Today there are a number of evidence-based treatment options available for PTSD and the number of options will continue to grow as research accumulates. The most recent clinical practice guidelines for PTSD have found that trauma-focused treatments are the most effective, but there are also effective medications and non-trauma-focused options with strong support (Hamblen et al, 2019). Guidelines provide consumers with a variety of choices but most lack recommendations on which treatment to try first. A few of the guidelines recommend trauma-focused psychotherapy over medications, but none distinguish between treatments rated at the same level. First-line treatments differ with respect to how they work, what they require of the patient, and their risk and benefit profiles. Individual patients, therefore, may have unique perspectives on which treatments are most and least desirable. Patient preference is cited as an important consideration in determining which treatment a patient should receive, especially when all options have demonstrated similar clinical effect. But what do we know about how patients determine their preference? And does it matter how the information is presented?
We surveyed 301 adults (half were Veterans, two-thirds were male) with PTSD symptoms. All respondents had experienced at least one traumatic event and screened positive for PTSD on the Primary Care PTSD Screen. We asked each participant to rate their preferences for five different first-line PTSD treatments. Treatments were selected based on their inclusion on the 2010 VA/DoD Guidelines for Management of PTSD: Cognitive Processing Therapy (CPT), Prolonged Exposure (PE), Eye Movement Desensitization and Reprocessing (EMDR), Stress Inoculation Training (SIT), and medications from two antidepressant classes: selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs). We presented the information in two different formats, either as sequential text descriptions or in a side-by-side comparison chart (Harik et al., 2020).
Patients Preferred Psychotherapy Over Medications
Several previous studies have shown that patients prefer psychotherapy over medications (e.g., Simiola, Neilson, Thompson, & Cook, 2015). However, little is known about preferences between different types of psychotherapy or about how strongly patients prefer one treatment over another. Ranking treatments does not tell us if any or all of the treatments are acceptable, it only tells us which is the most strongly preferred relative to the other options. Therefore, we asked participants about the acceptability of each treatment independently and then asked them to rank order the treatments. Among the presented choices, CPT was rated as the most acceptable and was also selected as the most common first choice. Medications were rated as least acceptable, with 29% of respondents saying they would “definitely not” try medications, and they were most often ranked last. A large proportion of participants stated that they would “definitely” or “probably” try each of the other psychotherapy options (CPT, PE, SIT and EMDR).
Format Can Influence Preference
Little is known about the impact of information format on preferences. For the most part, viewing the information as text or in the side-by-side chart had little effect on patient preference. The exceptions were for PE and medications. People who viewed the chart led to more favorable ratings of PE, assigning it a higher rank to PE, and stating more frequently that they might try PE, than those who read sequential text descriptions. For medications, viewing information in a chart format led to more moderate ratings for tolerability. Presumably, the chart format allowed participants to compare specific details of the treatment side-by-side with the other treatment options. This may have helped them to more accurately compare treatments than in the sequential format in which they may have had difficulty with cross comparison due to recall and ordering effects (Feldman-Stewart, Chammas, Hayter, Pater, Mackillop, 1996).
Other Influencers of Preference
There were a few other predictors of patient preference. Although medications were least preferred, it turns out that people who had a history of prior medication use and those who were older, rated medications more favorable. Perhaps they had had a good experience and were less concerned with side effects or long term use. And, if people had not taken medications before they more likely to assign a favorable rating to CPT.
Overall results show that people who screen positive for PTSD rated most treatments as acceptable, but preferred psychotherapy over medications, with a preference for CPT relative to other psychotherapy formats. Additionally, we found that the format in which treatment information is presented can influence treatment acceptability. Side-by-side comparison charts might offer an advantage over sequential text descriptions. When evaluating shared decision-making, it is important to not only consider the type of information provided, but also the format.
References
Hamblen, J. L., Norman, S. B., Sonis, J. H., Phelps, A. J., Bisson, J. I., Nunes, V. D., . . . Schnurr, P. P. (2019). A guide to guidelines for the treatment of posttraumatic stress disorder in adults: An update. Psychotherapy: Theory, Research, Practice, Training, doi:http://dx.doi.org/10.1037/pst0000231
Simiola, V., Neilson, E. C., Thompson, R., & Cook, J. M. (2015). Preferences for trauma treatment: A systematic review of the empirical literature. Psychological Trauma: Theory, Research, Practice, and Policy, 7, 516–524. doi:10.1037/tra0000038
Reference Article
Harik, J., Grubbs, K., & Hamblen, J. (2020). Format of Treatment Descriptions Shapes Patient Preferences for PTSD Treatment. Journal of Traumatic Stress.
Questions for Discussion
- Do you currently talk about PTSD treatment options with your patients?Do you tell them about all the evidence-based options or only those that you feel qualified to deliver?
- Does knowing that the way you present information on treatment effectiveness change your practice?Will you choose to use a side-by-side comparison chart such as the one available in the PTSD Decision Aid (https://www.ptsd.va.gov/apps/Decisionaid/compare.aspx)?
- Does knowing that most patients said they would at least “probably” be willing to try any of the first line psychotherapies change your practice?Does is help to know patients are open to trauma-focused therapies?Does is help to know that there is not just one treatment that patients find acceptable?
About the Authors
Jessica L. Hamblen is the Deputy for Education at the National Center for PTSD and Associate Professor at Geisel School of Medicine at Dartmouth. Dr. Hamblen's interests are in developing, disseminating, and evaluating cognitive behavioral treatments for PTSD and related conditions.
Kathleen M. Grubbs is a Staff Psychologist at VA San Diego Health Care System and an Assistant Professor of Psychiatry at the University of California, San Diego. Dr. Grubbs’ research focuses on improving access to care by utilizing technology and telemental health platforms to deliver evidence based psychotherapies delivered to Veterans and their families at home and in remote community based outpatient clinics.