A review of the inclusion of ethnoracial groups in empirically supported posttraumatic stress disorder treatment research.

Abstract

Objective: Empirically supported treatments (ESTs) have been criticized for lack of ethnoracial representation, which may limit the generalizability of findings for non-White patients. This study assessed ethnoracial representation in United States-based randomized controlled trials (RCTs) for three evidence-based treatments for posttraumatic stress disorder (PTSD)-Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), and Eye-Movement Desensitization and Reprocessing (EMDR). Method: Representation was measured by explicit inclusion of people of color in published PTSD RCTs. Follow-up emails were sent to corresponding authors if full demographic information was not included in the reviewed manuscripts. Information concerning participant remuneration was collected for descriptive purposes. Results: All three treatment modalities reported White participants as the majority in their sample. PE and CPT trials reported similar levels of ethnoracial diversity, while EMDR efficacy studies reported the least ethnoracial diversity. Across the reviewed studies, with few exceptions, we found low numbers of non-White participants in the majority of reviewed studies, which was compounded by poor or unclear methods of reporting ethnoracial information. Conclusions: This study demonstrates that the ESTs for PTSD are not adequately representative of the majority of non-White participants. Future RCTs should place a stronger emphasis on broad ethnoracial diversity in study participants to improve generalizability of findings. Clinical Impact StatementThis study highlights a concerning lack of ethnoracial representation in PTSD clinical trials for commonly used, evidence-based PTSD treatments. This lack of ethnoracial representation impairs our ability to detect cross-cultural differences in treatment response and offer culturally sensitive, evidence-based PTSD treatment. We encourage researchers to explicitly include larger numbers of non-White participants in PTSD clinical trials and to conduct analyses to detect ethnoracial differences in both symptom presentation and treatment response.

The inclusion of ethnoracial, sexual, and gender minority groups in randomized controlled trials of dialectical behavior therapy: A systematic review of the literature.

“…Despite these efforts, literature reviews of ethnoracial minority representation in clinical trials for obsessive compulsive disorder (OCD; Williams et al, 2010), panic disorder (Mendoza et al, 2012), depression (Polo et al, 2019), posttraumatic stress disorder (PTSD; Grau et al, 2021), and Prolonged Exposure (PE) therapy for PTSD (Benuto et al, 2020) reveal that ethnoracial minority groups are largely underrepresented in the RCTs that comprise the evidence base for these treatments. Fewer than half of the RCTs for OCD, panic disorder, and depression even reported the ethnoracial characteristics of the samples (Mendoza et al, 2012; Polo et al, 2019; Williams et al, 2010), though there is evidence that reporting practices in clinical trials for depression have improved over time (Polo et al, 2019).…”

“…Fewer than half of the RCTs for OCD, panic disorder, and depression even reported the ethnoracial characteristics of the samples (Mendoza et al, 2012; Polo et al, 2019; Williams et al, 2010), though there is evidence that reporting practices in clinical trials for depression have improved over time (Polo et al, 2019). Of the studies that did report ethnoracial data, the majority of participants were White in OCD trials (91.5%; Williams et al, 2010), panic disorder trials (82.7%; Mendoza et al, 2012), depression trials (80.7%; Polo et al, 2019), and PTSD trials (58.9%; Benuto et al, 2020; Grau et al, 2021). 3 Although PTSD trials have included the highest proportion of ethnoracial minority participants (41.1%), the representativeness of the samples varies considerably by treatment and ethnoracial subgroup (Benuto et al, 2020; Grau et al, 2021).…”

“…Of the studies that did report ethnoracial data, the majority of participants were White in OCD trials (91.5%; Williams et al, 2010), panic disorder trials (82.7%; Mendoza et al, 2012), depression trials (80.7%; Polo et al, 2019), and PTSD trials (58.9%; Benuto et al, 2020; Grau et al, 2021). 3 Although PTSD trials have included the highest proportion of ethnoracial minority participants (41.1%), the representativeness of the samples varies considerably by treatment and ethnoracial subgroup (Benuto et al, 2020; Grau et al, 2021). Several potential barriers for recruitment of ethnoracial minority populations have been identified, such as language barriers, limited access to care, and challenges with cross-cultural assessment (Alegria et al, 2004; Lau et al, 2010).…”

Representing all of us: Methodological and conceptual issues in the PTSD treatment literature, with a scoop of reality.

“…As such, this approach has not been able to guide the development of treatments that represent all of us. The design and conduct of a study explicitly intended to examine moderation however may be practically impossible, requiring a significant number of data collection sites, herculean between-site coordination, consideration of participant access, and as noted by Grau et al (2022), adequate remuneration of participants. Large scale, multi-site studies like those completed by STRONG STAR and the Consortium to Alleviate PTSD and in Department of Veterans Affairs Cooperative Studies (e.g., Schnurr et al, 2022) are the exceptions to the rule.…”

Clinical supervision in delivering cognitive behavior therapy across race, ethnicity, and culture.

“…Another study examining obsessivecompulsive disorder (OCD) randomized controlled trials from 1995 to 2008 found that samples (n = 2,221) were 91.5% White (Williams et al, 2010). Trials of eye movement desensitization and reprocessing have included almost no people of color at all (Grau et al, 2022). Therefore, trainees should understand that many treatments are not generalizable to people of color; as such, they may not work as intended and may need to be modified (e.g., Williams et al, 2014).…”