By James Armontrout, MD
fpamed Forensic Psychiatrist
When people think about psychotherapy often the image of years of weekly meetings with slow-paced and hard-won improvements comes to mind. While this can be the case for some conditions, many newer psychotherapies for Post-Traumatic Stress Disorder can often achieve remarkable results in a time-limited fashion. For example, a patient can typically complete a course of Cognitive Processing Therapy (CPT) or Prolonged Exposure (PE) in around three months (twelve weekly sessions) and may experience enduring improvement in their symptom profile thereafter.
For those with firsthand experience of Post-Traumatic Stress Disorder, it can sometimes be hard to believe that meaningful improvement would take place in such a short timeframe. Those who are familiar with the insomnia, nightmares, dissociative reactions, anger, intrusive thoughts, lack of positive emotion, and other cruel features of PTSD might be understandably skeptical that substantial improvement could be only weeks to months away with proper treatment. Fortunately, published data and clinical experience give good reason for hope.
A new study  was recently published carrying out what is called a Network Meta-Analysis of randomized controlled trials of psychotherapy. In other words, rather than simply comparing two treatments head-to-head the authors analyzed a total of 98 randomized controlled trials assessing various forms of psychotherapy for Post-Traumatic Stress Disorder. The 5,567 participants studied across these many trials allowed the authors to compare outcomes via many different psychotherapeutic approaches. Several conclusions of relevance to clinicians and attorneys that work with people who have Post-Traumatic Stress Disorder emerged.
Some approaches were more effective than others
The authors analyzed a total of nine therapies, along with “treatment as usual” and “no treatment” groups. Reduction of PTSD symptoms was the primary outcome assessed. The psychotherapies with the most robust symptom reduction immediately after treatment were:
- Cognitive Processing Therapy (CPT)
- Eye Movement Desensitization and Reprocessing Therapy (EMDR)
- Cognitive Therapy (CT)
In addition, Narrative Exposure Therapy (NET), Prolonged Exposure (PE), Cognitive Behavioral Therapy (CBT), and Person-Centered Therapy (PCT) produced positive results that were somewhat less robust than the approaches listed above.
Along with looking at outcomes at the time of treatment completion, the study authors looked at both short-term and long-term follow-up. 30 studies with short-term follow-up data showed moderate to large effects sizes for EMDR, CPT, CT, CBT, PE, and NET. 19 studies extended their data collection to assess long-term PTSD outcomes, and from these data CPT and EMDR demonstrated long-term improvement.
In other words, a range of approaches showed a substantial reduction of Post-Traumatic Stress Disorder symptoms at the time treatment concluded. Some approaches, such as CPT and EMDR, had good data to show persisting benefit long after treatment had concluded.
Multiple therapies were associated with remission, or “loss of PTSD Diagnosis”
With treatment, some individuals with PTSD will improve enough to no longer meet criteria for the disorder. This end point, or “loss of PTSD diagnosis,” was assessed using data from 46 of the analyzed trials. Compared to no treatment, participants were estimated to be:
- 2 – 5.8x more likely to achieve remission with CPT,
- 2.2 – 4.3x more likely to achieve remission with EMDR,
- 1.3 – 2.4x more likely to achieve remission with CT,
- 2.7- 11.4x more likely to achieve remission with NET
- A variable range of 1.1 to 3.9x more likely to achieve remission with PE, CBT, PCT, BEP, or treatment as usual
In addition to helping with PTSD, multiple approaches showed a robust positive impact on depression and anxiety levels
48 studies revealed an immediate post-treatment benefit on anxiety levels for NET, CT, CBT, EMDR, and PE. Looking at both short- and long-term follow up, EMDR, CBT, and CT showed enduring benefits on anxiety levels. 68 studies revealed data about depression, with CPT, CT, EMDR, NET, PE, and CBT demonstrating substantial reduction in depression. CPT, EMDR, and CBT showed a significant effect on depression at short-term follow up, and CPT showed enduring improvement in depression at long-term follow up.
These results can help guide clinicians and inform legal proceedings
While no approach to treatment can guarantee improvement, the approaches listed above often result in an improvement in symptoms of PTSD. As seen above, they can also result in full and sustained remission for some participants. Importantly, for many of these approaches an answer about response to treatment can be obtained relatively quickly. Many protocols can be completed in approximately three months, and once Post-Traumatic Stress Disorder has developed early treatment may both increase the odds of response and limit unnecessary suffering. At the same time, the individual’s response to first-line treatment can provide more information about their likely prognosis.
As with all treatments, there are downsides to engaging in trauma-focused psychotherapy. The most common downside is that many approaches involve intentional exposure to distressing thoughts, memories, and feelings related to the trauma. Avoidance of such exposures is a well-recognized hallmark of PTSD, and patients engaged in trauma-focused therapy may find that symptoms get worse before they start to get better. In many protocols, the early weeks can be thought of “opening the wound” with all the associated pain and distress, while the later sessions are more analogous to cleaning and closing the wound to promote proper healing. In addition, finding clinicians who are qualified and available to provide the approaches listed above can be a challenge. Depending on resource availability, some flexibility in the choice of treatment approach may be required.
Another notable downside to trauma-focused therapy is that an upfront commitment to treatment is needed. Advances in telehealth have made treatment more accessible and convenient, especially for patients located far from treatment centers. Still, the patient needs to be comfortable committing to a full course of weekly meetings. For some protocols, such as Prolonged Exposure, a few sessions of treatment followed by dropout may be worse than never having sought treatment at all. The patient may experience the initial worsening without the subsequent relief, and this may reinforce the patient’s belief that their Post-Traumatic Stress Disorder will not respond to treatment. Such an experience can cause unmerited and premature pessimism about treatment.
Despite the downside, the potential relief from suffering can make an investment in therapy very much worth the cost. While seeking treatment, a patient can also discuss whether medications would be a helpful addition to their treatment plan. Several antidepressant medications from the Selective Serotonin Reuptake Inhibitor (SSRI) and Serotonin-Norepinephrine Reuptake Inhibitor (SNRI) classes can also be beneficial for treating PTSD, either in combination with therapy or as a standalone treatment. While some cases of PTSD improve without treatment, the risk of progressing to chronic PTSD increases for those who do not receive adequate treatment.
While this meta-analysis provides useful insight about various treatment options, it remains useful to consult national guidelines about first-line treatment. Guidelines issued by the American Psychological Association  and the Department of Defense and Department of Veterans Affairs  list recommendations for many of the psychotherapeutic approaches discussed above. Whether analyses like this one will change the strength of recommendations for or against various therapeutic options in upcoming iterations of the guidelines remains to be seen.