CIPC Blog

Fortney et al., 2025

Primary care teams regularly care for patients who’ve been exposed to trauma and struggle with PTSD, many of whom often have limited access to traditional mental health services or who prefer to get their care only in primary care settings. Fortney et al. (2025) recently published a large pragmatic trial that highlights real-world evidence on effective approaches when treating PTSD directly in primary care. The study took place across 15 clinics in both Federally Qualified Health Centers and Veterans Administration practices (N=700), and compared trauma-focused written exposure therapy (WET) adapted for primary care with commonly used SSRIs. The study included a follow-up strategy for non-responders to initial treatment. There were 3 resulting arms of this study: 

• Arm 1: SSRI followed by WET augmentation, if needed
• Arm 2: SSRI followed by switch to SNRI, if needed
• Arm 3: WET followed by adding an SSRI, if needed 

This study adds empirical support to something most of us working in primary care already know…  delivering treatment for PTSD, including psychotherapy and pharmacotherapy approaches, in primary care is feasible and effective. 

Key Study Findings: 

SSRIs and written exposure therapy (WET) both led to meaningful symptom improvement.

• Patients in both groups showed clinically significant reductions in PTSD symptoms at 4 months.
• There was no significant difference in symptom reduction between initial assignments to either WET or SSRIs.
• Average baseline PTSD Checklist (PCL-5) scores were high (mean: 53), and both groups improved substantially.

The biggest challenge: engagement, not effectiveness

• Only 31.5% of patients assigned to WET completed all sessions, despite its brief structure.
  
• About 52% of those prescribed SSRIs reported medication adherence.
  
• Engagement challenges in this study are no surprise to those of us working in primary care! Complexity reigns… patients often face competing demands, ambivalence, stigma, other co-occurring conditions, and social health-related stressors. 

For nonresponders to SSRIs, switching to an SNRI outperformed adding WET.

• Among those who did not respond to SSRIs, switching to venlafaxine led to significantly greater symptom reduction compared with switching to WET.
  

What does this mean for those of us working in primary care? 

• Both WET and SSRIs are valid first options.  Patients in primary care with PTSD do not have to languish on long waiting lists for traditional care settings and our “gold standard” treatments of prolonged exposure (PE), cognitive processing therapy (CPT), and eye movement desensitization and reprocessing (EMDR). There are several impactful interventions that we can provide in primary care. It’s important that we always offer a menu of evidence-based options that patients have (both in primary care and in traditional MH care settings), and support patients in the choices that work best for them.
• Engagement matters more than the specific modality.  This highlights a reality that many of us working in primary care are quite familiar with. Flexibility and adaptability are where primary care shines, and it allows us to care for patients with complex needs. This study supports prioritizing low-barrier strategies, flexible scheduling, reminder systems, or integrated behavioral health check-ins to increase engagement. 
• If an SSRI isn’t working, switching to an SNRI is a strong evidence-based next step. This aligns with what many clinicians do already, but the trial provides rare, real-world, randomized support for the strategy.

WET can be delivered in primary care by trained clinicians, making trauma-focused therapy more accessible.

Reference: Fortney JC, Kaysen DL, Engel CC, et al. Pragmatic Comparative Effectiveness of Primary Care Treatments for Posttraumatic Stress Disorder: A Randomized Clinical Trial. JAMA Psychiatry. Published online October 15, 2025. doi:10.1001/jamapsychiatry.2025.2962