Do adjuvant interventions improve treatment outcome in adult patients with posttraumatic stress disorder receiving trauma-focused psychotherapy? A systematic review

Abstract

Background : According to clinical guidelines, trauma-focused psychotherapies (TF-PT) such as trauma-focused cognitive behavioural therapy (TF-CBT) and eye movement desensitization and reprocessing (EMDR) are recommended as first-line treatments for posttraumatic stress disorder (PTSD). TF-CBT and EMDR are equally effective and have large effect sizes. However, many patients fail to respond or have comorbid symptoms or disorders that only partially decline with TF-PT. Thus, there is growing interest in augmenting TF-PT through adjuvant interventions. Objective : The current systematic review aims to assess whether adjuvant interventions improve outcome among adult PTSD patients receiving TF-PT. Methods : We searched the databases PubMed, PILOTS, Web of Science and the Cochrane Library for controlled clinical trials examining whether adjuvant interventions lead to more symptom reduction in adult PTSD patients receiving TF-PT. Thirteen randomized controlled trials fitted the inclusion criteria. These were evaluated for internal risk of bias using the Cochrane Handbook for Systematic Review of Interventions. Results : Most studies have a substantial risk for internal bias, mainly due to small sample sizes. Thus, no strong conclusion can be drawn from the current empirical evidence. Preliminary evidence suggests that exercise and cortisol administration may have an adjuvant effect on PTSD symptom reduction. Breathing biofeedback showed a trend for an adjuvant effect and an effect for accelerated symptom reduction. Conclusions : Currently, it is not possible to formulate evidence-based clinical recommendations regarding adjuvants interventions. While several adjuvant interventions hold the potential to boost the effectiveness of TF-PT, the realization of sufficiently powered studies is crucial to separate plausible ideas from interventions proven to work in practice.

Developments of prolonged exposure in treatment effect of post‐traumatic stress disorder and controlling dropout rate: A meta‐analytic review

“…Moreover, hydrocortisone, DCS, oxytocin, yohimbine, and methylene blue were summarized as cognitive enhancers in the previous systematic reviews. It was suggested that cortisone administration might have an adjuvant effect on PTSD symptom reduction (Michael et al, 2019). The adjuvant effect of DCS on exposure therapy was not consistent across studies but was observed on PE and VRE (Mataix‐Cols et al, 2017).…”

“…And DCS was associated with lower symptom severity than those assigned to placebo at posttreatment and at follow‐up (Mataix‐Cols et al, 2017). Michael et al (2019) reviewed the studies containing trauma‐focused therapy with adjuvant (cognitive enhancers and behaviour‐based interventions) and preliminarily found that exercise and cortisol administration might have an adjuvant effect on the PTSD symptom reduction. And there was a faster symptom reduction in the trauma‐focused CBT plus breathing biofeedback group and a trend towards an enhanced treatment effect (Michael et al, 2019).…”

“…Michael et al (2019) reviewed the studies containing trauma‐focused therapy with adjuvant (cognitive enhancers and behaviour‐based interventions) and preliminarily found that exercise and cortisol administration might have an adjuvant effect on the PTSD symptom reduction. And there was a faster symptom reduction in the trauma‐focused CBT plus breathing biofeedback group and a trend towards an enhanced treatment effect (Michael et al, 2019). Based on abundant previous evidences, a comprehensive and direct comparison of mPE + PE/d and PE on PTSD treatment (including treatment effect and dropout rate control), by using meta‐analytic approach, is available now, but studies in this area are very few.…”

Frühinterventionen nach Traumatisierung

“…Anders als bei psychologischen Interventionen, bei denen oft Tage zwischen dem kritischen Ereignis und der Präventionsmaßnahme liegen, erfolgen pharmakologische Interventionen oft in einem knappen Zeitfenster von weniger als 12 Stunden (mit Ausnahme von SSRIs, die über einen längeren Zeitraum eingesetzt werden). Die angenommenen Wirkmechanismen verschiedener Substanzen sind heterogen, konzentrieren sich jedoch vor allem auf gedächtnismodulierende Effekte [9].…”

Investigation of early night sleep effects on subsequent fear extinction learning and recall

“…Clinical practice guidelines for the treatment of posttraumatic stress disorder (PTSD) strongly recommend trauma-focused cognitive behavioral therapy (TF-CBT), comprising exposure therapy as its core element (Hamblen et al, 2019). Despite TF-CBT’s effectiveness, rates of non-responders and dropouts are high (Schottenbauer et al, 2008), indicating the need for further improvements of treatment (Michael et al, 2019). Since PTSD and sleep disturbances are highly interrelated, it has been suggested that adjunctive treatments addressing sleep may enhance the efficacy of TF-CBT (Difede et al, 2014).…”