Written Exposure Therapy vs Prolonged Exposure Therapy in the Treatment of Posttraumatic Stress Disorder

Abstract

ImportanceEvidence-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.ObjectiveTo determine whether WET is noninferior to PE in treating PTSD among veterans.Design, Setting, and ParticipantsA 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.InterventionsParticipants 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 MeasuresThe 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.ResultsOf 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 RelevanceIn 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 RegistrationClinicalTrials.gov Identifier: NCT03962504

A systematic review of written exposure therapy for the treatment of posttraumatic stress symptoms.

“…Table 1 displays information regarding each of the 17 articles included in the review. Notably, 14 (82%) articles were published since 2020 (Ahmadi et al, 2022; Andrews et al, 2022; Ellis et al, 2023; LoSavio et al, 2023; Morissette et al, 2023; Nillni et al, 2023; Park et al, 2021; Schacht et al, 2023; Schumacher et al, 2023; Sloan et al, 2022, 2023; Tyler et al, 2022; Yun & Lee, 2022; Zolfa et al, 2023). Study sample sizes ranged from three to 277.…”

“…Seven (43%) of the studies used an RCT design, with four of these studies comparing WET with a more time-intensive trauma-focused treatment for PTSD (Ahmadi et al, 2022; Sloan et al, 2018, 2022, 2023); one RCT compared WET to a trauma-focused expressive writing condition (Ellis et al, 2023), and the other two RCTs compared WET with a no treatment condition (Sloan et al, 2012; Zolfa et al, 2023). One of the ten open trial studies was a large ( N = 277) hybrid implementation-effectiveness study conducted within the Department of Veterans Affairs (LoSavio et al, 2023); LoSavio et al is one of only three (Morrissette et al, 2023; Sloan et al, 2023) effectiveness studies conducted to date, with the remaining studies representing efficacy design. Seven studies (38%) were published by authors other than the developers of WET (Ahmadi et al, 2022; Andrews et al, 2022; Ellis et al, 2023; Park et al, 2021; Schacht et al, 2023; Yun & Lee, 2022; Zolfa et al, 2023).…”

“…Ten of the 17 included studies required a PTSD diagnosis for inclusion (LoSavio et al, 2023; Park et al, 2021; Schumacher et al, 2023; Sloan et al, 2012, 2013, 2018, 2022, 2023; Tyler et al, 2022; Yun & Lee, 2022), whereas seven studies used a cutoff score on a PTSD self-report measure for inclusion (Ahmadi et al, 2022; Andrews et al, 2022; Ellis et al, 2023; Morissette et al, 2023; Nillni et al, 2023; Schacht et al, 2023; Zolfa et al, 2023).…”

“…As displayed in Table 1, six studies used a semistructured interview to assess PTSD symptom severity treatment outcome (Park et al, 2021; Sloan et al, 2012, 2018, 2022, 2023; Yun & Lee, 2022). The other 11 studies used a PTSD self-report measure.…”

Truth in myth: Ancient Stories' windows on treating modern trauma

“…On the contrary if we find and fund a diversity of treatment types, we may attract more clinicians from more disciplines, like nursing, than if we proscript only a few. The development of WET for PTSD and its major strides in reducing dropout suggest room for creativity and growth (Sloan et al, 2023). Precision mental health, highly individualized, technology-guided treatment, is gaining traction but cannot reliably assist treatment decisions yet (Bickman, 2020).…”