The effectiveness of cognitive processing therapy and prolonged exposure in the Department of Veterans Affairs.

Abstract

Multiple randomized clinical trials have shown that cognitive processing therapy (CPT) and prolonged exposure (PE) are evidence-based treatments for posttraumatic stress disorder (PTSD). However, additional research should verify the effectiveness of CPT and PE in conditions more reflective of clinical practice. The present study evaluated the effectiveness of CPT and PE at reducing veterans' self-reported PTSD symptoms as measured by total scores on the PTSD Checklist (PCL). This study involved a retrospective review of 2,030 charts. 750 veterans from 10 U.S. states who received CPT or PE in individual psychotherapy from the Veterans Health Administration were included in the study (N participants in CPT = 376; N participants in PE = 374). The study used multilevel modeling to evaluate the absolute and relative effectiveness of both treatments and to determine the relationship between patient-level factors and total PCL scores during treatment. Results showed that both CPT and PE were equally effective at reducing total PCL scores, but that the effectiveness of both therapies was reduced when compared to results obtained in randomized clinical trials. Patients who completed therapy reported significantly larger reductions on the PCL than patients who did not complete therapy. On average, patients who did not complete a full course of therapy reported little to no improvement on the PCL. Encouragingly, as a group these patients did not report an increase in the severity of their total PCL scores prior to dropping out from therapy. Patients who reported more severe total PCL scores at baseline experienced significantly larger reductions in PCL scores during therapy, but veterans at all levels of initial PTSD symptom severity benefited from treatment. Older veterans and Hispanic veterans had higher total PCL scores at baseline. However, veterans across all ages and three racial/ethnic groups (Caucasian, African American, Hispanic) experienced equivalent rates of symptom reduction. Therapist effects were small, but statistically significant. The study discusses the significance of these findings in light of prior research on trauma-focused therapy, future directions for research, and implications for practice.