How effective and acceptable is psychotherapy for PTSD? A meta-analysis

What is it about?

We aimed at summarzing the efficacy and acceptability of psychological interventions for adult PTSD. We conducted a systematic literature search in April 2022 to identify relevant randomized controlled trials (RCTs). A total of 157 RCTs were included (N = 11,565 patients). Interventions were divided into four categories: 1) trauma-focused cognitive behaviour therapy (TF-CBT); 2) eye movement desensitization and reprocessing (EMDR); 3) other trauma-focused interventions; 4) non-trauma-focused interventions. Most RCTs (64%) that have accumulated up to April 2022 investigated the efficacy of TF-CBT. All therapies were effective when compared to passive and active control conditions. TF-CBT robustly yielded the highest efficacy both in the short and in the long run. TF-CBT yielded higher short- (g = 0.17, 95%CI: 0.03-0.31, k = 190), mid- (i.e., ≤ 5 months post-treatment, g = 0.23, 95%CI: 0.06-0.40, k = 73) and long-term efficacy (i.e., > 5 months post-treatment, g = 0.20, 95%CI: 0.04-0.35, k = 41) than non-trauma-focused interventions. Other than that, interventions did not differ significantly with regards to efficacy of lowering PTSD. In terms of dropout rates (proxy for acceptability), about as many patients dropped out from psychological interventions as did from passive and active control conditions illustrating good acceptability. While dropout rates generally did not differ between psychological interventions, slightly more patients dropped out from TF-CBT than from non-trauma-focused interventions (RR = 1.36; 95%CI: 1.08-1.70, k = 22). Results are in line with previous meta-analyses reporting that several effective and acceptable psychological interventions for adult PTSD exist and that trauma-focused interventions (and TF-CBT in particular, followed by EMDR) are the first-line treatment recommendation.

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Photo by Mohamed Nohassi on Unsplash

Photo by Mohamed Nohassi on Unsplash

Why is it important?

PTSD is a prevalent mental health condition with detrimental effects on affected people. Given the large societal burden imposed by PTSD, its effective treatment is a public health priority. Treatment efficacy and acceptability are best estimated in randomized controlled trials (RCTs) and dozens of RCTs investigating various psychological interventions have accumulated in the past four decades. The present network and pairwise meta-analysis is the largest quantitative review of psychological interventions for PTSD in adulthood to this date summarizing results of 157 RCTs. As such, the present work delivers the (statistically) most powerful estimates for the efficacy and acceptability (all-cause dropout rates) of TF-CBT, EMDR, other trauma-focused interventions and non-trauma-focused interventions. Comprehensive quantitative summaries such as the present one are informative for clinical practice for instance by informing treatment guidelines. The present work further educates various stakeholders (patients, researchers, clinicians) and contradicts several widespread myths and misconceptions around the treatment of PTSD (e.g., TF-CBT being a "harmful" and "inappropriate" treatment). Given that such myths and misconceptions may function as treatment barriers, the present state-of-the-art summary of the RCT-literature gives an evidence-based answer to opinionated and often heated debates.

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