Primary care clinicians can effectively use antidepressants to treat patients with symptoms of posttraumatic stress disorder (PTSD), a new study found.

The trial, published in JAMA Psychiatry, compared pharmacotherapy provided by primary care clinicians with trauma-focused psychotherapy delivered by therapists integrated within the clinics. The research showed treatment with selective serotonin reuptake inhibitors (SSRI) was more effective at reducing symptoms of PTSD than written exposure therapy (WET).

The findings may help clinicians who have patients experiencing posttraumatic stress but might not have immediate access to mental health care, said John Fortney, PhD, director of the Division of Population Health and professor in the Department of Psychiatry and Behavioral Sciences at the University of Washington School of Medicine in Seattle.

“People were getting better with both treatments, not perfectly cured by any stretch of the imagination, but it’s clinically meaningful,” Fortney told Medscape Medical News.

Most patients with PTSD do not make it to a mental health clinic for treatment, creating a gap that can be filled in primary care, said Forney, who is also a senior research career scientist at the Veterans Affairs (VA) Puget Sound Health Care System.

More than half of the 700 study participants received care at eight primary care clinics part of the VA, while the remaining 248 patients were enrolled at seven federally qualified health centers (FQHCs).

Staff at these sites systematically screened patients using a PTSD screener for primary care. They were included in the study if they then reported at least one traumatic event and if they scored 33 or higher on the PTSD Checklist for DSM-5 (PCL-5), an 80-point screening tool that assesses if patients have symptoms of PTSD.

Patients (mean age, 45.1 years; 62.1% men; 60.7% White) were randomly assigned to three groups to receive care over 4 months between April 2021 and June 2024. Two groups began treatment with SSRI, including sertraline, paroxetine, or fluoxetine (n = 352).

A third group received WET from mental health professionals embedded within the primary care clinics (n = 352). Over six 30-minute sessions, patients wrote about their memories, thoughts, and feelings before and after the event that led to their PTSD. The therapist assessed the patient’s subjective units of distress before and after writing the narrative and asked about their experience during the session.

Fortney said he and his colleagues chose WET because the modality is fairly easy for therapists to implement. Therapists read a manual, attended 6 hours of live or recorded training sessions, and talked to experts in the field for consultation while completing cases.

The most common traumatic event for patients at the VA was combat (50%), while physical assault was most common at FQHCs (29.4%). Nearly one quarter of patients were already taking an SSRI at baseline. PCL-5 scores were measured at the beginning and end of the intervention.

The mean PCL-5 score for the therapy group started at 52.63 and decreased to 40.52 after 4 months. The score for the SSRI groups decreased from 53 to 38.95 over the same timeframe (adjusted mean difference [aMD], 1.79; 95% CI, -0.76 to 4.34; P = .17).

Completion rates at the 4-month mark were 43.5% and 60.8% for those in the WET and SSRI groups, respectively.

A second part of the trial included 122 patients in the SSRI groups who did not show a significant response during initial treatment. Half received WET while the remaining patients were prescribed venlafaxine, a serotonin-norepinephrine reuptake inhibitor.

The mean PCL-5 score in the venlafaxine group dropped from 51.39 to 42.11 after another 4 months. The WET group experienced a drop from 53.32 to 49.35 over that period (aMD, 10.19; 95% CI, 4.97-15.41; P < .001).

Pharmaceutical treatment may have been more effective because patients were not actively seeking therapy for PTSD but were instead offered the modality. Patients may have better outcomes if they directly went to a mental health clinic for care, Fortney said.

“Primary care patients may be less ready, willing, or able to engage in trauma-focused psychotherapy than specialty mental health patients,” Fortney and his colleagues wrote.

Still, some patients might prefer counseling to medications, while other “patients do not respond to medications. So having another treatment option is valuable,” Fortney said.

Zachary Sartor, MD, MPH, of Waco Family Medicine in Texas, said he introduces the concepts of WET to his patients with PTSD before referring them to in-house behavioral health clinicians. He said most research on the modality has been conducted at large academic medical centers. But patients recruited through these institutions may not face the same challenges with food insecurity or employment as those served at FQHCs.

“Looking at this sort of FQHC specific data makes us feel even better about our ability to offer this service to folks in our community,” said Sartor, who is director of the residency program at the clinic.

He said primary care clinicians can talk to patients about the therapy in a similar way as they would about appendectomy, before referring them to mental health clinicians.

“In order to cure the appendicitis, the surgeon has to put you to sleep and cut into you and open you up and expose you to remove that appendix. But rest assured, the surgeon is going to put you back together, sew you up,” Sartor said.

The study received funding from the Patient-Centered Outcomes Research, National Center for Advancing Translational Sciences, and National Institute on Drug Abuse. One study author reported receiving royalty payments from the American Psychological Association for a published manual of WET outside the submitted work. Sartor reported having no relevant financial disclosures.

Kerry Dooley Young is a freelance journalist based in Washington, DC. She has covered medical research and healthcare policy for more than 20 years.