How Effective Are Evidence-Based Psychotherapies for PTSD in Real-World Clinical Practice?

What you need to know

• Cognitive processing therapy (CPT) and prolonged exposure (PE) therapy led to modest improvements in PTSD symptoms compared to non-evidence-based therapies in real-world clinical practice.
• CPT and PE were similarly effective, with no significant differences between the two treatments.
• While helpful, the level of improvement from these evidence-based therapies was lower than typically seen in controlled clinical trials.

Background on PTSD and Evidence-Based Psychotherapies

Post-traumatic stress disorder (PTSD) is a mental health condition that can develop after experiencing or witnessing a traumatic event. It is characterized by symptoms such as intrusive memories, avoidance behaviors, negative changes in thinking and mood, and changes in physical and emotional reactions. PTSD can significantly impact a person’s daily functioning and quality of life.

To address PTSD, mental health professionals have developed evidence-based psychotherapies (EBPs) - treatments that have been scientifically tested and found to be effective in clinical trials. Two of the most widely recognized EBPs for PTSD are cognitive processing therapy (CPT) and prolonged exposure (PE) therapy.

CPT is a type of cognitive-behavioral therapy that helps individuals process traumatic experiences by identifying and challenging unhelpful thoughts and beliefs related to the trauma. PE involves gradually confronting trauma-related memories, feelings, and situations that the individual has been avoiding. Both therapies aim to reduce PTSD symptoms and improve overall functioning.

While these treatments have shown promise in controlled research settings, their effectiveness in real-world clinical practice has been less clear. This study aimed to examine how well CPT and PE work for veterans receiving treatment in the Veterans Health Administration (VHA), the largest integrated healthcare system in the United States.

The Study: Examining Real-World Effectiveness

Researchers conducted a large-scale study using data from over 265,000 veterans who received mental health care in the VHA system. They used advanced statistical methods to create “emulated trials” that mimicked randomized controlled trials using real-world clinical data. This approach allowed them to compare the effectiveness of CPT and PE to non-evidence-based psychotherapies, as well as to each other.

The study focused on post-9/11 veterans diagnosed with PTSD who initiated mental health care between 2007 and 2017. Researchers used a sophisticated computer algorithm to identify when veterans received CPT or PE from their medical records. They then tracked changes in PTSD symptoms using a standardized measure called the PTSD Checklist (PCL).

Key Findings: Modest Improvements in PTSD Symptoms

The study found that both CPT and PE led to improvements in PTSD symptoms compared to non-evidence-based therapies. However, the level of improvement was more modest than what is typically seen in controlled clinical trials.

Cognitive Processing Therapy (CPT) Results

Veterans who completed at least 8 sessions of CPT showed greater improvement in their PTSD symptoms compared to those who received non-evidence-based therapies. On average, CPT completers had a 6.4-point greater reduction in PCL scores (which measure PTSD symptom severity) compared to the control group.

Additionally, veterans who completed CPT were more likely to experience a clinically significant improvement in their symptoms. About 12% more CPT completers achieved “recovery” (defined as a substantial decrease in symptoms and a final PCL score below a certain threshold) compared to those receiving non-evidence-based care.

Prolonged Exposure (PE) Therapy Results

The results for PE were similar to those for CPT. Veterans who completed at least 8 sessions of PE showed a 9.7-point greater reduction in PCL scores compared to those receiving non-evidence-based therapies.

However, the difference in recovery rates between PE completers and the control group was smaller and not statistically significant. This means that while PE led to greater symptom reduction overall, it did not necessarily result in more veterans achieving full recovery compared to other forms of therapy.

Comparing CPT and PE

When the researchers directly compared CPT and PE, they found no significant differences in effectiveness between the two treatments. Both therapies led to similar levels of symptom improvement and recovery rates.

Implications: Bridging the Gap Between Research and Practice

These findings have important implications for both healthcare providers and individuals seeking treatment for PTSD:

1. Evidence-based therapies work in real-world settings: The study confirms that CPT and PE can lead to meaningful improvements in PTSD symptoms, even outside of controlled research environments. This supports their continued use in clinical practice.

2. Expectations may need adjustment: The more modest improvements seen in this study compared to clinical trials suggest that patients and providers should have realistic expectations about treatment outcomes. While these therapies can be helpful, they may not always lead to dramatic or complete symptom resolution.

3. Treatment choice flexibility: Since CPT and PE showed similar effectiveness, healthcare providers can feel confident offering either option based on patient preferences and individual factors. This flexibility may help improve treatment engagement and completion rates.

4. Need for continued research and improvement: The study highlights that there is still room for improvement in PTSD treatments. Researchers and clinicians should continue working to enhance existing therapies or develop new approaches to achieve better outcomes for more patients.

5. Importance of treatment completion: The study found that completing at least 8 sessions of therapy was associated with better outcomes. This underscores the importance of supporting patients in engaging with and completing a full course of treatment.

Conclusions

• CPT and PE are effective treatments for PTSD in real-world clinical settings, leading to modest but meaningful improvements in symptoms.
• The level of improvement from these therapies in everyday practice may be lower than what is typically seen in controlled clinical trials.
• There is no significant difference in effectiveness between CPT and PE, allowing for flexibility in treatment selection.
• While evidence-based therapies for PTSD are helpful, there is still a need for research to further improve treatment outcomes for veterans and others with PTSD.

This study provides valuable insights into the real-world effectiveness of evidence-based psychotherapies for PTSD. By bridging the gap between controlled research and clinical practice, it helps set realistic expectations for treatment outcomes and highlights areas for future improvement in PTSD care.