Elsevier

Clinical Psychology Review

Volume 43, February 2016, Pages 128-141
Clinical Psychology Review

Psychological treatments for adults with posttraumatic stress disorder: A systematic review and meta-analysis,☆☆

https://doi.org/10.1016/j.cpr.2015.10.003Get rights and content

Highlights

  • We conducted a meta-analysis of psychological treatments for adults with PTSD.

  • We examined efficacy, comparative effectiveness, and harms.

  • Several therapies demonstrated efficacy, with strongest support for exposure.

  • Evidence was insufficient to determine comparative effectiveness.

  • Information on adverse events was generally not reported.

Abstract

Numerous guidelines have been developed over the past decade regarding treatments for Posttraumatic stress disorder (PTSD). However, given differences in guideline recommendations, some uncertainty exists regarding the selection of effective PTSD therapies. The current manuscript assessed the efficacy, comparative effectiveness, and adverse effects of psychological treatments for adults with PTSD. We searched MEDLINE, Cochrane Library, PILOTS, Embase, CINAHL, PsycINFO, and the Web of Science. Two reviewers independently selected trials. Two reviewers assessed risk of bias and graded strength of evidence (SOE). We included 64 trials; patients generally had severe PTSD. Evidence supports efficacy of exposure therapy (high SOE) including the manualized version Prolonged Exposure (PE); cognitive therapy (CT), cognitive processing therapy (CPT), cognitive behavioral therapy (CBT)-mixed therapies (moderate SOE); eye movement desensitization and reprocessing (EMDR) and narrative exposure therapy (low–moderate SOE). Effect sizes for reducing PTSD symptoms were large (e.g., Cohen's d ~− 1.0 or more compared with controls). Numbers needed to treat (NNTs) were < 4 to achieve loss of PTSD diagnosis for exposure therapy, CPT, CT, CBT-mixed, and EMDR. Several psychological treatments are effective for adults with PTSD. Head-to-head evidence was insufficient to determine these treatments' comparative effectiveness, and data regarding adverse events was absent from most studies.

Introduction

Posttraumatic stress disorder (PTSD) is an anxiety disorder that may develop following exposure to a traumatic event. The diagnosis of PTSD has undergone a number of changes since initial inclusion in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) (American Psychiatric Association, 2015). Some of the changes center on the definition of what constitutes a traumatic event. In DSM-III, PTSD was diagnosed following a “catastrophic stressor that was outside the range of usual human experience.” However, given the prevalence of many types of trauma, distinguishing between ordinary and extraordinary events can be challenging. With DSM-IV, the focus turned to the individual's peri-traumatic reaction of experiencing intense fear, helplessness or horror to define the stressor as traumatic. (American Psychiatric Association, 2000). However, many individuals fail to endorse this reaction at the time of the event. The most recent iteration of PTSD in the DSM-5 removes this criteria and instead identifies the types of events capable of producing PTSD (e.g., combat, death, threatened death, serious injury, sexual violence), which are either directly experienced, witnessed, experienced by a close family member or friend, or experienced through repeated or extreme exposure to aversive details of the traumatic event. The DSM-5 categorizes PTSD symptoms as: re-experiencing, avoidance, negative alterations in mood and cognition, and alterations in arousal and reactivity. (American Psychiatric Association, 2015). The addition of “persistent and exaggerated negative beliefs about oneself, others or the world;” and “persistent, distorted cognitions about the cause or consequences of the event(s)” are new in DSM-5 and reflect contemporary cognitive-behavioral theory and research on the after-effects of trauma (Cox, Resnick, & Kilpatrick, 2014).

PTSD develops in up to a third of individuals who are exposed to extreme stressors, and symptoms almost always emerge within days of the exposure (Committee on Treatment of Posttraumatic Stress Disorder, & Institute of Medicine, 2008). Shortly after exposure, many people experience some symptoms of PTSD. In most people, those symptoms resolve within several weeks. However, in approximately 10 to 20%, PTSD symptoms persist and are associated with impairment in functioning (Norris & Sloane, 2007). Although approximately 50% of those diagnosed with PTSD improve without treatment in 1 year, 10 to 20% develop a chronic unremitting course (Fletcher, Creamer, & Forbes, 2010). In 2000, the estimated lifetime prevalence of PTSD among adults in the United States was 6.8% and current (12-month) prevalence was 3.6% (Dohrenwend et al., 2006).

Many people with PTSD never receive treatment. For example, less than half of individuals who screened positive for PTSD after serving with the US military in Iraq or Afghanistan were referred for further evaluation or treatment, and of these, only 65% received care (Committee on the Assessment of Ongoing Effects in the Treatment of Posttraumatic Stress Disorder, I. o. M., 2012). Some possible reasons for never receiving treatment include stigma, access barriers, and uncertainty about which treatments are available and effective (Kuehn, 2012).

Treatments available for PTSD span a variety of psychological and pharmacological categories.

Among the psychological therapies are trauma-focused psychological interventions that treat PTSD by directly addressing thoughts, feelings, or memories of the traumatic event (e.g., exposure therapy, cognitive therapy); and non-trauma-focused psychological interventions, which aim to help the individual's experience of PTSD symptoms but do not directly target thoughts and feelings related to the trauma (e.g., relaxation, Stress Inoculation Training, and interpersonal therapy).

Numerous organizations have produced guidelines for the treatment of patients with PTSD, including the American Psychiatric Association (APA), the U.S. Department of Veterans Affairs (VA)/Department of Defense (DoD), the United Kingdom's National Institute for Health and Clinical Excellence (NICE), ISTSS, the Institute of Medicine (IOM), the American Academy of Child and Adolescent Psychiatry (AACAP), and the Australian National Health and Medical Research Council (NHMRC). Table 1 summarizes the previous guidelines. In addition to employing a wide range of methodologies, the various guidelines differ in the level of rigor of studies included in their review. For instance, some were based on expert review of the literature (VA/DoD, APA, and ISTSS). Other guidelines were based on meta-analysis of RCTs but did not have strict criteria for study inclusion (NICE, NHMRC). Finally, the IOM report had strict inclusion criteria based on randomized controlled trials, adequate sample sizes, minimal level of dropout, blinding of assessors, and adequate methods used to handle missing data. Each of the guidelines identified therapies that warranted a highest level of recommendation (Level I), followed by a second-level recommendation (Level II). The guidelines used different criteria for determining what merited a Level I recommendation, ranging from having at least one RCT (e.g., VA/DoD) to having at least one RCT meeting all of the strict criteria as outlined above (e.g., IOM). All of the existing guidelines agree that trauma-focused psychological interventions including exposure therapy and cognitive therapy are effective, empirically supported first-line treatments for PTSD. (American Psychiatric Association, 2004, Foa et al., 2008, Forbes et al., 2010, National Institute for Health and Clinical Excellence, 2005, VA/DoD Clinical Practice Guideline Working Group, 2004). In addition, four of the six guidelines (VA/DoD, NICE, NHMRC, and ISTSS) agree that EMDR is a first-line treatment for PTSD, and two of the guidelines agree that Stress Inoculation Therapy is a first-line treatment for PTSD. The IOM report concluded that only exposure therapy was efficacious and recommended as a first line treatment (Committee on Treatment of Posttraumatic Stress Disorder, & Institute of Medicine, 2008).

Most guidelines identify trauma-focused psychological treatments over pharmacological treatments as a preferred first step and view medications as an adjunct or a next line treatment (American Psychiatric Association, 2004; Australian National Health and Medical Research Council (NHMRC) Guidelines, & Australian Centre for Posttraumatic Mental Health, 2007; National Institute for Health and Clinical Excellence, 2005, VA/DoD Clinical Practice Guideline Working Group, 2004. Most recognize at least some benefit of pharmacologic treatment for PTSD, with the exception of one from the IOM. The IOM report found insufficient evidence to recommend any medication owing to poor study design or inconsistent results. Some guidelines acknowledge that practical considerations, such as unavailability of trauma-focused psychological treatment or patient preferences, may guide treatment decisions (Foa et al., 2008).

As a result of differences in methodologies and categorization of therapies, the available guidelines leave important questions unanswered. One important question is the relative magnitude of effect for exposure therapy and cognitive therapies separately, as previous reviews analyzed them together. Another question concerns the degree to which EMDR is beneficial, as all guidelines except for the more rigorous IOM report gave EMDR a primary or secondary level of recommendation. Further, these guidelines were developed between 7 and 11 years ago, and new trials have since been published that can add to the evidence base. Finally, the current manuscript attempted to address the potential adverse effects of treatments for PTSD, which had not been addressed in previous reviews.

In this article, we updated our prior meta-analyses of psychological treatments for PTSD that were conducted for the Effective Health Care Program of the Agency for Healthcare Research and Quality (AHRQ) (Jonas et al., 2013). The prior meta-analyses were part of a larger technical report on the efficacy, comparative effectiveness, and adverse effects of psychological and pharmacological treatments for adults with PTSD.

Section snippets

Methods

We developed and followed a standard protocol. Our previous technical report that further details methods and includes search strategies and additional evidence tables is available at: http://effectivehealthcare.ahrq.gov/ehc/products/347/1435/PTSD-adult-treatment-report-130403.pdf. The technical report addressed six questions (Table S1) (Jonas et al., 2013).

Results

We included 64 randomized controlled trials (Fig. 1). Sample sizes ranged from 10 to 563, and study duration ranged from 4 weeks to 2 years. Sixty trials evaluated psychological treatments, one (van der Kolk et al., 2007) compared psychological and pharmacological treatments, and three (Foa et al., 2013, Rothbaum et al., 2006, Schneier et al., 2012) evaluated combinations of psychological and pharmacological treatments compared with either one alone (Table S3). The included studies generally

Discussion

Our meta-analysis demonstrates efficacy of exposure therapy (including prolonged exposure) for improving PTSD symptoms (high SOE), and for number needed to treat and loss of diagnosis (moderate SOE). Evidence also supports efficacy of cognitive therapy, including CPT, and CBT-mixed therapies, (moderate SOE for all), eye movement desensitization and reprocessing (EMDR) (low SOE for PTSD symptom reduction, moderate SOE for loss of diagnosis) and NET (moderate SOE for PTSD symptom reduction, low

Role of funding sources

This review was supported in part by an American Recovery and Reinvestment Act (ARRA) contract from the Agency for Healthcare Research and Quality (AHRQ), Contract No. 290 2007 10056 I and partially funded by AHRQ. Staff at AHRQ participated in development of the scope of work and reviewed draft manuscripts. Copyright assertion from AHRQ was required before the manuscript could be submitted for publication, but the authors are solely responsible for the content and the decision to submit it for

Contributors

Karen Cusack, Ph.D. was involved in study ratings, study categorization, preparation of the manuscript and writing the first draft of the manuscript. Daniel E. Jonas, M.D., M.P.H. was involved in study design and writing of the protocol. He wrote the first draft of the technical report prepared for AHRQ. Catherine A. Forneris, Ph.D., A.B.B.P. was involved in study ratings, study categorization, and preparation of the manuscript. Candi Wines, MPH was involved in statistical analysis. Jeffrey

Conflict of interest

None of the investigators has any affiliations or financial involvement that conflicts with the material presented in this report. The authors report no financial relationships with commercial interests that pose a potential conflict of interest.

Acknowledgments

We express appreciation to the other members of the RTI International — University of North Carolina Evidence-based Practice Center who contributed to this effort: Ms. Megan Van Noord, MSIS, and Ms. Christiane Voisin, MSLS, for help in literature searching; Carol Woodell of RTI International for her project management expertise; Kathy Lohr of RTI International for reviewing and editing portions of the full technical report; Ms. Claire Baker for help in article retrieval; and Ms. Loraine Monroe

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    Funding/Support: Some of the work for this review was supported by an American Recovery and Reinvestment Act (ARRA) contract from the Agency for Healthcare Research and Quality (AHRQ), Contract No. 290 2007 10056 I.

    ☆☆

    Role of the sponsor: This review was funded in part by AHRQ. Staff at AHRQ participated in development of the scope of work and reviewed draft manuscripts. Copyright assertion from AHRQ was required before the manuscript could be submitted for publication, but the authors are solely responsible for the content and the decision to submit it for publication.

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