https://immattersacp.org/weekly/archives/2025/10/21/5.htm

Drugs, writing therapy compared for PTSD in primary care

Patients with post-traumatic stress disorder (PTSD) who were randomized to written exposure therapy after trying a selective serotonin reuptake inhibitor had smaller decreases in symptom severity than patients randomized to switch to a serotonin-norepinephrine reuptake inhibitor.


Treatment of post-traumatic stress disorder (PTSD) in primary care with either drugs or psychotherapy was feasible and effective, according to a study.

To learn whether brief trauma-focused psychotherapy was more effective than selective serotonin reuptake inhibitors (SSRIs) for the treatment of PTSD in primary care, researchers conducted a randomized clinical trial including 700 patients who met clinical criteria for PTSD from primary care clinics of seven federally qualified health centers and eight Veterans Affairs medical centers. Results were published online Oct. 15 by JAMA Psychiatry.

The pragmatic comparative effectiveness trial, conducted from April 2021 to June 2024, randomized patients to one of three treatment sequences: SSRI followed by written exposure therapy augmentation, SSRI followed by a switch to serotonin-norepinephrine reuptake inhibitors (SNRIs), or written therapy followed by SSRI. Written exposure therapy involved six 30-minute sessions in which patients wrote about the memory of their worst traumatic event for 20 minutes, with a focus on details, thoughts, and feelings that occurred during the event. Each session ended with the therapist instructing the patient to allow themselves to experience any trauma-related memories, images, thoughts, and feelings in the interval between sessions. The three SSRIs were sertraline, fluoxetine, or paroxetine, and the SNRI was venlafaxine.

Among the 700 patients, the mean score on the DSM-5 PTSD Checklist (PCL-5) at baseline was 52.8, indicating considerable symptom severity. At four months, 144 of 278 patients (51.8%) randomized to an SSRI were adherent and had an average 14.0-point decrease in PCL-5. In comparison, 11 of 352 patients (31.5%) randomized to written therapy completed all sessions and reported a 12.1-point decrease. There was no significant between-group difference (adjusted mean difference, 1.79 [95% CI, −0.76 to 4.34]; P=0.17). In the 122 of 295 patients (41.4%) who were randomized to an SSRI and did not respond to treatment, switching to the SNRI led to a 9.2-point PCL-5 decrease compared with a 2.3-point decrease with written therapy, a statistically significant between-group difference (adjusted mean difference, 10.19 [95% CI, 4.97 to 15.41]; P<0.001).

Patients' engagement with written therapy was substantially lower than with SSRIs, the study authors noted. They suggested that primary care patients screening positive for PTSD may be less ready, willing, or able to engage in trauma-focused psychotherapy than patients seeking treatment for PTSD in specialty mental health clinics. Nevertheless, the writing therapy yielded robust outcomes in busy primary care clinics across a heterogenous group of patients and therapists.

“For patients not responding to SSRIs, a switch to venlafaxine appears to yield better outcomes than augmentation with WET [written exposure therapy], although more research is needed,” the authors concluded. “To achieve full remission, many patients may need to seek additional trauma-focused psychotherapy in specialty mental health settings. Primary care patients completing WET may be more willing to be referred to specialty care.”