Psychological therapies for chronic post-traumatic stress disorder (PTSD) in adults

Summary & key facts

Researchers looked at about 70 studies that tested talking therapies for adults with long-standing post-traumatic stress disorder (PTSD), including trauma-focused cognitive behavioural therapy (a talking therapy that directly works with the traumatic memory) and EMDR (a therapy that uses guided eye movements while people recall the trauma). They found that trauma-focused therapy and EMDR reduced clinician-rated PTSD symptoms more than no treatment or usual care. Other kinds of talking therapy also helped compared with no treatment. However, the studies had a lot of problems, so the overall evidence is weak and we cannot be sure how long the benefits last.

Key facts:

• The review pooled about 70 studies that included roughly 4,800 adult participants with chronic PTSD.
• Trauma-focused cognitive behavioural therapy reduced PTSD symptoms more than being on a waitlist or getting usual care.
• EMDR also reduced PTSD symptoms more than waitlist or usual care.
• Right after treatment, trauma-focused therapy, EMDR, and non-trauma-focused CBT appeared roughly equally effective.
• Between about one to four months after treatment there was some evidence that trauma-focused therapy and EMDR worked better than non-trauma-focused CBT.
• Some forms of group trauma-focused therapy and other therapies were also better than no treatment.
• More people dropped out of active therapy groups than of control groups.
• Many of the included studies were small or had unclear or high risk of bias, and follow-up data were limited, so the overall quality of the evidence was rated very low.

Abstract

BACKGROUND: Post-traumatic stress disorder (PTSD) is a distressing condition, which is often treated with psychological therapies. Earlier versions of this review, and other meta-analyses, have found these to be effective, with trauma-focused treatments being more effective than non-trauma-focused treatments. This is an update of a Cochrane review first published in 2005 and updated in 2007. OBJECTIVES: To assess the effects of psychological therapies for the treatment of adults with chronic post-traumatic stress disorder (PTSD). SEARCH METHODS: For this update, we searched the Cochrane Depression, Anxiety and Neurosis Group's Specialised Register (CCDANCTR-Studies and CCDANCTR-References) all years to 12th April 2013. This register contains relevant randomised controlled trials from: The Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). In addition, we handsearched the Journal of Traumatic Stress, contacted experts in the field, searched bibliographies of included studies, and performed citation searches of identified articles. SELECTION CRITERIA: Randomised controlled trials of individual trauma-focused cognitive behavioural therapy (TFCBT), eye movement desensitisation and reprocessing (EMDR), non-trauma-focused CBT (non-TFCBT), other therapies (supportive therapy, non-directive counselling, psychodynamic therapy and present-centred therapy), group TFCBT, or group non-TFCBT, compared to one another or to a waitlist or usual care group for the treatment of chronic PTSD. The primary outcome measure was the severity of clinician-rated traumatic-stress symptoms. DATA COLLECTION AND ANALYSIS: We extracted data and entered them into Review Manager 5 software. We contacted authors to obtain missing data. Two review authors independently performed 'Risk of bias' assessments. We pooled the data where appropriate, and analysed for summary effects. MAIN RESULTS: We include 70 studies involving a total of 4761 participants in the review. The first primary outcome for this review was reduction in the severity of PTSD symptoms, using a standardised measure rated by a clinician. For this outcome, individual TFCBT and EMDR were more effective than waitlist/usual care (standardised mean difference (SMD) -1.62; 95% CI -2.03 to -1.21; 28 studies; n = 1256 and SMD -1.17; 95% CI -2.04 to -0.30; 6 studies; n = 183 respectively). There was no statistically significant difference between individual TFCBT, EMDR and Stress Management (SM) immediately post-treatment although there was some evidence that individual TFCBT and EMDR were superior to non-TFCBT at follow-up, and that individual TFCBT, EMDR and non-TFCBT were more effective than other therapies. Non-TFCBT was more effective than waitlist/usual care and other therapies. Other therapies were superior to waitlist/usual care control as was group TFCBT. There was some evidence of greater drop-out (the second primary outcome for this review) in active treatment groups. Many of the studies were rated as being at 'high' or 'unclear' risk of bias in multiple domains, and there was considerable unexplained heterogeneity; in addition, we assessed the quality of the evidence for each comparison as very low. As such, the findings of this review should be interpreted with caution. AUTHORS' CONCLUSIONS: The evidence for each of the comparisons made in this review was assessed as very low quality. This evidence showed that individual TFCBT and EMDR did better than waitlist/usual care in reducing clinician-assessed PTSD symptoms. There was evidence that individual TFCBT, EMDR and non-TFCBT are equally effective immediately post-treatment in the treatment of PTSD. There was some evidence that TFCBT and EMDR are superior to non-TFCBT between one to four months following treatment, and also that individual TFCBT, EMDR and non-TFCBT are more effective than other therapies. There was evidence of greater drop-out in active treatment groups. Although a substantial number of studies were included in the review, the conclusions are compromised by methodological issues evident in some. Sample sizes were small, and it is apparent that many of the studies were underpowered. There were limited follow-up data, which compromises conclusions regarding the long-term effects of psychological treatment.

Topics

Child Abuse and Trauma Posttraumatic Stress Disorder Research Traumatic Brain Injury Research

Categories

Clinical Psychology Psychology Social Sciences

Tags

Anxiety Clinical psychology Cochrane Library Depression (economics) Economics Internal medicine Law Macroeconomics Medicine MEDLINE Political science Psychiatry PsycINFO Randomized controlled trial Traumatic stress

Conditions & symptoms

Anxiety Anxiety or worry Feeling disconnected from others Poor sleep Sadness or low mood