From the Editor

How to help those with PTSD? Prolonged exposure therapy (PE) and cognitive processing therapy (CPT) are supported by good evidence but both are resource intense and often have high drop-out rates, partly because of the requirement that patients complete homework. Is there an alternative?

In the first selection, we look at a new study considering written exposure therapy (WET), an emerging therapy where patients write about traumatic events – but the therapy doesn’t demand so much from the system (in terms of resources) or patients (in terms of homework assignments). Denise Sloan (of Boston University) and her colleagues conducted a noninferiority trial, comparing this therapy with prolonged exposure therapy for US veterans with PTSD, involving 178 participants from three centres. “We found WET was noninferior to PE, a treatment that includes more treatment sessions, longer sessions, and between-session assignments.” We consider the study, an Editorial responding to it, and mull the clinical implications.

In the last selection, John W. Ayers (of the University of California San Diego, La Jolla) and his co-authors consider social media and medical education in JAMA. They argue that #MedEd is a dynamic platform with the potential to democratize medical education – but also warn of the problems of misinformation. “The potential for #MedEd to improve medical education and the health sciences is considerable, while the risks of dismissing #MedEd is potentially greater.”


Selection 1: “Written Exposure Therapy vs Prolonged Exposure Therapy in the Treatment of Posttraumatic Stress Disorder: A Randomized Clinical Trial”

Denise M. Sloan, Brian P. Marx, Ron Acierno, et al.

JAMA Psychiatry, 23 August 2023

Posttraumatic stress disorder (PTSD) is a commonly occurring condition, especially among military veterans. It is associated with various debilitating other psychiatric and physical health conditions. Fortunately, several evidence-based psychotherapies for PTSD are available; among these, prolonged exposure therapy (PE) and cognitive processing therapy (CPT) have the strongest empirical support. These interventions involve 8 to 15 individual sessions, lasting between 60 and 90 minutes per session and including between-session assignments. Importantly, many factors prevent those who could benefit from these treatments from either accessing or completing them, including limited time and finances for a full course of treatment and limited availability of trained therapists. Even when patients successfully access these treatments, many (eg, 35%-50%) drop out before completion…

Written exposure therapy (WET) is emerging as an alternative, efficacious brief intervention for PTSD that requires less time and fewer resources to deliver with fidelity. Written exposure therapy consists of 5 sessions during which patients write for 30 minutes each session about a specific traumatic event, with no between-session assignments. Written exposure therapy significantly reduces PTSD and depression symptoms, and these significant reductions are sustained for at least 1 year. Studies have also shown that WET is noninferior to CPT, with significantly fewer treatment dropouts. Moreover, PTSD symptom severity, psychiatric comorbidity, and symptom chronicity do not affect WET outcomes.

So begins a paper by Sloan et al.

Here’s what they did:

  • They conducted a randomized noninferiority clinical trial.
  • Participants were veterans with PTSD on “stable medications” who had been referred from three Veterans Affairs medical centers.
  • Exclusion criteria included participants being at high suicide risk or having active psychosis.
  • “Independent evaluations were conducted at baseline and 10, 20, and 30 weeks after the first treatment session.”
  • Interventions: “Participants assigned to WET received five to seven 45- to 60-minute sessions. Participants assigned to PE received eight to fifteen 90-minute sessions. The WET sessions included 30 minutes of writing-based imaginal exposure conducted in session, whereas PE sessions included 40 minutes of in-session imaginal exposure and between-session in vivo exposures.”
  • Main outcome: a change in PTSD symptom severity measured with the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5).

Here’s what they found:

  • 208 were assessed, with 30 excluded (the majority didn’t meet criteria for PTSD). 178 were then randomized: 88 to WET and 90 to PE.
  • Demographics. 75.3% were men, and the mean age was 44.97 years. In terms of race, 20.8% were Black; 62.9% were White; and 10.1% of other races.
  • Noninferiority. “Changes in PTSD symptom severity from baseline to all subsequent assessments among individuals randomized to WET were noninferior relative to individuals randomized to PE.” See figure below. Also, “The largest difference between treatments was observed at 10 weeks and was in favor of WET (mean difference, 2.42… points).” 
  • Drop outs. “Participants were significantly less likely to drop out of WET compared with PE (12.5% vs 35.6%…).” (!)

A few thoughts:

1. There is much to like here: a noninferiority RCT with a clear intervention, with randomized participation, and published in a big journal.

2. And the study is very, very practical.

3. The main finding in a sentence: “In this study, WET was noninferior to PE in PTSD symptom change and was associated with significantly less attrition.”

4. Like all studies, there are limitations. The authors note several, including: “most participants were men, and all were military veterans, which may limit the generalizability of the findings.”

5. In an accompanying Editorial, Charles T. Taylor and Dr. Murray B. Stein (both of the University of California, San Diego, La Jolla) consider the study in an accompanying Editorial, “Written Exposure Therapy Finds Solid Footing Alongside First-Line Psychotherapies for Posttraumatic Stress Disorder.”

Charles T. Taylor

The Editorial covers much ground with thoughtful analysis, including comments on measuring the success of a noninferiority trial and the need (or the lack of need) for homework in psychotherapies. 

Here, let’s focus on their comments about dose and psychotherapy:

“Why is dose important for psychotherapy? Others have convincingly argued for the value of parsimony in advancing quality therapies – parsimonious therapies require less clinical training, are easier to disseminate, and can lead to greater treatment integrity and adherence. WET achieved comparable reductions in PTSD symptoms through fewer sessions, shorter duration sessions, less therapist involvement, and no explicit prescription of homework. These findings should galvanize the psychotherapy field to design parsimonious treatments from the start, systematically testing the effects of different dose parameters. Though conceptualizing dose within psychotherapy trials has its challenges (at least 4 dose parameters varied between WET and PE: number of sessions, duration of sessions, therapist involvement, and homework assignments), doing so from the earliest stages of treatment development could advance interventions with potential for maximal clinical impact and reach.” Nice.

6. The implications of the study? Needless to say, the authors see many. “Briefer treatments such as WET can be delivered easily in standard clinical settings as well as other settings in which only brief interventions are possible (eg, primary care and medical and psychiatry inpatient units), which further increases access to evidence-based treatment. The finding herein and in a prior study that WET is effective when delivered via telehealth further promotes the accessibility of the intervention.” 

7. WET is an emerging therapy – and this study adds significantly to the literature.

The Editorial can be found here:

The full JAMA Psych paper can be found here:

Selection 2: “#MedEd: Medical Education and Knowledge Translation on Social Media”

John W. Ayers, Aaron M. Goodman, Davey M. Smith

JAMA, 29 August 2023  Online First

Social media has been the subject of intense scrutiny, particularly how the lay public uses social media for their health needs and consumes or shares misinformation. However, for health professionals, social media has become a valuable resource for medical education and knowledge translation. The popularity of the hashtag #MedEd underscores this trend…. On X, formerly known as Twitter, there were 4 397 691 original posts with the hashtag #MedEd on the platform from January 1, 2012, through 2022, with the number of posts increasing each year, most recently from 692 095 during 2021 to 1 178 647 during 2022. While the hashtag #MedEd is a vital indicator of this community, the applications of social media in health care are larger and more diverse, encompassing various platforms and approaches for professionals, educators, and students to share, discuss, and learn from the latest research findings and clinical experiences. The evolution of what is broadly called #MedEd has implications for how we understand and translate medical advancements and challenges us to explore the potential educational benefits of social media in the health sciences.

So begins a Viewpoint by Ayers et al.

The authors focus on three areas:

Crowdsourced Synthesis, Curation, Corrections

“The exponential growth of the PubMed database emphasizes the need for synthesis and curation. The real-time and interactive nature of #MedEd offers a dynamic platform for collectively synthesizing and curating medical knowledge. Participants in these online communities can share research summaries, extract key takeaways, and discuss practical implications.” They note interest in social media: 96% of med students report using it as a learning aid, yet the authors describe a lack of understanding of professional use.

They see an important role: “#MedEd communities have the potential to correct inaccuracies in the literature through instant peer review, mitigating the spread of misinformation among experts.” They write: “In a transparent, public space, flawed conclusions can be called out and debated, fostering a culture of scrutiny and intellectual rigor. #MedEd allows direct communication with knowledge gatekeepers and original investigators. Traditional education pathways, such as academic journals, have long recognized the value of incorporating the wisdom of crowds into their processes, where collective insights can sometimes surpass those of individual experts.”

Open-Sourcing Medical Education

“Medical schools and journals expend substantial effort assembling the most accurate and trustworthy information to educate health professionals, but social media cannot be ignored, especially given its pervasiveness. Social media’s global reach allows diverse voices to contribute to medical discussions, ensuring a multifaceted understanding of the literature through different lived experiences. Within this vein, #MedEd holds the potential to democratize medical knowledge. Social media allows learners from around the world instant access to leading experts and educators for lifelong learning, including those who lack access to and finances for traditional knowledge resources.”

They note that: “According to the Association of American Medical Colleges, the number of physicians in the US who maintain an affiliation with an academic health care institution continues to decline. Therefore, it is easy to imagine that social media can be an equitable vehicle for continuing medical education for some (especially global) health professionals who lack access to academic medical institutions.”

Harnessing Science to Meet #MedEd Challenges

“#MedEd has received insufficient scientific attention. During the 5-year period covering 2018 through 2022, only 4 studies archived on PubMed mention #MedEd in the title. It is crucial to embrace the scientific method and study #MedEd. Scientists could assess social media discourse to understand the process by which new discoveries or updated guidelines translate into practice. Indeed, a field dedicated to understanding #MedEd translational science must become a priority among scientific agencies…”

A few thoughts:

1. This Viewpoint is thoughtful and well argued. 

2. The authors see the importance of professionals joining and participating in social media. “It is crucial to harness the potential of #MedEd without succumbing to group-think or politicization, thereby ensuring scientific rigor and better understanding of the determinants of health and treatments that impact our patient populations.” To that end: “This includes prioritizing the development of professional and critical social media skills so future health professionals can navigate and effectively analyze and apply scientific evidence when using #MedEd, including debates on controversial topics.”

3. So, are you embracing #MedEd?

4. Ayers is doing interesting work by considering new data sets, and thus offering new insights. In a recent Reading of the Week, we looked at the paper he first authored on physician and ChatGPT-generated answers to patient questions, which can be found here:

The full JAMA Viewpoint can be found here:

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.