WHAT WOULD YOU CHOOSE? SERTRALINE OR PROLONGED EXPOSURE IN COMMUNITY AND PTSD TREATMENT SEEKING WOMEN

Both cognitive-behavioral (CBT[1]) and pharmacological interventions[2,3] have been shown to be helpful for chronic posttraumatic stress disorder (PTSD). However, key questions regarding their efficacy and effectiveness remain unaddressed. Indeed, the recent Institute of Medicine[4] report on PTSD treatment highlighted the need for additional study of PTSD interventions, and in particular, for trials directly comparing CBT and pharmacotherapy. To date, only two trials[5,6] have compared a psychotherapy to pharmacotherapy for PTSD. In the first, a small trial (n = 16) conducted outside the United States suggested a potential advantage of CBT over paroxetine on self-report, but not clinician ratings.[5] In a larger randomized trial (n = 88), eye movement desensitization and reprocessing (EMDR) and fluoxetine did not differ at posttreatment; however, both were superior to placebo.[6] At six-month follow-up though, EMDR was superior to fluoxetine for both PTSD and depression symptoms.[6] In addition to the need to learn more about relative efficacy, there is growing recognition of the need to systematically explore factors such as patient preference that may influence the clinical utility of these treatments. For example, despite the established efficacy of exposure therapy for PTSD, some have questioned its acceptability;[7,8] thus it is particularly important to understand how potential patients react to this treatment approach. This is further underscored given IOM's positive conclusion regarding exposure therapy and its usage with our returning veteran population. Indeed, the NIMH workshop report on greater public health relevance for intervention research[9] has called for “...the study of patient attitudes, knowledge, and beliefs about treatment as they pertain to the decision to enter treatment, subsequent compliance, and satisfaction with care...” (p. 130). Accordingly, understanding what factors influence choice and how those factors impact treatment are crucial. Clearly, psychotherapy and pharmacotherapy for PTSD are radically different in nature. In prolonged exposure (PE), for example, clients are encouraged to approach trauma memories and fears. With pharmacotherapy (e.g., sertraline, SER), this level of engagement is not necessary. Thus, the experience of these therapies may be quite different, and the clients who choose one or the other may also be different. To date, we know little regarding what factors influence women with chronic PTSD to seek either PE or pharmacotherapy. Within the trauma literature so far, while several studies have examined treatment preferences, no choice study[10–13] has examined a sample in which the majority of participants meet criteria for PTSD. Indeed, all but one study[11] in this small body of work has examined samples comprised of college students and used hypothetical traumas.[10,12,13] Thus, we sought to explore trauma-exposed women's choices regarding psychosocial and pharmacological interventions for chronic PTSD. We were particularly interested in understanding preferences between a psychotherapy and a pharmacotherapy and factors underlying such preference differences. We chose to examine PE and FDA-approved SER specifically due to their relative equipoise, at the time of the study, with regard to efficacy data. In Study 1, a community sample of trauma-exposed women reported their choices between two treatment options: SER and PE. In Study 2, we extended this work to provide treatment and follow-up in a sample of assault survivors with PTSD. We had two aims: (1) to examine treatment preferences for chronic PTSD; and (2) to conduct a preliminary exploration of the comparative effectiveness of SER and PE among women who choose their treatment.