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JAMA Insights
Clinical Update
January 30, 2020

First-line Psychotherapies for Military-Related PTSD

Author Affiliations
  • 1New York University School of Medicine, New York
  • 2Massachusetts Veterans Epidemiological Research and Information Center (MAVERIC), Veterans Affairs Boston Healthcare System, Boston, Massachusetts
  • 3Boston University School of Medicine, Boston, Massachusetts
  • 4Center for Alcohol Use Disorder and Posttraumatic Stress Disorder, Steven and Alexandra Cohen Veterans Center for Posttraumatic Stress and Traumatic Brain Injury, New York University School of Medicine, New York
JAMA. 2020;323(7):656-657. doi:10.1001/jama.2019.20825

Two well-established first-line cognitive-behavioral psychotherapies for posttraumatic stress disorder (PTSD), prolonged exposure therapy (PE) and cognitive processing therapy (CPT), are used in the US Department of Veterans Affairs (VA) and US Department of Defense (DoD) based chiefly on good outcomes in randomized clinical trials (RCTs) with civilians. PE and CPT are manualized (ie, protocolized in a session-by-session manner) trauma-focused therapies that are based on processing the emotional and cognitive aspects of the traumatic event. Consequently, these treatments are emotionally demanding for patients because PTSD is characterized by a strong motivation to avoid talking about the trauma and rekindling negative emotions associated with it. The prominence of PE and CPT in treating individuals with military-related PTSD has been increasingly challenged in recent years because RCTs of veterans and military personnel have yielded mixed results, with patients often not obtaining clinically meaningful symptom improvement. These findings have led to questions about the extent to which these therapies should be prioritized and how military-related PTSD is best conceptualized, namely as a disorder that can be reliably managed by brief (approximately 12 session) monotherapies or as a highly complex and multiform condition requiring more individualized and comprehensive intervention.