Early Psychotherapy, Not SSRI Therapy, Prevents Chronic PTSD in Large Trial

Marlene Busko

December 21, 2007

December 21, 2007 — Adult survivors of traumatic events who had acute posttraumatic stress disorder (PTSD) and received either cognitive therapy or prolonged exposure therapy (a type of cognitive behavioral therapy) within 1 month had a reduced prevalence and severity of PTSD at 5 months, in a large randomized controlled trial.

Individuals who received early treatment with the selective serotonin reuptake inhibitor (SSRI) escitalopram, however, fared no better than individuals randomized to placebo or spontaneous recovery (wait-list) groups.

These results, from the Jerusalem Trauma Outreach and Prevention Study (J-TOPS), were presented by Arieh Y. Shalev, MD, director of the Center for Traumatic Stress at Hadassah University Hospital, in Jerusalem, Israel, at the American College of Neuropsychopharmacology 46th Annual Meeting, in Boca Raton, Florida.

"Both psychotherapies — cognitive therapy and prolonged exposure therapy — were equally effective, and effective in a major way," Dr. Shalev told Medscape Psychiatry. They reduced the prevalence of PTSD to 20% after 12 weeks of treatment, compared with about 60% in the wait-list group, which is "fantastic," he noted.

He added that it was disappointing that the study did not find any benefits from taking an SSRI, since compared with providing psychotherapy, administering a drug would be an easier way to reach a large number of trauma survivors. Further exploration of SSRIs for early treatment of PTSD is warranted, he observed.

Does Early Treatment Help?

Chronic PTSD is disabling and difficult to treat, and the first months following trauma exposure provide a window of opportunity for preventing chronic PTSD, according to small prior studies, said Dr. Shalev. The effectiveness of early treatment had not previously been evaluated in large groups, however, and there were no studies comparing different treatment modalities or evaluating SSRIs for this use.

The current report is from the ongoing J-TOPS randomized controlled study of adult civilians with recent trauma exposure. The investigators sought to determine which forms of treatment given soon after a traumatic event can prevent the development of chronic PTSD.

Adult survivors of traumatic events who were seen at a university hospital in Jerusalem over a 2.5-year period were contacted by phone to complete an interview. The 4220 people who were interviewed had experienced the following traumatic events: motor vehicle accidents (76%), work accidents (13%), terror attack (4%), or other event (7%).

A total of 289 survivors of traumatic events who met the criteria for full PTSD were randomized, in an equipoise-stratified randomization, to receive cognitive therapy (n = 51), prolonged exposure therapy (n = 73), or wait list (no early treatment, n = 113) or to blindly receive an SSRI (escitalopram 10 to 20 mg/day; n = 26), or placebo (n = 26).

The interventions (except for those in the wait-list group) started within 28 days of the traumatic event and lasted 12 weeks.

Significant Improvement With Psychotherapy

The 2 trauma-focused cognitive therapy interventions (1 with and 1 without exposure), given early, were equally and significantly effective in reducing the prevalence of PTSD at 5 months after the traumatic event.

Prevalence of Chronic PTSD* by Early-Intervention Type

Early Intervention Type
n
PTSD (%)
Cognitive therapy
51
18.2
Prolonged exposure therapy
73
21.4
SSRI (escitalopram)
26
61.9
Placebo
26
58.8
Wait list
113
57.4

*Chronic PTSD at 5 months after a traumatic event.
†Interventions were given for 12 weeks, starting within a month after a traumatic event.

Early intervention with psychotherapy also effectively reduced the severity of PTSD at 5 months, as measured by Clinician-Administered PTSD Scale (CAPS) scores.

Subjects in the wait-list group who had PTSD at 4 months received 12 weeks of late prolonged exposure therapy starting then. Early and late prolonged exposure therapy produced comparable results, but earlier therapy reduced the length of suffering.

Who Needs Treatment?

The results suggest that survivors of traumatic events who remain symptomatic 1 month following exposure should receive cognitive therapy or cognitive behavioral therapy, said Dr. Shalev.

A subanalysis of 55 survivors with subthreshold symptoms showed that they recovered equally well with or without treatment, suggesting that therapy should be allocated to patients with full PTSD.

"It might be better to wait for 1 or 2 months until most people recover, because the therapy is expensive and demanding and should be reserved for those who continue to express the full syndrome for some time," he added.

Removing Barriers to Care

The study found significant barriers to treatment, mainly related to the first face-to-face contact with a clinician. Following initial contact by phone, 49% of symptomatic trauma survivors declined a clinical assessment. In addition, 27% of individuals who were assessed by clinicians and then invited to treatment declined early treatment.

Telephone interventions were accepted by 94% of the sample, however, and they should be considered for further interventions, Dr. Shalev added.

The study was supported by a Public Health Service/National Institute for Mental Health grant; Lundbeck Pharmaceuticals Ltd; the United Jewish Appeal — Federation of Jewish Philanthropies of New York; the Jerry Lee Foundation; and CMS Companies.

American College of Neuropsychopharmacology 46th Annual Meeting: December 8-12, 2007.

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