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Original Investigation
March 2018

A Brief Exposure-Based Treatment vs Cognitive Processing Therapy for Posttraumatic Stress Disorder: A Randomized Noninferiority Clinical Trial

Author Affiliations
  • 1National Center for PTSD, Veterans Affairs Boston Health Care System, Boston, Massachusetts
  • 2Boston University School of Medicine, Boston, Massachusetts
  • 3Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
JAMA Psychiatry. 2018;75(3):233-239. doi:10.1001/jamapsychiatry.2017.4249
Key Points

Question  Is a brief, exposure-based treatment noninferior to the more time-intensive cognitive processing therapy in the treatment of posttraumatic stress disorder?

Findings  In this randomized noninferiority clinical trial of 126 adults who received a diagnosis of posttraumatic stress disorder, those treated with written exposure therapy, a 5-session treatment, and those treated with cognitive processing therapy improved significantly, with large effect sizes observed. Despite the substantial dose difference, written exposure therapy was noninferior to cognitive processing therapy.

Meaning  The findings provide evidence that written exposure therapy and cognitive processing therapy are effective for treatment of posttraumatic stress disorder, and that posttraumatic stress disorder can be effectively treated with a 5-session psychotherapy.


Importance  Written exposure therapy (WET), a 5-session intervention, has been shown to efficaciously treat posttraumatic stress disorder (PTSD). However, this treatment has not yet been directly compared with a first-line PTSD treatment such as cognitive processing therapy (CPT).

Objective  To determine if WET is noninferior to CPT in patients with PTSD.

Design, Setting, and Participants  In this randomized clinical trial conducted at a Veterans Affairs medical facility between February 28, 2013, and November 6, 2016, 126 veteran and nonveteran adults were randomized to either WET or CPT. Inclusion criteria were a primary diagnosis of PTSD and stable medication therapy. Exclusion criteria included current psychotherapy for PTSD, high risk of suicide, diagnosis of psychosis, and unstable bipolar illness. Analysis was performed on an intent-to-treat basis.

Interventions  Participants assigned to CPT (n = 63) received 12 sessions and participants assigned to WET (n = 63) received 5 sessions. The CPT protocol that includes written accounts was delivered individually in 60-minute weekly sessions. The first WET session requires 60 minutes while the remaining 4 sessions require 40 minutes.

Main Outcomes and Measures  The primary outcome was the total score on the Clinician-Administered PTSD Scale for DSM-5; noninferiority was defined by a score of 10 points. Blinded evaluations were conducted at baseline and 6, 12, 24, and 36 weeks after the first treatment session. Treatment dropout was also examined.

Results  For the 126 participants (66 men and 60 women; mean [SD] age, 43.9 [14.6] years), improvements in PTSD symptoms in the WET condition were noninferior to improvements in the CPT condition at each of the assessment periods. The largest difference between treatments was observed at the 24-week assessment (mean difference, 4.31 points; 95% CI, –1.37 to 9.99). There were significantly fewer dropouts in the WET vs CPT condition (4 [6.4%] vs 25 [39.7%]; χ21 = 12.84, Cramer V = 0.40).

Conclusions and Relevance  Although WET involves fewer sessions, it was noninferior to CPT in reducing symptoms of PTSD. 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.

Trial Registration  clinicaltrials.gov Identifier: NCT01800773