Post-traumatic stress disorder: is psychotherapy more effective than medication?

Researchers recommend that the choice between medication and psychotherapy for PTSD not be based on their comparative effectiveness, which has yet to be determined, but on patient preferences

American researchers reviewed scientific literature on psychotherapy and medication for post-traumatic stress disorder (PTSD) to determine which method was most effective in treating patients. 

Post-traumatic stress disorder refers to the psychological and physical after-effects that a person may experience as a result of violent or traumatic events (warfare, terrorist attacks, bereavement). A new study published in Psychiatry Research aims to determine whether treatment with serotonin or norepinephrine reuptake inhibitors was more effective than trauma-focused psychotherapy or vice versa.

Most guidelines for the treatment of PTSD in adults recommend that trauma-focused psychotherapy be used as the first-line treatment and that medication be used as a second-line treatment, explained Jeffrey Sonis, an associate professor of social medicine and family medicine at the University of North Carolina at Chapel Hill, who led the study.

Now it seems these recommendations may be flawed. Randomized trials that compare psychotherapy to control groups do demonstrate larger effect sizes (quantitative measures of the difference between two groups) than studies that evaluate the effectiveness of treatment with medication as opposed to a placebo. However, several factors may justify this difference, notably the fact that blinding, which is routine in medication trials but impossible in psychotherapy trials, is usually associated with reduced beneficial effects.

No solid evidence to favor psychotherapy over medication 

For a fair comparison of these two methods, the authors of this meta-analysis focused only on data from studies in which an experimental drug was directly compared to the existing standard of care, which was psychotherapy.

"We found that the best estimate of the effect, comparing psychotherapy and medications, was that there was no difference between the two. However, the 95% confidence interval was very wide, indicating that true effect may favor psychotherapy or it may favor medications. We concluded that there is still insufficient evidence to determine whether psychotherapy or medications were more effective for treatment of PTSD in adults," said Sonis.

Until there is stronger evidence on the comparative efficacy of the two treatment options, the researchers recommend that clinicians present both psychotherapy and medication options, and base their decision to choose one of them on patient preference and patient-specific factors like the relative risk of adverse effects from medication.