could have had an affect on outcomes, the researchers said.

Sloan and colleagues suggested future studies test the efficacy of written exposure therapy in a broader range of settings, like primary care.

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