By Marilynn Larkin
NEW YORK—Written exposure therapy (WET) is noninferior to first-line cognitive processing therapy (CPT) for treating posttraumatic stress disorder (PTSD) and can be delivered in fewer sessions, researchers say.
WET involves writing about a traumatic experience under clinical guidance, using a structured format.
“Our study has important implications for clinicians, as it suggests that PTSD can be effectively treated using a much shorter, less burdensome intervention – i.e., five sessions, minimal face-to-face time with the therapist, no between-session homework assignments - than what is typically used in clinical practice,” Dr. Denise Sloan of National Center for PTSD, VA Boston Healthcare System, told Reuters Health.
“This is important because clinicians and patients frequently face time and resource barriers that preclude the provision and receipt of other evidence-based practices for PTSD,” she said by email.
“Having an effective, brief treatment such as WET for PTSD allows for more patients to access and receive effective treatment.”
Dr. Sloan and colleagues compared WET to CPT in a randomized noninferiority trial of 126 veterans and nonveterans (mean age, 44; about half women) conducted at a single VA center.
Participants randomized to CPT received 12 sessions, whereas WET participants received five. The CPT protocol used in this study includes written accounts; it was delivered one-on-one in hour-long weekly sessions. The first WET session required an hour and the remaining four sessions, 40 minutes each.
Assessments were conducted at baseline and at 6, 12, 24, and 36 weeks after the first treatment session.
As reported in JAMA Psychiatry, online January 17, improvements in PTSD symptoms in the WET group were noninferior to improvements in the CPT group at each assessment period.
The largest difference between treatments was observed at the week 24 assessment (mean difference, 4.31 points). Fewer than half of participants in both groups had PTSD at weeks 24 and 36. A PTSD diagnosis was not more likely in either group at any assessment.
Significantly fewer participants dropped out of WET versus CPT (6.4% vs. 39.7%).
“Although WET involves fewer sessions, it was noninferior to CPT in reducing symptoms of PTSD,” the authors state. “The findings suggest that WET is an efficacious and efficient PTSD treatment that may reduce attrition and transcend previously observed barriers to PTSD treatment for both patients and providers.”
For WET, “the quality of the patient’s writing does not matter as much as the degree to which he or she follows the instructions and, in so doing, confronts the traumatic memory,” Dr. Sloan said.
“Education level or verbal ability does not affect the outcome associated with WET,” she stressed. “In addition, WET has been found to be beneficial among individuals for whom English is not their primary language, and a Spanish language version of the manual is available.”
Dr. Andrew McAleavey, a psychologist at Weill Cornell Medicine and NewYork-Presbyterian in New York City, told Reuters Health, “I have never used WET; however, it is a fairly recently developed adaptation of probably the best-researched treatment for PTSD, which is Prolonged Exposure, with which I am very familiar.”
“Overall, the study results are very promising and encouraging,” he said by email. “They certainly suggest that this brief treatment makes a large difference in patients’ lives, comparable to one of the gold-standard treatments available right now.”
“An intervention like WET is almost certainly highly cost-effective because it requires minimal clinician time and training (two hours total training for this group of experienced therapists),” he added.
“With any treatment in a relatively early state of development, there are some unknowns; the biggest might be long-term outcomes, as this study only followed patients for 36 weeks after the start of treatment,” he noted.
“Another uncertainty is the mechanism of treatment action for WET,” Dr. McAleavey continued. “The researchers have proposed exposure as the primary mechanism, but many other possibilities exist, including cognitive re-appraisal. This study did not establish exactly why WET seems to be effective.”
“If the mechanism is the same as that of the gold-standard comparator treatment and the dose is all that differs between them,” he said, “we would be likely to lean towards treatments that offer similar (results) with lower doses.”
“If the mechanisms differ, the treatments are more likely to be effective for different subsets of patients,” he suggested, “and the larger dose of therapy in one condition may be necessary for some people.”
“This is a very exciting development in PTSD treatment, but this study does not mean that patients can effectively treat their symptoms by unstructured, independent journaling,” he cautioned.
“While we have a good amount of evidence that expressive writing can be helpful when done in a structured way, the WET intervention includes other components, (including) a trained clinician to guide treatment and answer questions,” he said.
“Additional work will need to be done to determine what patients are best suited for this type of treatment, and who may benefit from other treatments,” he concluded.
JAMA Psychiatry 2018.
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