To the Editor In the network and pairwise meta-analysis comparing psychotherapy with medication for treatment of posttraumatic stress disorder (PTSD), Merz et al1 report no difference at the end of the short-term treatment period but greater benefit for psychotherapy at long-term follow-up. However, their results from the long-term pairwise meta-analysis of medications and psychotherapy are of uncertain validity because 2 of the 3 trials included in that comparison should be considered to have a high risk of bias. Merz and colleagues1 rated one of those trials as having a high risk of bias but rated another trial2 as moderate risk of bias, despite rating it to have a high risk of attrition bias and reporting bias. In that trial, which was rated to have a high risk of bias by a 2018 comprehensive meta-analysis of PTSD treatments,3 47% of the patients randomized to paroxetine refused to participate in the assigned treatment, while none of those randomized to psychotherapy refused. Based on the revised Cochrane risk-of-bias tool, this attrition would be characterized as a “deviation from the intended intervention that arose because of the experimental context”4 and would be sufficient to rate the trial as having a high risk of bias, given uncertainty about the effect of that deviation on the outcome. It is unwise to draw the conclusion that psychotherapy has greater long-term effectiveness than medications for PTSD based on a sample in which 2 of the 3 studies, comprising 75% of the participants, should be considered to have a high risk of bias.
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Sonis J, Cook JM. Concerns Regarding a Meta-analysis Comparing Psychotherapy With Medications for Posttraumatic Stress Disorder. JAMA Psychiatry. Published online October 02, 2019. doi:10.1001/jamapsychiatry.2019.2921
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