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

This meta-analysis examined the efficacy of prolonged exposure (PE) therapy for PTSD by identifying fifty-two randomized controlled trials of trauma-focused (including EMDR therapy) and non-trauma-focused therapies.

Article 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.

Highlights:

• Systematic review of 52 PE RCTs for PTSD; 43 meta-analyzed (N = 4964)
• PE outperformed inactive controls (g = 0.74) and active treatments (g = 0.24).
• PE showed no advantage over other trauma-focused therapies (g = 0.04).
• Complex-presentation estimates did not differ significantly; uncertainty remained.
• Session number did not predict effect size; briefer protocols warrant evaluation.“

—Description from publisher

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Zhao, H., Cai, M., Kang, X., Zhang, T., Ke, Y., & Liang, B. (2026). Prolonged exposure therapy for posttraumatic stress disorder: A systematic review and meta-analysis of randomized controlled trials. Journal of Affective Disorders, 122612. https://doi.org/10.1016/j.jad.2026.122612(opens in new tab)

About the Journal

“The Journal of Affective Disorders publishes papers concerned with affective disorders in the widest sense: depression, mania, mood spectrum, emotions and personality, anxiety and stress. It is interdisciplinary and aims to bring together different approaches for a diverse readership. Top quality papers will be accepted dealing with any aspect of affective disorders, including neuroimaging, cognitive neurosciences, genetics, molecular biology, experimental and clinical neurosciences, pharmacology, neuroimmunoendocrinology, intervention and treatment trials.”

—Description from publisher