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Psychological treatments for chronic post-traumatic stress disorder: Systematic review and meta-analysis

  • Jonathan I. Bisson (a1), Anke Ehlers (a2), Rosa Matthews (a3), Stephen Pilling (a3), David Richards (a4) and Stuart Turner (a5)...
Abstract
Background

The relative efficacy of different psychological treatments for chronic post-traumatic stress disorder (PTSD) is unclear.

Aims

To determine the efficacy of specific psychological treatments for chronic PTSD.

Method

In a systematic review of randomised controlled trials, eligible studies were assessed against methodological qualitycriteria and data were extracted and analysed.

Results

Thirty-eight randomised controlled trials were included in the meta-analysis. Trauma-focused cognitive-behavioural therapy (TFCBT), eye movement desensitisation and reprocessing (EMDR), stress management and group cognitive-behavioural therapy improved PTSD symptoms more than waiting-list or usual care. There was inconclusive evidence regarding other therapies. There was no evidence of a difference in efficacy between TFCBT and EMDR butthere was some evidence that TFCBT and EMDR were superior to stress management and other therapies, and that stress management was superior to other therapies.

Conclusions

The first-line psychological treatment for PTSD should be trauma-focused (TFCBTor EMDR).

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Copyright
Corresponding author
Dr Jonathan Bisson, Department of Psychological Medicine, Monmouth House, University Hospital of Wales, Heath Park, Cardiff CF14 4XN, UK. Email: bissonji@cf.ac.uk
Footnotes
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Studies that were part of the meta-analysis.

Declaration of interest

None.

Footnotes
References
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Psychological treatments for chronic post-traumatic stress disorder: Systematic review and meta-analysis

  • Jonathan I. Bisson (a1), Anke Ehlers (a2), Rosa Matthews (a3), Stephen Pilling (a3), David Richards (a4) and Stuart Turner (a5)...
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eLetters

Re: Reply to Psychological Treatments for PTSD article.

Jonathon Bisson, Senior Lecturer in Psychiatry
28 March 2007

Since we completed our systematic review and meta-analysis several new randomised controlled trials of psychological treatments for chronic post-traumatic stress disorder have been completed. We are aware of the interest in using MDMA as an adjunct to psychological treatment and the hypothesised reasons that this may be an effective combination. We will monitor with interest the progress of the work in this area but it is premature to say that this approach is set to become an important treatment for PTSD in the future. As with all interventions it will be extremely important to consider its efficacy and potential adverse effectsthrough properly designed randomised controlled trials before determining what, if any, place it has. ... More

Conflict of interest: None Declared

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Reply to Psychological Treatments for PTSD article.

Ben SJ Sessa, Consultant Psychiatrist
15 February 2007

Letter to The Editor, Dr Peter Tyrer:

Re: ‘Psychological treatments for chronic post-traumatic stress disorder. Systematic review and meta-analysis.’ By Bisson et al. British Journal of Psychiatry, February 2007 Vol 190.

Dear Sir,

I read the excellent article on ‘Psychological Treatments for PTSD’ (Bisson et al 2007) with interest and, I confess, a slight sense of mischievous insider knowledge, because I knew that missing from the article would be some brand new studies that are set to become important treatments for PTSD in the future. As Bisson's piece is intended to bring readers up to date with current psychological inputs for PTSD I feel obliged to bring these new studies to the attention of readers.

The studies I am referring to are those that are currently underway at several centres throughout the world involving entactogen-assisted psychotherapy (see the website for The Multidisciplinary Association for Psychedelic Studies (MAPS) for all the details of these studies).They are unique trials that combine elements of Trauma Focused Cognitive Behavioural Therapy (considered to be favourable by Bisson et al) with thepharmacological support of the drug 3,4-Methylene-dioxy-methyl-amphetamine(MDMA). The acute effects of MDMA are highly empathogenic and anxiolytic. They allow the user to access repressed painful memories and actively explore and re-process past traumas in real-time with the guide of the therapist. The drug is taken several times in therapy sessions amongst a course of non-drug sessions.

These studies are part of an increasing interest within psychiatry toexplore the therapeutic potential of the psychedelic drugs, particularly in the treatment of anxiety disorders, where they have consistently been demonstrated to be effective at loosening the ego and improving the depth and effectiveness of psychotherapy(Sessa 2007).

Bisson et al mentioned that the most effective studies paid attentionto ‘establishing a trusting therapeutic relationship’ between patient and therapist in order to reduce withdrawal rates. An important characteristicof MDMA is its ability to facilitate an improved relationship between patient and therapist (Cami et al 2000). Bisson also suggested the future for PTSD treatment research must include well-designed trials and an exploration of combination treatments – particularly involving both psychotherapy and pharmacological agents. The MDMA for PTSD trial underway in the USA by Dr Michael Mithoefer, and similar trials in Switzerland and Israel (looking at PTSD sufferers from the Israeli-Palestinian conflict) addresses these suggestions.

There is a hope that the entactogenic and psychedelic agents, once demonised in the wake of the 1960s drug culture, may now begin again to have an important new role in the treatment of anxiety disorders in the future. I look forward to reading future reviews of the progress for treating the anxiety disorders and seeing psychedelic and entactogenic drug-assisted psychotherapy trials included.

Yours Sincerely

Dr Ben Sessa

Consultant PsychiatristDepartment of PsychopharmacologyBristol Universitywww.drbensessa@hotmail.com

References

1. Cami J, Farre M, Mas M, Roset PN, Poudevida S, Mas A, San L, de laTorre R (2000) Human pharmacology of 3,4-methylenedioxymethamphetamine ("ecstasy"): psychomotor performance and subjective effects. J Clin Psychopharmacology 20: 455-4662. Sessa (2007) Is there a role for MDMA-assisted Psychotherapy in the UK?Journal of Psychopharmacology 2006, doi:10.1177/0269881106069029 (Initially published Online. Paper version in print).3. Bisson 2007The British Journal of Psychiatry (2007) 190: 97-104. doi: 10.1192/bjp.bp.106.021402 4. http://www.maps.org/mdma/#news
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