Psychological treatments for chronic post
Transcrição
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 B I S S ON E T A L 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 RONI ONI C P T S D 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 able 1 B I S S ON E T A L AUTHOR’S PROOF T R E AT M E N T OF C H R RONI ONI C P T S D AUTHOR’S PROOF 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. *Cooper, N. A. & Clum, G. A. (1989) Imaginal flooding as a supplementary treatment for PTSD in combat veterans: a controlled study. Behavior Therapy, Therapy, 20, 20, 381^391. *Kubany, E. S., Hill, E. E. & Owens, J. A. (2003) DerSimonian, R. & Laird, N. (1986) Meta-analysis in clinical trials. Controlled Clinical Trials, Trials, 7, 177^188. *Devilly, G. J. & Spence, S. H. (1999) The relative efficacy and treatment distress of EMDR and a cognitive ^ behaviour trauma treatment protocol in the amelioration of posttraumatic stress disorder. Journal of Anxiety Disorders, Disorders, 13, 13, 131^157. *Echeburua, E., de Corral, P., Zubizarreta, I., et al (1997) Psychological treatment of chronic posttraumatic stress disorder in victims of sexual aggression. Behavior Modification, Modification, 21, 21, 433^56. *Ehlers, A., Clark, D., Hackmann, A., et al (2005) Cognitive therapy for posttraumatic stress disorder: development and evaluation. Behaviour Research and Therapy, Therapy, 43, 43, 413^431. *Fecteau, G. & Nicki, R. (1999) Cognitive behavioural treatment of post traumatic stress disorder after motor vehicle accident. Behavioural and Cognitive Psychotherapy, Psychotherapy, 27, 27, 201^214. *Foa, E. B., Rothbaum, B. O., Riggs, D. S., et al (1991) Treatment of posttraumatic stress disorder in rape victims: a comparison between cognitive ^ behavioral procedures and counseling. Journal of Consulting and Clinical Psychology, Psychology, 59, 59, 715^723. *Foa, E. B., Dancu, C.V., Hembree, E. A., et al (1999) Treatments delivered in groups 5. Group cognitive ^ behavioural therapy. REFERENCES *Blanchard, E. B., Hickling, E. J., Devineni, T., et al (2003) A controlled evaluation of cognitive behavioural therapy for posttraumatic stress in motor vehicle accident survivors. Behaviour Research and Therapy, Therapy, 41, 41, 79^96. 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Depression: Management of Depression in Primary and Secondary Care. Care. National Institute for Clinical Excellence. National Collaborating Centre for Mental Health (2005) Clinical Guideline 26. Post-Traumatic Stress Disorder: The Management of PTSD in Adults and Children in Primary and Secondary Care. Care. National Institute for Clinical Excellence. National Collaborating Centre for Primary Care (2004) Clinical Guideline 22. Anxiety: Management of Anxiety (Panic Disorder,With or Without Agoraphobia, and Generalized Anxiety Disorder) in Adults in Primary, Secondary and Community Care. Care. National Institute for Clinical Excellence. *Neuner, F., Schauer, M., Klaschik, C., et al (2004) A comparison of narrative exposure therapy, supportive counselling and psychoeducation for treating posttraumatic stress disorder in an African refugee settlement. Journal of Consulting and Clinical Psychology, Psychology, 72, 72, 579^587. *Paunovic, N. & Ost, L. G. (2001) Cognitive ^ behaviour therapy vs exposure therapy in the treatment of PTSD in refugees. Behaviour Research and Therapy, Therapy, 39, 39, 1183^1197. *Peniston, E. G. & Kulkosky, P. J. (1991) Alpha ^ theta brainwave neuro-feedback therapy for Vietnam veterans with combat-related post-traumatic stress disorder. Medical Psychotherapy, Psychotherapy, 4, 47^60. Pitman, R. K., Altman, B., Greenwald, E., et al (1991) Psychiatric complications during flooding therapy for post-traumatic stress disorder. Journal of Clinical Psychiatry, Psychiatry, 52, 52, 17^20. *Power, K., McGoldrick, T., Brown, K., et al (2002) A controlled comparison of eye movement desensitisation and reprocessing versus exposure plus cognitive restructuring versus waiting list in the treatment of 103 B I S S ON E T A L AUTHOR’S PROOF post-traumatic stress disorder. Clinical Psychology and Psychotherapy, Psychotherapy, 9, 299^318. *Resick, P. A., Nishith, P.,Weaver,T. L., et al (2002) A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. Journal of Consulting and Clinical Psychology, Psychology, 70, 70, 867^879. *Rothbaum, B. (1997) A controlled study of eye movement desensitization and reprocessing in the treatment of post-traumatic stress disordered sexual assault victims. Bulletin of the Menninger Clinic, Clinic, 61, 61, 317^334. *Rothbaum, B. O., Astin, M. C. & Marsteller, F. (2005) Prolonged exposure vs. EMDR for PTSD rape victims. Journal of Traumatic Stress, Stress, 18, 18, 607^616. 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) imaginal exposure in the treatment of chronic posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, Psychology, 67, 67, 13^18. disorder: a meta-analysis. Clinical Psychology and Psychotherapy, Psychotherapy, 5, 126^145. *Vaughan, K., Armstrong, M. S., Gold, R., et al (1994) A trial of eye movement desensitization *Scheck, M., Schaeffer, J. A. & Gillette, C. (1998) *Tarrier, *Tarrier, N., Sommerfield, C., Pilgrim, H., et al (1999b (1999b) Cognitive therapy or imaginal exposure in the Brief psychological intervention with traumatized young women: the efficacy of eye movement desensitization and reprocessing. Journal of Traumatic Stress, Stress, 11, 11, 24^44. treatment of post-traumatic stress disorder. Twelve month follow-up. British Journal of Psychiatry, Psychiatry, 175, 175, 571^575. *Schnurr, P. P., Friedman, M. J., Foy, D. W., et al (2003) Randomized trial of trauma-focused group *Taylor, *Taylor, S., Thordarson, D. S., Maxfield, L., et al (2003) Comparative efficacy, speed, and adverse effects therapy for posttraumatic stress disorder: results from a Department of Veterans’Affairs cooperative study. Archives of General Psychiatry, Psychiatry, 60, 60, 481^489. of three PTSD treatments: exposure therapy, EMDR and relaxation training. Journal of Consulting and Clinical Psychology, Psychology, 71, 71, 330^338. *Tarrier, N., Pilgrim, H., Sommerfield, C., et al (1999a (1999a) A randomized trial of cognitive therapy and Van Etten, M. L. & T Taylor, aylor, S. (1988) Comparative 10 4 efficacy of treatments for post-traumatic stress compared to image habituation training and applied muscle relaxation in post-traumatic stress disorder. Journal of Behavior Therapy and Experimental Psychiatry, Psychiatry, 25, 25, 283^291. *Zlotnick, C., Shea, T. M., Rosen, K., et al (1997) An affect-management group for women with posttraumatic stress disorder and histories of childhood sexual abuse. Journal of Traumatic Stress, Stress, 10, 10, 425^436. *Studies that were part of the meta-analysis. 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. 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