Reliable symptom worsening among veterans receiving cognitive processing therapy or prolonged exposure therapy for posttraumatic stress disorder in routine Veterans Health Administration care.

Clinical practice guidelines recommend trauma-focused evidence-based psychotherapy (EBP) to treat posttraumatic stress disorder (PTSD). Some veterans and clinicians report concerns that discussion of trauma will make PTSD symptoms worse. We studied the frequency and correlates of reliable symptom worsening during PTSD EBPs in routine clinical practice. Using national electronic health record data from the Veterans Health Administration, we identified veterans (n = 25,768) who initiated PTSD EBP between 1/2018-1/2023 and had PTSD symptom measurements (i.e., PTSD Checklist for DSM-5; PCL-5). We defined reliable symptom worsening as a 10-point PCL-5 increase from baseline. Using hierarchical Bayesian zero inflated binomial logistic regression, we modeled the probability of experiencing reliable symptom worsening across demographic, military, clinical and service delivery characteristics. In our sample, 22.9 % of veterans experienced reliable symptom worsening. However, most demographic, military, clinical, and service delivery characteristics were poorly associated with reliable symptom worsening. One exception was receipt of a first PTSD EBP session in an inpatient setting, which was associated with a lower likelihood of experiencing reliable symptom worsening (MPOR = 0.73, 90 % CI = 0.66, 0.81; 2 % in ROPE). Reliable symptom worsening was an uncommon (but not rare) occurrence during PTSD EBPs and assessed correlates were poorly related to likelihood of experiencing reliable worsening. Further research is needed to understand the drivers of reliable symptom worsening and to compare rates observed in the current study to reliable symptom worsening that occurs naturally over time and that occurs during any PTSD treatment.