Abstract
Posttraumatic stress disorder (PTSD) occurs more commonly among military service members than among civilians; however, despite the availability of several evidence-based treatments, there is a need for more efficient evidence-based PTSD treatments to better address the needs of service members. Written exposure therapy is a brief PTSD intervention that consists of 5 sessions with no between-session assignments, has demonstrated efficacy, and is associated with low treatment dropout rates, but prior randomized clinical trials of this intervention have focused on civilian populations. To investigate whether the brief intervention, written exposure therapy, is noninferior in the treatment of PTSD vs the more time-intensive cognitive processing therapy among service members diagnosed with PTSD. The study used a randomized, noninferiority design with a 1:1 randomization allocation. Recruitment for the study took place from August 2016 through October 2020. Participants were active-duty military service members diagnosed with posttraumatic stress disorder. The study was conducted in an outpatient setting for service members seeking PTSD treatment at military bases in San Antonio or Killeen, Texas. Participants received either written exposure therapy, which consisted of 5 weekly sessions, or cognitive processing therapy, which consisted of 12 twice-weekly sessions. Participants were assessed at baseline and at 10, 20, and 30 weeks after the first treatment session. The primary outcome measure was PTSD symptom severity assessed with the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5). Noninferiority was defined as the difference between the 2 groups being less than the upper bound of the 1-sided 95% CI-specified margin of 10 points on the CAPS-5. Overall, 169 participants were included in the study. Participants were predominantly male (136 [80.5%]), serving in the Army (167 [98.8%]), with a mean (SD) age of 34 (8) years. Eighty-five participants were randomly assigned to written exposure therapy, with 65 (76.5%) completing all treatment sessions, and 84 to cognitive processing therapy, with 47 (54.8%) completing all treatment sessions. Findings indicated that written exposure therapy was noninferior to cognitive processing therapy, with the largest difference in change in outcome between the treatment conditions of 3.96 points on the outcome measure. The 1-sided 95% CI upper limit was less than 10 points across time points in both groups and ranged from 4.59 at week 30 to 6.81 at week 10. Within-condition effect sizes ranged from a Cohen d of 0.48 for the written exposure therapy group in the intention-to-treat analysis at week 10 to 0.95 for the cognitive processing therapy group in the per-protocol analysis at week 10, and between-condition effect size ranged from 0.06 in the intention-to-treat analysis at week 30 to 0.22 in the per-protocol analysis at week 10. In this randomized clinical trial, support was found for an effective and more efficient PTSD treatment approach for service members. Future research should determine who does and does not benefit from PTSD treatment to best maximize treatment outcomes. ClinicalTrials.gov Identifier: NCT03033602.
Highlights
Posttraumatic stress disorder (PTSD) is a prevalent and debilitating disorder
Dropout rates for written exposure therapy were significantly lower than for cognitive processing therapy. Meaning These findings suggest that written exposure therapy, a more efficient treatment approach for PTSD than cognitive processing therapy, should be considered for military service members
This study examined whether Written exposure therapy11 (WET) is noninferior to the cognitive processing therapy (CPT) protocol that does not include written trauma accounts in PTSD symptom change and whether it reduces treatment dropout among service members
Summary
Posttraumatic stress disorder (PTSD) is a prevalent and debilitating disorder. The prevalence of PTSD is greater among military service members[1] than among the general population.[2] Prior studies suggest that service members with PTSD may be treated effectively with evidence-based treatments, such as prolonged exposure[3] and cognitive processing therapy (CPT).[4,5] service members are often reluctant to seek mental health care,[6] and when they do receive care for PTSD, a higher percentage drop out of treatment prematurely compared with civilians who receive PTSD treatment.[7] there are numerous reasons for not seeking PTSD treatment or dropping out prematurely, one possible explanation is that those with PTSD have competing demands on their time.[8] Evidence-based PTSD treatments typically require 8 to 15 sessions, as well as betweensession assignments that can require a substantial amount of time to complete.[9,10] The time investment may be challenging for patients. Many service members struggling with PTSD may not have an opportunity to engage in these treatments, especially if they are undergoing intensive military training assignments, are required to travel on temporary duty assignments, or are preparing for a deployment
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