Why Patients Choose Psychotherapy or Sertraline: From a Clinical Trial of PTSD Treatment

Stephanie Keller, MA
Doctoral Candidate; Department of Psychological Sciences, Case Western Reserve University, OH

First published in Psychiatry Weekly, October 21, 2013, 8(22).


Why do some psychiatric patients prefer a particular treatment modality—or modalities—to another? This question is particularly conspicuous in the context of treating posttraumatic stress disorder (PTSD), for which several psychotherapy protocols show robust evidence of efficacy and exactly two medications—sertraline and paroxetine—have received FDA approval. Numerous lines of research have looked at whether patient preferences for PTSD treatment are shaped by the type of trauma experienced, ethnicity, sex, psychiatric comorbidity, previous PTSD treatment, and perceptions of how or why a treatment is believed to work.

A group of PTSD researchers, led by Dr. Norah Feeny, of Case Western Reserve University, and Dr. Lori Zoellner at the University of Washington, recently conducted the first study of what shapes treatment preferences in a treatment-seeking sample of patients with a primary diagnosis of PTSD.

“We want to understand what shapes people’s preferences for either psychotherapy (prolonged exposure therapy) or medication (sertraline) for PTSD,” explains Stephanie Keller, who co-authored the study. “Prolonged exposure is currently one of the strongest evidence-based treatments for PTSD, and sertraline is approved by the FDA for treating PTSD. At this point, there are no conclusive trials as to whether one is more effective than the other for PTSD in general.”


The present study included a sample of 200 treatment-seeking individuals with a primary diagnosis of chronic PTSD. The sample was composed predominantly of women (75.5%) with a mean age of 37.4 years (SD=11.3 years) who were white (65.5%) and who were not college educated (70%). Nearly half (48.5%) of the sample reported an annual income of <$20,000. The types of target-traumas reported by this sample included adult sexual assault (31%) adult non-sexual assault (22.5%), and childhood assault (24%). Only 2.5% of the sample reported combat/war-related trauma.

Subjects were presented with a standardized videotaped rationale for prolonged exposure therapy and sertraline. Each video discussed the efficacy profile of each treatment, its known side effects, and the mechanisms through which it is believed to work.

“These individuals were part of a doubly-randomized preference trial, so they would potentially receive one of the treatments that we asked them to choose between,” says Ms. Keller. “After we presented the participants with the rationale for each treatment, we asked them which treatment they preferred, and to then list their top 5 reasons for that preference.”

The “Why” Behind Treatment Preferences

Subjects’ reasons for their particular treatment preference were grouped in categories similar to those delineated in earlier studies. The most common reasons cited for preferring one treatment to another concerned the mechanism of treatment (eg, I need to talk about the trauma; 45.5%); the efficacy profile of the treatment (eg, medication will help me; 31.5%); and health concerns (eg, I don’t want side effects from medication; 18%).

“I think what we found most surprising was that practical reasons, such as time, logistics, and costs associated with treatment were the least commonly cited reasons (4.5%) for preferring one treatment to another,” says Ms. Keller. “An additional, somewhat surprising, finding was that age, sex, income, education, time since trauma, and severity of psychopathology did not reliably predict treatment preferences.”


Overall, when asked why they preferred either psychotherapy (prolonged exposure) or medication (sertraline) to treat their PTSD symptoms, participants cited both mechanism (eg, I need to talk about my traumatic event) and efficacy (eg, I believe medication will reduce my PTSD) as the two most common reasons that guided their decision.

“These findings can help guide treatment providers when discussing potential treatment options with their patients who have PTSD,” says Ms. Keller. “Explaining the mechanisms of these treatments, that is, how we believe these treatments exert their effect, can help patients to make an educated decision when deciding between psychotherapy or medication for their PTSD symptoms.”

Although practical reasons, such as the time or cost associated with treatment, were not commonly cited reasons for treatment preference, clinicians may want to have a discussion about these factors with their patients, in order to possibly reduce the likelihood of treatment drop-out.

“Overall,” says Ms. Keller, “it seems that patients want a treatment that will address the issues that they believe led to their symptoms of PTSD.”


Disclosure: This research was supported by NIMH grants awarded to Drs. Feeny and Zoellner (R01 MH066347, R01 MH066348).


Chen JA, Keller SM, Zoellner LA, Feeny NC. “How will it help me?” Reasons underlying treatment preferences between sertraline and prolonged exposure in posttraumatic stress disorder. J Nerv Ment Dis. 2013;201:691-697.