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A Brief Exposure-Based Treatment vs Cognitive Processing Therapy for Posttraumatic Stress Disorder: A Randomized Noninferiority Clinical Trial
Open accessAbstract
Importance: Written exposure therapy (WET), a 5-session intervention, has been shown to efficaciously treat posttraumatic stress disorder (PTSD). However, this treatment has not yet been directly compared with a first-line PTSD treatment such as cognitive processing therapy (CPT). Objective: To determine if WET is noninferior to CPT in patients with PTSD. Design, Setting, and Participants: In this randomized clinical trial conducted at a Veterans Affairs medical facility between February 28, 2013, and November 6, 2016, 126 veteran and nonveteran adults were randomized to either WET or CPT. Inclusion criteria were a primary diagnosis of PTSD and stable medication therapy. Exclusion criteria included current psychotherapy for PTSD, high risk of suicide, diagnosis of psychosis, and unstable bipolar illness. Analysis was performed on an intent-to-treat basis. Interventions: Participants assigned to CPT (n = 63) received 12 sessions and participants assigned to WET (n = 63) received 5 sessions. The CPT protocol that 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. Main Outcomes and Measures: The primary outcome was the total score on the Clinician-Administered PTSD Scale for DSM-5; noninferiority was defined by a score of 10 points. Blinded evaluations were conducted at baseline and 6, 12, 24, and 36 weeks after the first treatment session. Treatment dropout was also examined. Results: For the 126 participants (66 men and 60 women; mean [SD] age, 43.9 [14.6] years), improvements in PTSD symptoms in the WET condition were noninferior to improvements in the CPT condition at each of the assessment periods. The largest difference between treatments was observed at the 24-week assessment (mean difference, 4.31 points; 95% CI, -1.37 to 9.99). There were significantly fewer dropouts in the WET vs CPT condition (4 [6.4%] vs 25 [39.7%]; χ21 = 12.84, Cramer V = 0.40). Conclusions and Relevance: Although WET involves fewer sessions, it was noninferior to CPT in reducing symptoms of PTSD. The findings suggest that WET is an efficacious and efficient PTSD treatment that may reduce attrition and transcend previously observed barriers to PTSD treatment for both patients and providers. Trial Registration: clinicaltrials.gov Identifier: NCT01800773.
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“WET is an effective treatment for PTSD and is noninferior to other gold standard PTSD treatments (e.g., Cognitive Processing Therapy) and has lower dropout rates [18–21].”
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“However, this is consistent with previous trials of first-line PTSD treatments [19] and in routine clinical care settings [46] and, importantly, higher than what is seen in a PTSD exposure-based treatment trial with a PTSD/SUD population [47].”
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Metadata
- Authors
- Sloan, D. M., Marx, B. P., Lee, D. J., & Resick, P. A.
- Affiliations
- Boston University (US)
- VA Boston Healthcare System (US)
- Duke Medical Center (US)
- Corresponding author
- Sloan, Denise M.
- Venue
- JAMA Psychiatry
- Publisher
- American Medical Association (AMA)
- Published
- 2018-03-01
- Volume
- 75
- Issue
- 3
- Pages
- 233
- ISSN
- 2168-622X (ISSN-L)
- PMC
- PMC5843538
- OpenAlex
- W2784527080
- Cited by
- 232
- References
- 31
- Citations by year
- 2026: 24 · 2025: 24 · 2024: 27 · 2023: 33 · 2022: 31 · 2021: 25 · 2020: 32 · 2019: 20 · 2018: 15
- FWCI
- 27.03
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- JAMA Psychiatry (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Institutes of Health (4r01mh095737-05)
- National Institute of Mental Health (R01‐MH095737, R0MH095737)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Posttraumatic Stress Disorder Research
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
- Keywords
- post-traumatic stress disorder, written exposure therapy, cognitive processing therapy, non-inferiority, veterans, PTSD symptom severity, treatment discontinuation, psychotherapy comparison, brief psychotherapy, suicide risk, psychosis risk, treatment efficacy, treatment acceptability
- MeSH terms
- Equivalence Trials as Topic, Adult, Boston, Female, Humans, Implosive Therapy, Male, Middle Aged, Patient Dropouts, Psychotherapy, Brief, Stress Disorders, Post-Traumatic, Veterans, Writing, Cognitive Behavioral Therapy, Treatment Outcome
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