Online stepped care for the treatment of posttraumatic stress disorder: A randomized controlled noninferiority trial

Stepped care approaches can improve access to posttraumatic stress disorder (PTSD) treatments by matching clients to an intervention level that suits their needs. This randomized controlled non-inferiority trial evaluated the efficacy of an online stepped care approach for PTSD. The approach had two treatment steps: (1) This Way Up (TWU; an online self-guided therapy); and (2) cognitive processing therapy (CPT; standard format therapy), adopting pre-specified criteria for stepping up between treatment steps. Stepped care was evaluated compared to CPT delivered via telehealth among 84 adults with PTSD and subthreshold PTSD (86% female, 87% white, aged 18-79). Stepped care cost less than CPT in terms of clinician time (by 8-10%), but CPT had less dropout (26% versus 43%). Both groups demonstrated significant improvements in PTSD (CAPS-5: g = 1.19 to 2.09; PCL-5: g = 1.23 to 2.59), depression (DASS-21: g = 0.63 to 1.13), and quality of life (AQoL-8D: g = -0.46 to -1.02) over time (baseline, post-treatment, 3-month follow-up, 6-month follow-up), with no differential rates of change over time. Stepped care was non-inferior to CPT on the clinician-rated PTSD measure (at post-treatment) and for depression at all time points. Non-inferiority could not be established for the PCL-5 and quality of life measures, with outcomes favoring CPT. The stepped care approach was feasible, even among participants with high symptom severity and complexities. However, future research is needed to address attrition and improve outcomes compared to CPT, and to identify which clients would benefit from initially receiving low-intensity therapies.