Key PointsQuestion
Is written exposure therapy (WET) noninferior to the more
time-intensive prolonged exposure therapy (PE) in treating posttraumatic
stress disorder (PTSD)?
Findings
In this randomized clinical trial of 178 veterans diagnosed
with PTSD, participants in both treatments improved significantly, with
large observed effect sizes. Despite a considerable difference in the
number of treatment sessions, WET was noninferior to PE, and treatment
retention was significantly better among those who received WET.
Meaning
These findings suggest that WET is a viable option for PTSD
treatment and has the potential to reach a greater number of individuals
who are in need of PTSD treatment.
Importance
Evidence-based treatments for posttraumatic stress disorder
(PTSD) exist, but all require 8 to 15 sessions and thus are less likely
to be completed than brief treatments. Written exposure therapy (WET) is
a brief and efficacious treatment that has not been directly compared
with prolonged exposure therapy (PE), a more time-intensive,
exposure-based treatment.
Objective
To determine whether WET is noninferior to PE in treating PTSD among veterans.
Design, Setting, and Participants
A randomized noninferiority clinical trial was conducted
between September 9, 2019, and April 30, 2022. Participants were 178
veterans with PTSD presenting to 1 of 3 Veterans Affairs medical
centers. Inclusion criteria consisted of a primary diagnosis of PTSD and
stable medication. Exclusion criteria included current psychotherapy
for PTSD, high suicide risk, active psychosis, unstable bipolar
disorder, and severe cognitive impairment. Independent evaluations were
conducted at baseline and 10, 20, and 30 weeks after the first treatment
session. Data were analyzed from January 1 to March 31, 2023.
Interventions
Participants assigned to WET (n = 88) received five to seven
45- to 60-minute sessions. Participants assigned to PE (n = 90) received
eight to fifteen 90-minute sessions. The WET sessions included 30
minutes of writing-based imaginal exposure conducted in session, whereas
PE sessions included 40 minutes of in-session imaginal exposure and
between-session in vivo exposures.
Main Outcomes and Measures
The primary outcome was change in PTSD symptom severity measured with the Clinician-Administered PTSD Scale for DSM-5
(CAPS-5) from baseline to the 20-week assessment; noninferiority was
defined as a less than 10-point difference between the 2 treatment
groups. Difference in treatment dropout was also examined.
Results
Of the 178 participants, 134 (75.3%) were men, and the mean
(SD) age was 44.97 (13.66) years. In terms of race, 37 participants
(20.8%) were Black, 112 (62.9%) were White, 11 (6.2%) were more than 1
race, and 18 (10.1%) were of other race (including American Indian or
Alaska Native, Asian, and Native Hawaiian or Other Pacific Islander
[some participants did not specify their race when selecting the
category “other”]); in terms of ethnicity, 19 participants (10.7%) were
Hispanic. Changes in PTSD symptom severity from baseline to all
subsequent assessments among individuals randomized to WET were
noninferior relative to individuals randomized to PE. The largest
difference between treatments was observed at 10 weeks and was in favor
of WET (mean difference, 2.42 [95% CI, 0.35-1.46] points). Participants
were significantly less likely to drop out of WET compared with PE (11
[12.5%] vs 32 [35.6%]; χ2 = 12.91; Cramer V = 0.27).
Conclusions and Relevance
In this study, WET was noninferior to PE in PTSD symptom
change and was associated with significantly less attrition. Findings
suggest that WET may transcend previously observed barriers to PTSD
treatment for both patients and clinicians.
Trial Registration
ClinicalTrials.gov Identifier: NCT03962504
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