Psychological treatments for post-traumatic stress disorder in adults: a network meta-analysis

Abstract

BackgroundPost-traumatic stress disorder (PTSD) is a potentially chronic and disabling disorder affecting a significant minority of people exposed to trauma. Various psychological treatments have been shown to be effective, but their relative effects are not well established.MethodsWe undertook a systematic review and network meta-analyses of psychological interventions for adults with PTSD. Outcomes included PTSD symptom change scores post-treatment and at 1–4-month follow-up, and remission post-treatment.ResultsWe included 90 trials, 6560 individuals and 22 interventions. Evidence was of moderate-to-low quality. Eye movement desensitisation and reprocessing (EMDR) [standardised mean difference (SMD) −2.07; 95% credible interval (CrI) −2.70 to −1.44], combined somatic/cognitive therapies (SMD −1.69; 95% CrI −2.66 to −0.73), trauma-focused cognitive behavioural therapy (TF-CBT) (SMD −1.46; 95% CrI −1.87 to −1.05) and self-help with support (SMD −1.46; 95% CrI −2.33 to −0.59) appeared to be most effective at reducing PTSD symptoms post-treatment v. waitlist, followed by non-TF-CBT, TF-CBT combined with a selective serotonin reuptake inhibitor (SSRI), SSRIs, self-help without support and counselling. EMDR and TF-CBT showed sustained effects at 1–4-month follow-up. EMDR, TF-CBT, self-help with support and counselling improved remission rates post-treatment. Results for other interventions were either inconclusive or based on limited evidence.ConclusionsEMDR and TF-CBT appear to be most effective at reducing symptoms and improving remission rates in adults with PTSD. They are also effective at sustaining symptom improvements beyond treatment endpoint. Further research needs to explore the long-term comparative effectiveness of psychological therapies for adults with PTSD and also the impact of severity and complexity of PTSD on treatment outcomes.

Cost-effectiveness of psychological treatments for post-traumatic stress disorder in adults

“…EMDR was found to be the most cost-effective intervention for adults with PTSD, with the highest NMB at the cost-effectiveness threshold of £20,000/QALY. This was followed by [3]; standardised mean differences converted to odds ratios according to [34]; distribution based on 300,000 samples from posterior distributions outputted from NMAs, thinned by 30 to obtain 10,000 values 3-6-month probability of remission for SSRIs assumed to equal the probability of remission of SSRIs during initial treatment (0-3 months); 3-6-month probability of remission for combined TF-CBT/SSRIs borrowed from TF-CBT.…”

“…The interventions considered in the economic analysis were selected from those considered in a network meta-analysis (NMA) of randomised controlled trials (RCTs) of psychological treatments for adults with PTSD ( [3]; see S2 Appendix for inclusion criteria for the NMA). We included only interventions that had been tested on at least 100 individuals in the NMA of changes in PTSD symptoms at treatment endpoint, as this was deemed the minimum adequate evidence base that would enable robust conclusions to be drawn on clinical and cost-effectiveness.…”

“…We obtained effectiveness data from a systematic review and NMA of psychological treatments for adults with PTSD [3]. We utilised the results of 2 NMAs of changes in PTSD symptoms: between baseline and treatment endpoint; and between baseline and 1-4-month follow-up.…”

“…EMDR appears to be the most cost-effective intervention for adults with PTSD more than 3 months after trauma, followed by combined somatic/cognitive therapies, self-help with support, psychoeducation, SSRIs, TF-CBT, self-help without support, non-TF-CBT and combined TF-CBT/SSRIs. Counselling appears to be less cost-effective than no treatment, due to its relatively low clinical effectiveness (the lowest amongst all active treatments assessed in the economic analysis), as shown in the NMAs that informed the economic analysis [3], which was not enough to offset its relatively high intervention cost. The low effectiveness found for counselling can be attributed to counselling's non-directive person-centred approach, which is less likely to help the person overcome avoidance (which is one of the criteria for PTSD), and thus less likely to reduce PTSD symptoms.…”

“…PTSD is a severe and disabling condition that may lead to functional impairment and reduced productivity [2]. A number of psychological interventions have been shown to be effective in the treatment of PTSD in adults, predominantly eye movement desensitisation and reprocessing (EMDR) and trauma-focused cognitive behavioural therapy (TF-CBT) [3]. However, many people with PTSD delay seeking help or are not identified by health services [4].…”