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Psychological treatments for post-traumatic stress disorder in adults: a network meta-analysis

Published online by Cambridge University Press:  17 February 2020

Ifigeneia Mavranezouli*
Affiliation:
Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational & Health Psychology, University College London, 1-19 Torrington Place, LondonWC1E 7HB, UK National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, LondonSE1 1SZ, UK
Odette Megnin-Viggars
Affiliation:
Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational & Health Psychology, University College London, 1-19 Torrington Place, LondonWC1E 7HB, UK National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, LondonSE1 1SZ, UK
Caitlin Daly
Affiliation:
Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, BristolBS8 2PS, UK
Sofia Dias
Affiliation:
Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, BristolBS8 2PS, UK
Nicky J. Welton
Affiliation:
Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, BristolBS8 2PS, UK
Sarah Stockton
Affiliation:
National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, LondonSE1 1SZ, UK
Gita Bhutani
Affiliation:
Lancashire & South Cumbria NHS Foundation Trust, Bamber Bridge, PrestonPR5 6AW, UK University of Liverpool, LiverpoolL69 3BX, UK
Nick Grey
Affiliation:
Sussex Partnership NHS Foundation Trust, Aldrington House, 35 New Church Road, Hove, BN3 4AG, UK School of Psychology, University of Sussex, Sussex House, Brighton, BN1 9RH, UK
Jonathan Leach
Affiliation:
Davenal House Surgery, BromsgroveB61 0DD, UK
Neil Greenberg
Affiliation:
King's Centre for Military Health Research, King's College London, Weston Education Centre, 10 Cutcombe Road, LondonSE5 9RJ, UK
Cornelius Katona
Affiliation:
Helen Bamber Foundation, Bruges Place, 15-20 Baynes Street, LondonNW1 0TF, UK Division of Psychiatry, University College London, 6th Floor, Wings A and B, Maple House, 149 Tottenham Court Road, LondonW1T 7NF, UK
Sharif El-Leithy
Affiliation:
Traumatic Stress Service, Springfield Hospital, LondonSW17 7DJ, UK
Stephen Pilling
Affiliation:
Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational & Health Psychology, University College London, 1-19 Torrington Place, LondonWC1E 7HB, UK National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, LondonSE1 1SZ, UK Camden and Islington NHS Foundation Trust, St Pancras Hospital, 4 St Pancras Way, LondonNW1 0PE, UK
*
Author for correspondence: Ifigeneia Mavranezouli, E-mail: i.mavranezouli@ucl.ac.uk

Abstract

Background

Post-traumatic stress disorder (PTSD) is a potentially chronic and disabling disorder affecting a significant minority of people exposed to trauma. Various psychological treatments have been shown to be effective, but their relative effects are not well established.

Methods

We undertook a systematic review and network meta-analyses of psychological interventions for adults with PTSD. Outcomes included PTSD symptom change scores post-treatment and at 1–4-month follow-up, and remission post-treatment.

Results

We included 90 trials, 6560 individuals and 22 interventions. Evidence was of moderate-to-low quality. Eye movement desensitisation and reprocessing (EMDR) [standardised mean difference (SMD) −2.07; 95% credible interval (CrI) −2.70 to −1.44], combined somatic/cognitive therapies (SMD −1.69; 95% CrI −2.66 to −0.73), trauma-focused cognitive behavioural therapy (TF-CBT) (SMD −1.46; 95% CrI −1.87 to −1.05) and self-help with support (SMD −1.46; 95% CrI −2.33 to −0.59) appeared to be most effective at reducing PTSD symptoms post-treatment v. waitlist, followed by non-TF-CBT, TF-CBT combined with a selective serotonin reuptake inhibitor (SSRI), SSRIs, self-help without support and counselling. EMDR and TF-CBT showed sustained effects at 1–4-month follow-up. EMDR, TF-CBT, self-help with support and counselling improved remission rates post-treatment. Results for other interventions were either inconclusive or based on limited evidence.

Conclusions

EMDR and TF-CBT appear to be most effective at reducing symptoms and improving remission rates in adults with PTSD. They are also effective at sustaining symptom improvements beyond treatment endpoint. Further research needs to explore the long-term comparative effectiveness of psychological therapies for adults with PTSD and also the impact of severity and complexity of PTSD on treatment outcomes.

Type
Review Article
Copyright
© The Author(s) 2020. Published by Cambridge University Press

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Footnotes

*

Current affiliation: Centre for Reviews and Dissemination, University of York, Heslington, York YO10 5DD, UK.

References

Ahmadi, N., Hajsadeghi, F., Mirshkarlo, H. B., Budoff, M., Yehuda, R., & Ebrahimi, R. (2011). Post-traumatic stress disorder, coronary atherosclerosis, and mortality. American Journal of Cardiology, 108, 2933.10.1016/j.amjcard.2011.02.340CrossRefGoogle ScholarPubMed
Alonso, J., Angermeyer, M. C., Bernert, S., Bruffaerts, R., Brugha, T. S., Bryson, H., … Vollebergh, W. A. (2004). Disability and quality of life impact of mental disorders in Europe: Results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project. Acta Psychiatrica Scandinavica 109, Supplementum 420, 3846.Google ScholarPubMed
American Psychological Association (2017). Clinical practice guideline for the treatment of PTSD. Washington, DC: American Psychological Association. Retrieved October 22, 2019, from https://www.apa.org/ptsd-guideline/ptsd.pdfGoogle Scholar
Bisson, J. I., Roberts, N. P., Andrew, M., Cooper, R., & Lewis, C. (2013). Psychological therapies for chronic post-traumatic stress disorder (PTSD) in adults. Cochrane Database of Systematic Reviews, 12, CD003388.Google Scholar
Brewin, C. R., Cloitre, M., Hyland, P., Shevlin, M., Maercker, A., Bryant, R. A., … Reed, G. M. (2017). A review of current evidence regarding the ICD-11 proposals for diagnosing PTSD and complex PTSD. Clinical Psychology Review, 58, 115.CrossRefGoogle ScholarPubMed
Caldwell, D. M., Ades, A. E., & Higgins, J. P. (2005). Simultaneous comparison of multiple treatments: Combining direct and indirect evidence. BMJ, 331, 897900.CrossRefGoogle ScholarPubMed
Church, D., Hawk, C., Brooks, A. J., Toukolehto, O., Wren, M., Dinter, I., & Stein, P. (2013). Psychological trauma symptom improvement in veterans using emotional freedom techniques: A randomized controlled trial. The Journal of Nervous and Mental Disease, 201, 153160.CrossRefGoogle ScholarPubMed
Cohen, J. (1969). Statistical power analysis for the behavioral sciences. New York: Academic Press.Google Scholar
Cuijpers, P., Li, J., Hofmann, S. G., & Andersson, G. (2010). Self-reported versus clinician-rated symptoms of depression as outcome measures in psychotherapy research on depression: A meta-analysis. Clinical Psychology Review, 30, 768778.CrossRefGoogle ScholarPubMed
Cusack, K., Jonas, D. E., Forneris, C. A., Wines, C., Sonis, J., Middleton, J. C., … Gaynes, B. N. (2016). Psychological treatments for adults with posttraumatic stress disorder: A systematic review and meta-analysis. Clinical Psychology Review, 43, 128141.CrossRefGoogle ScholarPubMed
Department of Veterans Affairs and Department of Defence (VA/DoD) (2017). VA/Dod clinical practice guideline for the management of posttraumatic stress disorder and acute stress disorder. Washington, DC: VA/DoD. Retrieved October 16, 2019, from https://www.healthquality.va.gov/guidelines/MH/ptsd/Google Scholar
Dias, S., Ades, A. E., Welton, N. J., Jansen, J. P., & Sutton, A. J. (2018). Network meta-analysis for decision-making. Hoboken, NJ: Wiley.CrossRefGoogle Scholar
Dias, S., Sutton, A. J., Ades, A. E., & Welton, N. J. (2013a). Evidence synthesis for decision making 2: A generalized linear modeling framework for pairwise and network meta-analysis of randomized controlled trials. Medical Decision Making, 33, 607617.CrossRefGoogle Scholar
Dias, S., Welton, N. J., Caldwell, D. M., & Ades, A. E. (2010). Checking consistency in mixed treatment comparison meta-analysis. Statistics in Medicine, 29, 932944.CrossRefGoogle ScholarPubMed
Dias, S., Welton, N. J., Sutton, A. J., Caldwell, D. M., Lu, G., & Ades, A. E. (2013b). Evidence synthesis for decision making 4: Inconsistency in networks of evidence based on randomized controlled trials. Medical Decision Making, 33, 641656.CrossRefGoogle Scholar
Forman-Hoffman, V., Middleton, J. C., Feltner, C., Gaynes, B. N., Weber, R. P., Bann, C., … Green, J. (2018). Psychological and Pharmacological Treatments for Adults with Posttraumatic Stress Disorder: A Systematic Review Update. Comparative Effectiveness Review No. 207. (Prepared by the RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center under Contract No. 290-2015-00011-I for AHRQ and PCORI.) AHRQ Publication No. 18-EHC011-EF. PCORI Publication No. 2018-SR-01. Agency for Healthcare Research and Quality: Rockville, MD.Google Scholar
Frost, N. D., Laska, K. M., & Wampold, B. E. (2014). The evidence for present-centered therapy as a treatment for posttraumatic stress disorder. Journal of Traumatic Stress, 27, 18.CrossRefGoogle ScholarPubMed
Gerger, H., Munder, T., Gemperli, A., Nüesch, E., Trelle, S., Juni, P., & Barth, J. (2014). Integrating fragmented evidence by network meta-analysis: Relative effectiveness of psychological interventions for adults with post-traumatic stress disorder. Psychological Medicine, 44, 31513164.CrossRefGoogle ScholarPubMed
Hamblen, J. L., Norman, S. B., Sonis, J. H., Phelps, A. J., Bisson, J. I., Nunes, V. D., … Schnurr, P. P. (2019). A guide to guidelines for the treatment of posttraumatic stress disorder in adults: An update. Psychotherapy, 56, 359373.CrossRefGoogle ScholarPubMed
Higgins, J. P. T., Alman, D. G., & Sterne, J. A. C. (Eds.) (2011). Assessing risk of bias in included studies. In Higgins, J. P. T. & Green, S. (Eds.), Cochrane handbook for systematic reviews of interventions version 5.1.0 [updated march 2011]. The Cochrane Collaboration. Retrieved June 1, 2018, from www.handbook.cochrane.orgGoogle Scholar
International Society for Traumatic Stress Studies (2019). ISTSS PTSD Prevention and Treatment Guidelines Methodology and Recommendations. Retrieved October 16, 2019, from www.istss.org/treating-trauma/new-istss-prevention-and-treatment-guidelinesGoogle Scholar
Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 10481060.CrossRefGoogle ScholarPubMed
Khan, A. M., Dar, S., Ahmed, R., Bachu, R., Adnan, M., & Kotapati, V. P. (2018). Cognitive behavioral therapy versus eye movement desensitization and reprocessing in patients with post-traumatic stress disorder: Systematic review and meta-analysis of randomized clinical trials. Cureus, 10, e3250.Google ScholarPubMed
Kitchiner, N. J., Lewis, C., Roberts, N. P., & Bisson, J. I. (2019). Active duty and ex-serving military personnel with post-traumatic stress disorder treated with psychological therapies: Systematic review and meta-analysis. European Journal of Psychotraumatology, 10, 1684226.CrossRefGoogle ScholarPubMed
Koenen, K. C., Ratanatharathorn, A., Ng, L., McLaughlin, K. A., Bromet, E. J., Stein, D. J., … Kessler, R. C. (2017). Posttraumatic stress disorder in the World Mental Health Surveys. Psychological Medicine, 47, 22602274.CrossRefGoogle ScholarPubMed
Kuester, A., Niemeyer, H., & Knaevelsrud, C. (2016). Internet-based interventions for posttraumatic stress: A meta-analysis of randomized controlled trials. Clinical Psychology Review, 43, 116.CrossRefGoogle ScholarPubMed
Lu, G., & Ades, A. E. (2004). Combination of direct and indirect evidence in mixed treatment comparisons. Statistics in Medicine, 23, 31053124.CrossRefGoogle ScholarPubMed
Lunn, D. J., Thomas, A., Best, N., & Spiegelhalter, D. (2000). WinBUGS – A Bayesian modelling framework: Concepts, structure, and extensibility. Statistics and Computing, 10, 325337.CrossRefGoogle Scholar
Mavranezouli, I., Megnin-Viggars, O., Daly, C., Dias, S., Stockton, S., Meiser-Stedman, R., … Pilling, S. (2020). Research review: Psychological and psychosocial treatments for children and young people with posttraumatic stress disorder: A network meta-analysis. Journal of Child Psychology and Psychiatry, 61, 1829.CrossRefGoogle Scholar
Mavranezouli, I., Megnin-Viggars, O., Grey, N., Bhutani, G., Leach, J., Daly, C., … Pilling, S. (under review). Cost effectiveness of psychological interventions for post-traumatic stress disorder in adults. PLoS ONE, under review.Google Scholar
Mavridis, D., Giannatsi, M., Cipriani, A., & Salanti, G. (2015). A primer on network meta-analysis with emphasis on mental health. Evidence Based Mental Health, 18, 4046.CrossRefGoogle ScholarPubMed
Moher, D., Liberati, A., Tetzlaff, J., & Altman, D. G. (2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. Journal of Clinical Epidemiology, 62, 10061012.CrossRefGoogle ScholarPubMed
National Institute for Health and Care Excellence (2011). Common mental health problems: Identification and pathways to care. NICE Retrieved December 9, 2019, from https://www.nice.org.uk/guidance/cg123Google Scholar
National Institute for Health and Care Excellence (2014). Developing NICE guidelines: the manual (last updated October 2018). NICE Retrieved October 7, 2019, from https://www.nice.org.uk/process/pmg20Google Scholar
National Institute for Health and Care Excellence (2018a). Post-traumatic stress disorder. NICE Retrieved May 10, 2019, from https://www.nice.org.uk/guidance/ng116Google Scholar
National Institute for Health and Care Excellence (2018b). Evidence report D. Evidence reviews for psychological, psychosocial and other non-pharmacological interventions for the treatment of PTSD in adults. NICE Retrieved October 21, 2019, from https://www.nice.org.uk/guidance/ng116/evidenceGoogle Scholar
Nüesch, E., Trelle, S., Reichenbach, S., Rutjes, A. W. S., Bürgi, E., Scherer, M., … Jüni, P. (2009). The effects of excluding patients from the analysis in randomised controlled trials: Meta-epidemiological study. British Medical Journal, 339, b3244.CrossRefGoogle ScholarPubMed
Phoenix Australia-Centre for Posttraumatic Mental Health (2013). Australian Guidelines for the treatment of acute stress disorder & posttraumatic stress disorder. Phoenix Australia, Melbourne, Victoria. Retrieved December 10, 2019, from https://www.phoenixaustralia.org/resources/ptsd-guidelines/Google Scholar
Pike, H. (2019). Statistical significance should be abandoned, say scientists. BMJ, 364, l1374.10.1136/bmj.l1374CrossRefGoogle ScholarPubMed
Robson, R. H., Robson, P. M., Ludwig, R., Mitabu, C., & Phillips, C. (2016). Effectiveness of thought field therapy provided by newly instructed community workers to a traumatized population in Uganda: A randomized trial. Current Research in Psychology, 7, 111.CrossRefGoogle Scholar
Schnyder, U., Ehlers, A., Elbert, T., Foa, E. B., Gersons, B. P. R., Resick, P. A., … Cloitre, M. (2015). Psychotherapies for PTSD: What do they have in common? European Journal of Psychotraumatology, 6. doi: 10.3402/ejpt.v6.28186.CrossRefGoogle ScholarPubMed
Seidler, G. H., & Wagner, F. E. (2006). Comparing the efficacy of EMDR and trauma-focused cognitive-behavioral therapy in the treatment of PTSD: A meta-analytic study. Psychological Medicine, 36, 15151522.CrossRefGoogle ScholarPubMed
Sijbrandij, M., Kunovski, I., & Cuijpers, P. (2016). Effectiveness of internet-delivered cognitive behavioral therapy for posttraumatic stress disorder: A systematic review and meta-analysis. Depression and Anxiety, 33, 783791.CrossRefGoogle ScholarPubMed
Spiegelhalter, D., Thomas, A., Best, N., & Lunn, D. J. (2003). WinBUGS user manual: Version 1.4. Cambridge: MRC Biostatistics Unit.Google Scholar
Uher, R., Perlis, R. H., Placentino, A., Dernovšek, M. Z., Henigsberg, N., Mors, O., … Farmer, A. (2012). Self-report and clinician-rated measures of depression severity: Can one replace the other? Depression and Anxiety, 29, 10431049.CrossRefGoogle ScholarPubMed
van Emmerik, A. A., Reijntjes, A., & Kamphuis, J. H. (2013). Writing therapy for posttraumatic stress: A meta-analysis. Psychotherapy and Psychosomatics, 82, 8288.CrossRefGoogle ScholarPubMed
van Valkenhoef, G., Dias, S., Ades, A. E., & Welton, N. J. (2016). Automated generation of node-splitting models for assessment of inconsistency in network meta-analysis. Research Synthesis Methods, 7, 8093.CrossRefGoogle ScholarPubMed
van Valkenhoef, G., & Kuiper, J. (2016). gemtc: Network Meta-Analysis Using Bayesian Methods. R package version 0.8-2. Retrieved June 5, 2018, from https://CRAN.R-project.org/package=gemtcGoogle Scholar
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