A multiyear clinical trial comparing medication and mental health counseling in the treatment of post-traumatic stress disorder shows that patients who chose their form of treatment — whether drugs or therapy — improved more than those who were simply prescribed one or the other regardless of the patient’s preference.

The study, led by the 91̽�� and Case Western Reserve University, was conducted at outpatient clinics in Seattle and Cleveland. It found that both a medication — Sertraline, marketed as Zoloft — and a specific form a therapy known as prolonged exposure were effective in reducing PTSD symptoms during the course of treatment, with improvements maintained at least two years later. But patients who received their choice between the two possible treatments showed greater reduction in symptoms, were more apt to stick to their treatment program and even lost their PTSD diagnosis over time.

The , published Oct. 19 in the American Journal of Psychiatry, is the first large-scale trial of hundreds of PTSD patients, including veterans and survivors of sexual assault, to measure whether patient preference in the course of treatment impacts the effectiveness of a type of  cognitive behavioral therapy and use of selective serotonin reuptake inhibitors, a type of antidepressant often prescribed for PTSD.

“In any form of health care, when receiving a recommendation from a provider, patients may or may not be given a choice of approaches to address their problems,” said the study’s lead author,  , a 91̽��professor of psychology and director of the . “This research suggests that prolonged exposure and Sertraline are both good, evidence-based options for PTSD treatment — and that providing information to make an informed choice enhances long-term outcomes.”

The 200 subjects in the study, all adults, had been diagnosed with chronic PTSD. At the start of the study, all participants expressed a treatment preference between two options — medication or 10 weeks of therapy — at the outset of the trial. The study was doubly randomized, meaning that participants were randomly assigned to a group in which they received their preferred treatment, or to a group in which they were also randomly assigned to one treatment program or the other. All participants were evaluated by clinicians for PTSD symptoms, along with the patients’ own reports of feelings and behaviors, before, immediately after, and at three, six, 12 and 24 months later.

In this study, 61 percent of participants expressed a preference for prolonged exposure therapy. is often used to treat PTSD because it encourages patients to talk about what happened to them, learn coping strategies and explore their thoughts and feelings through repeatedly approaching the trauma memory and reminders of the trauma.

Of those participants who received prolonged exposure therapy, nearly 70 percent were determined to be free of their PTSD diagnosis two years after the therapy ended, compared with 55 percent of those who had taken and stayed on Sertraline through the follow-up.

Comparing medication to psychotherapy is rare in a clinical trial because it is time- and labor-intensive, Zoellner explained. In this case, both treatments had positive effects, though therapy demonstrated a slight edge.

“When both interventions reduce symptoms, it is often difficult to detect a difference because of patients’ varying responses — some get a lot better, some do not.  This study showed both prolonged exposure and Sertraline provide generally large and clinically meaningful effects to reduce PTSD and related symptoms,” she said. “Prolonged exposure psychotherapy for PTSD is as good as Sertraline, if not better, for the treatment of PTSD.”

When treatment preference is taken into account, results are more dramatic. Of those who wanted and received therapy, 74 percent had lost their PTSD diagnosis two years later; of those who preferred therapy but received medication instead, only 37 percent were PTSD-free after two years.

Whether patients received their choice of treatment appeared to directly affect their commitment: Nearly 75 percent of those who were “matched” with their preferred method completed their full treatment program, while more than half of those who were “mismatched” with a treatment method did not complete that course of treatment.

Though PTSD is commonly associated with combat veterans, more than half the participants in the study were diagnosed with chronic PTSD due to a sexual assault, in either childhood or adulthood. Three-quarters of participants were women.

Not all survivors of sexual assault have PTSD or depression, Zoellner pointed out, but those who do may not know that short-term therapy or a medication can yield significant long-term benefits.

“Sexual assault often has a long-term impact on the trauma survivor, but for many it need not be in the form of chronic psychiatric problems,” she said. “Survivors should know good, short options exist and need not suffer in silence.”

, released in 2014, showed that patient choice in treatment also saved money, in the form of fewer emergency department visits, hospitalizations and other care, as well as indirect savings such as fewer lost work hours.

Overall, the trial indicates the importance of tailoring PTSD treatment to the patient, said study co-author , a psychology professor at Case Western Reserve University.

“Dr. Zoellner and our team showed that we’ve got two effective, very different interventions for chronic PTSD and associated difficulties,” Feeny said. “Given this, and the fact that getting a treatment you prefer confers significant benefit, we are now able to move toward better personalized treatment for those suffering after trauma. These findings have significant public health impact and should inform practice.”

Other authors of the study were , a 91̽��emeritus professor of psychiatry in private practice; and , a professor of psychiatry at Case Western Reserve University.

The study was funded by the National Institute of Mental Health. Pfizer supplied the medication for the study.

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For more information, contact Zoellner at zoellner@uw.edu or 206-685-3126.

Grant numbers: R01MH066347, R01MH066348, UL1 RR024989

In a , published in the Journal of Clinical Psychiatry, PTSD patients allowed to choose between therapies ended up costing about $1,622 less on average per patient per year compared with patients who were assigned treatment. Among patients not given a choice, treatment with prolonged exposure psychotherapy cost less than sertraline.

“This is one of the first studies to look at the cost of providing mental health care and comparing different treatments for PTSD,” said , co-author of the study and director of the 91̽��’s . “It has tremendous implications for how large health care systems such as the U.S. Department of Veterans Affairs proceed with treating PTSD.”

The National Institute of Mental Health funded the study, with additional funding from the American Association of Colleges of Pharmacy.

“In evaluating how well a treatment works, we seldom pay attention to the role of a patient’s preference, although it could be particularly important in mental health treatments,” Zoellner said. “Trauma survivors with PTSD often have strong opinions about wanting to talk about the trauma or not in therapy, some believing they really need to talk about it to heal and others really wanting to avoid talking about it. They may experience greater relief when they receive the treatment that they prefer.”

Since randomized clinical trials – the gold-standard in research – don’t accommodate patients’ preferences, Zoellner and her research team used a study design called a “doubly randomized preference trial” to investigate whether giving patients a choice affects their treatment outcomes.

“Most clinical studies try to answer which treatment works best but do not factor in how giving patients choices could affect their health,” said , lead author and an assistant professor of pharmacy at Western University of Health Sciences in Pomona, Calif. “With this study design we could isolate the effects of this patient choice and see if it is cost-effective.”

The 200 participants – all diagnosed with PTSD and aged 18 to 65 years – were assigned to a group that was allowed to select their own treatment or a group that had their treatment chosen for them.

They were then given 10 weeks of treatment with either the drug sertraline or counseling called “.” Sertraline, prescribed under the names Zoloft and Lustral, is an antidepressant manufactured by Pfizer, Inc., which supplied the drug for use in the study.

When study participants were given a choice, their treatment cost each year an average of $6,156 compared with $7,778 for those assigned a treatment – a difference of approximately $1,622 per patient per year.

Among the patients not given a choice of treatment, counseling with prolonged exposure therapy cost on average slightly less than pharmacotherapy with sertraline – $7,030 versus $8,650 per patient per year.

“If it isn’t possible to allow patients to choose, prolonged exposure therapy rather than the medication is a cost-effective treatment option,” Zoellner said.

The costs in 2012 U.S. dollars included the therapy, outpatient services, hospitalization, emergency department visits, pharmacy services and nonmedical services, as well as indirect costs such as losses in worker productivity.

Other co-authors of the paper are , who leads the research project with Zoellner and is a professor at Case Western Reserve University in Cleveland, Ohio; and Jason Doctor of the University of Southern California.

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For more information, contact Zoellner at 206-685-3126 or zoellner@uw.edu.