Original article 85

Remission in post-traumatic stress disorder (PTSD): effects

of sertraline as assessed by the Davidson Trauma Scale,
Clinical Global Impressions and the Clinician-Administered
PTSD scale
Jonathan R. T. Davidson
Rates of remission were examined in two controlled
12-week studies of sertraline and placebo for
post-traumatic stress disorder (PTSD). The performance
of three scales was evaluated: the self-rated Davidson
Trauma Scale (DTS), and two interviewer scales:
the Clinician Administered PTSD Scale (CAPS) and
Clinical Global Impressions (CGI). Sertraline proved
significantly superior to placebo with respect to
remission on all three ratings. Rates of remission
were very similar for all scales, ranging from 23.126.3%
for sertraline and 13.914.9% for placebo. Traditional
thresholds for the CAPS and DTS were tested relative to
the CGI and to each other. The CAPS and DTS thresholds
of < 20 and < 18 were found to be valid. Int Clin

Introduction
Studies with fluoxetine (Connor et al., 1999), sertraline
(Davidson et al., 2001a) and paroxetine (Tucker et al.,
2001) have shown that symptom remission can be
attained in the treatment of post-traumatic stress
disorder (PTSD). In the case of sertraline, although data
indicate that prolonged open-label treatment can dissolve
most symptoms, actual rates of remission have not been
published.
Definitions of remission in the PTSD literature have
largely been chosen on an ad hoc basis. For example, in
the fluoxetine study (Connor et al., 1999), remission
was defined as a Composite High Endstate Function
score, based upon asymptomatic status on a self-rating
the Davidson Trauma Scale (DTS) (Davidson, 1996)
and observer rating the Treatment Outcome PTSD
Scale (Davidson et al., 1997) of PTSD, and a self-rating
of disability. In this case, the self-rated DTS score
was required to be no higher than 17. In a study of
paroxetine (Tucker et al., 2001), remission was set at a
total Clinician Administered PTSD Scale (CAPS) (Blake
et al., 1995) score of less than 20. Although these scores
are intuitively reasonable, they have not been tested in
comparison with a more objective index of clinical
remission. One such index could be a separate clinical
global rating which indicates at least: (i) very much
improvement and (ii) symptoms no worse than of mild
intensity.
c 2004 Lippincott Williams & Wilkins
0268-1315 !

Psychopharmacol 19:8587
Wilkins.

!
c

2004 Lippincott Williams &

International Clinical Psychopharmacology 2004, 19:8587

Keywords: CAPS, CGI, DTS, PTSD, remission, sertraline
Department of Psychiatry and Behavioral Sciences, Duke University Medical
Center, Durham, North Carolina, USA.
Correspondence and requests for reprints to Jonathan R. T. Davidson,
Department of Psychiatry and Behavioral Sciences, Duke University Medical
Center, Durham, North Carolina 27710, USA.
Tel: + 1919 684 2880; fax: + 1919 684 8866;
e-mail: jonathan.davidson@duke.edu
Received 17 November 2003 Accepted 19 November 2003

This study aimed to present rates of sertraline-induced

remission for each of the three definitions (i.e. DTS
< 18, CAPS < 20 and a Clinical Global Impressions
(CGI) based interviewer rating (Guy, 1977). The results
are obtained from two previously published clinical trials
of sertraline versus placebo (Davidson et al., 2001b; Brady
et al., 2000), which clearly demonstrated broad-spectrum
superiority over placebo, with drug response rates of 55%
and 60%, respectively, according to the CGI-Improvement (CGI-I), and placebo response rates of 30% and
38%. A second goal was to evaluate the customary DTS
and CAPS definitions of remission relative to an
independent CGI rating, which would permit statements
about diagnostic accuracy for the given scores and for
empirically defined scores on the basis of test sensitivity
analyses.

Methods
Subjects were obtained from two double-blind, placebocontrolled, 12-week trials of sertraline and PTSD (Brady
et al., 2000; Davidson et al., 2001b). All subjects were at
least 18 years of age, fulfilled DSM-III-R (American
Psychiatric Association, 1987) criteria for PTSD, along
with a CAPS-I score of at least 50. Each study had been
approved by a local institutional Institutional Review
Board, and all subjects provided their written informed
consent. The material presented in the results is based
upon the final visit DTS, CAPS and CGI-I and CGISeverity (CGI-S) scores.
DOI: 10.1097/01.yic.0000113107.67404.cd

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86

International Clinical Psychopharmacology 2004, Vol 19 No 2

Sensitivity, specificity, positive likelihood ratio (PLR),

positive predictive value (PPV) and diagnostic accuracy
(efficiency) were calculated as follows. Using a CAPS
threshold of less than 20 to define remission, the
optimum DTS cut-off score was evaluated using the full
range of scores. Similarly, using the DTS < 18 as a
reference definition of remission, analyses were conducted to determine which CAPS score best corresponded to this threshold. Third, both the DTS and
CAPS were compared against the CGI based definition of
remission (CGI-I = 1 and CGI-S = 1, 2 or 3; i.e. no
symptoms, borderline or mild symptoms, respectively).

Results
Three hundred and eighty-four subjects were available
for analysis, of whom 290 (75.5%) were female, and 323
(84.2%) were white. The mean (SD) age of subjects was
38.4 (10.4) years.
Rates of remission with sertraline and placebo

As shown in Fig. 1, 50 out of 190 (26.3%) of sertraline

patients, and 27 out of 194 (13.9%) placebo subjects, met
CGI-I remission criterion (chi squared = 9.04, 1 d.f.,
P = 0.003). Using a CAPS cut-off below 20, 44 out of 191
(23.0%) of subjects on sertraline, and 27 of 194 (13.9%) of
subjects on placebo, met this criterion for remission (chi
squared = 5.32, 1 d.f., P = 0.021). According to the DTS
cut-off point of less than 18, 47 of 190 (24.7%) subjects
on sertraline, and 29 of 194 (14.9%) of subjects on
placebo, met criterion for remission (chi squared = 5.79,
1 d.f., P = 0.016). Expressed as the number-needed-totreat to obtain one extra case of remission relative to
placebo, values were 8, 11 and 10 for the CGI, CAPS and
DTS, respectively.

of 17 and 20. Using the current convention of r 17 on

the DTS, the efficiency is 0.914.
CAPS scores in relation to DTS cut-off score of below 18

Highest diagnostic efficiency (0.919) for the CAPS was

found at a score of 18. The conventional CAPS threshold
of 20 yields a diagnostic efficiency of 0.914 (Table 2).
DTS threshold scores relative to CGI-based definition of
remission

As shown in Table 3, best efficiency scores for the DTS

(0.857) were found at scores of 11 and 14 relative to the
CGI. For the currently used threshold of below 18 on the
DTS, the efficiency score was 0.862.
CAPS threshold relative to the CGI-based definition of
remission

Best efficiency scores (0.883) for the CAPS were found at

a score of 17 relative to the CGI. Using the current
Performance of Davidson Trauma Scale (DTS) relative to
Clinician-Administered Post-Traumatic Stress Disorder Scale
(CAPS) threshold of < 20

Table 1

DTS cut-off
score
16
17
18
19
20

17
18
19
20
21

30%

CGI-I = 1and
CGI-S = 1,2,3

20%
13.9

13.9

10%

SERT PBO

SERT PBO

0.952
0.952
0.939
0.936
0.936

0.747
0.803
0.803
0.817
0.873

0.943
0.955
0.955
0.958
0.970

3.755
4.828
4.764
5.113
7.385

0.914
0.925
0.919
0.914
0.925

Sensitivity

Specificity

PPV

PLR

Efficiency

0.974
0.964
0.964
0.955
0.942

0.632
0.697
0.737
0.750
0.776

0.915
0.928
0.937
0.939
0.945

2.644
3.186
3.664
3.818
4.209

0.906
0.911
0.919
0.914
0.909

PPV, Positive predictive value; PLR, positive likelihood ratio.

Performance of Davidson Trauma Scale (DTS) and

Clinician-Administered Post-Traumatic Stress Disorder Scale
(CAPS) relative to Clinical Global Impressions-based definition of
remission

23.0
14.9

Efficiency

Table 3

26.2

24.7

PLR

Performance of Clinician-Administered Post-Traumatic

Stress Disorder Scale (CAPS) relative to Davidson Trauma Scale
(DTS) threshold of < 18

As shown in Table 1, threshold analysis reveals that the

highest efficiency (0.925) occurred at DTS cut-off scores

CAPS < 20

PPV

Table 2

CAPS cutoff score

DTS <18

Specificity

PPV, Positive predictive value; PLR, positive likelihood ratio.

Optimum DTS remission score relative to CAPS cut-off

of below 20

Fig. 1

Sensitivity

SERT PBO

Rates of remission according to definition on sertraline (SERT) and

placebo (PBO).

Sensitivity
DTS cut-off score
11
0.961
14
0.945
17
0.915
20
0.896
CAPS cut-off score
16
0.971
18
0.948
19
0.941
20
0.928

Specificity

PPV

PLR

Efficiency

0.442
0.507
0.597
0.649

0.873
0.884
0.901
0.911

1.721
1.914
2.274
2.555

0.857
0.857
0.852
0.846

0.520
0.623
0.636
0.638

0.890
0.909
0.912
0.911

2.020
2.517
2.589
2.553

0.880
0.883
0.880
0.870

PPV, Positive predictive value; PLR, positive likelihood ratio.

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Remission in post-traumatic stress disorder Davidson 87

standard definition of a CAPS score below 20, efficiency

scores are high (0.870).

Discussion
Sertraline lead to remission significantly more often than
placebo on all three PTSD outcomes, making it the only
drug so far known to produce remission on several
measures in a large multicentre PTSD sample. The
difference in remission rates of 912% between drug
and placebo is similar to the 12.9% difference reported
for paroxetine versus placebo on the CAPS (Tucker
et al., 2001).
Our results also established that the initially adopted
DTS and CAPS thresholds to define remission are
clinically valid with reference to a CGI-based definition
of remission. Indeed, the respective scores fall very close
to the cut-offs that were shown to have the highest
diagnostic accuracy in the test threshold analyses. It
would appear as though either scale (CAPS or DTS) can
serve as a clinically valid reflection of symptom remission,
using the originally proposed cut-offs, although a slight
adjustment of the threshold might lead to marginally
higher accuracy relative to a clinical global rating.
Normative general population scores are available for the
DTS (Davidson et al., 1996; Davidson et al., 2002), and
they indicate a mean score of 11.0 for all traumatized
individuals. This turns out to correspond closely to the
optimum range of scores (Londborg et al., 2001; Tucker
et al., 2001; Weathers et al., 2001) found to match the
CGI-based definition of remission. The overall rates of
remission on sertraline and placebo were practically
identical across the three definitions, ranging from
23.126.3% for sertraline, and 13.914.9% for placebo. It
is noted that longer-term treatment can perhaps increase
the numbers of subjects who achieve clinical remission
from PTSD (Londborg et al., 2001). Indeed, when the
data of Londborg et al. (2001) were assessed for patients
who were treated with only sertraline for 9 months,
remission rates according to the CAPS increased from
31% after 14 weeks to 63.5% at endpoint. This would
suggest a potential doubling of the remission rate if
treatment persists beyond 3 months for up to 9 months.

We conclude that: (i) sertraline produces a significantly

higher rate of remission in PTSD according to three
different measures; (ii) any one of the three definitions
gives a similar remission rate; and (iii) the previously
chosen thresholds on the DTS (below 18) and the CAPS
(below 20) are justified.

Acknowledgements
Funding was provided to the author by Pfizer, Inc, for
whom he has serves as an investigator, consultant and
speaker.

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