Psychotherapy and Pharmacotherapy Show Comparable Benefits for PTSD
Key Clinical Summary
- In a 700-patient trial, both SSRIs and written exposure therapy (WET) produced clinically meaningful PTSD symptom improvement.
- No significant difference in symptom reduction was found between initial psychotherapy and pharmacotherapy arms.
- For SSRI nonresponders, switching to an SNRI was more effective than augmenting with WET.
Primary care patients with posttraumatic stress disorder (PTSD) can achieve clinically meaningful improvements in symptom severity from both brief trauma-focused psychotherapy and pharmacotherapy, though treatment engagement remains a challenge across modalities, according to study results published in JAMA Psychiatry.
The randomized clinical trial included 700 patients who met the clinical criteria for PTSD and were recruited from the primary care clinics of 8 Department of Veterans Affairs (VA) medical centers and 7 federally qualified health centers. Participants were randomized to 1 of 3 treatment groups:
- Selective serotonin reuptake inhibitor (SSRI) treatment followed by written exposure therapy (WET) augmentation if needed (n=278),
- WET followed by SSRI treatment if needed (n=352),
- SSRI treatment followed by a switch to venlafaxine, a serotonin-norepinephrine reuptake inhibitor (SNRI), if needed (n=295).
The primary outcome was change in PTSD symptom severity as measured by the DSM-5 PTSD Checklist (PCL-5) over 4 months.
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At baseline, the mean (SD) PCL-5 score was 52.8 (11.1), indicating significant symptom severity. At 4 months, 51.8% of patients who were randomized to SSRI treatment were adherent and saw a 14.0-point decrease in PCL-5, while 31.5% of those randomized to WET were adherent and reported a 12.1-point PCL-5 decrease. The between-group difference in improvement was not statistically significant (adjusted mean difference [MD], 1.79; 95% CI, −0.76 to 4.34; P = .17).
“These findings indicate that primary care patients with posttraumatic stress disorder benefit from both brief trauma-focused psychotherapy and pharmacotherapy, but additional support may be needed to better promote treatment engagement,” wrote John C. Fortney, PhD, Department of Psychiatry and Behavioral Sciences, Division of Population Health, School of Medicine, University of Washington, Seattle, and study coauthors.
Additional analyses showed that for the 41.4% of patients randomized to an SSRI who did not respond to treatment, switching to an SNRI was more effective than WET augmentation; those who switched to an SNRI saw 9.2-point PCL-5 decrease, while those who switched to WET saw a 2.3-point decrease (adjusted MD, 10.19; 95% CI, 4.97-15.41; P < .001).
“For patients not responding to SSRIs, a switch to venlafaxine appears to yield better outcomes than augmentation with WET, although more research is needed,” the authors wrote. “To achieve full remission, many patients may need to seek additional trauma-focused psychotherapy in specialty mental health settings.”
