Psychological treatments for chronic post

REVIEW ARTICLE
B R I T I S H J O U R N A L O F P S YC H I AT RY ( 2 0 0 7 ) , 1 9 0 , 9 7 ^ 1 0 4 . d o i : 1 0 . 11 9 2 / b j p . b p . 1 0 6 . 0 2 1 4 0 2
AUTHOR’S PROOF
Psychological treatments for chronic
post-traumatic stress disorder
Systematic review and meta-analysis
JONATHAN I. BISSON, ANKE EHLERS, ROSA MAT THE WS,
STEPHEN PILLING, DAVID RICHARDS and STUART TURNER
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 quality criteria and data
were extracted and analysed.
Results Thirty-eight randomised
controlled trials were included in the
meta-analysis.T
meta-analysis.Trauma-focused
rauma-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 betweenTFCBTand
EMDR butthere was some evidence that
TFCBTand 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).
Declaration of interest
None.
Chronic post-traumatic stress disorder
(PTSD) is a common disorder that people
may develop after exceptionally threatening
and distressing events. Psychological treatments from various theoretical perspectives
have been found to be effective for chronic
PTSD in previous reviews (Van Etten &
Taylor, 1988; Bradley et al,
al, 2005). Some of
the earlier reviews had to rely on uncontrolled trials as well as controlled ones,
and on uncontrolled effect sizes. There are
now sufficient numbers of randomised controlled trials of psychological treatments of
chronic PTSD to allow a meta-analysis of effect sizes in such trials. We present a comprehensive systematic review and meta-analysis
of randomised controlled trials assessing the
efficacy of psychological treatments in reducing symptoms of chronic PTSD, and comparing the efficacy of different types of
psychological treatment in reducing symptoms of this disorder.
METHOD
This review and meta-analysis derive from
work undertaken in the preparation of
PTSD treatment guidelines for the National
Institute for Health and Clinical Excellence
(NICE) in the UK (National Collaborating
Centre for Mental Health, 2005). Further
details of the protocol are published within
the full guideline.
A systematic bibliographic search was
undertaken to find randomised controlled
trials of psychological treatments for PTSD
from databases (EMBASE, Medline,
PsycINFO and CINAHL) and the Cochrane
Library, with each database being searched
from inception to August 2004. Additional
papers were found by hand-searching the
references of retrieved articles, previous
systematic reviews and meta-analyses of psychological treatments for PTSD. The search
was restricted to papers with Englishlanguage abstracts. In addition, data from
unpublished studies or papers in press were
sought by contacting experts within the field.
Selection
Studies were only considered if PTSD
symptoms were the main target of treatment, all participants had had PTSD symptoms for at least 3 months following a
traumatic event, at least 70% of participants had a diagnosis of PTSD, and PTSD
symptoms were measured using a recognised scale. To be included studies had to
be of randomised controlled design, with
adult (4
(416 years old) participants; the
studies had to report at least pre-treatment
and post-treatment measures, and retain at
least 50% of the original sample at the
post-treatment assessment. There was no
restriction regarding type of traumatic
event. The minimum duration of symptoms
was 1 month. Early intervention trials that
only included participants with recent onset
of PTSD were not included and are considered in a separate review (further details
available from the author upon request).
The searching and selection were done by
a team of systematic reviewers led by
R.M. Any disagreements with regard to inclusion or exclusion of a study were resolved by discussion with the other authors.
Validity assessment
All published and unpublished papers were
assessed against the following quality
criteria: random sequence generation,
concealment of allocation, masked assessment of outcomes, number of withdrawals,
tolerability, adequate reporting of data and
intention-to-treat analysis.
Data abstraction
Study details including the nature of the
traumatic events, participants’ characteristics and type of intervention were entered
into a Microsoft Access database (version
2000), the quality criteria were applied
and outcome data for included studies were
entered into Review Manager version 4.2.3
for Windows. The application of quality
criteria and the accuracy of outcome data
were double-checked by a second reviewer.
Study characteristics
An initial narrative synthesis was undertaken
to describe the scope (participants, settings,
intervention type, comparators, measures of
effect), quality and outcomes of the studies.
Three main efficacy outcomes were considered: one dichotomous outcome (retaining a
diagnosis of PTSD) and two continuous outcomes (assessor-rated and self-reported severity of PTSD symptoms). Among the main
97
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AUTHOR’S PROOF
outcomes, the primary outcome was clinician-rated severity of PTSD symptoms,
although this was not present for all studies.
Quantitative data synthesis
Where possible, meta-analysis was used to
synthesise data, including additional metaanalyses for anxiety and depression measures where available, and numbers leaving
the study early, using Review Manager.
Post-treatment data (or change scores if
reported instead of post-treatment data)
for the psychological treatment and control
condition were entered in the Review
Manager tables. Dichotomous outcomes
(PTSD diagnosis and leaving the study early
for any reason) were analysed as a relative
risk number and were calculated on an
intention-to-treat basis (i.e. a ‘once randomised always analyse’ basis). This makes
the conservative assumption that all participants who ceased to engage in the study
had an unfavourable outcome, e.g. they left
because the treatment was not acceptable
and still had a diagnosis of PTSD. Continuous outcomes were analysed as standardised
mean differences (SMDs) to allow for ease of
comparison across studies. It was not possible to obtain intention-to-treat data for most
of the trials, and we therefore used completer
data for all continuous outcomes.
For consistency of presentation all data
were entered into Review Manager in such
a way that negative effect sizes or relative risk
numbers less than 1 represented an effect that
favoured the active treatment compared with
the waiting-list control. Data were pooled
from more than one study using a fixedeffects meta-analysis except where heterogeneity was present, in which case a randomeffects model was used as described below.
In the random-effects analysis, heterogeneity
is accounted for both in the width of confidence intervals and in the estimate of the
treatment effect. With decreasing heterogeneity the random-effects approach moves
asymptotically towards a fixed-effects model.
An I2 of 30–50% was taken to indicate moderate heterogeneity. In this case, both the w2test of heterogeneity and a visual inspection
of the forest plot were used to decide between
a fixed- and random-effects model.
In order to explore heterogeneity
further, sensitivity analyses were performed
to consider the influence of higher-quality
methodology (this was done by considering
studies that used masked assessment, and
those that used an intention-to-treat analysis), studies that only included females and
those that only included Vietnam veterans.
Clinical effectiveness
Where psychological interventions were
compared against waiting-list control
groups an effect size (SMD) of 70.8 or less
(e.g. a larger negative number) was considered clinically meaningful for continuous
variables (a ‘large’ effect size; Cohen,
1988) and for dichotomous outcomes a relative risk of 0.65 or less (or greater than
1.54) was considered clinically meaningful.
Where two active treatments were compared lower thresholds were set with an
SMD of 70.5 or +0.5 for continuous
variables (a ‘medium’ effect size), and for
dichotomous outcomes a relative risk of
0.80 or less or 1.25 or greater was considered clinically meaningful. These thresholds
came from discussions in the NICE Guideline Development Group in advance of
undertaking the meta-analyses and were
based on clinical experience and thresholds
used in the literature (Schnurr et al,
al, 2003).
In order to be considered clinically meaningful the value had to meet the threshold
criterion and the 95% confidence interval
had to be greater than the threshold. If
the SMD and relative risk met the threshold
criterion but the 95% CI included values in
the non-clinically significant range, this was
interpreted as limited evidence for an effect.
Similarly, if the SMD or relative risk value
was below the threshold, the 95% CIs were
examined to determine whether the evidence
was inconclusive (in case the 95% CI included numbers greater than the threshold)
or whether it could be stated that there was
evidence suggesting that an effect was
unlikely (where the 95% CI was entirely
outside the clinically meaningful range).
Psychological treatment categories
Five separate psychological treatment categories were defined (see Appendix). These
came from discussions by the NICE Guideline Development Group in advance of
undertaking the meta-analyses and were
based on clinical experience and categories
used in the literature (Foa et al,
al, 2000).
RESULTS
Thirty-eight studies were included in the
meta-analysis. Figure 1 shows the metaanalysis profile summarising trial flow.
Heterogeneity
To check for heterogeneity between studies,
both the I2-test of heterogeneity and the w2test of heterogeneity (P
(P50.10) as well as
visual inspection of the forest plots were used.
The I2 statistic describes the proportion of total variation in study estimates that is due to
heterogeneity (Higgins & Thompson, 2002).
An I2 of less than 30% was taken to indicate
mild heterogeneity and a fixed-effects model
was used to synthesise the results. An I2 of
more than 50% was taken as notable heterogeneity; in this case an attempt was made to
explain the variation. If studies with heterogeneous results were found to be comparable,
a random-effects model was used to summarise the results (DerSimonian & Laird, 1986).
98
Fig. 1 Trial flow (PTSD, post-traumatic stress disorder; RCT, randomised controlled trial).
7 studies
n¼267
267
RR¼1.14
RR 1.14
(95% CI 0.70 to 1.85)
6 studies
n¼187
187
SMD¼0.02
SMD 0.02
(95% CI 70.5 to 0.55)
(95% CI 0.31 to 1.01)
(95% CI 71.14 to 70.31)
?
RR¼0.56
RR 0.56
SMD¼7
SMD 70.72
(E¼T)
(E T)
n¼48
48
n¼97
97
EMDR v.TFCBT
1 study
1 study
?
list/usual care
(95% CI 70.98 to 70.24)
?
Group CBT v. waiting
(95% CI 70.48 to 0.20)
SMD¼7
SMD 70.14
SMD¼7
SMD 70.17
(95% CI 70.45 to 0.11)
n¼136
136
4 studies
(E¼T)
(E T)
No data
(95% CI 70.82 to 70.14)
SMD¼7
SMD 70.48
n¼153
153
n¼206
206
7 studies
(E¼T)
(E T)
(95% CI 71.2 to 70.22)
SMD¼7
SMD 70.71
n¼71
71
2 studies
SMD¼7
SMD 70.61
n¼132
132
2 studies
(GC4
(GC4W)
(O4
(O4W)
(O4
(O4W)
3 studies
(95% CI 71.23 to 70.31)
SMD¼7
SMD 70.77
n¼82
82
3 studies
?
(95% CI 71.54 to 70.85)
SMD¼7
SMD 71.20
n¼156
156
5 studies
E4W
(95% CI 71.20 to 70.78)
SMD¼7
SMD 70.99
n¼415
415
11 studies
(T4
(T4W)
Anxiety
(95% CI 70.47 to 1.14)
SMD¼0.33
SMD 0.33
(95% CI 0.53 to 1.18)
(95% CI 0.47 to 0.87)
(95% CI 71.62 to 70.67)
(95% CI 70.9 to 0.04)
RR¼0.64
RR 0.64
SMD¼7
SMD 71.14
n¼24
24
RR¼0.79
RR 0.79
n¼121
121
n¼86
86
usual care
1 study
?
SMD¼7
SMD 70.43
4 studies
3 studies
v. waiting list/
n¼166
166
(S4
(S4W)
(S4
(S4W)
Stress management
(95% CI 72.13 to 70.13)
SMD¼7
SMD 71.13
n¼72
72
(95% CI 0.28 to 0.86)
(95% CI 71.87 to 71.15)
3 studies
RR¼0.49
RR 0.49
SMD¼7
SMD 71.51
n¼156
156
2 studies
n¼217
217
n¼162
162
5 studies
(E4
(E4W)
waiting list/usual care
6 studies
5 studies
list/usual care
?
(E4
(E4W)
E4W
EMDR v. waiting
(95% CI 72.17 to 71.24)
?
(95% CI 0.35 to 0.57)
(95% CI 71.89 to 70.91)
SMD¼7
SMD 71.70
n¼428
428
9 studies
T4W
Self-rated PTSD symptoms
Other therapies v.
n¼763
763
15 studies
14 studies
list/usual care
RR¼0.44
RR 0.44
T4W
T4W
TFCBT v. waiting
SMD¼7
SMD 71.40
(intent-to-treat)
PTSD symptoms
n¼649
649
PTSD diagnosis
Clinician-rated
Comparison
Table
Table 1 Summary of meta-analysis of comparisons of psychological treatments v. waiting list conditions
(95% CI 70.9 to 0.26)
SMD¼7
SMD 70.32
n¼206
206
7 studies
?
No data
(95% CI 70.71 to 0.22)
SMD¼7
SMD 70.25
n¼72
72
2 studies
?
(95% CI 71.12 to 70.33)
SMD¼7
SMD 70.73
n¼109
109
4 studies
?
(95% CI 71.84 to ^1.12)
SMD¼7
SMD 71.48
n¼160
160
5 studies
E4W
(95% CI 71.69 to 70.82)
SMD¼7
SMD 71.26
n¼625
625
14 studies
T4W
Depression
(Continued)
Continued)
(95% CI 0.58 to 1.30)
RR¼0.87
RR 0.87
n¼287
287
8 studies
?
(95% CI 0.64 to 1.56)
RR¼1.00
RR 1.00
n¼271
271
3 studies
?
(95% CI 1.19 to 12.29)
RR¼3.82
RR 3.82
n¼166
166
3 studies
(W4
(W4O)
(95% CI 0.71 to 6.73)
6.73)
RR¼2.19
RR 2.19
n¼121
121
4 studies
?
(95% CI 0.66 to 2.22)
RR¼1.21
RR 1.21
n¼216
216
6 studies
?
(95% CI 1.05 to 1.94)
RR¼1.42
RR 1.42
n¼861
861
15 studies
(W4
(W4T)
Withdrawal rate
T R E AT M E N T OF C H R
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AUTHOR’S PROOF
99
10 0
(Continued)
Continued )
(intent-to-treat)
PTSD symptoms
(95% CI 72.32 to 70.03)
?
n¼284
284
RR¼0.78
RR 0.78
(95% CI 0.61 to 0.99)
(T4
(T4O)
5 studies
n¼286
286
RR¼0.71
RR 0.71
(95% CI 0.56 to 0.89)
(E4
(E4S)
6 studies
n¼239
239
SMD¼7
SMD 70.27
(95% CI 70.71 to 0.16)
(T4
(T4O)
3 studies
n¼120
120
SMD¼7
SMD 70.81
(95% CI 71.19 to 70.42)
TFCBT v. other
therapies
(T4
(T4O)
(95% CI 0.46 to 1.04)
(E4
(E4O)
SMD¼7
SMD 70.35
(95% CI 70.90 to 0.19)
n¼360
360
RR¼0.98
RR 0.98
(95% CI 0.83 to 1.16)
n¼325
325
SMD¼7
SMD 70.12
(95% CI 70.34 to 0.1)
(non-trauma-focused)
No data
No data
(95% CI 71.32 to 0.29)
SMD¼7
SMD 70.51
n¼25
25
1 study
?
No data
(95% CI 71.31 to 0.30)
RR¼7
RR 70.51
n¼25
25
1 study
?
(95% CI 71.03 to 70.32)
SMD¼7
SMD 70.67
n¼127
127
2 studies
(T4
(T4O)
(95% CI 71.14 to 70.20)
SMD¼7
SMD 70.67
n¼75
75
3 studies
(E4
(E4S)
(95% CI 71.03 to 70.28)
SMD¼7
SMD 70.65
n¼120
120
3 studies
(T4
(T4O)
(95% CI 70.57 to 0.08)
SMD¼7
SMD 70.25
n¼161
161
5 studies
?
Depression
(95% CI 1.00 to 1.90)
RR¼1.38
RR 1.38
n¼360
360
1 study
(GC4
(GC4GT)
(95% CI 0.2 to 3.46)
RR¼0.82
RR 0.82
n¼31
31
1 study
?
(95% CI 0.26 to 8.54)
RR¼1.48
RR 1.48
n¼127
127
2 studies
(O4
(O4T)
(95% CI 0.37 to 2.88)
RR¼1.03
RR 1.03
n¼84
84
3 studies
?
(95% CI 0.68 to 1.90)
RR¼1.14
RR 1.14
n¼290
290
5 studies
?
(95% CI 0.69 to 2.0)
RR¼1.17
RR 1.17
n¼284
284
6 studies
?
Withdrawal rate
1. Key to comparison: X4Y, evidence that X has clinically important advantages over Y; (X
(X4Y ), limited evidence that X has clinically important advantages over Y; ?, evidence is inconclusive so it is not possible to determine whether there is a
clinically important difference; (X
(X¼Y
Y ), there is evidence suggesting that there is unlikely to be a clinically important difference.
CBT, cognitive ^behavioural therapy; EMDR, eye movement desensitisation and reprocessing; GC, group CBT, non-trauma-focused; GT, groupTFCBT; O, other therapies; PTSD, post-traumatic stress disorder; RR, relative risk; S, stress
management; SMD, standardised mean difference; TFCBT, trauma-focused CBT; W, waiting list/usual care.
1 study
1 study
v. group CBT
(95% CI 0.30 to 1.11)
(95% CI 72.09 to 70.35)
(GT¼GC)
(GT GC)
RR¼0.58
RR 0.58
SMD¼7
SMD 71.22
(GT¼GC)
(GT GC)
n¼31
31
n¼25
25
Group TFCBT
1 study
1 study
v. other therapies
No data
(95% CI 71.08 to 70.36)
(95% CI 71.21 to 70.47)
(95% CI 0.19 to 0.84)
?
SMD¼7
SMD 70.72
SMD¼7
SMD 70.84
RR¼0.4
RR 0.4
(S4
(S4O)
n¼126
126
n¼124
124
n¼67
67
2 studies
(T4
(T4O)
(95% CI 71.36 to 70.13)
SMD¼7
SMD 70.75
n¼45
45
2 studies
SMD¼7
SMD 70.40
n¼75
75
2 studies
(E4
(E4S)
(95% CI 71.11 to 0.17)
SMD¼7
SMD 70.47
n¼197
197
4 studies
?
(95% CI 70.49 to 0.26)
SMD¼7
SMD 70.12
n¼127
127
4 studies
(T¼S)
(T S)
Anxiety
1 study
Stress management
therapies
No data
RR¼0.69
RR 0.69
n¼53
53
EMDR v. other
(95% CI 70.86 to 0.06)
n¼84
84
2 studies
management
3 studies
3 studies
?
EMDR v. stress
SMD¼7
SMD 71.18
n¼176
176
3 studies
(T4
(T4O)
(95% CI 70.74 to 0.01)
SMD¼7
SMD 70.37
n¼127
127
3 studies
6 studies
?
?
Self-rated PTSD symptoms
management
(T4
(T4S)
PTSD diagnosis
Clinician-rated
TFCBT v. stress
Comparison
T
Table
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AUTHOR’S PROOF
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Study characteristics
Details of the studies included appear in the
data supplement to the online version of
this article. Twenty-five studies compared
trauma-focused
cognitive–behavioural
therapy (TFCBT) with waiting-list or other
psychological interventions: Blanchard et al
(2003), Brom et al (1989), Bryant et al
(2003), Cloitre et al (2002), Cooper &
Clum (1989), Devilly & Spence (1999),
Echeburua et al (1997), Ehlers et al
(2005), Fecteau & Nicki (1999), Foa et al
(1991, 1999), Gersons et al (2000), Ironson
et al (2002), Keane et al (1989), Kubany et
al (2003), Kubany et al (2004), Lee et al
(2002), Marks et al (1998), Paunovic &
Ost (2001), Peniston & Kulkosky (1991),
Power et al (2002), Resick et al (2002),
Rothbaum et al (2005), Taylor et al
(2003) and Vaughan et al (1994). Twelve
studies compared eye movement desensitisation and reprocessing (EMDR) with
waiting-list or other psychological interventions: Carlson et al (1998), Devilly &
Spence (1999), Ironson et al (2002), Jensen
(1994), Lee et al (2002), Marcus et al
(1997), Power et al (2002), Rothbaum
(1997), Rothbaum et al (2005), Scheck et
al (1998), Taylor et al (2003) and Vaughan
et al (1994). Seven studies compared stress
management with waiting-list or other
psychological interventions: Carlson et al
(1998), Echeburua et al (1997), Foa et al
(1991, 1999), Marks et al (1998), Taylor
et al (2003) and Vaughan et al (1994). Six
studies compared ‘other therapies’ with
waiting-list or other psychological interventions: Blanchard et al (2003), Brom et
al (1989), Bryant et al (2003), Foa et al
(1991), Marcus et al (1997) and Scheck
et al (1998). Four studies compared group
cognitive–behavioural
therapy
with
waiting-list or other psychological interventions: Classen et al (2001), Krakow et
al (2001), Schnurr et al (2003) and Zlotnick
et al (1997).
Two additional randomised controlled
trials met inclusion criteria but differed in
mode of delivery (Lange et al,
al, 2003; Neuner
et al,
al, 2004), and one further trial compared
two versions of TFCBT (exposure and
cognitive therapy) with each other (Tarrier
et al,
al, 1999a
1999a,b). These studies could not be
included in the meta-analysis.
Quantitative data synthesis
Table 1 provides details of the quantitative
data synthesis. It highlights that TFCBT
and EMDR were better than waiting-list/
control on most outcome measures. Stress
management was better on some outcomes,
and ‘other therapies’ appeared to be the
least effective. Unfortunately none of the
studies reported adverse effects and
therefore it was not possible to analyse
these. However, most studies did report
withdrawal rates and these are included in
Table 1.
Sensitivity analyses
Masked assessment
The EMDR studies using masked assessment showed evidence favouring EMDR
over waiting-list on reducing the severity
of PTSD symptoms (clinician-rated measures) (three studies, n¼120;
120; SMD¼7
SMD 71.54,
1.54, 95% CI 71.95 to 71.12) similar to
that in all EMDR studies (see Table 1).
The TFCBT studies using masked assessment showed evidence favouring TFCBT
over waiting-list on reducing the severity of
PTSD symptoms (clinician-rated
(clinician-rated measures)
(seven studies, n¼308;
308; SMD¼7
SMD 71.70; 95%
CI 72.47 to 70.93) similar to that in all
TFCBT studies.
Vietnam veteran studies
One EMDR study considered only Vietnam
veterans. This showed less evidence
favouring EMDR over waiting-list on
reducing the severity of PTSD symptoms
(clinician-rated measures) (one study,
n¼25;
25; SMD¼7
SMD 70.97, 95% CI 71.81 to
70.13) than the other EMDR studies (see
Table 1). One TFCBT study considered
only Vietnam veterans using the primary
outcome measure; this showed less evidence
favouring TFCBT over waiting-list on reducing the severity of PTSD symptoms (clinician-rated measures) (one study, n¼24;
24;
SMD¼7
SMD 70.22, 95% CI 71.03 to 0.58)
than the other TFCBT studies.
Female studies
The EMDR studies including only female
participants showed evidence favouring
EMDR over waiting-list on reducing the
severity of PTSD symptoms (clinician-rated
measures) (two studies, n¼57;
57; SMD¼
SMD
71.67, 95% CI 72.30 to 71.04) similar
to that in all EMDR studies. The TFCBT
studies including only female participants
showed more evidence favouring TFCBT
over waiting-list on reducing the severity
of PTSD symptoms (clinician-rated measures) (six studies, n¼358;
358; SMD¼7
SMD 72.06,
95% CI 72.70 to 71.42) than all TFCBT
studies.
Intention-to-treat analysis
None of the EMDR studies reported using
an intention-to-treat analysis so this could
not be assessed. The TFCBT studies using
an intention-to-treat analysis showed more
evidence favouring TFCBT over waiting-list
on reducing the severity of PTSD symptoms
(clinician-rated measures) (six studies,
n¼332;
332; SMD¼7
SMD 71.82, 95% CI 72.76 to
70.89) than all TFCBT studies.
DISCUSSION
We identified 38 randomised controlled
trials of psychological treatments for PTSD.
Trauma-focused
cognitive–behavioural
therapy showed clinically important benefits over waiting-list or usual care on all
measures of PTSD symptoms. In addition,
there was limited evidence that it also has
clinically important effects on depression
and anxiety. The effectiveness of eye movement desensitisation and reprocessing
was also generally supported by the metaanalysis, but the evidence base was not as
strong as that for TFCBT, both in terms
of the number of trials available and the
certainty with which clinical benefit was established. Furthermore, there was limited
evidence that TFCBT and EMDR were
superior to supportive/non-directive treatments, hence it is highly unlikely that their
effectiveness is due to non-specific factors
such as attention. There was limited evidence for stress management and group
cognitive–behavioural
cognitive–behavioural therapy, but ‘other
therapy’ (supportive/non-directive therapy,
psychodynamic therapies and hypnotherapies) that focused on current or past
aspects of the patient’s life other than the
trauma or on general support did not show
clinically important effects on PTSD symptoms, depression or anxiety. However, this
might be due to the limited number of
studies available and does not mean
that these treatments were shown to be
ineffective.
The treatments most supported by the
review (individually delivered TFCBT and
EMDR) are both trauma-focused psychological treatments that specifically address
the patient’s troubling memories of the
traumatic event and the personal meanings
of the event and its consequences. Direct
comparisons of these two approaches did
not reveal any significant advantages of
101
B I S S ON E T A L
AUTHOR’S PROOF
one over the other, with respect to either
treatment outcome or speed of therapeutic
change (Taylor et al,
al, 2003).
Heterogeneity
There is clearly considerable clinical
diversity within the studies considered.
The separation of different active interventions into groups partially addresses
their impact on clinical diversity, but not
all trials within the same group used identical interventions. The differences were
most marked in the ‘other therapy’ group,
which had in common the absence of
cognitive–behavioural
techniques
and
trauma-focused work. There was also
diversity in the TFCBT group, which
included both exposure-only and traumafocused cognitive therapy interventions.
Another source of heterogeneity was
the quality of the studies. Sensitivity
analyses of higher-quality and lowerquality studies were performed to explore
this further. There was some limited
evidence that higher-quality studies (those
including masked assessment of outcome
or intention-to-treat analysis) showed
better outcomes than the lower-quality
studies. This finding contradicts previous
research (Moher et al,
al, 1998) that has found
an association between poorer methodology and more favourable results for the
intervention. It may reflect the fact that
the better studies tended to be more recent
and associated with refinement of techniques. They also included most of the
female-only studies. The fact that femaleonly studies showed a better response to
TFCBT than mixed studies and male-only
studies is difficult to interpret. It may be
that the female-only studies used more
effective interventions, that the trauma of
rape is more amenable than other traumas
to effective TFCBT, or that for some undetermined reason women are more responsive to TFCBT than men. Interestingly, a
similar superiority in female response has
been found for pharmacological treatment
of PTSD (National Collaborating Centre
for Mental Health, 2005). The finding that
studies including only Vietnam veterans
produced worse responses to TFCBT and
EMDR might have contributed to the
female studies finding and also suggests
that Vietnam veterans are a particularly
difficult population to treat.
As with all psychological treatment
trials, there are issues with the control
group. The development of a psychological
10 2
treatment placebo is difficult, if not impossible, as is masking of participants and
therapists. In several of the waiting-list or
usual care conditions it was apparent that
some (usually poorly defined) treatment
was going on. The main effect of this is
likely to have made it more difficult for
the active intervention to show itself to be
superior to the control condition.
Tolerability
Unfortunately none of the studies reported
adverse effects. It remains unclear whether
no adverse effects occurred, or whether
they were not described. This is a key shortcoming in the trials identified. Most studies
reported withdrawals by group. There are
likely to be several different factors that
determine withdrawal rates, including the
tolerability of the intervention. There was
limited evidence that TFCBT and other
therapies fared worse than waiting-list or
usual care on this outcome measure, but
there was no significant difference in withdrawal rates in direct comparisons between
any of the active treatments. The higherquality TFCBT studies showed no difference in withdrawal rates when compared
with waiting-list or usual care. Some people
find it difficult to fully engage in psychological treatment because it requires a
significant commitment of time and emotion. For some people with PTSD it may
initially be difficult and overwhelming to
disclose details of their traumatic events.
It is also well recognised that some patients
may be subject to initial adverse effects
such as increased re-experiencing following
exposure treatment (Pitman et al,
al, 1991; Foa
et al,
al, 2002; Hackmann et al,
al, 2004). Withdrawal rates of up to 30% in some studies
suggest that the active treatments were not
always acceptable to those receiving them.
It is possible that in these cases devoting
several sessions to establishing a trusting
therapeutic relationship and emotional stabilisation, before addressing the traumatic
event, might lead to greater acceptability.
Limitations of the meta-analysis
Although this meta-analysis provides a
systematic and comprehensive comparison
of the different psychological treatments
of PTSD, it is not without methodological
problems. The randomised controlled trials
analysed usually reported unadjusted
means for the treatment conditions after
therapy and at follow-up.
follow-up. Sample sizes
were usually small, raising the chance that
baseline differences present before treatment influenced scores after treatment.
Indeed, some studies showed baseline
differences between the study conditions
that remained uncorrected in our analysis.
However, across studies no systematic
baseline difference existed, so the conclusions remain valid. Furthermore, the Review Manager program does not allow
entering a score of 0 for both groups. Thus,
the withdrawal rates reported are slight
overestimates of the true rates.
Clinical implications
Our results suggest that trauma-focused
psychological treatments (TFCBT or
EMDR) are effective for chronic PTSD.
Indeed, the effect sizes compare favourably
with those found for cognitive–behavioural
therapy in depressive and anxiety disorders
(National Collaborating Centre for Mental
Health, 2004; National Collaborating
Centre for Primary Care, 2004). These
treatments are normally delivered on an
individual out-patient basis over 8–12
sessions. A course of trauma-focused
psychological treatment should be offered
to everyone with chronic PTSD. The results
also suggest that not all chronic PTSD will
benefit from these treatments; other
approaches should then be considered,
including extending the number of sessions,
trying an alternative form of traumafocused psychological treatment and the
augmentation of trauma-focused psychological treatment with a course of pharmacological treatment. A recent meta-analysis
has suggested that pharmacological
interventions are unlikely to be as clinically
effective as trauma-focused psychological
interventions and should therefore be used
as a second-line treatment (National
Collaborating Centre for Mental Health,
2005).
Future research
Further well-designed trials of psychological treatments are required, including
further comparison studies of one type of
psychological treatment against another.
There is a need for large-scale studies
(phase 4) to find out whether the results
will survive in real practice. Future trials
should consider adverse events and tolerability of treatment in more detail. Our results suggest that several of the currently
available treatments might benefit from
modifications that would make them more
acceptable to people with chronic PTSD
T R E AT M E N T OF C H R
RONI
ONI C P T S D
AUTHOR’S PROOF
and possibly also more effective. There is
also potential for research concerning the
direct comparison of psychological treatments with pharmacological treatments,
the effectiveness of a combination of the
two, and the implications of the high degree
of comorbidity with other disorders for the
choice of treatment.
APPENDIX
Psychological treatment categories
Treatments delivered on an individual basis
that focused on the memory for the traumatic
event and its meaning
1. Trauma-focused
Trauma-focused cognitive ^ behavioural therapy
(TFCBT).
2. Eye movement desensitisation and reprocessing
(EMDR).
Treatments delivered on an individual basis
that do not place the main focus of treatment
on the trauma
3. Stress management and relaxation.
4. Other therapies (including supportive therapy/
non-directive counselling, psychodynamic therapies
and hypnotherapy).
Cohen, J. (1988) Statistical Power Analysis for the
Behavioral Sciences.
Sciences. Erlbaum.
disorder: a randomized controlled trial. JAMA,
JAMA, 286,
286,
537^545.
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DerSimonian, R. & Laird, N. (1986) Meta-analysis in
clinical trials. Controlled Clinical Trials,
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cognitive ^ behaviour trauma treatment protocol in the
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Cognitive therapy for posttraumatic stress disorder:
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Therapy,
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43, 413^431.
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27,
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*Foa, E. B., Dancu, C.V., Hembree, E. A., et al (1999)
Treatments delivered in groups
5. Group cognitive ^ behavioural therapy.
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JONATHAN I. BISSON,
BISSON, Department of Psychological Medicine, Cardiff University; ANKE EHLERS,
EHLERS, Institute of
Psychiatry, King’s College London; ROSA MATTHEWS, STEPHEN PILLING,
PILLING, National Collaborating Centre for
Mental Health, London; DAVID RICHARDS,
RICHARDS, Department of Mental Health, University of York; STUART
TURNER,
TURNER, University College London, London, UK
Correspondence: Dr Jonathan Bisson, Department of Psychological Medicine, Monmouth House,
University Hospital of Wales, Heath Park,Cardiff CF14 4XN,UK. Email: bissonji@
bissonji @cf.ac.uk
(First received 5 January 2006, final revision 27 April 2006, accepted 2 June 2006)
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DATA SUP P LE
L E MENT TO B R IT I S H J O U R NA L O F P SYC H IAT RY ( 2 0 0 7 ) , 1 9 0 , 9 7 ^ 1 0 4
Table
Table DS1 Studies included in the meta-analysis
Study reference
Participants ran-
Age, years
Female
Traumatic
Mean duration
Types of
Duration
PTSD
Follow-up
domised/
mean (s.d.)1
%
events
of symptoms/
treatment
of
outcome
period
in post-
time since
and control
treatment
measures
treatment
trauma
and country
Randomisation
ITT
Masking
analysis
of
concealment
assessor
analysis, n
Brom et al,
al, 1989
112
42 (14.3)
79
Mixed
(The Netherlands) 100 completed
Less than
OT1 (psycho-
Mean 14^19
SCL^90 (trauma
Post-
5 years
dynamic
sessions
symptoms)
treatment,
3 MFU
(12 drop-outs
therapy)
IES
reported)
OT2
(intrusion and
(hypnotherapy)
avoidance)
Not given
Completers
Not given
only
TFCBT (trauma desensitisation)
Waiting list
Cooper & Clum
22 randomised
1989 (USA)
14 included in
37
0
Combat
Not given
TFCBT
Six to fourteen
Self-monitoring
Post-
(imaginal
1.5 h sessions
of
treatment
analysis (8 did
flooding)
including
re-experiencing
3 MFU
not complete)
Standard care
introduction
symptoms and
(psychological
and assess-
sleep
and pharma-
ment
Modified Vietnam
cological)
(maximum 9
Experiences Ques-
active flooding
tionnaire (non-vali-
sessions)
dated)
(Vietnam)
Not given
Completers
Not given
only
Behavioural
avoidance test
SUDS
Keane et al,
al, 1989
24
(USA)
24 completed
34.6 (4.3)
0
Combat
Not given
(Vietnam)
TFCBT
Fourteen to
PTSD symptom
Post-
(implosive
sixteen 90 min
checklist
treatment
flooding)
sessions
(Jackson
6 MFU (CBT),
Structured
4.5 MFU
Interview)
(waiting list)
Waiting list
Not given
Yes
No
Not given
Completers
Not given
MMPI (PTSD
sub-scale)
Foa et al,
al, 1991
45
(USA)
35
31.8 (8.2)
100
Rape
6.2 (6.7)
SM (stress
years
inoculation)
TFCBT (prolonged
13.5 h
Clinician-rated
Post-
PTSD severity
treatment,
only
3 MFU
exposure)
OT (supportive
counselling)
Waiting list
(Continued)
DATA SUP P LE
L E MENT TO B R IT I S H J O U R NA L O F P SYC H IAT RY ( 2 0 0 7 ) , 1 9 0 , 9 7 ^ 1 0 4
Peniston &
29
Kulkosky, 1991
29
36.6 (2.82)
0
Combat
12^15 years
(Vietnam)
(USA)
Jensen, 1994
29
(USA)
25
Vaughan et al,
al,
36
1994 (Australia)
36
41.3 (2.84)
0
Combat
Not given
TFCBT (neuro-
4 h pre-
feedback
training+
treatment,
evaluation
training)
15 h active
30 MFU
of MMPI
Usual care
intervention
EMDR Control
Not given
Structured
Post-
(3 sessions in all)
Interview for
treatment
(Vietnam)
32 (14.7)
64
Mixed
Not given
MMPI^R
Post-
Yes
Masked
data
PTSD
only
EMDR
Four 50 min
PTSD
Post-
TFCBT (image
sessions (all
Structured
treatment,
habituation
conditions)
Interview
3 MFU
training)
Not given
Not given
Completers
Not given
only
Not given
Yes
Yes
Not given
Yes
No
Not given
Unclear
No
Not given
Completers
No (inde-
only
pendent
IES
SM (applied
muscle
relaxation)
Echeburua et
et al,
al,
20
20 (7.09)
100
1997 (Spain)
Sexual
Not given
TFCBT (gradual
Six 70 min self-
aggression
self-exposure
exposure sessions interview
treatment,
(childhood and
and cognitive
Six 45 min
1MFU, 3 MFU,
adult)
restructuring)
relaxation sessions Scale of Severity
Structured
(scored on
Post-
6 MFU, 12 MFU
SM (progressive
of PTSD
relaxation training)
Symptoms)
EMDR
No set duration;
Modified PTSD
Mid-therapy
Standard care
at least three
scale
(after 3
drop-out
(including
50 min sessions
IES
sessions),
reported)
psychological and
SCL^90
post-treatment
pharmacological)
SUDS
Marcus et al,
al,
67
1997 (USA)
66 completed (1
Rothbaum, 1997
21
(USA)
18 completed (3
41.0 (range
79
Mixed
Not given
18^73)
34.2 (11.1)
100
Rape
Not given
EMDR
One
Structured
Post-
(adulthood)
Mean 104
Waiting list
information-
interview (PSS)
treatment,
3 MFU
drop-outs
months
gathering
IES
reported)
since rape
session then
Rape Aftermath
(s.d.¼106.6)
(s.d. 106.6)
three 90 min
Symptom Test
but not
masked)
active EMDR
sessions
Zlotnick et al,
al,
48
1997 (USA)
33 completed
39 (9.59)
100
Childhood
Not given
Group CBT
One 2 h session
CAPS^1
Post-
sexual abuse
Mean age of
(affect manage-
per week for
Davidson
treatment
(13 drop-outs
first abuse
ment group)
15 weeks
Trauma Scale
reported;
6.86 years
Waiting list
2 unaccounted
(s.d.¼2.36)
(s.d. 2.36)
Not given
Completers
Not given
only
SCL^90^R
for)
(Continued)
Continued)
DATA SUP P LE
L E MENT TO B R IT I S H J O U R NA L O F P SYC H IAT RY ( 2 0 0 7 ) , 1 9 0 , 9 7 ^ 1 0 4
Carlson et al,
al,
1998 (USA)
Marks et al,
al,
1998 (UK)
35
34 completed
(1 drop-out up
to posttreatment
assessment,
30 at 3 MFU,
12 at 9 MFU)
87
77 completed
(10 drop-outs
reported)
CAPS^1
PTSD Symptom
Scale
IES
Mississippi Scale
for CombatRelated PTSD
Not given
Posttreatment (all)
3 MFU, 9 MFU
(intervention
groups only)
TFCBT 1
(prolonged
imaginal and
live exposure
therapy)
TFCBT 2 (cognitive
restructuring)
TFCBT 3
(combined
prolonged
exposure and
cognitive
restructuring)
SM (relaxation)
EMDR
Two 90 min
OT (active
sessions (both
listening)
conditions)
CAPS^2
IES
PSS
Not given
Posttreatment,
1MFU, 3 MFU,
6 MFU
Penn Inventory
for PTSD
IES
Posttreatment,
3 MFU
Not given
Completers
only
TFCBT
(CBT ^ trauma
treatment
protocol)
EMDR
SCL^90^R
SUDS
Civilian
Mississippi Scale
for PTSD
IES
PSS^SR
PTSD Interview
CAPS
IES
PSS^I
Posttreatment,
2 weeks,
3 months
Not given
Completers
only
6 MFU
Not given
12 MFU
Not given
Completers Not given
only
Completers Not given
only
48 (8.6)
0
Combat
Not given
EMDR
SM
(biofeedbackassisted relaxation) Waiting list
38 (10)
36
Various
At least 6
months,
mean 46
months
(s.d.¼58)
(s.d. 58)
100
Mixed: 50%
sexual trauma
Not given
Scheck et al,
al,
1998 (USA)
67
20.9
60 completed (7 (range 16^25)
drop-outs reported)
Devilly & Spence,
1999 (Australia)
32
23 completed (9
drop-outs reported)
37.96 (12.82)
Fecteau & Nicki,
1999 (Canada)
Foa et al,
al, 1999
(USA)
23
20
96
79
41.3
(range 25^63)
34.9 (10.6)
65
Not given
(of completers)
70
RTA
100
Assault of
which 72%
sexual assault
Not given
18.8 months
(mean)
Not given
EMDR: twelve
60^75 min
sessions over
6 weeks
Relaxation:
twelve 40 min
sessions over
6 weeks
All conditions,
ten 90 min sessions (105 min for
combined group)
CBT: nine
sessions (6
(6
90 min
+3120
+3 120 min)
EMDR: up to
eight
90^120 min
sessions
TFCBT
8h
Waiting list
approximately
TFCBT (exposure 10.5 h
therapy) SM (stress
inoculation training) TFCBT+SM
(combination exposure and stress
inoculation)
Waiting list
Completers Postonly
treatment/
3 MFU masking unclear
Masked
assessment
reported at
9 MFU
Yes
Completers
only
Masked administration
at end-point,
masking of
assessment
unclear
3 MFU not
masked
Not given
(Continued)
DATA SUP P LE
L E MENT TO B R IT I S H J O U R NA L O F P SYC H IAT RY ( 2 0 0 7 ) , 1 9 0 , 9 7 ^ 1 0 4
Tarrier et al,
al,
72
TFCBT 1
Sixteen 60 min
IES
Post-
1999a
1999a (UK)
62 completed;
37.9 (11.8)
41
Mixed
Not given
(imaginal
sessions in both
CAPS
treatment,
57 at 6 MFU,
exposure)
conditions
Penn Inventory for 12 MFU
54 at 12 MFU
TFCBT 2 (cogni-
(mean
PTSD
tive therapy)
attendance
Not given
Completers
Yes
only
11.2 sessions,
s.d.¼4.5)
s.d. 4.5)
Tarrier et al,
al,
72
1999b
1999b (UK)
62 completed
8.6 (11.6)
42
Mixed
34% 512
TFCBT 1
Sixteen sessions
IES
(non-CSA)
months
(imaginal
60 min in both
CAPS
40%
exposure)
conditions
Penn Inventory for
1^2 years
TFCBT 2 (cognitive
26%
therapy)
57 at 6 MFU
6 MFU
Not given
Completers
Yes
only
PTSD
2^10 years
Gersons et al,
al,
42
2000
23 completed
36.5 (7)
22
(The Netherlands) (1 drop-out
included in
Traumatic
3 years
TFCBT (brief
event at work
eclectic psy-
(all police
chotherapy)
officers)
Waiting list
16 h
Clinician-rated
3 MFU
Not given
Yes
Yes
6 MFU
Not given
Completers
Not given
PTSD symptoms
analysis)
Classen et al,
al,
55
2001
2001 (USA)
52
Not given
100
Adult
Not given
Group TFCBT
36 h
Trauma
survivors
(trauma-focused
Symptom
of CSA
group therapy)
Checklist^40
only
Group CBT
(present-centred
group therapy)
Waiting list
Krakow et al,
al,
168
Group CBT (group Three 3 h
DSS
Post-
2001
2001 (USA)
114 (end-point)
(adult and
imagery rehearsal) sessions
CAPS
treatmemt,
96 (3 MFU)
CSA)
Waiting list
36.9 (12.7)
100
Sexual assault
Not given
Not given
Yes
Yes
Not given
Completers
No
3 MFU, 6 MFU
99 (6 MFU)
Paunovic & Ost,
20
Mixed
7.8 years
TFCBT 1
Sixteen to
CAPS^IV
Post-
2001
2001 (Sweden)
16 completed
(refugee
(s.d.¼7.0)
(s.d. 7.0)
(trauma-
twenty
IES^R
treatment,
(4 drop-outs
reported)
population)
focused CBT)
TFCBT 2 (expo-
60^120 min
(both
PSS
6 MFU
sure therapy)
conditions)
TFCBT (CBT
20 h
CAPS
9 MFU
Cloitre et al,
al,
58
2002 (USA)
46
37.9 (7.6)
34 (7.22)
19
100
Adult
Not given
survivors
and modified
Modified
of CSA
prolonged
PSS^SR
only
Not given
Completers
Not given
only
exposure)
Waiting list
(Continued)
Continued)
DATA SUP P LE
L E MENT TO B R IT I S H J O U R NA L O F P SYC H IAT RY ( 2 0 0 7 ) , 1 9 0 , 9 7 ^ 1 0 4
Ironson et al,
al,
2002 (USA)
Limited data
22
19 completed given (range 16^
62 years)
(3 drop-outs reported)
12 at 3 MFU
Lee et al,
al, 2002
(USA)
24
21 completed
(3 drop-outs reported)
Power et al,
al,
2002 (UK)
105
72 completed
(33 drop-outs
reported)
Completers:
39.2 (11.8)
Resick et al,
al, 2002
(USA)
171
121 completed
(50 drop-outs
reported)
32 (9.9)
Blanchard et al,
al, 2003 73
(USA)
53
Bryant et al,
al,
2003 (Australia)
58
45 completed
Kubany et al,
al,
2003 (USA)
37
32 completed (5
drop-outs reported)
25 at 3 MFU
35.3 (17.16)
41 (13.1)
35.2 (12.31)
36.4 (9.1)
SUDS
PostIn both
EMDR
PSS^SR
treatment,
conditions
TFCBT (pro3 MFU
longed exposure) 3 non-active
sessions, 3 active
sessions with
homework
PostSeven 90 min
SI^PTSD
46
Mixed
Time since trau- EMDR
treatment,
sessions
IES
ma: mean 14.9 SM+TFCBT
Keane’s PTSD scale 3 MFU
(stress inoculation
months
from the MMPI
training with
(s.d.¼15.71)
(s.d. 15.71)
prolonged
exposure)
PostMaximum of
CAPS
EMDR
58 (of
Mixed
Time since
treatment,
ten 90 min sessions IES
TFCBT
completers)
trauma
15 MFU
SI^PTSD (self(completers): (cognitive
report version)
restructuring
mean 199.3
and exposure
weeks
therapy)
(s.d.¼426)
(s.d. 426)
Waiting list
PostTFCBT 1 (cogni- Total 13 h active CAPS
100
Rape (during At least 3
PSS
treatment,
treatment over
months since tive processing
childhood
3 MFU, 9 MFU
6 weeks, plus
trauma, mean therapy)
and/or
homework
TFCBT 2
8.5 years
adulthood)
(TFCBT 1 mean
(prolonged
(s.d.¼8.5)
(s.d. 8.5)
22.6 h, TFCBT 2
exposure)
Minimal attention mean 44.8 h)
CAPS
3 MFU
8^12 sessions
73
RTA
9.8^15.1 months TFCBT
IES
(length
OT (supportive
average
unspecified)
psychotherapy)
duration
Waiting list
across treatment groups
CAPS^2
PostAll conditions:
Mininum
TFCBT 1
52
Mixed
IES
treatment,
eight 90 min
3 months
(prolonged
(excluding
6 MFU
sessions
imaginal
sexual assault)
exposure and
cognitive
restructuring)
TFCBT 2 (prolonged imaginal exposure)
OT (supportive
counselling)
Mean 8.5 (range 7^ CAPS
PostNot given
TFCBT
100
Mixed
11) sessions
treatment,
(cognitive
traumas within a
(90 min)
3 MFU
trauma therapy
population of
for battered
‘battered
women)
women’
Waiting list
77
Mixed
Not given
Not given
Completers
only
No
Not given
Completers
only
No
Not given
Completers
only
Yes
Not given
Yes
Not given
Not given
Completers
only
Yes
Not given
Yes
Yes
Not given
Yes
Yes
DATA SUP P LE
L E MENT TO B R IT I S H J O U R NA L O F P SYC H IAT RY ( 2 0 0 7 ) , 1 9 0 , 9 7 ^ 1 0 4
Lange et al,
al, 2003
184
(The Netherlands) 101
101 at post-
Completers:
39.0 (10.5)
80
Mixed
At least 3
months since
treatment
trauma, mean
(83 drop-outs
9.0 years
reported)
(s.d.¼11.6)
(s.d. 11.6)
Interapy
Waiting list
Ten 45 min writing SCL^90
exercises
IES
Posttreatment,
Not given
Completers
only
Not given
Not given
Both
Yes
6 weeks FU
57 at 6 weeks
Taylor et al,
al, 2003
60
(Canada)
45 completed
37 (10)
75
Schnurr et al,
al,
2003 (USA)
360
253 completed
(325 participated in
follow-up)
50.7 (3.7)
0
Ehlers et al,
al,
2005 (UK)
28
28
36.6 (11.2)
Kubany et al,
al,
2004 (USA)
125
85 analysed
post-treatment
Neuner et al,
al,
2004 (Germany)
Rothbaum et al,
al,
2005 (USA)
Mixed
Mean
EMDR
All conditions:
CAPS
Post-
duration
TFCBT
eight 90 min
PSS
treatment,
completer and
8.7 years
(s.d.¼10.8)
(s.d. 10.8)
(exposure
therapy)
sessions
3 MFU
(limited) ITT
analyses re-
Combat
(Vietnam)
Not given
53.5
Mixed
11.5 months
(median)
42.2 (10.1)
100
Mixed
traumas
within a
population
of ‘battered
women’
43
40 analysed
posttreatment,
38 at 12 MFU
33.1 (7.9)
60
Refugee
population
(Sudanese
civil war)
Where
trauma was
partner
abuse,
mean 5.0
years since
last abuse
(s.d.¼7.4)
(s.d. 7.4)
Mean 7.5 years
since ‘worst’
trauma
(s.d.¼3.3)
(s.d. 3.3)
74
60 completed
Completers:
33.77 (11.03)
100
More than
Rape in
adulthood (4
(412 3 months
since trauma
years
old)
SM (relaxation)
Both conditions:
Group TFCBT
thirty 90^
Group CBT
120 min sessions,
(presentthen five 90 min
centred
‘booster’ sessions
group
therapy)
Up to 15
TFCBT
sessions
(trauma(mean 12.4)
focused
cognitive
therapy)
Waiting list
TFCBT (immediate 8^11 sessions
of 90 min
cognitive
trauma therapy)
Waiting list
TFCBT and
TFCBT
OT 1: four
(narrative
90^120 min
exposure
sessions
therapy)
Psychoeducation:
OT 1
one
(supportive
90^120 min
counselling)
Psychoeducation session
TFCBT (prolonged Both conditions:
nine 90 min
exposure)
sessions
EMDR
Waiting list
CAPS
PTSD
Checklist
SF^36
CAPS
PDS
Not given
Posttreatment,
12 months
(end of booster
period) 18 MFU,
24 MFU
6 MFU
Not given
ported
Yes
Yes
Yes
Yes
CAPS
Distressing
Event
Questionnaire
PostNot given
treatment,
3 MFU, 6 MFU
Both completer and
ITT analyses
reported
Yes
PDS
CIDI^PTSD
part
PostNot given
treatment,
4 MFU, 12 MFU
Completers
only
Yes
CAPS
SCID
PSS^SR
IES^R
Post-treatment, Not given
6 MFU, 12 MFU
Completers
only
Yes
CAPS, Clinician Administered PTSD Scale; CBT, cognitive ^behavioural therapy; CIDI, Composite International Diagnostic Interview; CSA, childhood sexual abuse; DSS, Depression Symptom Scale; EMDR, eye movement desensitisation and reprocessing;
IES(^R), Impact of Events Scale (Revised); ITT, intention-to-treat; MFU, months of follow-up; MMPI(^R), Minnesota Multiphasic Personality Interview (Revised); OT, other therapies; PDS, PTSD Diagnostic Scale; PSS(I, SR), PTSD Symptom Scale (Interview,
Self-Report); PTSD, post-traumatic stress disorder; RTA, road traffic accident; SCID, Structured Clinical Interview for DSM^IV; SCL^90 ^R, Symptom Checklist 90 ^ Revised; SI^PTSD, Structured Interview for PTSD; SM, stress management; SUDS,
Subjective Units of Distress Scale; TFCBT, trauma-focused cognitive ^behavioural therapy.
1. Where standard deviations are given for each treatment group separately, the highest across treatment groups is reported.
Psychological treatments for chronic post-traumatic stress
disorder: Systematic review and meta-analysis
JONATHAN I. BISSON, ANKE EHLERS, ROSA MATTHEWS, STEPHEN PILLING, DAVID RICHARDS
and STUART TURNER
BJP 2007, 190:97-104.
Access the most recent version at DOI: 10.1192/bjp.bp.106.021402
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