First-line psychotherapy tops medications for PTSD

  • Merz J & al.
  • JAMA Psychiatry
  • 12 Jun 2019

  • International Clinical Digest
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  • A new meta-analysis suggests that first-line treatment with psychotherapy is more effective than first-line pharmacological treatments for posttraumatic stress disorder (PTSD).

Why this matters

  • Different treatment guidelines offer competing recommendations on the use of pharmacological therapy as a first-line treatment for PTSD, with the American Psychological Association and the International Society for Traumatic Stress advocating their first-line use, whereas the National Health and Medical Research Council and the National Institute of Health and Care Excellence advise the use of pharmacological therapies for second-line or adjuvant therapy only.

Study design

  • Meta-analysis of 12 randomized clinical trials involving 922 participants with PTSD who received pharmacologic, psychotherapeutic, or combination treatment.
  • Primary outcome: PTSD symptom severity.
  • Funding: None disclosed.

Key results

  • At the longest available follow-up, psychotherapy showed significantly greater benefit vs pharmacologic treatments in network (standard mean difference [SMD], −0.83; 95% CI, −1.59 to −0.07) and pairwise (SMD, −0.63; 95% CI, −1.18 to −0.09; 3 RCTs) meta-analyses.
  • No difference was observed between psychotherapy and combination treatment.
  • Combination treatment was significantly more beneficial than pharmacological treatments alone in network (SMD, −0.96; 95% CI, −1.87 to −0.04), but not pairwise meta-analysis, which included 2 RCTs (SMD, 1.02; 95% CI, 2.77 to 0.72). 
  • All 3 options were similarly accepted by patients.


  • Heterogeneity between studies.

Coauthored with Antara Ghosh, PhD

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