The efficacy of posttraumatic stress disorder (PTSD) treatments in psychosis has not been examined in a randomized
clinical trial to our knowledge. Psychosis is an exclusion criterion in most PTSD trials.
the efficacy and safety of prolonged exposure (PE) therapy and eye movement desensitization and reprocessing (EMDR) therapy
in patients with psychotic disorders and comorbid PTSD.
Design, Setting, and Participants
A single-blind randomized
clinical trial with 3 arms (N = 155), including PE therapy, EMDR therapy, and waiting list (WL) of 13 outpatient mental health
services among patients with a lifetime psychotic disorder and current chronic PTSD. Baseline, posttreatment, and 6-month
follow-up assessments were made.
Participants were randomized to receive 8 weekly 90-minute sessions
of PE (n = 53), EMDR (n = 55), or WL (n = 47). Standard protocols were used, and treatment was not preceded by stabilizing
Main Outcomes and Measures
Clinician-rated severity of PTSD symptoms, PTSD diagnosis,
and full remission (on the Clinician-Administered PTSD Scale) were primary outcomes. Self-reported PTSD symptoms and posttraumatic
cognitions were secondary outcomes.
Data were analyzed as intent to treat with linear mixed models and
generalized estimating equations. Participants in the PE and EMDR conditions showed a greater reduction of PTSD symptoms than
those in the WL condition. Between-group effect sizes were 0.78 (P < .001) in PE and 0.65 (P = .001) in EMDR. Participants
in the PE condition (56.6%; odds ratio [OR], 3.41; P = .006) or the EMDR condition (60.0%; OR, 3.92; P < .001) were significantly
more likely to achieve loss of diagnosis during treatment than those in the WL condition (27.7%). Participants in the PE condition
(28.3%; OR, 5.79; P = .01), but not those in the EMDR condition (16.4%; OR, 2.87; P = .10), were more likely to gain full
remission than those in the WL condition (6.4%). Treatment effects were maintained at the 6-month follow-up in PE and EMDR.
Similar results were obtained regarding secondary outcomes. There were no differences in severe adverse events between conditions
(2 in PE, 1 in EMDR, and 4 in WL). The PE therapy and EMDR therapy showed no difference in any of the outcomes and no difference
in participant dropout (24.5% in PE and 20.0% in EMDR, P = .57).
Conclusions and Relevance
Standard PE and EMDR
protocols are effective, safe, and feasible in patients with PTSD and severe psychotic disorders, including current symptoms.
A priori exclusion of individuals with psychosis from evidence-based PTSD treatments may not be justifiable.