Reducing Sessions of PTSD Therapy Does Not Impact Effectiveness

This is the first study to compare WET directly with another PTSD treatment.

Denise Sloan, PhD

New study results find that those with Posttraumatic Stress Disorder (PTSD) treated with as few as 5 sessions of trauma-focused psychotherapy find it equally effective as receiving 12 sessions of treatment.

The findings, published in JAMA Psychiatry, have important implications for treating PTSD with regard to identifying a treatment time-efficient for patients and providers, which addresses a significant barrier to care.

Written exposure therapy (WET), a 5-session intervention, has been shown to efficaciously treat PTSD, however, this is the first study directly comparing it with a first-line PTSD treatment such as cognitive processing therapy (CPT).

“Written exposure therapy is a good option for providers who have limited time available to treat patients with PTSD,” Denise Sloan, PhD, associate director, behavioral science division, National Center for PTSD, professor of psychiatry, Boston University School of Medicine, told MD Magazine. “An important finding is that only 6% of those patients assigned to WET dropout of treatment prematurely compared to 39% of those assigned to CPT. The greater tolerability in combination with the efficiency are important beneficial factors of WET.”

The primary focus of the study was to assess if WET, a brief, exposure-based treatment is noninferior to CPT, the more time-intensive cognitive processing therapy.

In the randomized clinical trial conducted at a Veteran Affairs medical facility between February 2013—November 2016, researchers studied 126 veteran and nonveteran adults who received a diagnosis of PTSD. Participants were randomized to either WET or CPT therapy and analyzed on an intent-to-treat basis.

Those assigned to CPT (n=63) received 12 sessions, while participants assigned to WET (n=63) received 63 sessions of treatment.

CPT protocol, which 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.

During WET sessions, patients are instructed to write for 30 minutes each session about a specific traumatic event and include the details, and thoughts and feelings that occurred during the event. There are no assignments between sessions.

Patients randomized to CPT therapy sessions are taught to recognize and challenge dysfunctional cognitions about their traumatic event and thoughts about themselves, others and society, as well as write about 2 trauma accounts.

The accounts, written at home after sessions 3 and 4, allow participants to provide sensory details, thoughts and feelings associated with the trauma. Unlimited time is allotted for the narrative. Furthermore, in between sessions, patients are given additional between-session assignments.

The primary outcome included the total score on the Clinician-Administered PTSD Scale for DSM-5, with noninferiority defined by a score of 10 points. Blind evaluations were conducted at baseline, 6, 12, 24 and 36 weeks after the first treatment. Dropout of the treatment was also studied.

The findings concluded that improvements in PTSD symptoms in the WET therapy were noninferior to improvements in the CPT therapy at the assessment periods. The largest observed difference between the treatments was observed at the 24-week assessment (mean different, 4.31 points; 95% CI, -1.37 to 9.99).

There were significantly fewer dropouts in the WET versus CPT treatment session. Twenty participants in the CPT group dropped out of the study within the first 5 sessions, versus 4 in the WET group. The total treatment dropout rate across all 12 CPT sessions was 39.7% (n=25).

Participants in both treatments experienced high levels of satisfaction with the treatment received, with no significant between-condition differences observed.

Approximately 6 (9.5%) patients randomized to CPT reported 7 adverse effects, while 5 patients (7.9%) randomized to WET also reported 7 adverse effects. There were no significant differences in the nature, frequency, or severity of effects reported.

Even though WET involves fewer treatment sessions, researchers concluded it was noninferior to CPT in reducing symptoms of PTSD. This suggests that WET is an efficacious and efficient PTSD treatment which may reduce attrition, surpassing previous barriers that providers and patients with PTSD endure, Sloan said.

“The results suggest an alternative treatment approach for PTSD that is much shorter and tolerable than other trauma-focused treatment approaches,” Sloan added.

Study findings suggest that the dose of therapy needed for beneficial outcomes is not as large as previously thought. PTSD symptoms can be reduced significantly with less therapeutic exposure and therapy sessions.

The study, "A Brief Exposure-Based Treatment vs Cognitive Processing Therapy for Posttraumatic Stress Disorder " was published in JAMA Psychiatry January 2018.

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