Title

Comparison of Prolonged Exposure vs Cognitive Processing Therapy for Treatment of Posttraumatic Stress Disorder Among US Veterans: A Randomized Clinical Trial

Authors

Paula P. Schnurr, Executive Division, National Center for PTSD, White River Junction, Vermont.
Kathleen M. Chard, Cincinnati VA Medical Center, Cincinnati, Ohio.
Josef I. Ruzek, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California.
Bruce K. Chow, VA Cooperative Studies Program Coordinating Center, Palo Alto, California.
Patricia A. Resick, Duke Health, Durham, North Carolina.
Edna B. Foa, University of Pennsylvania Perelman School of Medicine, Department of Psychiatry, Philadelphia.
Brian P. Marx, Behavioral Science Division, National Center for PTSD, Boston, Massachusetts.
Matthew J. Friedman, Executive Division, National Center for PTSD, White River Junction, Vermont.
Michelle J. Bovin, Behavioral Science Division, National Center for PTSD, Boston, Massachusetts.
Kristina L. Caudle, Executive Division, National Center for PTSD, White River Junction, Vermont.
Diane Castillo, Center of Excellence, Central Texas VA Health Care System, Waco.
Kyle T. Curry, Minneapolis VA Medical Center, Minneapolis, Minnesota.
Michael Hollifield, Tibor Rubin VA Medical Center, Long Beach, California.
Grant D. Huang, Cooperative Studies Program Central Office, Department of Veterans Affairs Office of Research & Development, Washington, District of Columbia.
Christine L. Chee, Raymond G. Murphy VA Medical Center, Albuquerque, New Mexico.
Millie C. Astin, Atlanta VA Medical Center, Atlanta, Georgia.
Benjamin Dickstein, Cincinnati VA Medical Center, Cincinnati, Ohio.
Kerry Renner, VA Northeast Ohio Healthcare System, Cleveland.
Carolina P. Clancy, Durham VA Medical Center, Durham, North Carolina.
Claire Collie, Durham VA Medical Center, Durham, North Carolina.
Kelly Maieritsch, Edward Hines Jr. VA Hospital, Hines, Illinois.
Su Bailey, Michael E. DeBakey VA Medical Center, Houston, Texas.
Karin Thompson, Michael E. DeBakey VA Medical Center, Houston, Texas.
Michael Messina, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin.
Laurel Franklin, New Orleans VA Medical Center, New Orleans, Louisiana.
Steve Lindley, Palo Alto VA Medical Center, Palo Alto, California.
Karen Kattar, Phoenix VA Medical Center, Phoenix, Arizona.
Brandi Luedtke, Phoenix VA Medical Center, Phoenix, Arizona.
Jennifer Romesser, George E. Whalen VA Medical Center, Salt Lake City, Utah.
John McQuaid, San Francisco VA Medical Center, San Francisco, California.
Patrick Sylvers, VA Puget Sound Health Care System, American Lake Division, Tacoma, Washington.
Ruth Varkovitzky, VA Puget Sound Health Care System, American Lake Division, Tacoma, Washington.

Document Type

Journal Article

Publication Date

1-4-2022

Journal

JAMA network open

Volume

5

Issue

1

DOI

10.1001/jamanetworkopen.2021.36921

Abstract

Importance: Posttraumatic stress disorder (PTSD) is a prevalent and serious mental health problem. Although there are effective psychotherapies for PTSD, there is little information about their comparative effectiveness. Objective: To compare the effectiveness of prolonged exposure (PE) vs cognitive processing therapy (CPT) for treating PTSD in veterans. Design, Setting, and Participants: This randomized clinical trial assessed the comparative effectiveness of PE vs CPT among veterans with military-related PTSD recruited from outpatient mental health clinics at 17 Department of Veterans Affairs medical centers across the US from October 31, 2014, to February 1, 2018, with follow-up through February 1, 2019. The primary outcome was assessed using centralized masking. Tested hypotheses were prespecified before trial initiation. Data were analyzed from October 5, 2020, to May 5, 2021. Interventions: Participants were randomized to 1 of 2 individual cognitive-behavioral therapies, PE or CPT, delivered according to a flexible protocol of 10 to 14 sessions. Main Outcomes and Measures: The primary outcome was change in PTSD symptom severity on the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) from before treatment to the mean after treatment across posttreatment and 3- and 6-month follow-ups. Secondary outcomes included other symptoms, functioning, and quality of life. Results: Analyses were based on all 916 randomized participants (730 [79.7%] men and 186 [20.3%] women; mean [range] age 45.2 [21-80] years), with 455 participants randomized to PE (mean CAPS-5 score at baseline, 39.9 [95% CI, 39.1-40.7] points) and 461 participants randomized to CPT (mean CAPS-5 score at baseline, 40.3 [95% CI, 39.5-41.1] points). PTSD severity on the CAPS-5 improved substantially in both PE (standardized mean difference [SMD], 0.99 [95% CI, 0.89-1.08]) and CPT (SMD, 0.71 [95% CI, 0.61-0.80]) groups from before to after treatment. Mean improvement was greater in PE than CPT (least square mean, 2.42 [95% CI, 0.53-4.31]; P = .01), but the difference was not clinically significant (SMD, 0.17). Results for self-reported PTSD symptoms were comparable with CAPS-5 findings. The PE group had higher odds of response (odds ratio [OR], 1.32 [95% CI, 1.00-1.65]; P < .001), loss of diagnosis (OR, 1.43 [95% CI, 1.12-1.74]; P < .001), and remission (OR, 1.62 [95% CI, 1.24-2.00]; P < .001) compared with the CPT group. Groups did not differ on other outcomes. Treatment dropout was higher in PE (254 participants [55.8%]) than in CPT (215 participants [46.6%]; P < .01). Three participants in the PE group and 1 participant in the CPT group were withdrawn from treatment, and 3 participants in each treatment dropped out owing to serious adverse events. Conclusions and Relevance: This randomized clinical trial found that although PE was statistically more effective than CPT, the difference was not clinically significant, and improvements in PTSD were meaningful in both treatment groups. These findings highlight the importance of shared decision-making to help patients understand the evidence and select their preferred treatment. Trial Registration: ClinicalTrials.gov Identifier: NCT01928732.

Department

Psychiatry and Behavioral Sciences

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