One-on-One Cognitive Therapy Bests Group Approach in PTSD

Megan Brooks

November 29, 2016

Both group and individual cognitive processing therapy (CPT) ease symptoms of posttraumatic stress disorder (PTSD) in active-duty military service members, but individual CPT appears to be better and faster, a large study indicates.

Patients who attended individual therapy saw more significant improvements in the severity of their PTSD symptoms, and the improvements were seen more quickly.

The finding has "public policy implications," lead investigator Patricia Resick, PhD, professor of psychiatry and behavioral sciences at Duke University School of Medicine in Durham, North Carolina, told Medscape Medical News.

"It means that the military should be providing individual therapy as the first line, or at least start patients with group, and those who don't benefit should be able to move to individual treatment," Dr Resick said.

The study was published online November 23 in JAMA Psychiatry.

Reliable, Durable Change

The authors of an accompanying editorial, led by Charles Hoge, MD, Walter Reed Army Institute of Research, Silver Spring, Maryland, describe the research as "one of the most important clinical trials to emerge from the Department of Defense and Veteran Affairs (DoD/VA) research portfolio."

The study included 268 active-duty personnel seeking treatment for PTSD at Fort Hood, in Killeen, Texas, after being deployed near Iraq or Afghanistan. The vast majority (91%) were men. Their average age was 33 years.

They were randomly allocated to receive CPT in either 90-minute group sessions (133 participants) or 60-minute individual sessions (135 participants) twice weekly for 6 weeks. The 12 group and individual sessions were conducted concurrently.

The primary outcome measures were scores on the Posttraumatic Symptom Scale–Interview Version (PSS-I) and the stressor-specific Posttraumatic Stress Disorder Checklist (PCL-S). Secondary measures were scores on the Beck Depression Inventory–II (BDI-II) and the Beck Scale for Suicidal Ideation (BSSI). Assessments were made at baseline and 2 weeks and 6 months after treatment by independent evaluators masked to treatment condition.

Scores on the PSS-I and the PCL-S improved significantly both for patients who received group CPT and for those who received individual CPT, but patients in individual CPT improved about twice as much as those in group CPT at the 2-week posttreatment assessment. Effect sizes were "very large for individual CPT and medium for group CPT," the investigators report.


Outcome Group CPT Individual CPT Mean Difference
PSS-I total score -4.0 -7.8 -3.7 (Cohen d = 0.6)
PCL-S total score -6.3 -12.6 -6.3 (Cohen d = 0.6)


"Reliable change" on the PSS-I occurred in an estimated 43% of patients who received individual treatment and in 17% of those who received group treatment. On the PCL-S, an estimated 52% of patients who received individual treatment had reliable change vs 30% of those who received group treatment.

Symptoms of depression and suicidal thoughts improved equally in both groups, and all improvements were maintained at 6 months.

Nearly half of the participants in individual CPT and about 40% in group CPT no longer met PSS-I diagnostic criteria for PTSD after treatment. This is "encouraging, but I think the improvement in the severity of their scores is more important than whether they lose their diagnosis," Dr Resick told Medscape Medical News.

The researchers speculate that the lower efficacy of group CPT may stem from less individual attention with group CPT or less engagement in the therapeutic process.

Those who missed sessions of group CPT missed content that could not be replaced, whereas patients in individual CPT were able to reschedule if they were unable to attend a session. Also, patients in group CPT may have felt "less accountable" for completing practice assignments, the researchers note.

"Extremely Valuable" Data

The current study was established through the STRONG STAR Consortium, a multi-institutional initiative funded by the US Department of Defense to develop and evaluate effective prevention, detection, and treatment of combat-related PTSD.

Evidenced-based cognitive-behavioral therapies such as CPT and prolonged exposure therapy are the "leading treatments for PTSD, with the most scientific support for their effectiveness," Alan Peterson, PhD, director of the STRONG STAR Consortium and professor of psychiatry at the University of Texas Health Science Center at San Antonio, said in a statement.

"However, both were developed primarily for civilians, and until the STRONG STAR Consortium was developed, they had never been evaluated in clinical trials with an active-duty military population," said Dr Peterson, who is a retired US Air Force lieutenant colonel.

"This study shows that CPT is effective, but it still needs to be adapted and tailored in ways that increase its effectiveness with combat-related PTSD so that more patients can fully recover," he added.

"Although these results are not what the field may have hoped for, this trial provides extremely valuable evidence to refine our knowledge of trauma-focused treatments and outline remaining challenges," Dr Hoge and coauthors write in their editorial.

"To begin with, group interventions should not be abandoned; they remain a solid second-line treatment. Although less effective than individual trauma-focused therapy, the research overall demonstrates that group psychotherapy (ie, CPT or PCT [present-centered therapy]) produces significant and sustained clinical improvements for PTSD and comorbid conditions (eg, depression, suicidal ideation) with medium to large effect sizes extending 6 to 12 months after treatment," they point out.

"Provided that clinicians appreciate the inferiority of group therapy (in this case CPT or PCT) compared with individual therapy, it is reasonable to consider group psychotherapy along with other evidence-based approaches or in situations where first-line treatments are unavailable," they conclude.

The study was supported by the US Department of Defense through the US Army Medical Research and Materiel Command, Congressionally Directed Medical Research Programs, and the Psychological Health and Traumatic Brain Injury Research Program. The authors and editorialists have disclosed no relevant financial relationships.

JAMA Psychiatry. Published online November 23, 2016. Full text, Editorial


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