Prolonged exposure therapy for posttraumatic stress disorder: A systematic review and meta-analysis of randomized controlled trials.

Abstract

This meta-analysis examined the efficacy of prolonged exposure (PE) therapy for posttraumatic stress disorder (PTSD). Fifty-two randomized controlled trials were identified through systematic searches of five electronic databases through March 2026; 43 studies (54 comparisons; N = 4964) were included in quantitative synthesis. PE produced medium-to-large effects on PTSD severity relative to inactive controls (Hedges' g = 0.74, 95% CI [0.51, 0.98]; k = 20) and a small but significant advantage over active treatments (g = 0.24 [0.12, 0.36]; k = 34). This advantage was almost entirely attributable to comparisons with non-trauma-focused therapies (g = 0.40); PE showed no meaningful superiority over other trauma-focused protocols such as Cognitive Processing Therapy (CPT) and Eye Movement Desensitization and Reprocessing (EMDR; g = 0.04). Neither trauma type nor population (military vs. civilian) significantly moderated outcomes. Session number did not predict effect size; briefer protocols warrant evaluation. In an exploratory analysis, effect estimates for complex-presentation samples (k = 14, g = 0.50 [0.32, 0.68]) and unselected samples (k = 40, g = 0.37 [0.21, 0.52]) were not significantly different; however, the imprecision of the estimated contrast precludes conclusions of equivalence. Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) certainty was moderate for both primary comparisons, downgraded for inconsistency. These findings support PE as a first-line PTSD treatment while indicating that its efficacy is shared with other trauma-focused approaches. The exploratory subgroup finding requires confirmation in better-powered studies using prospectively specified classifications.