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his pragmatic randomized clinical trial compared treatment sequences for posttraumatic stress disorder (PTSD) in primary care, addressing the limited evidence directly comparing medication and trauma-focused psychotherapy in routine-care settings. The study enrolled 700 patients from seven federally qualified health centres and eight Veterans Affairs medical centres. Participants were allocated to one of three strategies: a selective serotonin reuptake inhibitor (SSRI) followed by written exposure therapy (WET) augmentation, an SSRI followed by a switch to the serotonin–norepinephrine reuptake inhibitor venlafaxine, or WET followed by an SSRI. At four months, patients who adhered to SSRI treatment reported a 14.0-point reduction in PTSD Checklist for DSM-5 (PCL-5) scores, while those completing all WET sessions reported a 12.1-point reduction. The between-group difference was not statistically significant (adjusted mean difference, 1.79; 95% CI, −0.76 to 4.34; P = 0.17). Among patients who did not respond to an SSRI, switching to venlafaxine produced a 9.2-point reduction, compared with a 2.3-point reduction with WET augmentation; this difference was statistically significant (adjusted mean difference, 10.19; 95% CI, 4.97–15.41; P < 0.001). Conclusion: Both SSRIs and brief written exposure therapy were feasible and effective in primary care. For patients who do not respond to an SSRI, switching to venlafaxine may be more effective than adding WET, although treatment engagement and adherence remain important considerations.
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his pragmatic randomized clinical trial compared treatment sequences for posttraumatic stress disorder (PTSD) in primary care, addressing the limited evidence directly comparing medication and trauma-focused psychotherapy in routine-care settings. The study enrolled 700 patients from seven federally qualified health centres and eight Veterans Affairs medical centres. Participants were allocated to one of three strategies: a selective serotonin reuptake inhibitor (SSRI) followed by written exposure therapy (WET) augmentation, an SSRI followed by a switch to the serotonin–norepinephrine reuptake inhibitor venlafaxine, or WET followed by an SSRI. At four months, patients who adhered to SSRI treatment reported a 14.0-point reduction in PTSD Checklist for DSM-5 (PCL-5) scores, while those completing all WET sessions reported a 12.1-point reduction. The between-group difference was not statistically significant (adjusted mean difference, 1.79; 95% CI, −0.76 to 4.34; P = 0.17). Among patients who did not respond to an SSRI, switching to venlafaxine produced a 9.2-point reduction, compared with a 2.3-point reduction with WET augmentation; this difference was statistically significant (adjusted mean difference, 10.19; 95% CI, 4.97–15.41; P < 0.001). Conclusion: Both SSRIs and brief written exposure therapy were feasible and effective in primary care. For patients who do not respond to an SSRI, switching to venlafaxine may be more effective than adding WET, although treatment engagement and adherence remain important considerations.
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