title: PSYCHOTHERAPY VERSUS PHARMACOTHERAPY FOR POSTTRAUMATIC STRESS DISORDER: SYSTEMIC REVIEW AND META-ANALYSES TO DETERMINE FIRST-LINE TREATMENTS.
abstract: Current clinical practice guidelines (CPGs) for posttraumatic stress disorder (PTSD) offer contradictory recommendations regarding use of medications or psychotherapy as first-line treatment. Direct head-to-head comparisons are lacking.
  
  
  
  Systemic review of Medline, EMBASE, PILOTS, Cochrane Central Register of Controlled Trials, PsycINFO, and Global Health Library was conducted without language restrictions. Randomized clinical trials ≥8 weeks in duration using structured clinical interview-based outcome measures, active-control conditions (e.g. supportive psychotherapy), and intent-to-treat analysis were selected for analyses. Independent review, data abstraction, and bias assessment were performed using standardized processes. Study outcomes were grouped around conventional follow-up time periods (3, 6, and 9 months). Combined effect sizes were computed using meta-analyses for medication versus control, medication pre-/posttreatment, psychotherapy versus control, and psychotherapy pre-/posttreatment.
  
  
  
  Effect sizes for trauma-focused psychotherapies (TFPs) versus active control conditions were greater than medications versus placebo and other psychotherapies versus active controls. TFPs resulted in greater sustained benefit over time than medications. Sertraline, venlafaxine, and nefazodone outperformed other medications, although potential for methodological biases were high. Improvement following paroxetine and fluoxetine treatment was small. Venlafaxine and stress inoculation training (SIT) demonstrated large initial effects that decreased over time. Bupropion, citalopram, divalproex, mirtazapine, tiagabine, and topiramate failed to differentiate from placebo. Aripiprazole, divalproex, guanfacine, and olanzapine failed to differentiate from placebo when combined with an antidepressant.
  
  
  
  Study findings support use of TFPs over nontrauma-focused psychotherapy or medication as first-line interventions. Second-line interventions include SIT, and potentially sertraline or venlafaxine, rather than entire classes of medication, such as SSRIs. Future revisions of CPGs should prioritize studies that utilize active controls over waitlist or treatment-as-usual conditions. Direct head-to-head trials of TFPs versus sertraline or venlafaxine are needed.
authors.affiliation: Office of Evidence Based Practice, JBSA Fort Sam Houston, San Antonio, Texas. Daniel.J.Lee82.mil@mail.mil, Dr.Daniel.James.Lee@gmail.com.|Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland. Daniel.J.Lee82.mil@mail.mil, Dr.Daniel.James.Lee@gmail.com.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Lee
authors.affiliation: Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland.|Department of Behavioral Health, Bayne-Jones Army Community Hospital, Fort Polk, Louisiana.
authors.forename: Carla W
authors.initials: CW
authors.lastname: Schnitzlein
authors.affiliation: National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland.
authors.forename: Jonathan P
authors.initials: JP
authors.lastname: Wolf
authors.affiliation: Headquarters U.S. Marine Corps, Health Services, Arlington, Virginia.
authors.forename: Meena
authors.initials: M
authors.lastname: Vythilingam
authors.affiliation: Women's Health Science Division, National Center for PTSD, VA Boston Healthcare System, Boston University School of Medicine, Boston, Massachusetts.|Department of Veterans Affairs, Boston University School of Medicine, Boston, Massachusetts.|Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts.
authors.forename: Ann M
authors.initials: AM
authors.lastname: Rasmusson
authors.affiliation: Center for Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland.
authors.forename: Charles W
authors.initials: CW
authors.lastname: Hoge
mesh_terms: D000928:Antidepressive Agents / Q000627:therapeutic use*; D003131:Combined Modality Therapy; D006801:Humans; D010879:Piperazines; D011613:Psychotherapy / Q000379:methods*; D016032:Randomized Controlled Trials as Topic; D017367:Selective Serotonin Reuptake Inhibitors / Q000627:therapeutic use; D020280:Sertraline / Q000627:therapeutic use; D013313:Stress Disorders, Post-Traumatic / Q000628:therapy; D016896:Treatment Outcome; D014230:Triazoles / Q000627:therapeutic use; D000069470:Venlafaxine Hydrochloride / Q000627:therapeutic use
chemical_list: D000928:Antidepressive Agents; D010879:Piperazines; D017367:Selective Serotonin Reuptake Inhibitors; D020280:Sertraline; D014230:Triazoles; D000069470:Venlafaxine Hydrochloride; C051752:nefazodone
keywords: Australian; Department of Defense; ISTSS; International Society for the Study of Traumatic Stress; NICE; National Institute for Clinical Excellence; PTSD; VA/DoD; WHO; World Health Organization; pharmacotherapy; posttraumatic stress disorder; psychotherapy