Determining what works in the treatment of PTSD

Many researchers accept that trauma-focused treatments are superior to non-trauma focused treatments for Post-Traumatic Stress Disorder (PTSD). However, Benish, Imel, and Wampold (2008) recently published a meta-analysis of clinical trials directly comparing ‘bona fide’ PTSD treatments that failed to reject the null hypothesis that PTSD treatments are similarly effective. They concluded that the results of previous meta-analysis may have been influenced by several confounds, including the use of control treatments, to make conclusions about the relative efficacy of specific PTSD treatments. Ehlers et al. (2010) claim that the selection procedures of the Benish et al. meta-analysis were biased and cite results from individual studies and previous meta-analyses that suggest trauma-focused psychological treatments are superior to non-trauma focused treatments. We first offer a review and justification of the coding criteria and procedure used in Benish et al. In addition, we discuss the appropriateness of utilizing treatments designed to control for non-specifics or common factors such as ‘supportive therapy’ for determining the relative efficacy of specific PTSD treatments. Finally, we note several additional confounds, such as therapist effects, allegiance, and alteration of legitimate protocols, in PTSD research and describe conceptual problems involved in the classification scheme used to determine the “trauma focus” of interventions, which lead to inappropriate conclusions about what works in the treatment of PTSD.     

Psychological treatments for concurrent posttraumatic stress disorder and substance use disorder: a systematic review

This article gives an overview of research into psychological treatments for concurrent posttraumatic stress disorder (PTSD) and substance used disorder (SUD), with a special focus on the effectiveness of treatments addressing both disorders compared to treatments addressing one of the disorders alone. In addition, a distinction is made between trauma-focused versus non-trauma-focused therapies for concurrent PTSD and SUD. The databases Embase, Psychinfo, Medline and Web of science were searched for relevant articles. In total, seventeen studies were identified evaluating ten treatments protocols (six trauma-focused and four non-trauma-focused treatment approaches). In general, the studies showed pre-post reductions for PTSD and/or SUD symptoms. Although most treatments for concurrent PTSD and SUD did not prove to be superior to regular SUD treatments, there are some promising preliminary results suggesting that some patients might benefit from trauma-focused interventions. However, the lack of methodologically sound treatment trials makes it difficult to draw firm conclusions. Methodological limitations are discussed, along with recommendations for future research.     

Do all psychological treatments really work the same in posttraumatic stress disorder?

A recent meta-analysis by Benish, Imel, and Wampold (2008, Clinical Psychology Review, 28, 746–758) concluded that all bona fide treatments are equally effective in posttraumatic stress disorder (PTSD). In contrast, seven other meta-analyses or systematic reviews concluded that there is good evidence that trauma-focused psychological treatments (trauma-focused cognitive behavior therapy and eye movement desensitization and reprocessing) are effective in PTSD; but that treatments that do not focus on the patients' trauma memories or their meanings are either less effective or not yet sufficiently studied. International treatment guidelines therefore recommend trauma-focused psychological treatments as first-line treatments for PTSD. We examine possible reasons for the discrepant conclusions and argue that (1) the selection procedure of the available evidence used in Benish et al.'s (2008)meta-analysis introduces bias, and (2) the analysis and conclusions fail to take into account the need to demonstrate that treatments for PTSD are more effective than natural recovery. Furthermore, significant increases in effect sizes of trauma-focused cognitive behavior therapies over the past two decades contradict the conclusion that content of treatment does not matter. To advance understanding of the optimal treatment for PTSD, we recommend further research into the active mechanisms of therapeutic change, including treatment elements commonly considered to be non-specific. We also recommend transparency in reporting exclusions in meta-analyses and suggest that bona fide treatments should be defined on empirical and theoretical grounds rather than by judgments of the investigators' intent.     

Trauma-Focused Art Therapy in the Treatment of Posttraumatic Stress Disorder: A Pilot Study

Research showed that more than 30% of patients with Posttraumatic Stress Disorder (PTSD) do not benefit from evidence-based treatments: Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) or Eye Movement Desensitization and Reprocessing (EMDR). These are patients with prolonged and multiple traumatization, with poor verbal memory, and patients with emotional over-modulation. Retelling traumatic experiences in detail is poorly tolerated by these patients and might be a reason for not starting or not completing the recommended treatments. Due to lack of evidence, no alternative treatments are recommended yet. Art therapy may offer an alternative and suitable treatment, because the nonverbal and experiential character of art therapy appears to be an appropriate approach to the often wordless and visual nature of traumatic memories. The objective of this pilot study was to test the acceptability, feasibility, and applicability of trauma-focused art therapy for adults with PTSD due to multiple and prolonged traumatization (patients with early childhood traumatization and refugees from different cultures). Another objective was to identify the preliminary effectiveness of art therapy. Results showed willingness to participate and adherence to treatment of patients. Therapists considered trauma-focused art therapy feasible and applicable and patients reported beneficial effects, such as more relaxation, externalization of memories and emotions into artwork, less intrusive thoughts of traumatic experiences and more confidence in the future. The preliminary findings on PTSD symptom severity showed a decrease of symptoms in some participants, and an increase of symptoms in other participants. Further research into the effectiveness of art therapy and PTSD is needed.     

Meta-analysis of psychological treatments for posttraumatic stress disorder in adult survivors of childhood abuse

Posttraumatic stress disorder (PTSD) is highly prevalent in adult survivors of childhood sexual and/or physical abuse. However, intervention studies focusing on this group of patients are underrepresented in earlier meta-analyses on the efficacy of PTSD treatments. The current meta-analysis exclusively focused on studies evaluating the efficacy of psychological interventions for PTSD in adult survivors of childhood abuse. Sixteen randomized controlled trials meeting inclusion criteria could be identified that were subdivided into trauma-focused cognitive behavior therapy (CBT), non-trauma-focused CBT, eye movement desensitization and reprocessing, and other treatments (interpersonal, emotion-focused). Results showed that psychological interventions are efficacious for PTSD in adult survivors of childhood abuse, with an aggregated uncontrolled effect size of g = 1.24 (pre- vs. post-treatment), and aggregated controlled effect sizes of g = 0.72 (post-treatment, comparison to waitlist control conditions) and g = 0.50 (post-treatment, comparison with TAU/placebo control conditions), respectively. Effect sizes remained stable at follow-up. As the heterogeneity between studies was large, we examined the influence of two a priori specified moderator variables on treatment efficacy. Results showed that trauma-focused treatments were more efficacious than non-trauma-focused interventions, and that treatments including individual sessions yielded larger effect sizes than pure group treatments. As a whole, the findings are in line with earlier meta-analyses showing that the best effects can be achieved with individual trauma-focused treatments.     

Comparing the efficacy of EMDR and trauma-focused cognitive-behavioral therapy in the treatment of PTSD: a meta-analytic study

BACKGROUND: Eye movement desensitization and reprocessing (EMDR) and trauma-focused cognitive-behavioral therapy (CBT) are both widely used in the treatment of post-traumatic stress disorder (PTSD). There has, however, been debate regarding the advantages of one approach over the other. This study sought to determine whether there was any evidence that one treatment was superior to the other. METHOD: We performed a systematic review of the literature dating from 1989 to 2005 and identified eight publications describing treatment outcomes of EMDR and CBT in active-active comparisons. Seven of these studies were investigated meta-analytically. RESULTS: The superiority of one treatment over the other could not be demonstrated. Trauma-focused CBT and EMDR tend to be equally efficacious. Differences between the two forms of treatment are probably not of clinical significance. While the data indicate that moderator variables influence treatment efficacy, we argue that because of the small number of original studies, little benefit is to be gained from a closer examination of these variables. Further research is needed within the framework of randomized controlled trials. CONCLUSIONS: Our results suggest that in the treatment of PTSD, both therapy methods tend to be equally efficacious. We suggest that future research should not restrict its focus to the efficacy, effectiveness and efficiency of these therapy methods but should also attempt to establish which trauma patients are more likely to benefit from one method or the other. What remains unclear is the contribution of the eye movement component in EMDR to treatment outcome.     

Cognitive‐Behavioral therapy for PTSD in the real world: Do interpersonal relationships make a real difference?

The goal of this effectiveness study was to investigate the role of pre-treatment interpersonal relationship functioning in two forms of group cognitive-behavioral treatment (CBT) for veterans with PTSD. Analysis of data from 45 veterans who completed either trauma- or skills-focused CBT indicated no overall differences between the two treatments in PTSD symptomatology, alcohol abuse, or violence perpetration at four months post-treatment. However, there was a stronger inverse relationship between intimate relationship functioning and violence outcomes in the trauma-focused group versus the skills-focused group. While no differences in violence outcomes were found between the treatments at poorer levels of pre-treatment intimate relationship functioning, those receiving trauma-focused treatment with better pre-treatment intimate relationships reported less violence. Extended relationship functioning and violence outcomes were less strongly associated in the trauma-focused group versus the skills-focused group. The theoretical implications of these results, as well as the clinical opportunities to improve CBT for PTSD by capitalizing on patients' relationships, are discussed.     

A comparison of Narrative Exposure Therapy and Prolonged Exposure therapy for PTSD

The purpose of this review was to compare and contrast Prolonged Exposure (PE) and Narrative Exposure Therapy (NET). We examined the treatment manuals to describe the theoretical foundation, treatment components, and procedures, including the type, manner, and focus of exposure techniques and recording methods used. We examined extant clinical trials to investigate the range of treatment formats reported, populations studied, and clinical outcome data. Our search resulted in 32 studies on PE and 15 studies on NET. Consistent with prior reviews of PTSD treatment, it is evident that PE has a solid evidence base and its current status as a first line treatment for the populations studied to this date is warranted. We argue that NET may have advantages in treating complex traumatization seen in asylum seekers and refugees, and for this population NET should be considered a recommended treatment. NET and PE have several commonalities, and it is recommended that studies of these treatments include a broader range of populations and trauma types to expand the current knowledge on the treatment of PTSD.     

The emerging evidence for Narrative Exposure Therapy: A review

Individuals who have experienced multiple traumatic events over long periods as a result of war, conflict and organised violence, may represent a unique group amongst PTSD patients in terms of psychological and neurobiological sequelae. Narrative Exposure Therapy (NET) is a short-term therapy for individuals who have PTSD symptoms as a result of these types of traumatic experiences. Originally developed for use in low-income countries, it has since been used to treat asylum seekers and refugees in high-income settings. The treatment involves emotional exposure to the memories of traumatic events and the reorganisation of these memories into a coherent chronological narrative. This review of all the currently available literature investigates the effectiveness of NET in treatment trials of adults and also of KIDNET, an adapted version for children. Results from treatment trials in adults have demonstrated the superiority of NET in reducing PTSD symptoms compared with other therapeutic approaches. Most trials demonstrated that further improvements had been made at follow-up suggesting sustained change. Treatment trials of KIDNET have shown its effectiveness in reducing PTSD amongst children. Emerging evidence suggests that NET is an effective treatment for PTSD in individuals who have been traumatised by conflict and organised violence, even in settings that remain volatile and insecure.     

PTSD symptoms associated with the experiences of psychosis and hospitalisation: A review of the literature

There is evidence of high rates of PTSD in people with psychosis, but the influence that symptoms or hospitalisation have on PTSD in individuals with psychosis is less clear. This paper reviewed studies investigating the prevalence of PTSD induced as a result of the experience of psychosis and hospitalisation and factors that might influence its development. The review included 24 studies, published between 1980 and 2011. Studies showed high levels of PTSD resulting from the trauma of symptoms and/or hospitalisation, with prevalence rates for actual PTSD resulting from these traumas varying from 11% to 67%. In line with studies of PTSD related to other traumatic events, there were inconsistent associations between PTSD and severity of positive and negative symptoms, but there were consistent associations between affective symptoms and PTSD. There were also inconsistent associations between hospital experiences and PTSD. Consistent with the general PTSD literature, there was some evidence that psychosis-related PTSD was associated with trauma history. There was also some emerging evidence that psychological variables, such as appraisals and coping style may influence psychosis-related PTSD. The review highlights the need for further research into psychological mechanisms that could increase vulnerability to psychosis-related PTSD and treatment approaches.     

Eye Movement Desensitization and Reprocessing Treatment for Posttraumatic Stress Disorder

A qualitative review of experimental and quasi-experimental outcome studies of eye movement desensitization and reprocessing (EMDR) treatment for persons with posttraumatic stress disorder (PTSD) suggests that the treatment is effective for civilian but not combat PTSD. The current data indicate that additional research into EMDR's efficacy for PTSD is warranted. Further studies should include comparisons to placebo control procedures and existing validated treatments for PTSD, an adequate treatment dose, systematic efforts to establish and assess treatment integrity and quality, and long-term follow-up data. The therapeutic mechanisms underlying EMDR's observed benefits remain elusive. Whether the eye movement or some other type of stimulation is essential to EMDR's effects cannot be determined from the current data.     

Psychotherapy for military-related posttraumatic stress disorder: Review of the evidence

Approximately 20% of the two million troops who have deployed to Iraq and Afghanistan may require treatment for posttraumatic stress disorder (PTSD). We review treatment outcome studies on individual outpatient therapy for military-related PTSD, and consider the extent to which veterans initiate and complete available PTSD treatments. We conclude with considerations for future research.     

A comparison of narrative exposure therapy, supportive counseling, and psychoeducation for treating posttraumatic stress disorder in an african refugee settlement

Little is known about the usefulness of psychotherapeutic approaches for traumatized refugees who continue to live in dangerous conditions. Narrative exposure therapy (NET) is a short-term approach based on cognitive-behavioral therapy and testimony therapy. The efficacy of narrative exposure therapy was evaluated in a randomized controlled trial. Sudanese refugees living in a Ugandan refugee settlement (N = 43) who were diagnosed as suffering from posttraumatic stress disorder (PTSD) either received 4 sessions of NET, 4 sessions of supportive counseling (SC), or psychoeducation (PE) completed in 1 session. One year after treatment, only 29% of the NET participants but 79% of the SC group and 80% of the PE group still fulfilled PTSD criteria. These results indicate that NET is a promising approach for the treatment of PTSD for refugees living in unsafe conditions.     

Psychological interventions for posttraumatic stress disorder and depression in refugees: A meta‐analysis of randomized controlled trials

Millions of refugees around the globe suffer from posttraumatic stress disorder (PTSD) and/or depression. We conducted a meta‐analysis of randomized controlled trials (RCTs) to determine the efficacy of psychological interventions for PTSD and/or depression in refugees. The meta‐analysis was registered on the PROSPERO database (CRD42017071384). A search using the Medline, PsycINFO, and PILOTS databases was conducted in January 2019, resulting in 17 RCTs, of which 14 were conducted with adult refugees (1,108 participants) and 3 with young refugees (<18 years; 151 participants). Further inclusion criteria were at least 10 participants completing an active psychological intervention for PTSD, depression, or both and less than 50% of participants receiving concurrent psychotropic drugs. Random effects models showed that active interventions for adult PTSD yielded a medium to large aggregated effect size (g = 0.77; 95% confidence interval [CI] [0.26, 1.28]) at posttreatment when compared with passive and active control conditions. Active interventions for adult depression also produced large controlled effect sizes at posttreatment (g = 0.82; 95% CI [0.24, 1.40]). The effects appeared to persist over the average follow‐up period of 6 months. The findings suggest that psychological interventions can effectively reduce symptoms of both PTSD and depression in adult refugees. However, the considerable heterogeneity between studies indicates that the efficacy may vary significantly. Future studies should aim to explore the substantial heterogeneity in effect sizes between studies with adult refugees. Additionally, more trials with young refugees suffering from PTSD or depression are needed to determine treatment efficacy for this population.     

Helping Vulnerable Populations: A Comprehensive Review of the Treatment Outcome Literature on Substance Use Disorder and PTSD

We review treatment studies for comorbid substance use disorder (SUD) and posttraumatic stress disorder (PTSD). Results show positive outcomes on multiple domains. Most models had more effect on PTSD than SUD, suggesting SUD is harder to treat. Seeking Safety (SS) is the most studied model. It shows positive outcomes, and is the only treatment outperforming a control on both PTSD and SUD. Partial‐dose SS had more mixed results than the full dose. This first‐generation of PTSD/SUD research addresses complex samples excluded from “gold standard” PTSD‐alone literature. Treatments for PTSD/SUD are generally longer than PTSD‐alone treatments and present‐focused, emphasizing stabilization and coping. The few models with past‐focused (exposure‐based) components also incorporated present‐focused approaches for these vulnerable clients. We discuss public health perspectives to advance the field.     

A review of the efficacy of transcranial magnetic stimulation (TMS) treatment for depression, and current and future strategies to optimize efficacy

BACKGROUND: There is a growing interest in extending the use of repetitive transcranial magnetic stimulation (rTMS) beyond research centres to the widespread clinical treatment of depression. Thus it is timely to critically review the evidence for the efficacy of rTMS as an antidepressant treatment. Factors relevant to the efficacy of rTMS are discussed along with the implications of these for the further optimization of rTMS. METHOD: Clinical trials of the efficacy of rTMS in depressed subjects are summarized and reviewed, focusing mainly on sham-controlled studies and meta-analyses published to date. RESULTS: There is a fairly consistent statistical evidence for the superiority of rTMS over a sham control, though the degree of clinical improvement is not large. However, this data is derived mainly from two-week comparisons of rTMS versus sham, and evidence suggests greater efficacy with longer treatment courses. Studies so far have also varied greatly in approaches to rTMS stimulation (with respect to stimulation site, stimulus parameters etc) with little empirical evidence to inform on the relative merits of these approaches. LIMITATIONS: Only studies published in English were reviewed. Many of the studies in the literature had small sample sizes and different methodologies, making comparisons between studies difficult. CONCLUSIONS: Current published studies and meta-analyses have evaluated the efficacy of rTMS as given in treatment paradigms that are almost certainly suboptimal (e.g of two weeks' duration). While the data nevertheless supports positive outcomes for rTMS, there is much scope for the further refinement and development of rTMS as an antidepressant treatment. Ongoing research is critical for optimizing the efficacy of rTMS.     

Psychopharmacotherapy of posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) is a psychiatric disorder that develops after a psychological trauma usually caused by a situation perceived as deeply threatening to a person’s life or integrity. Complex neurobiological changes triggered by such a traumatic and stressful experience may explain a wide range of PTSD symptoms and provide the rationale for psychopharmacological treatment. Selective serotonin-reuptake inhibitors make the first-line treatment of PTSD. Clinical experience has shown that they are more effective than noradrenalin-reuptake inhibitors or tricyclic antidepressants. Antipsychotic drugs, especially atypical ones, have been shown effective in PTSD patients with psychotic characteristics or refractoriness to other treatments. Mood stabilizers seem to reduce mostly autonomous overreactions to stress, whereas the evidence for effectiveness of monoamine oxidase inhibitors is largely inconclusive. Other groups of medications, such as serotonin agonists and antagonists, new antidepressants, dual inhibitors of serotonin- and noradrenalin-reuptake, anticonvulsants, and opiate antagonists are also sometimes used in PTSD treatment. However, as shown in the present review, most clinical studies performed to date to investigate the effectiveness of different psychopharmacological agents in the therapy of PTSD have serious limitations in terms of small sample size, lack of blinding and randomization, and small effect size. More rigorously designed, comparative studies are needed to determine the usefulness, efficacy, tolerability, and safety of particular psychopharmaceutical drugs in the treatment of this therapeutically and functionally challenging disorder.     

The relative efficacy of bona fide psychotherapies for treating post-traumatic stress disorder: a meta-analysis of direct comparisons

Psychotherapy has been found to be an effective treatment of post-traumatic stress disorder (PTSD), but meta-analyses have yielded inconsistent results on relative efficacy of psychotherapies in the treatment of PTSD. The present meta-analysis controlled for potential confounds in previous PTSD meta-analyses by including only bona fide psychotherapies, avoiding categorization of psychotherapy treatments, and using direct comparison studies only. The primary analysis revealed that effect sizes were homogenously distributed around zero for measures of PTSD symptomology, and for all measures of psychological functioning, indicating that there were no differences between psychotherapies. Additionally, the upper bound of the true effect size between PTSD psychotherapies was quite small. The results suggest that despite strong evidence of psychotherapy efficaciousness vis-à-vis no treatment or common factor controls, bona fide psychotherapies produce equivalent benefits for patients with PTSD.     

Treatment augmentation for posttraumatic stress disorder: A systematic review

This systematic review examined the efficacy of all augmentation approaches for first‐line posttraumatic stress disorder (PTSD) interventions. From 9,890 records, 34 trials were eligible for inclusion, covering 28 different augmentation approaches. Overall, augmentation approaches were ineffective if they targeted a mechanism similar to the first‐line treatment. Augmentation approaches combining two guideline‐recommended treatments were largely ineffective, reflecting ceiling effects. Pharmacological augmentation approaches targeting fear extinction mechanisms were largely ineffective, or worsened outcomes relative to prolonged exposure alone, as these approaches may inadvertently strengthen fear memories. Augmentation approaches targeting general cognitive enhancement showed promise and provided support for augmentation interventions that require little cognitive or emotional work and target mechanisms different than the first‐line treatment.