Prolonged exposure or cognitive processing therapy for PTSD?
Cognitive processing therapy and prolonged exposure are the two main trauma-focused cognitive behavioral psychotherapies used for Veterans Affairs patients with PTSD.
Research has shown that both treatments are effective with veterans and non-veterans. However, the researchers had never compared the two treatments head-to-head in a population of military veterans to find out which is more effective.
In the first paper comparing the two psychotherapies in veterans, a VA study of over 900 veterans with PTSD found that prolonged exposure was statistically more effective than cognitive processing therapy in easing PTSD symptoms. But the difference was not clinically significant, with most veterans showing significant improvement from both treatments. The researchers recommended shared decision-making between clinicians and patients to help patients understand the evidence and select their preferred treatment.
Paula Schnurr, executive director of VA’s National Center for PTSD, was lead author on the study, which was also the largest psychotherapy study of PTSD to date. in any population of the total number of participants: 916. The results are published in JAMA network open.
Schnurr said deciding which psychotherapy to use should be done through provider-patient consultation.
“Shared decision making is a collaborative process between a patient and a provider to help the patient choose a preferred treatment,” she says. “It’s about giving the patient evidence-based information about treatment options, effectiveness, benefits, and risks, and helping them clarify their goals and preferences in order to select their preferred treatment.”
Kate Chard of VA Cincinnati and Joe Ruzek, former head of the National Center for PTSD Outreach and Education Division, co-directed the study, which was supported by the VA Cooperative Studies Program.
The two psychotherapies at the center of the study adopt different approaches.
Prolonged exposure helps people with PTSD gradually address trauma-related memories, feelings, and situations that they have avoided since their trauma. Patients are repeatedly asked to recall and describe aloud the details of their traumatic experience. By coping with these challenges, patients can reduce their PTSD symptoms. Between sessions, they listen to a recording of themselves describing their traumatic moments.
Cognitive processing therapy helps people with PTSD assess upsetting thoughts that have existed since the trauma, with a focus on changing the way they view themselves and the world. Therapists teach skills that help patients decide if there are better ways to think about the trauma. Patients learn to challenge their trauma-related beliefs through critical thinking and the use of daily worksheets.
Unlike much of the traditional healthcare industry, prolonged exposure and cognitive processing therapy is widely available in VA, as the agency launched a nationwide training program in 2006 requiring all VA medical centers to offer to patients. Both therapies are included in a broader training that covers 17 evidence-based psychotherapies for mental disorders.
Understanding the complex nature of post-traumatic stress disorder, commonly referred to as PTSD, is one of VA’s most pressing challenges. The agency says many veterans who fought in Vietnam, the Gulf War and the post-9/11 conflicts in Iraq and Afghanistan have had this mental health issue at some point in their lives.
The symptoms of PTSD are well documented: reliving trauma through flashbacks and nightmares; avoidance of reminders of a traumatic event; changes in thoughts and feelings, such as guilt and emotional numbness; and hyperarousal.
In the study, 916 veterans from 17 VA medical centers were equally randomized to receive prolonged exposure or cognitive processing therapy. Both groups participated in 12 weekly one-hour sessions. Therapists trained in psychotherapies were assigned to each site. Participants who improved faster could attend fewer sessions, and those who improved more slowly were offered additional sessions. Over 70% of veterans in both groups reported combat exposure, just over a third reported military sexual trauma, and over 90% experienced a psychiatric disorder other than PTSD.
The participants did not know in advance which treatment they were receiving, but discovered it once the sessions began. It was on purpose, says Schnurr, who is also a professor of psychiatry at Dartmouth College. Blinding was important during the randomization phase of the study, but once treatment began, it was critical that participants understood the treatment they were receiving.
“Part of what makes psychotherapy useful is showing that patients have adequate knowledge and understanding of why they are doing the treatment and what it involves,” Schnurr says. “They need to understand that they’re not just being exposed for a long time, but what it is and what they’re going to do during the treatment sessions. This is different from a drug study where the standard is to blind patients to the treatment they are receiving, whether it is an active drug or a placebo. In psychotherapy studies, it is important that patients understand the rationale for treatment.
The average age of the participants was 45 years old. Eighty percent were men and 58% served in Iraq and Afghanistan. The dropout rates – 56% in the prolonged exposure cohort and 47% in the cognitive treatment group – were comparable to dropout rates in other recent studies of psychotherapy for PTSD in veterans and practice of psychotherapy in the real world.
The primary outcome was changes in PTSD symptom severity based on the DSM-5 Clinician-Administered PTSD Scale (CAPS-5), considered the gold standard for assessing PTSD symptoms. CAPS-5 is a 30-item structured interview that assesses the presence and severity of all symptoms of PTSD and can be used to diagnose the condition.
Investigators measured improvement in PTSD symptoms at the end of treatment and at three- and six-month follow-up visits.
Regarding the results, Schnurr says she was surprised that prolonged exposure was more effective than cognitive processing therapy because, as she points out, there was no solid evidence in the prior literature for back that up. But she stressed that the difference between the treatments was not clinically significant. The findings, she says, support VA’s decision to train providers in both psychotherapies to improve veterans’ access to effective treatments for PTSD.
“The results of this randomized clinical trial support VA’s strategy of promoting prolonged exposure and cognitive processing therapy and reinforce the guideline recommendations for these treatments as first-line therapies,” the researchers write. “Given that the difference in the primary outcome was not clinically meaningful, the absence of differences between treatments on outcomes other than PTSD, and higher attrition with prolonged exposure, we do not believe that our results support a recommendation for prolonged exposure versus cognitive processing therapy. ”
The study had limitations, including the fact that the participants were veterans with coexisting health conditions and functional impairment. Therefore, the results may not apply to non-veterans or patients with less complex conditions. The results may also not be generalizable to women, since 80% of participants were men. Additionally, the high dropout rate in the study may have reduced the potential benefits of the treatments.
Currently, Schnurr and his colleagues are analyzing the data to help veterans understand which of the two treatments might work best for them based on their personal characteristics, experiences, and clinical needs. The researchers already have educational material on the psychotherapies and the decisions that are made to facilitate the patient’s choice.
“I and other members of the study team will continue to study these treatments, particularly to find ways to make them more effective, efficient and available,” Schnurr said. “I’m also interested in studying shared decision-making for PTSD because it’s such a critical part of delivering veteran-centered care.”
Republished with kind permission from Veterans Affairs Research. Photo: Erin Romero, clinical psychologist and trauma recovery program manager at Baltimore VA Medical Center, is one of thousands of VA mental health clinicians who provide PTSD treatment to veterans.