Published by the Students of Johns Hopkins since 1896
July 4, 2020

A choice in treatment helps those with PTSD

By ISAAC CHEN | November 1, 2018




PTSD patients who pursue treatment preferences have better outcomes.

Post-traumatic stress disorder (PTSD) affects about 7.7 million American adults every year, according to PTSD United, a non-profit organization dedicated to supporting and providing resources for sufferers of PTSD. Characterized by nightmares, flashbacks and frightening thoughts, PTSD is a disorder that develops in people who have experienced a shocking, scary or dangerous event. 

As further described in psychiatrist Judith Herman’s book Trauma and Recovery: The Aftermath of Violence — From Domestic Abuse to Political Terror, trauma arises not only from the event itself, but also from an individual’s internal struggle with oneself. 

“The conflict between the will to deny horrible events and the will to proclaim them aloud is the central dialectic of psychological trauma,” Herman wrote.

While there are several available effective treatments for PTSD, it is unclear whether providers should accommodate patient preference or try to persuade them to accept one treatment over another. In other words, past PTSD studies have not examined how the effects of treatment preference can affect outcomes. 

Psychologist Lori Zoellner, from the University of Washington, commented on the health care system. 

“In any form of health care, when receiving a recommendation from a provider, patients may or may not be given a choice of approaches to address their problems,” Zoellner said in a press release. 

Researchers from the University of Washington and Case Western University specifically conducted a doubly randomized preference trial to shed light on this gap in knowledge by recruiting patients from outpatient centers in Cleveland and Seattle. Their results were published in the American Journal of Psychology. They found that patients who had the option of choosing a preferred treatment had a better chance of recovering from PTSD.

In the study, 200 participants diagnosed with PTSD first watched a videotape explaining treatment rationales and then indicated their preference between two treatments, either Sertraline or prolonged exposure. Sertraline, or more commonly known as Zoloft, is one of the two selective serotine reuptake inhibitors approved by the Food and Drug Administration to treat PTSD. 

Prolonged exposure is a type of cognitive-behavioral therapy that teaches patients to gradually confront their trauma-related memories and emotions related to them. Prolonged exposure was delivered in 10 weekly 90 to 120 minute sessions that involved discussion and homework assignments. 

Afterward the participants were randomly divided into a choice condition or a no-choice condition. The former entered patients in their preferred treatment while the latter entered patients in the other treatment. 

Within the choice condition, 63 percent of the subjects chose prolonged exposure and 37 percent of the subjects choose Sertraline. While both treatments improved scores from the pre-treatment to post-treatment assessment, patients who received their preferred treatment were significantly more likely than those who did not to achieve a loss of PTSD diagnosis. 

“This research suggests that prolonged exposure and Sertraline are both good, evidence-based options for PTSD treatment - and that providing information to make an informed choice enhances long-term outcomes,” Zoellner said.

In addition, although there were few predictors of preference, participants who preferred prolonged exposure were more likely to have a college education and to report slightly lowered depressive symptoms. This suggests that prolonged exposure might benefit participants who have more motivation. 

Psychologist Norah Feeny from Case Western University, a co-author of the study, commented on the results.

“Dr. Zoellner and our team showed that we’ve got two effective, very different interventions for chronic PTSD and associated difficulties,” Feeny said in a press release. 

“Given this, and the fact that getting a treatment you prefer confers significant benefit, we are now able to move toward better personalized treatment for those suffering after trauma,” Feeny said. “These findings have significant public health impact and should inform practice.”

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