Psychological treatment of post-traumatic stress disorder

Background Psychological interventions are widely used in the treatment of post-traumatic stress disorder (PTSD). Objectives To perform a systematic review of randomised controlled trials of all psychological treatments following the guidelines of The Cochrane Collaboration. Search strategy Systematic searches of computerised databases, hand search of the Journal of Traumatic Stress, searches of reference lists, known websites and discussion fora, and personal communication with key workers. Selection criteria Types of studies - Any randomised controlled trial of a psychological treatment. Types of participants - Adults suffering from traumatic stress symptoms for three months or more. Types of interventions - Trauma-focused cognitive behavioural therapy/exposure therapy (TFCBT); stress management (SM); other therapies (supportive therapy, non-directive counselling, psychodynamic therapy and hypnotherapy); group cognitive behavioural therapy (group CBT); eye movement desensitisation and reprocessing (EMDR). Types of outcomes - Severity of clinician rated traumatic stress symptoms. Secondary measures included self-reported traumatic stress symptoms, depressive symptoms, anxiety symptoms, adverse effects and dropouts. Data collection and analysis Data were entered using Review Manager software. Quality assessments were performed. Data were analysed for summary effects using Review Manager 4.2. Main results Thirty-three studies were included in the review. With regards to reduction of clinician assessed PTSD symptoms measured immediately after treatment TFCBT did significantly better than waitlist/usual care (standardised mean difference (SMD) =-1.40; 95% CI,-1.89 to-0.91; 14 studies; n = 649). There was no significant difference between TFCBT and SM (SMD =-0.27; 95% CI,-0.71 to 0.16; 6 studies; n = 239). TFCBT did significantly better than other therapies (SMD =-0.81; 95% CI,-1.19 to-0.42; 3 studies; n = 120). Stress management did significantly better than waitlist/usual care (SMD =-1.14; 95% CI,-1.62 to-0.67; 3 studies; n = 86) and than other therapies (SMD =-1.22; 95% CI,-2.09 to-0.35; 1 study; n = 25). There was no significant difference between other therapies and waitlist/usual care control (SMD =-0.43; 95% CI,-0.90 to 0.04; 2 studies; n = 72). Group TFCBT was significantly better than waitlist/usual care (SMD =-0.72; 95% CI,-1.14 to-0.31). EMDR did significantly better than waitlist/usual care (SMD =-1.51; 95% CI, -1.87 to -1.15; 5 studies; n = 162). There was no significant difference between EMDR and TFCBT (SMD = 0.02; 95% CI, -0.28 to 0.31; 6 studies; n = 187). There was no significant difference between EMDR and SM (SMD = -0.35; 95% CI, -0.90 to 0.19; 2 studies; n = 53). EMDR did significantly better than other therapies (self-report) (SMD = -0.84; 95% CI, -1.21 to -0.47; 2 studies; n = 124). Authors' conclusions There was evidence individual TFCBT, EMDR, stress management and group TFCBT are effective in the treatment of PTSD. Other non-trauma focused psychological treatments did not reduce PTSDsymptoms as significantly. There was some evidence that individual TFCBT and EMDR are superior to stress management in the treatment of PTSD at between 2 and 5 months following treatment, and also that TFCBT, EMDR and stress management were more effective than other therapies. There was insufficient evidence to determine whether psychological treatment is harmful. There was some evidence of greater drop-out in active treatment groups. The considerable unexplained heterogeneity observed in these comparisons, and the potential impact of publication bias on these data, suggest the need for caution in interpreting the results of this review.