Patient preferences important when considering PTSD treatments, study suggests

Prolonged exposure had a slight advantage over cognitive processing therapy for PTSD symptoms, although both treatments offered meaningful improvements, according to results of a randomized clinical trial published in JAMA Network Open.

Thus, clinicians should consider patient preferences regarding these interventions, researchers noted.

“The Agency for Healthcare Research and Quality has called for studies that compare psychological treatments for PTSD with the best evidence of efficacy,” Paula P. Schnurr, PhD, of the National Center for PTSD in Vermont, and colleagues wrote. “Therefore, we conducted a multisite randomized clinical trial comparing [prolonged exposure] and [cognitive processing therapy] among veterans with PTSD. To our knowledge, no study has compared these treatments directly in veterans, who can be challenging to treat successfully.”

Schnurr and colleagues examined the comparative effectiveness of prolonged exposure vs. cognitive processing therapy in 916 (79.7% men; mean age, 45.2 years) veterans with PTSD linked to military service. They recruited participants from outpatient mental health clinics at 17 Department of Veterans Affairs medical centers in the U.S. between Oct. 31, 2014, and Feb. 1, 2018. Follow-up occurred through Feb. 1, 2019.

The researchers randomly assigned 455 participants to prolonged exposure and 461 participants to cognitive processing therapy, delivered based on a flexible protocol of 10 to 14 sessions. PTSD symptoms severity on the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) from prior to treatment to the mean after treatment across posttreatment and follow-ups of 3 and 6 months served as the primary outcome. Other symptoms, functioning and quality of life served as secondary outcomes.

Results showed a significant improvement in PTSD severity on the CAPS-5 in both prolonged exposure (standardized mean difference [SMD] = 0.99; 95% CI, 0.89-1.08) and cognitive processing therapy (SMD = 0.71; 95% CI, 0.61-0.8) groups from before to after treatment. The prolonged exposure group had a greater mean improvement than the cognitive processing therapy group; however, the difference was not clinically significant (SMD = 0.17). Schnurr and colleagues noted comparable results for self-reported PTSD symptoms and CAPS-5 findings. Those in the prolonged exposure group exhibited higher likelihood of response (OR = 1.32; 95% CI, 1-1.65), loss of diagnosis (OR = 1.43; 95% CI, 1.12-1.74) and remission (OR = 1.62; 95% CI, 1.24-2) vs. those in the cognitive processing therapy group. Other outcomes did not appear different between the groups. The prolonged exposure group had higher treatment dropout than the cognitive processing group (55.8% vs. 46.6%, respectively). A total of three participants in the prolonged exposure group and one participant in the cognitive processing therapy group were withdrawn from treatment, and three participants in each treatment dropped out due to serious adverse events.

“Given that the difference on the primary outcome was not clinically significant, lack of differences between treatments on outcomes other than PTSD, and higher attrition in [prolonged exposure], we do not believe our findings support a recommendation for [prolonged exposure] over [cognitive processing therapy],” Schnurr and colleagues wrote. “Clinicians and systems of care may prioritize the categorical outcomes of response, loss of diagnosis and remission because these outcomes have benefit at the population level.

“In contrast, patient preferences may be more influenced by treatment characteristics, such as session content and homework,” they wrote. “We recommend shared decision-making to help patients understand the evidence and select their preferred treatment.”