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Psychological interventions for adult PTSD are effective irrespective of concurrent psychotropic medication intake: A meta- analysis of randomized controlled trials
Abstract
Background:
Participants are allowed to stay on their prescribed psychotropic medication in most trials examining psychological interventions for adult post-traumatic stress disorder (PTSD).
Objectives:
We aimed to conduct the first meta-analysis investigating the potential influence of such concurrent medication on efficacy.
Method:
To this end, we searched Medline, PsycINFO, Web of Science, and PTSDpubs from inception to April 21, 2022, for trials meeting the following criteria: (1) randomized controlled trial (RCT), (2) PTSD as primary treatment focus, (3) interview-based PTSD baseline rate ≥70%, (4) N ≥ 20, (5) mean age ≥18 years. Trials were excluded when intake of psychotropics was not (sufficiently) reported.
Results:
Most published trials did not report on the intake of psychotropic medication. A total of 75 RCTs (N = 4,901 patients) met inclusion criteria. Trauma-focused cognitive behavior therapy (TF-CBT) was the most well-researched intervention. Short-term efficacy of psychological treatments did not differ by the proportion of participants taking concurrent psychotropic medication during psychological treatment in all but one analysis. In trials comparing TF-CBT and active control conditions at posttreatment, TF-CBT was more effective when most participants were concurrently medicated (g = 0.87, 95% CI 0.53-1.22) rather than unmedicated (g = 0.27; 95% CI 0.01-0.54, p = 0.017), with younger age (b1 = -0.04, p = 0.008) and higher proportion of females (b1 = 0.01, p = 0.014) being associated with higher efficacy only in trials with high proportions of medicated participants. No differences in efficacy by proportions of participants taking concurrent psychotropic medication were found at follow-up.
Conclusions:
Results suggest that psychological interventions are effective for PTSD irrespective of concurrent intake of psychotropics.
... The more severe the disorder, the more difficult it is to treat. This is particularly true for complex PTSD, which often does not respond to treatment [4,5]. Using the PTSD example, we can understand how over time, the accumulation of "wear and tear" on multiple organs and tissues results in allostatic load, leading to physiological dysregulation and, in extreme cases, physical or mental illness due to allostatic overload [6]. ...
Predicting the trajectory of psychiatric conditions is a crucial area of clinical research.
There is increasing emphasis on how early intervention for mental disorders can reduce the severity and subsequent burden of mental disorders and, in some cases, delay the development of full-threshold disorders. Since childhood trauma is a risk factor for several mental disorders to better understand its impact in the immune system is crucial in order to develop interventions focused on possible prevention of mental disorders.
EMDR (eye movement desensitization and reprocessing) therapy is a well-established therapeutic approach developed in the 1980s by the American psychologist Francine Shapiro. It relies on the use of dual attention bilateral stimulation, such as eye movements, alternating tones, or tapping stimuli, to facilitate the processing of traumatic experiences. The procedure involves directing the patient’s attention to distressing memories while attending to the bilateral stimulation, allowing the brain to reprocess these experiences in a more adaptive manner.
Numerous scientific studies support the effectiveness of EMDR therapy in treating post-traumatic stress disorder (PTSD) and other disorders. Randomized controlled studies (RCTs) and meta-analyses have demonstrated that this treatment can lead to significant improvements in psychopathological symptoms, promoting rapid and enduring reduction of distress.
Currently, EMDR therapy is widely used to treat a variety of disorders, including trauma from abuse, grief, depression, anxiety, mood disorders, and phobias. Its application has also extended to other contexts, such as the treatment of eating disorders and addictions.
In future applications, EMDR therapy could be further explored and adapted to address new clinical challenges. Research may focus on its effectiveness in combination with other therapies or in the application to new clinical populations. Additionally, technology may play a role in the dissemination and accessibility of the treatment, such as using digital applications or online therapy.
In summary, EMDR therapy represents a promising and well-established therapeutic option with a solid scientific foundation. Its continued use and future development could significantly contribute to the treatment of a wide range of psychological disorders.
Post-traumatic stress disorder (PTSD) is a psychiatric disorder that develops and persists after an individual experiences a major traumatic or life-threatening event. While phar-macological treatment and psychological interventions can alleviate some symptoms, pharmacotherapy is time-consuming with low patient compliance, and psychological interventions are costly. Repetitive Transcranial Magnetic Stimulation (rTMS) is a safe and effective technique for treating PTSD, with advantages such as high compliance, low cost, and simplicity of implementation. It can even simultaneously improve depressive symp-toms in some patients. Current research indicates that high-frequency rTMS shows better therapeutic effects compared to low-frequency rTMS, with no significant difference in the likelihood of adverse reactions between the two. Theta Burst Stimulation (TBS) exhibits similar efficacy to high-frequency rTMS, with shorter duration and significant improve-ment in depressive symptoms. However, it carries a slightly higher risk of adverse reac-tions compared to traditional high-frequency rTMS. Combining rTMS with psychological therapy appears to be more effective in improving PTSD symptoms, with early onset of effects and longer duration, albeit at higher cost and requiring individualized patient con-trol. The most common adverse effect of treatment is headache, which can be improved by stopping treatment or using analgesics. Despite these encouraging data, several aspects remain unknown. Given the highly heterogeneous nature of PTSD, defining unique treat-ment methods for this patient population is quite challenging. There are also considerable differences between trials regarding stimulation parameters, therapeutic effects, and the role of combined psychological therapy, which future research needs to address.
Objectives
Journaling is a common non-pharmacological tool in the management of mental illness, however, no clear evidence-based guideline exists informing primary care providers on its use. We seek here to present this synthesis that may begin to inform future research and eventual evidence-based guideline development.
Design
Of the 3797 articles retrieved from MEDLINE, EMBASE, PsycINFO, 20 peer-reviewed randomised control trials (31 outcomes) met inclusion criteria. These studies addressed the impact of a journaling intervention on PTSD, other anxiety disorders, depression or a combination of the aforementioned.
Eligibility criteria
Peer reviewed, randomised control trials on the impact of journaling on mental illness were included.
Information sources
MEDLINE, EMBASE and PsycINFO.
Results
The data are highly heterogeneous (control arm=I ² of 71.2%, intervention arm=I ² of 83.8%) combined with a B-level Strength of Recommendation Taxonomy recommendation. It was additionally found that there is a significant pre–post psychometric scale difference between control (−0.01, 95% CI −0.03 to 0.00) and intervention arms (−0.06, 95% CI −0.09 to −0.03). This 5% difference between groups indicates that a journaling intervention resulted in a greater reduction in scores on patient health measures. Cohen’s d effect size analysis of studies suggests a small to moderate benefit.
Conclusion
Further studies are needed to better define the outcomes. Our review suggests that while there is some randomised control data to support the benefit of journaling, high degrees of heterogeneity and methodological flaws limit our ability to definitively draw conclusions about the benefit and effect size of journaling in a wide array of mental illnesses. Given the low risk of adverse effects, low resource requirement and emphasis on self-efficacy, primary care providers should consider this as an adjunct therapy to complement current evidence-based management.
Objectives
The goals of this study are to identify and analyse interventions that aim to treat post-traumatic stress disorder (PTSD) and complex PTSD in people who are vulnerably housed and to describe how these treatments have been delivered using trauma-informed care.
Design
Scoping review.
Search strategy
We searched electronic databases including MEDLINE, Embase, PsycINFO, CINAHL, the Cochrane Library, Web of Science and PTSDpubs for published literature up to November 2021 for any studies that examined the treatment of PTSD in adults who were vulnerably housed. Websites of relevant organisations and other grey literature sources were searched to supplement the electronic database search. The characteristics and effect of the interventions were analysed. We also explored how the interventions were delivered and the elements of trauma-informed care that were described.
Results
28 studies were included. We identified four types of interventions: (1) trauma focused psychotherapies; (2) non-trauma psychotherapies; (3) housing interventions and (4) pharmacotherapies. The trauma-informed interventions were small case series and the non-trauma focused therapies included four randomised controlled trials, were generally ineffective. Of the 10 studies which described trauma-informed care the most commonly named elements were physical and emotional safety, the experience of feeling heard and understood, and flexibility of choice. The literature also commented on the difficulty of providing care to this population including lack of private space to deliver therapy; the co-occurrence of substance use; and barriers to follow-up including limited length of stay in different shelters and high staff turnover.
Conclusions
This scoping review identified a lack of high-quality trials to address PTSD in people who are vulnerably housed. There is a need to conduct well designed trials that take into account the unique setting of this population and which describe those elements of trauma-informed care that are most important and necessary.
Background
An emerging body of empirical research on trauma-focused interventions for older adults experiencing symptoms of posttraumatic stress disorder or PTSD has yielded encouraging results. Nevertheless, up to date, the evidence remains scattered and is developed within rather specific groups, while studies have focused mostly on individual psychopathology, overlooking the relevance of resilience and recovering in one's social environment.
Objective
This study aims at summarizing the emerging evidence on treating trauma-related disorders in older adults, followed by implications for clinical practice and future research. Specifically, the following research questions are addressed: Which factors may optimize access to intervention, what treatment benefits can be realized, and how to improve resilience by using individual as well as community-oriented approaches?
Methods
A systematic literature research of intervention studies on PTSD among older adults, published between 1980 and December 2021, was expanded by cross-referencing, summarized in a narrative synthesis and supplemented with a clinical vignette reflecting qualitative outcomes.
Results
Five RCTs compared varying types of trauma-focused Cognitive Behavioral Therapy with non-trauma-focused control conditions. From one of them, qualitative results were reported as well. The most recent studies reported encouraging results, confirming the suggestion that evidence-based psychotherapy for PTSD can be safely and effectively used with older adults.
Conclusions
Since evidence-based psychotherapy for PTSD can be safely and effectively used with older adults, new avenues for practice and research may be found in a resilience perspective and a public mental health framework.
This systematic review synthesizes the evidence on pretreatment patient characteristics and program features associated with treatment retention, response, and remission in military populations with posttraumatic stress disorder (PTSD).
Background
Up to 39% of women who experience perinatal bereavement proceed to develop Post-Traumatic-Stress-Disorder (PTSD), with this large proportion meriting treatment. Before setting-up a treatment service for postnatal women who are experiencing psychological trauma, it is important to identify what therapies have been used in-the-past to address this problem.
Aim
To scope for research that has implemented therapies to treat psychological trauma post perinatal bereavement, for potential inclusion in a flexible treatment package.
Method
A scoping review mapped coverage, range, and type of research that has reported on prior therapies used to treat psychological trauma post perinatal bereavement.
Findings
Due to the dearth of papers that directly addressed perinatal bereavement, we widened the scope of the review to view what treatments had been used to treat psychological trauma post-childbirth. Out of 23 studies that report on effectiveness of therapies used to treat psychological trauma post-childbirth, only 4-focused upon treating PTSD post perinatal bereavement (3 effective/1 ineffective). Successful treatments were reported by Kersting et al. (2013), who found CBT effective at reducing PTSD symptoms post-miscarriage, termination for medical reasons, and stillbirth (n = 33 & n = 115), and Navidian et al. (2s017)) found that 4-sessions of grief-counselling reduced trauma symptoms post-stillbirth in (n = 50) women. One study by Huberty et al. (2020found on-line yoga to be ineffective at reducing PTSD symptoms post-stillbirth.
Conclusions
A dearth of research has explored effectiveness of therapies for treating psychological trauma post perinatal bereavement and post-childbirth, with need to develop and test a research informed flexible counselling package.
Background
Cognitive behavioral therapy (CBT) is the gold standard of psychotherapy for psychiatric disorders. However, the format of delivering CBT in person limits access to the intervention. The advancements in information and communication technology, especially the internet, present an opportunity for cognitive behavioral therapists to service patients or clients in remote areas through videoconferencing. Although many randomized controlled trials of videoconference-delivered cognitive behavioral therapy (VCBT) have already been conducted, the overall estimated effect size of VCBT for psychiatric disorders has not been examined by systematic reviews and meta-analyses.
Objective
This study attempts to evaluate the effectiveness of VCBT for psychiatric disorders through a systematic and meta-analytic review.
MethodsA systematic review and meta-analysis of studies in which VCBT was directly compared to control groups (such as treatment as usual, attention control, wait-list control, and other minimal supports) was carried out. To identify previous studies that meet our study objective, 2 independent reviewers undertook a systematic search through seven databases: MEDLINE (via PubMed), Web of Science, Science Direct, PsycINFO, CINAHL, LILACS, and SciELO. Other databases (ClinicalTrials.gov and Cochrane Central Resister of Controlled Trials) were also checked. All studies included in the review were assessed using the quality criteria of the Cochrane Collaboration. Statistical analysis was performed by using Cochrane Review Manager (RevMan, version 5.4.0). Standardized mean difference was used in major meta-analyses where a P value of .05 or less was the threshold for statistical significance. A heterogeneity test and the chi-square test were performed to assess the presence and extent of statistical heterogeneity with significance set at P
Background:
Posttraumatic stress disorder (PTSD) is overrepresented in prison relative to community populations and can be difficult to manage in an environment which can inherently exacerbate trauma-related symptomology. Little is known about the effectiveness of trauma-focused interventions in prison and less is known about factors that moderate the effectiveness of these interventions.
Aim/Methods:
We examined the effectiveness of trauma-focused interventions in prison relative to prison controls using meta-analytic techniques. We further used meta-regression analysis to examine treatment, methodological and participant-level moderators to determine factors that increased the effectiveness of these interventions.
Results:
From 16 studies eligible for the meta-analysis, we found a small but significant effect size for trauma-focused interventions. Phase 2 trauma processing interventions and interventions delivered individually led to greater reductions in PTSD symptoms. Studies utilizing an active treatment control resulted in smaller effect sizes than those using waitlist or no contact controls. Treatment length, study quality, outcome type, and gender were not significant moderators of treatment effectiveness.
Conclusion:
Findings from this review are encouraging but should be interpreted with caution. Results suggest that trauma processing therapies, and individual modality trauma-focused interventions can be effective and delivered successfully in prison. However, inadequate comparison groups do not allow a firm conclusion to be drawn. There is a need for high quality Randomized Controlled Trial’s that additionally measure Complex PTSD, utilize a modular treatment approach, and include treatments recommended in the National Institute for health and Care Excellence (NICE) guidelines such as Trauma-focused CBT and Eye Movement Desensitization Reprocessing (EMDR).
Terrorism, though not well-defined, is a violent act that has been shown to have longstanding effects on the mental health of those who witness it. The aim of this general literature review is to explore the effect that terrorism has on posttraumatic stress disorder (PTSD), major depressive disorder (MDD) and anxiety disorders, as well as the bio-psycho-social determinants that mediate its impact. This paper describes the prevalence, risk factors, protective factors, common presentations and interventions identified for PTSD, depression and anxiety disorders occurring following terrorist attacks. We conducted a literature search in MEDLINE using a number of keywords detailed below. After applying inclusion and exclusion criteria, we kept 80 articles, which we summarized in tabular form. A majority of articles found detailed the impact of terrorism on PTSD, and took place in a Western, mainly American setting. The main factors that impacted the presentation of mental illness include gender, ethnicity, social supports, socioeconomic status, level of preparedness, level of exposure, pre-existing trauma and mental illness, and subsequent life stressors. The main intervention detailed in this article as showing evidence post-terrorism is trauma-focused cognitive-behavioural therapy. This study highlights the importance of this topic, and in particular, its implications for public health policy and practice.
Trauma is a significant public health concern that has widespread and adverse effects on people. There is a high prevalence of trauma and PTSD in general populations, and that prevalence greatly increases among the clinical populations that social workers serve. To address the hidden epidemic of trauma, there are various trauma-specific treatments for PTSD. Scholars have highlighted a critical use of research evidence as a starting consideration in clinical decision-making and named the necessity to map out effective interventions according to population and types of trauma, including both conventional and non-conventional treatments. A rapid systematic review was conducted to fill this gap and found thirty-four empirically supported studies, including nineteen conventional and seven non-conventional treatment approaches for PTSD. The included conventional therapies are cognitive behavioral therapy (CBT), sleep-specific CBT, trauma-focused CBT, internet CBT, virtual reality exposure therapy, prolonged exposure, narrative exposure therapy, cognitive processing therapy, eye movement desensitization and reprocessing (EMDR), hypnotherapy, emotion focused therapy, skills training in affect and interpersonal regulations (STAIR), interpersonal psychotherapy (IPT), dialectical behavioral therapy (DBT), seeking safety, trauma incident reduction, accelerated resolution therapy (ART), metacognitive therapy, and imaginary rehearsal therapy. The non-conventional approaches included are yoga, physical activities, emotion freedom technique, acupuncture, mantram repetition program, mind–body therapy, and music therapy. We further explored the therapy content, population, type of trauma, outcomes, and strengths/limitations under each treatment to guide clinicians to select the best practice for idiosyncratic clients. Lastly, we discussed limitations of the current review, clinical considerations in selecting empirically supported treatment for PTSD and future research implications to guide clinical social workers.
Background:
The aim of this review was to assess the quality of international treatment guidelines for post-traumatic stress disorder (PTSD), and identify differences between guideline recommendations, with a focus on the treatment of nightmares.
Methods:
Guidelines were identified through electronic searches of MEDLINE, CINAHL, PubMed, Embase and Science Direct, as well as web-based searches of international guideline repositories, websites of psychiatric organisations and targeted web-searches for guidelines from the three most populous English-speaking countries in each continent. Data in relation to recommendations were extracted and the AGREE II criteria were applied to assess for quality.
Results:
Fourteen guidelines, published between 2004-2020, were identified for inclusion in this review. Only five were less than 5 years old. Three guidelines scored highly across all AGREE II domains, while others varied between domains. Most guidelines consider both psychological and pharmacological therapies as first-line in PTSD. All but one guideline recommended cognitive behavioural therapy (CBT) as first-line psychological treatment, and selective serotonin reuptake inhibitors (SSRIs) as first-line pharmacological treatment. Most guidelines do not mention the targeted treatment of nightmares as a symptom of PTSD. Prazosin is discussed in several guidelines for the treatment of nightmares, but recommendations vary widely. Most PTSD guidelines were deemed to be of good quality; however, many could be considered out of date. Recommendations for core PTSD symptoms do not differ greatly between guidelines. However, despite the availability of targeted treatments for nightmares, most guidelines do not adequately address this.
Conclusions:
Guidelines need to be kept current to maintain clinical utility. Improvements are most needed in the AGREE II key domains of 'applicability', 'rigour of development' and 'stakeholder involvement'. Due to the treatment-resistant nature of nightmares, guideline development groups should consider producing more detailed recommendations for their targeted treatment. More high-quality trials are also required to provide a solid foundation for making these clinical recommendations for the management of nightmares in PTSD.
Writing Therapy (WT) is defined as a process of investigation about personal thoughts and feelings using the act of writing as an instrument, with the aim of promoting self-healing and personal growth. WT has been integrated in specific psychotherapies with the aim of treating specific mental disorders (PTSD, depression, etc.). More recently, WT has been included in several Positive Interventions (PI) as a useful tool to promote psychological well-being. This narrative review was conducted by searching on scientific databases and analyzing essential studies, academic books and journal articles where writing therapy was applied. The aim of this review is to describe and summarize the use of WT across various psychotherapies, from the traditional applications as expressive writing, or guided autobiography, to the phenomenological-existential approach (Logotherapy) and, more recently, to the use of WT within Acceptance and Commitment Therapy (ACT). Finally, the novel applications of writing techniques from a positive psychology perspective will be analyzed. Accordingly, the applications of WT for promoting forgiveness, gratitude, wisdom and other positive dimensions will be illustrated. The results of this review show that WT yield therapeutic effects on symptoms and distress, but it also promotes psychological well-being. The use of writing can be a standalone treatment or it can be easily integrated as supplement in other therapeutic approaches. This review might help clinician and counsellors to apply the simple instrument of writing to promote insight, healing and well-being in clients, according to their specific clinical needs and therapeutic goals.
Purpose of review
The scope of this article is to summarize (a) what is known about the relationships between spirituality and trauma outcomes and (b) outline options for spiritually integrated trauma care.
Recent findings
Research on relationships between spirituality and psychological trauma outcomes has advanced to the point that there is no doubt that interventions addressing spiritual distress can provide critically needed help to trauma survivors who want spiritually integrated care. There are now many options for providing spiritually integrated care for trauma, including both implicitly and explicitly spiritually integrated options, group and individual options, and options for chaplaincy and mental health providers.
Summary
This review focused on spiritually integrated interventions for posttraumatic stress disorder that have at least one randomized controlled trial in the peer-reviewed literature. Eight interventions with that level of evidence are described with a review of clinical recommendations for their use.
Introduction
The Psychological Health Center of Excellence conducted a rapid review of the literature to investigate the effectiveness of behavioral health treatments (i.e., evidence-based psychotherapy and psychiatry) delivered in person compared to telehealth (TH; i.e., video teleconference and telephone).
Materials and Methods
The rapid review methods included a systematic search of a single database (PubMed), hand-searching of relevant systematic reviews, dual screening, single-person data abstraction verified by a second person, and dual risk of bias assessment. Due to heterogeneity across studies, no quantitative analyses were conducted.
Results
Twenty-two randomized controlled trials (RCTs), eight of which were non-inferiority trials, evaluated the effectiveness of TH via telephone or video teleconferencing compared to in-person (IP) delivery for patient populations with posttraumatic stress disorder, depression, and mixed diagnoses. The majority of RCTs and all but one of the eight non-inferiority trials found that clinical outcomes did not differ between TH and IP treatment delivery. Two studies found that subgroups with higher symptom severity (hopelessness and anxiety disorders, respectively) in the TH group had worse treatment-related outcomes than IP participants with similar symptom profiles. The majority of studies found no significant differences in satisfaction with care, quality of the therapeutic alliance, or study discontinuation between TH and IP groups.
Conclusion
Based on evidence from 22 RCTs, the use of TH platforms, including video conference and telephone modalities, generally produces similar outcomes as face-to-face provision of psychotherapy and psychiatry services.
Background
Meta-analytic results indicate that posttraumatic stress disorder (PTSD) is associated with hypoactivation of the medial prefrontal cortex (mPFC), hyperactivation of the amygdala, and volume reductions of the hippocampus. Effective psychotherapeutic treatments were hypothesized to normalize these neural patterns via upregulation of prefrontal structures, which in turn downregulate limbic regions.
Objective
To gain a sound understanding of the effects of successful psychotherapy on the brain, neural changes from pre- to post-treatment in PTSD patients will be aggregated.
Method
A systematic literature search identified 24 original studies employing structural or functional MRI measurements both before and after treatment of patients diagnosed with PTSD.
Results
In conjunction, the review returned little evidence of an activation increase in the mPFC/rostral anterior cingulate cortex (rACC) following successful treatment. Five out of 12 studies observed such an increase (especially during emotion processing tasks), albeit in partially non-overlapping brain regions. Conversely, neither the putative related activation decrease in the amygdala nor volumetric changes or altered activation during the resting state could be convincingly established.
Conclusion
Successful psychological treatments might potentially work via upregulation of the mPFC, which thus may be involved in symptom reduction. However, the role of the amygdala in recovery from PTSD remains unclear. There is currently no indication that the various PTSD treatment approaches employed by the reviewed studies differ regarding their action mechanisms, but further research on this topic is needed.
Background
Modern slavery is a term which incorporates a range of exploitative situations that involve the violation of human rights and the subjugation of individuals. It presents a significant public health concern. Post-release, survivors of modern slavery have complex mental health needs. Whilst mental health provision is a component of international and national policy, the delivery of evidence-based support remains a gap in the global anti-slavery response.
Aim
To identify and synthesise the evidence base for mental health interventions developed and evaluated for use in a post-slavery survivor population.
Methods
A systematic literature review was undertaken. The review protocol was prospectively registered with PROSPERO and followed the PRISMA guidance in its reporting. A multi-stage search strategy was utilised to retrieve studies. Quality appraisal was undertaken using the QualSyst tool. Due to heterogeneity in study design, a narrative approach to synthesising the findings was undertaken.
Results
Nine studies met the final inclusion criteria. The narrative synthesis clustered the studies in three themes: study design and population; type of intervention; and outcomes reported. The included studies focussed on specific subpopulations, namely child soldiering, child labour or sex trafficking.
Conclusion
This review has highlighted not only important theory-practice gaps in relation to the provision of evidence-based mental health support but scant evidence limited to specific sub-groups (child soldiering, child labour or sex trafficking). The emphasis placed on PTSD within the interventions tested risks mental health support becoming exclusionary to those with other needs. When assessing intervention efficacy, the complex socio-political context in which survivors exist as well as the increasing emphasis on holistic care, personal recovery and lived experience need to be considered. Taking this into account, the case can be made for the inclusion of a wider range of non-clinical outcomes in the assessment of mental health intervention effectiveness.
Several types of psychological treatment for posttraumatic stress disorder (PTSD) are considered well established and effective, but evidence of their long-term efficacy is limited. This systematic review and meta-analysis aimed to investigate the long-term outcomes across psychological treatments for PTSD. MEDLINE, Cochrane Library, PTSDpubs, PsycINFO, PSYNDEX, and related articles were searched for randomized controlled trials with at least 12 months of follow-up. Twenty-two studies ( N = 2638) met inclusion criteria, and 43 comparisons of cognitive behavioral therapy (CBT) were available at follow-up. Active treatments for PTSD yielded large effect sizes from pretest to follow-up and a small controlled effect size compared with non-directive control groups at follow-up. Trauma-focused treatment (TFT) and non-TFT showed large improvements from pretest to follow-up, and effect sizes did not significantly differ from each other. Active treatments for comorbid depressive symptoms revealed small to medium effect sizes at follow-up, and improved PTSD and depressive symptoms remained stable from treatment end to follow-up. Military personnel, low proportion of female patients, and self-rated PTSD measures were associated with decreased effect sizes for PTSD at follow-up. The findings suggest that CBT for PTSD is efficacious in the long term. Future studies are needed to determine the lasting efficacy of other psychological treatments and to confirm benefits beyond 12-month follow-up.
Background
Health inequities remain a public health concern. Chronic adversity such as discrimination or racism as trauma may perpetuate health inequities in marginalized populations. There is a growing body of the literature on trauma informed and culturally competent care as essential elements of promoting health equity, yet no prior review has systematically addressed trauma informed interventions. The purpose of this study was to appraise the types, setting, scope, and delivery of trauma informed interventions and associated outcomes.
Methods
We performed database searches— PubMed, Embase, CINAHL, SCOPUS and PsycINFO—to identify quantitative studies published in English before June 2019. Thirty-two unique studies with one companion article met the eligibility criteria.
Results
More than half of the 32 studies were randomized controlled trials (n = 19). Thirteen studies were conducted in the United States. Child abuse, domestic violence, or sexual assault were the most common types of trauma addressed (n = 16). While the interventions were largely focused on reducing symptoms of post-traumatic stress disorder (PTSD) (n = 23), depression (n = 16), or anxiety (n = 10), trauma informed interventions were mostly delivered in an outpatient setting (n = 20) by medical professionals (n = 21). Two most frequently used interventions were eye movement desensitization and reprocessing (n = 6) and cognitive behavioral therapy (n = 5). Intervention fidelity was addressed in 16 studies. Trauma informed interventions significantly reduced PTSD symptoms in 11 of 23 studies. Fifteen studies found improvements in three main psychological outcomes including PTSD symptoms (11 of 23), depression (9 of 16), and anxiety (5 of 10). Cognitive behavioral therapy consistently improved a wide range of outcomes including depression, anxiety, emotional dysregulation, interpersonal problems, and risky behaviors (n = 5).
Conclusions
There is inconsistent evidence to support trauma informed interventions as an effective approach for psychological outcomes. Future trauma informed intervention should be expanded in scope to address a wide range of trauma types such as racism and discrimination. Additionally, a wider range of trauma outcomes should be studied.
Background: Although personality disorders are common in PTSD patients, it remains unclear to what extent this comorbidity affects PTSD treatment outcome.
Objective: This constitutes the first meta-analysis investigating whether patients with and without comorbid personality disorders can equally benefit from psychotherapy for PTSD.
Method: A systematic literature search was conducted in PubMed, EMBASE, PsychINFO and Cochrane databases from inception through 31 January 2020, to identify clinical trials examining psychotherapies for PTSD in PTSD patients with and without comorbid personality disorders (PROSPERO reference CRD42020156472).
Results: Of the 1830 studies identified, 12 studies reporting on 918 patients were included. Effect sizes were synthesized using a random-effects model. Patients with comorbid personality disorders did not have significantly higher baseline PTSD severity (Hedges’ g = 0.23, 95%CI −0.09–0.55, p = .140), nor were at higher risk for dropout from PTSD treatment (RR = 1.19, 95%CI 0.83–1.72, p = .297). Whilst pre- to post-treatment PTSD symptom improvements were large in patients with comorbid PDs (Hedges’ g = 1.31, 95%CI 0.89–1.74, p < .001) as well as in patients without comorbid PDs (Hedges’ g = 1.57, 95%CI 1.08–2.07, p < .001), personality disorders were associated with a significantly smaller symptom improvement at post-treatment (Hedges’ g = 0.22, 95%CI 0.05–0.38, p = .010).
Conclusion: Although the presence of personality disorders does not preclude a good treatment response, patients with comorbid personality disorders might benefit less from PTSD treatment than patients without comorbid personality disorders.
Objective:
Identify non-pharmacological therapies for the treatment of post-traumatic stress disorder in emergency responders.
Method:
Scope review according to the guidelines of the Joanna Briggs Institute and the PRISMA-ScR protocol. A search was conducted in nine databases, portals of theses and dissertations, and using an electronic search engine.
Results:
In total, 23 studies were selected and analyzed, and then categorized into six thematic fields - therapy with omega 3 food supplement, art therapy, physical exercise therapy, mindfulness-based therapy, therapy with elements of nature, and psychotherapy - which were considered non-pharmacological treatments for this psychopathology among emergency responders, as well as the use of psychotherapy via telehealth as an option for treatment.
Conclusion:
More evidence supporting diet therapy is required, while the other therapeutic options presented positive results, finding support in national and international recommendations of treatment and clinical practice.
Purpose
Posttraumatic stress disorder (PTSD) is a significant global mental health concern, especially in the military. This study aimed to estimate the efficacy of mindfulness meditation in the treatment of military-related PTSD, by synthesizing evidences from randomized controlled trials.
Methods
Five electronic databases (Pubmed, EBSCO Medline, Embase, PsychINFO and Cochrane Library) were searched for randomized controlled trials focusing on the treatment effect of mindfulness meditation on military-related PTSD. Information about study characteristics, participant characteristics, intervention details, PTSD outcomes, as well as potential adverse effects was extracted from the included studies. Risk of bias of all the included studies was critically assessed using the Cochrane Collaboration’s tool. R Statistical software was performed for data analysis.
Results
A total of 1899 records were initially identified and screened. Finally, 19 articles in English language with 1326 participants were included through strict inclusion and exclusion criteria. The results revealed that mindfulness meditation had a significantly larger effect on alleviating military-related PTSD symptoms compared with control conditions, such as treatment as usual, present-centered group therapy and PTSD health education (standardized mean difference = -0.33; 95% CI, -0.45, -0.21; p < 0.0001). Mindfulness interventions with different control conditions (active or non-active control), formats of delivery (group-based or individual-based) and intervention durations (short-term or standard duration) were equally effective in improving military-related PTSD symptoms.
Conclusion
Findings from this meta-analysis consolidate the efficacy and feasibility of mindfulness meditation in the treatment of military-related PTSD. Further evidences with higher quality and more rigorous design are needed in the future.
Importance
Additional options are needed for treatment of posttraumatic stress disorder (PTSD) among veterans.
Objective
To determine whether group loving-kindness meditation is noninferior to group cognitive processing therapy for treatment of PTSD.
Design, Setting, and Participants
This randomized clinical noninferiority trial assessed PTSD and depression at baseline, posttreatment, and 3- and 6-month follow-up. Veterans were recruited from September 24, 2014, to February 5, 2018, from a large Veternas Affairs medical center in Seattle, Washington. A total of 184 veteran volunteers who met Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) criteria for PTSD were randomized. Data collection was completed November 28, 2018, and data analyses were conducted from December 10, 2018, to November 5, 2019.
Interventions
Each intervention comprised 12 weekly 90-minute group sessions. Loving-kindness meditation (n = 91) involves silent repetition of phrases intended to elicit feelings of kindness for oneself and others. Cognitive processing therapy (n = 93) combines cognitive restructuring with emotional processing of trauma-related content.
Main Outcomes and Measures
Co–primary outcomes were change in PTSD and depression scores over 6-month follow-up, assessed by the Clinician-Administered PTSD Scale (CAPS-5; range, 0-80; higher is worse) and Patient-Reported Outcome Measurement Information System (PROMIS; reported as standardized T-score with mean [SD] of 50 [10] points; higher is worse) depression measures. Noninferiority margins were 5 points on the CAPS-5 and 4 points on the PROMIS depression measure.
Results
Among the 184 veterans (mean [SD] age, 57.1 [13.1] years; 153 men [83.2%]; 107 White participants [58.2%]) included in the study, 91 (49.5%) were randomized to the loving-kindness group, and 93 (50.5%) were randomized to the cognitive processing group. The mean (SD) baseline CAPS-5 score was 35.5 (11.8) and mean (SD) PROMIS depression score was 60.9 (7.9). A total of 121 veterans (66%) completed 6-month follow-up. At 6 months posttreatment, mean CAPS-5 scores were 28.02 (95% CI, 24.72-31.32) for cognitive processing therapy and 25.92 (95% CI, 22.62-29.23) for loving-kindness meditation (difference, 2.09; 95% CI, −2.59 to 6.78), and mean PROMIS depression scores were 61.22 (95% CI, 59.21-63.23) for cognitive processing therapy and 58.88 (95% CI, 56.86-60.91) for loving-kindness meditation (difference, 2.34; 95% CI, −0.52 to 5.19). In superiority analyses, there were no significant between-group differences in CAPS-5 scores, whereas for PROMIS depression scores, greater reductions were found for loving-kindness meditation vs cognitive processing therapy (for patients attending ≥6 visits, ≥4-point improvement was noted in 24 [39.3%] veterans receiving loving-kindness meditation vs 9 (18.0%) receiving cognitive processing therapy; P = .03).
Conclusions and Relevance
Among veterans with PTSD, loving-kindness meditation resulted in reductions in PTSD symptoms that were noninferior to group cognitive processing therapy. For both interventions, the magnitude of improvement in PTSD symptoms was modest. Change over time in depressive symptoms was greater for loving-kindness meditation than for cognitive processing therapy.
Trial Registration
Clinicaltrials.gov Identifier: NCT01962714
Background
Research indicates that higher study quality may be associated with smaller treatment effects. Yet, knowledge about the association between study quality and treatment efficacy for posttraumatic stress disorder (PTSD) is limited. We aimed at evaluating the efficacy of psychological interventions for adult PTSD and the association between study quality and treatment effects.
Methods
We conducted a systematic search to identify randomized controlled trials (RCTs) that examined the efficacy of psychological interventions for chronic PTSD symptoms in adult samples with at least 70% of patients being diagnosed with PTSD by means of a structured interview. We assessed study quality using the following eight criteria from prior research: N ⩾ 50, all patients met criteria for PTSD, a treatment manual was used, therapists were trained, treatment integrity was checked, intent-to-treat analyses were applied, randomization was conducted by an independent party, and treatment outcome was conducted by blind assessors.
Results
The search resulted in 136 RCTs with 8978 patients. Active treatment conditions were largely effective in reducing PTSD symptoms at posttreatment and follow-up (Hedges' g = 1.09 and 0.81, respectively) when compared to passive control conditions. The comparison to active control conditions at posttreatment and follow-up resulted in medium effect sizes. A total of 14 trials met all study quality criteria and these trials produced large effect sizes when compared to passive control conditions at posttreatment and follow-up.
Conclusions
Overall, study quality was not significantly associated with effect size. The findings indicate that psychological interventions can effectively reduce PTSD symptoms irrespective of study quality.
Background: Animal-assisted interventions (AAI) are increasingly applied for people with post-traumatic stress disorder (PTSD) symptoms albeit its effectiveness is unclear.
Objectives: To examine the effectiveness of AAI for treating PTSD symptoms.
Method: We searched 11 major electronic databases for studies reporting quantitative data on effects of AAI for children and adults with PTSD symptoms. Of 22ʹ211 records identified, we included 41 studies with 1111 participants in the systematic review comprising eight controlled studies with 469 participants in the meta-analysis. We conducted random-effects meta-analyses with all controlled studies based on standardized mean differences (SMD), and calculated standardized mean change (SMC) as effect sizes for studies with a pre-post one-group design. Two independent researchers assessed the quality of the included studies using the NIH Study Quality Assessment Tools. The primary outcome was PTSD or depression symptom severity measured via a standardized measurement at pre- and post-intervention assessments.
Results: There was a small but not statistically significant superiority of AAI over standard PTSD psychotherapy (SMD = −0.26, 95% CI: −0.56 to 0.04) in reducing PTSD symptom severity while AAI was superior to waitlist (SMD = −0.82, 95% CI: −1.56 to 0.08). Getting a service dog was superior to waiting for a service dog (SMD = −0.58, 95% CI: −0.88 to −0.28). AAI led to comparable effects in reducing depression as standard PTSD psychotherapy (SMD = −0.03, CI: −0.88 to 0.83). Pre-post comparisons showed large variation for the reduction in PTSD symptom severity, with SMCs ranging from −0.38 to −1.64, and for depression symptom severity, ranging from 0.01 to −2.76. Getting a service dog lowered PTSD symptoms between −0.43 and −1.10 and depression with medium effect size of −0.74.
Conclusions: The results indicate that AAI are efficacious in reducing PTSD symptomatology and depression. Future studies with robust study designs and large samples are needed for valid conclusions.
Objective: Scalable, efficiently delivered treatments are needed to address the needs of women Veterans with PTSD. This randomized clinical trial compared an online, coach-assisted cognitive behavioral intervention tailored for women Veterans with PTSD to phone monitoring only. Method: Women Veterans who met diagnostic criteria for PTSD were randomized to an 8-week web-based intervention, called DElivery of Self TRaining and Education for Stressful Situations (DESTRESS)–Women Veterans version (WV), or to phone monitoring only (N = 102). DESTRESS–WV consisted of online sessions and 15-min weekly phone calls from a study coach. Phone monitoring included 15-min weekly phone calls from a study coach to offer general support. PTSD symptom severity (PTSD Symptom-Checklist-Version 5 [PCL-5]) was evaluated pre and posttreatment, and at 3 and 6 months posttreatment. Results: More participants completed phone monitoring than DESTRESS–WV (96% vs. 76%, p = 0.01), although treatment satisfaction was significantly greater in the DESTRESS–WV condition. We failed to confirm the superiority of DESTRESS–WV in intent-to-treat slope changes in PTSD symptom severity. Both treatments were associated with significant reductions in PTSD symptom severity over time. However, post hoc analyses of treatment completers and of those with baseline PCL ≥ 33 revealed that the DESTRESS–WV group had greater improvement in PTSD symptom severity relative to phone monitoring with significant differences at the 3-month follow-up assessment. Conclusions: Both DESTRESS–WV and phone monitoring resulted in significant improvements in women Veterans’ PTSD symptoms. DESTRESS–WV may be an appropriate care model for women Veterans who can engage in the demands of the treatment and have higher baseline symptoms. Future research should explore characteristics of and the methods of reliably identifying women Veterans who are most likely to benefit.
Objective:
Narrative exposure therapy (NET) is a psychological intervention conditionally recommended for the prevention and intervention of posttraumatic stress disorder (PTSD). Previous study reported that NET had medium effect on PTSD, but the evidence base of NET is still weak. In this article, we conducted a meta-analysis to explore the efficacy of NET for PTSD symptom reduction and loss of diagnosis.
Method:
Databases were searched for randomized controlled trials of NET for PTSD. Effect sizes were calculated by Hedges' g and ratio of risk (RR) with 95% confidence intervals (CIs). Study heterogeneity was assessed by Q, Tau2 and I2 and explored by subgroup analyses and metaregression analyses.
Results:
18 studies which met full inclusion criteria were included. The finding showed that NET had moderate between-group effect size (g = -.57, 95% CI [-0.87, -0.28], p < .01) and large within-group effect size (g = -1.31, [-1.54, -1.09], p < .01) at first postintervention assessment. The mean RR of loss of diagnosis between NET and comparators was 2.20 ([1.23, 3.92], p < .01). However, there were no differences between groups in both symptom reduction and loss of diagnosis when accounting for publication bias. And the heterogeneity could not be explained sufficiently.
Conclusion:
Although the article indicated the efficacy of NET for PTSD symptom reduction and the loss of diagnosis, it is difficult to draw meaningful conclusions considering the heterogeneity and publication bias in samples. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
Background: While Internet- and mobile-based interventions (IMIs) are potential options to increase the access to evidence-based therapies for post-traumatic stress disorder (PTSD), comprehensive knowledge on their working mechanisms is still scarce.
Objective: We aimed to evaluate studies investigating the efficacy and mechanisms of change in IMIs for adults with PTSD.
Method: In this systematic review and meta-analysis (PROSPERO CRD42019130314), five databases were consulted to identify relevant studies, complemented by forward (i.e. citation search) and backward (i.e. review of reference lists from included studies) searches. Randomized controlled trials (RCTs) investigating the efficacy of IMIs compared to active controls, as well as component and mediation studies were included. Two independent reviewers extracted the data and assessed the risk of bias and requirements for process research. Random-effects meta-analyses on PTSD symptom severity as primary outcome were conducted and further information was synthesized qualitatively.
Results: In total, 33 RCTs were included (N = 5421). The meta-analysis comparing IMIs to non-bonafide active controls yielded a significant standardized mean difference (SMD) of −0.36 (95%CI −0.53 to −0.19) favouring IMIs. Although meta-analytic pooling was not possible for the component and mediation studies, evidence suggests no differential effects regarding PTSD symptom reduction between different levels of support and personalization and between different types of exposure. Moreover, mediation studies revealed significant intervening variable effects for self-efficacy beliefs, perceived physical impairment, social acknowledgement, and trauma disclosure.
Conclusions: Results indicate that IMIs for PTSD are superior to active controls. Furthermore, findings may contribute to the development of new interventions by outlining important directions for future research (e.g. regarding requirements for process research) and highlighting potential mechanisms of change (i.e. self-efficacy, perceived physical impairment, social acknowledgement, and trauma disclosure).
The purpose of the present study was to examine, via meta-analysis, the efficacy of third wave therapies in reducing posttraumatic stress (PTS) symptoms. A secondary aim was to identify whether treatment efficacy was moderated by treatment type, treatment duration, use of exposure, use of intent-to-treat samples, and treatment format (i.e., individual, group, both). Risk of bias was also assessed. A literature search returned 37 studies with a pooled sample of 1,268 participants that met study inclusion criteria. The mean differences between pre-and post-treatment PTS symptoms were estimated using a random effects model (i.e., uncontrolled effect). Additionally, in a subset of studies that utilized a control condition, a controlled effect in which pre-to post-treatment PTS symptom changes accounted for symptom changes in the control condition was calculated. The overall uncontrolled effect of third wave therapies in reducing PTS symptoms was medium to large (Hedges' g = 0.88 [0.72-1.03]). Treatment type, use of intent-to-treat analysis, inclusion of exposure, and format moderated the uncontrolled effect, but treatment duration did not. The controlled effect of third wave therapies was small to large in size (Hedges' g = 0.50 [0.20-0.80]). Findings suggest that third wave therapies demonstrate enough promise in treating individuals with PTS symptoms to warrant further investigation. Implications and suggestions for future third wave research are discussed.
Purpose of Review
It is vitally important that providers treating post-traumatic stress disorder continue to stay abreast of research advances in the treatment of this disorder. This article updates the reader about advances in research in PTSD treatment in the past four years as well as the evolving recommendations of clinical practice guidelines.
Recent Findings
One of the most important developments is that trauma-focused therapy (TFT) has emerged as the first-line treatment for PTSD with pharmacologic options often being noted as second-line or adjunctive.
Summary
The quality and quantity of research into the treatment of PTSD continue to grow; however, the pace of research into treatment options lags behind our understanding of the development, course, and prognosis of the disorder. The development of new research-based evidence in the treatment of PTSD, both pharmacologic and psychotherapeutic, is needed and likely to necessitate frequent updates and re-evaluations of clinical practice guidelines.
There is growing interest in expanding mental health treatment options for individuals suffering from posttraumatic stress disorder (PTSD), and mindfulness interventions encompass a family of approaches that are gaining popularity and empirical support. “Mindfulness interventions” is a broad umbrella term used in this article to encompass a diverse range of psychological and mind-body interventions that incorporate mindfulness practice as a core component. In this article, our primary aims are to (a) briefly define mindfulness and mindfulness interventions, (b) summarize recent randomized control trials on mindfulness interventions for PTSD, (c) highlight hypothesized mechanisms of these interventions (i.e., improved interoceptive awareness and arousal regulation, acceptance, and attentional control), and (d) offer clinical tips for practitioners aiming to incorporate or implement diverse mindfulness interventions with their clients. Throughout, we include clinical examples and applications from our work implementing mindfulness interventions with survivors of trauma experiencing PTSD. We conclude this article by offering potential directions for future research.
Objective: PTSD in female veterans and service members (SMs) is understudied, and new, effective treatments for PTSD are needed. Reconsolidation of Traumatic Memories (RTM) is a brief, manualized treatment for PTSD previously piloted in RCTs of male veterans and SMs. Here we examine RTM's effect on military women with PTSD. Method: We report a waitlist RCT using 30 military-connected females with DSM-IV-TR PTSD diagnoses, including current-month nightmares or flashbacks. Trauma types include military sexual trauma, other sexual traumas, combat, and other trauma types. Participants were randomized to treatment or waitlist. Of those enrolled, 97% completed treatment. Independent psychometricians, blinded to treatment condition, evaluated participants at intake, postwait, and two weeks post. The clinician took follow-up measures at six months and one year. The primary measure was the PTSD Symptom Scale-Interview (PSS-I). The secondary measure was the PTSD Checklist. Participants received up to three 120-min sessions of RTM. Results: RTM eliminated intrusive symptoms and significantly decreased symptom scale ratings in 90% (n = 27) of participants, versus 0% of controls (p < .001). Two-week treatment group PSS-I scores dropped 33.9 points versus 3.9 points for postwait controls (g = 3.7; 95% CI [2.5, 4.8]; p < .001). Treatment results were stable to 1 year. Conclusions: RTM effectively treated PTSD, independent of trauma source in female SMs and veterans effectively replicating previous results in male populations. Further research is recommended. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
Background
In recent years, mindfulness-based interventions (MBIs) have experienced exponential growth in terms of development, application, and research. However, few studies have examined implementation and efficacy of these interventions in particular populations, such as military Veterans. Such studies are needed as one cannot assume that the literature on MBIs implemented with the general population or other specific populations apply equally well to Veterans. This population is unique regarding professional competencies, military ethos, high degrees of medical comorbidities and barriers to treatment. The aim of this work was to review and summarize the literature over the previous five years (2014–2020) assessing the use of MBIs among military Veterans to guide clinical care and future research.
Methods
Systematic literature review.
Results
A total of 88 articles were found. Screening titles and abstracts resulted in 49 articles being excluded. The remaining 39 articles were read in full, and of these, 12 were excluded due to not fully meeting the inclusion criteria. Thus, the present review included a total of 27 articles, 3 of which used qualitative methods and 24 of which used quantitative methods.
Conclusions
MBIs hold promise as complementary adjunctive interventions for Veterans with PTSD and possibly other psychiatric disorders. Currently there are significant gaps in the literature that must be addressed to move the field forward. The main deficiency is, with a few exceptions, the lack of rigorous RCTs. Another major concern is the lack of generalizability to female and non-white Veterans given that the subject samples across all studies reviewed were 85% male and 76% white. At this time, MBSR, PCBMT and MBCT can be recommended as adjunctive complementary interventions for the reduction of PTSD symptoms. Research recommendations to move the field forward are provided.
Trauma‐focused psychotherapies, such as prolonged exposure (PE), are strongly recommended to treat posttraumatic stress disorder due to their effects in reducing symptoms. However, such therapies may also suffer from high dropout rates. To investigate how clients might benefit from trauma‐focused therapy while minimizing dropout, we conducted a meta‐analysis of 1,508 adults from 35 randomized controlled trials (RCTs) of outpatient PE programs to evaluate treatment frequency as a predictor of dropout. When an RCT prescribed PE sessions at least twice weekly compared to less frequently, the dropout rate was significantly lower at 21.0%, 95% CI [13.9%, 30.4%], compared to 34.0%, 95% CI [28.9%, 39.4%], OR = 0.52, 95% CI [0.30, 0.89], p = .018. It was not possible to draw causal conclusions, as only one RCT compared two PE treatment frequencies head‐to‐head. Nonetheless, the findings remained significant after controlling for study characteristics. These data invite reconsideration of the common practice of weekly psychotherapy in favor of twice‐weekly sessions in standard outpatient treatment.
The goal of this study was to create simple visual displays to help patients understand the benefits of evidence‐based treatment for posttraumatic stress disorder (PTSD). We reviewed randomized trials of the most effective individual, trauma‐focused psychotherapies and first‐line antidepressants for adults with PTSD. The analytic sample included 65 treatment arms from 41 trials. We used binomial logistic regression to estimate the proportion of participants who lost their PTSD diagnosis at posttreatment and created a sample icon array to display these estimates. We provide a range of estimates (0–100) based on varying the percentage of the sample with a military affiliation. The percentage of participants who no longer met the diagnostic criteria for PTSD among civilian populations was 64.3% for trauma‐focused treatment, 56.9% for SSRI/SNRI, and 16.7% for waitlist/minimal attention. For military populations, the proportions of participants who no longer met the diagnostic criteria were 44.2%, 36.7%, and 8.1%, respectively. We present icon arrays for 0%, 7%, 50%, and 100% military affiliation displaying 100 icons, a portion of which were shaded to indicate the number of participants that no longer met the PTSD criteria following treatment. After evidence‐based treatment, between one third and two thirds of participants no longer met the PTSD criteria. Providers can use the icon array developed in this study with patients to facilitate communication regarding PTSD treatment effectiveness.
Aims and objectives:
The aim of this study was to investigate the effectiveness of mindfulness-based interventions on psychological well-being, burnout and post-traumatic stress disorder symptoms among working registered nurses.
Background:
Nurses account for nearly half of the global healthcare workforce and are considered significant contributors in multi-disciplinary healthcare teams. Yet, nurses face high levels of psychological distress, leading to burnout and post-traumatic stress disorder. Mindfulness-based training is a strategy that has been introduced to foster a state of awareness of present physical, emotional and cognitive experiences to regulate behaviour.
Design:
This systematic review of randomised controlled trials was designed according to PRISMA guidelines. Eligible studies were screened and extracted. Methodological quality was evaluated by two researchers, independently. RevMan 5.4 was used to conduct the meta-analysis.
Results:
Fourteen studies including a total of 1077 nurses were included, of which only eleven were included in the meta-analysis as the remaining had missing or incomplete data. Meta-analysis revealed that MBI was more effective than passive comparators in reducing psychological distress, stress, depression and burnout-personal accomplishment. When compared to active comparators, MBI was also found to be more effective in reducing psychological distress and was as effective in reducing stress, anxiety, depression and burnout. Evidence on the effects of MBIs on PTSD was scarce.
Conclusion:
Mindfulness-based interventions can effectively reduce psychological distress, stress, depression and some dimensions of burnout. However, evidence remains scarce in the literature. There is a need for more methodologically sound research on mindfulness-based training among nurses.
Relevance for clinical practice:
An important aspect that relates to the success of mindfulness-based interventions is the continued and dedicated individual practice of the skills taught during mindfulness training amidst demanding clinical work environments. Therefore, relevant support for nurses must be accounted for in the planning, design and implementation of future mindfulness-based interventions.
Mental disorders represent a worldwide public health concern. Psychotherapies and pharmacotherapies are recommended as first line treatments. However, evidence has emerged that their efficacy may be overestimated, due to a variety of shortcomings in clinical trials (e.g., publication bias, weak control conditions such as waiting list). We performed an umbrella review of recent meta-analyses of randomized controlled trials (RCTs) of psychotherapies and pharmacotherapies for the main mental disorders in adults. We selected meta-analyses that formally assessed risk of bias or quality of studies, excluded weak comparators, and used effect sizes for target symptoms as primary outcome. We searched PubMed and PsycINFO and individual records of the Cochrane Library for meta-analyses published between January 2014 and March 2021 comparing psychotherapies or pharmacotherapies with placebo or treatment-as-usual (TAU), or psychotherapies vs. pharmacotherapies head-to-head, or the combination of psychotherapy with pharmacotherapy to either monotherapy. One hundred and two meta-analyses, encompassing 3,782 RCTs and 650,514 patients, were included, covering depressive disorders, anxiety disorders, post-traumatic stress disorder, obsessive-compulsive disorder, somatoform disorders, eating disorders, attention-deficit/hyperactivity disorder, substance use disorders, insomnia, schizophrenia spectrum disorders, and bipolar disorder. Across disorders and treatments, the majority of effect sizes for target symptoms were small. A random effect meta-analytic evaluation of the effect sizes reported by the largest meta-analyses per disorder yielded a standardized mean difference (SMD) of 0.34 (95% CI: 0.26-0.42) for psychotherapies and 0.36 (95% CI: 0.32-0.41) for pharmacotherapies compared with placebo or TAU. The SMD for head-to-head comparisons of psychotherapies vs. pharmacotherapies was 0.11 (95% CI: –0.05 to 0.26). The SMD for the combined treatment compared with either monotherapy was 0.31 (95% CI: 0.19-0.44). Risk of bias was often high. After more than half a century of research, thousands of RCTs and millions of invested funds, the effect sizes of psychotherapies and pharmacotherapies for mental disorders are limited, suggesting a ceiling effect for treatment research as presently conducted. A paradigm shift in research seems to be required to achieve further progress.
Considering the adverse impact that traumatic childbirth experiences can have on parental mental well-being, studies that have investigated the potential of providing postnatal psychological support for this group of parents require evaluation. This systematic review aimed to examine the effectiveness of psychological interventions at improving the mental well-being of parents who have experienced traumatic childbirth in terms of anxiety, depression, fear of childbirth, and post-traumatic stress disorder (PTSD) symptoms. Seven electronic databases were searched from their respective inception dates up to January 2021. Only quantitative studies that reported the effects of psychological interventions on anxiety, depression, fear of childbirth, and/or PTSD symptoms in selective (at risk of traumatic childbirth experience) or indicated (self-defined childbirth experience as traumatic for any reason) populations of parents (mothers and/or fathers) were included. Eight studies were included and meta-analyses were conducted using a random-effect model. All studies were conducted on mothers only, and one study had minimal father involvement. Results showed that psychological interventions were more effective in reducing fear of childbirth and improving PTSD symptoms compared to anxiety and depression. Greater improvement in depression was reported at 3–8 weeks’ follow-up than at immediate post-intervention. Subgroup analyses showed that technology-based interventions were feasible, and indicated interventions were more effective than selective interventions. Conducting future interventions in more geographical regions, engaging and including fathers more actively, incorporating both personalized professional therapy and informal peer support, striving for flexibility and convenience, as well as addressing topics on self-doubt and coping skills can improve current interventions.
Introduction:
The recommended treatments for post-traumatic stress disorder (PTSD) are psychological therapies and medication, but the best approach is still discussed. Exposure to traumatic events in psychotherapy tends to cause high drop-out rates. Likewise, little effect or adverse events of medications may lead to attrition. The aim of this study was to compare the outcomes of treatment by psychotherapy and medications. An additional aim was to explore the combinations of treatment modalities in adults with PTSD and to investigate differences in drop-out rates.
Methods:
A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. PubMed and Embase were searched for relevant randomised clinical trials. The Cochrane risk-of-bias tool was used to assess the quality of the retrieved trials.
Results:
Seven eligible studies were identified. Three studies showed that psychotherapy was superior to selective serotonin reuptake inhibitors. Two studies showed an augmenting effect with prolonged exposure. Two studies showed no differences across the treatment groups. In four of the included studies, patients treated with psychotherapy were more likely to drop out.
Conclusions:
Extant evidence is insufficient to assess whether combined therapy is superior to monotherapy. Both medication and psychotherapy have an effect on PTSD, but psychotherapy tends to provide greater and more long-lasting outcome improvements. Trauma type, PTSD severity and other variables affect drop-out rates and treatment outcomes.
Background
In the United States, the majority of patients who require behavioral health care do not receive it due to an overall shortage of behavioral health specialists. The Collaborative Care Model (CoCM) is a team-based, highly-coordinated approach to treating common mental health conditions in primary care that has a robust evidence base. Several recent randomized controlled trials (RCTs) have demonstrated the effectiveness of remote CoCM teams. As telehealth technology and uptake expands, understanding the evidence for remote CoCM becomes increasingly crucial to inform CoCM practice and implementation.
Objective
To systematically review RCTs regarding the effectiveness of remote CoCM teams in treating common psychiatric conditions in primary care and medical settings.
Methods
Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were used to structure our review. Our search strategy and development of search terms was informed by knowledge and review of the CoCM literature. Articles were reviewed by three authors and once selected, sent to two authors for further data extraction to describe various study characteristics and process measures relating to remote CoCM.
Results
The literature search identified 13,211 articles, nine of which met inclusion criteria. The nine studies collectively demonstrate effectiveness of remote CoCM in treating a range of behavioral health conditions [(depression (n=7), anxiety (n=2), and PTSD (n=1)], across various populations and settings. Sample sizes ranged from 191 patients to 704 patients, publication dates from 2004 to 2018, and studies were conducted from 2000 to 2014. Various process measures were also reported.
Conclusions
As the nine studies included in our systematic review demonstrate, remote CoCM can be effective in treating a range of behavioral health conditions in various primary care and specialty medical settings. These findings suggest organizations may have more flexibility in building their CoCM team and drawing upon wider workforces than previously recognized. As recent shifts in telehealth policy and practice continue to motivate telehealth approaches, further research that can inform best practices for remote CoCM will be useful and valuable to those making organizational decisions when implementing integrated care models.
Introduction
Approximately 16% of the world’s burden of disease is attributable to traumatic injury. Psychological symptoms, including post-traumatic stress disorder (PTSD), are prevalent in this population and impact recovery from physical injury. Nevertheless, mental health has not been considered to the same degree as physical health. Psychological interventions are used widely as treatments for PTSD.
Methods
Systematic searches of computerised databases were conducted. Randomised controlled trials of psychological treatments for PTSD following major physical civilian trauma were included. The main outcome measure was clinician-assessed symptoms of PTSD (CAPS), with findings for anxiety and depression also reported. Included studies data were extracted and entered using RevMan 5.3 software. Quality assessments were performed, and data were analysed for summary effects.
Results
10 studies were included. With regard to CAPS <6 months, individual CBT did significantly better than usual care/wait list (SMD (95% CI) = −1.24 [−1.82, −0.67]) and non-CBT treatments (SMD (95% CI) = −1.32 [−2.64, −0.04]). Non-CBT treatments were not significantly better than usual care/wait list (SMD (95% CI) −1.40 [−2.91, 0.11]). CBT was superior to usual care/wait list for reducing depressive (SMD (95% CI) −0.67 [−0.98, −0.37]) and anxiety (SMD (95% CI) −0.70 [−1.22, −0.18]) symptoms both in the shorter and longer term.
Conclusion
Individual CBT was superior to wait list/usual care, and there was limited evidence for non-CBT treatments in reducing clinician and self-rated PTSD, depressive and anxiety symptoms in the shorter term; however, the latter comparison was based on few studies with small sample sizes. Longer-term effects of treatments remain uncertain. There is a need for adequately powered RCTs investigating PTSD treatments following major physical civilian trauma in the longer term. There was considerable heterogeneity in the studies, so care must be taken in interpreting the results of this review.
Introduction: Individuals with intellectual disability (ID) are at significant risk of developing emotional trauma and post-traumatic stress disorder (PTSD) due to altered neuropsychological functioning, increased chance of experiencing adverse life events, difficulty expressing emotions, diagnostic overshadowing and institutional failures. Eye Movement Desensitization and Reprocessing Therapy (EMDR) is efficacious in the general population, but research lacks evidence to suggest EMDR remains effective in ID. This paper assesses the evidence available on the use of EMDR to treat PTSD in ID and provide direction for future research.
Methods: A scoping review using PRISMA guidance was conducted. PsychInfo, Embase and Medline were completed using the NICE Health Databases Advanced Search in March 2020. Supplementary searches of Joanna Briggs and ongoing randomized controlled trials were also conducted. The terms used related to Intellectual disability and EMDR therapy. Searches were conducted without the use of PTSD or trauma-related terms to increase the number of identified articles. Inclusion criteria involved the use of EMDR therapy as the primary intervention using a population of individuals with ID. Only articles available in English were included. There were no exclusions related to the study design. All study designs and publication types were included in this review to capture the breadth of information that might be available on the topic. Articles identified were summarized, appraised and collated into tables. Papers were assessed for quality using the GRADE criteria.
Results: Out of 16 identified publications, 13 demonstrated positive results and 3 less favorable. Heterogeneity among participants, variations in EMDR protocol/adaptations, and variation in trauma and PTSD assessment were prevalent.
Conclusions: It is not possible to conclude whether EMDR is efficacious in people with ID. Future studies need to use homogenized populations, standardized EMDR protocol and validated trauma and PTSD assessments.
Purpose:
Most patients with depression are treated by general practitioners, and most of those patients prefer psychotherapy over pharmacotherapy. No network meta-analyses have examined the effects of psychotherapy compared with pharmacotherapy, combined treatment, care as usual, and other control conditions among patients in primary care.
Methods:
We conducted systematic searches of bibliographic databases to identify randomized trials comparing psychotherapy with pharmacotherapy, combined treatment, care as usual, waitlist, and pill placebo. The main outcome was treatment response (50% improvement of depressive symptoms from baseline to end point).
Results:
A total of 58 studies with 9,301 patients were included. Both psychotherapy and pharmacotherapy were significantly more effective than care as usual (relative risk [RR] for response = 1.60; 95% CI, 1.40-1.83 and RR = 1.65; 95% CI, 1.35-2.03, respectively) and waitlist (RR = 2.35; 95% CI, 1.57-3.51 and RR = 2.43; 95% CI, 1.57-3.74, respectively) control groups. We found no significant differences between psychotherapy and pharmacotherapy (RR = 1.03; 95% CI, 0.88-1.22). The effects were significantly greater for combined treatment compared with psychotherapy alone (RR = 1.35; 95% CI, 1.00-1.81). The difference between combined treatment and pharmacotherapy became significant when limited to studies with low risk of bias and studies limited to cognitive behavior therapy.
Conclusions:
Psychotherapy is likely effective for the treatment of depression when compared with care as usual or waitlist, with effects comparable to those of pharmacotherapy. Combined treatment might be better than either psychotherapy or pharmacotherapy alone.
Background:
Despite a burgeoning of research on moral injury in the past decade, existing reviews have not explored the breadth of consequences and the multitude of pathways through which moral injury and potentially morally injurious experiences (PMIEs) influence mental and behavioral health outcomes.
Purpose:
To identify associations between moral injury on mental and behavioral health.
Procedure:
Literature searches of psychological and medical databases were conducted through April 2020. Eligible studies measured moral injury or PMIEs, and health outcomes (e.g., depression, substance use, suicidality).
Main findings:
Fifty-seven publications representing 49 separate samples were included. Studies examined the impact of moral injury on PTSD (n=43); depression (n=32); anxiety (n=15); suicide (n=15); substance use (n=14); and "other" health outcomes, including pain, burnout, sleep disturbance, and treatment-seeking behaviors (n=11). The majority of studies found significant positive associations between moral injury-related constructs, mental health, and behavioral health outcomes; however, the majority were also cross-sectional and focused on military samples. Proposed mediators included lack of social support, negative cognitions, and meaning-making. Moderators included self-compassion, pre-deployment mental health education, and mindfulness.
Conclusions:
Moral injury is associated with a variety of negative health outcomes. Research is needed to determine the mechanisms by which moral injury may influence these outcomes over time.
The present study reports on the first ever controlled comparison between eye movement desensitization and reprocessing (EMDR) and emotional freedom techniques (EFT) for posttraumatic stress disorder. A total of 46 participants were randomized to either EMDR (n = 23) or EFT (n = 23). The participants were assessed at baseline and then reassessed after an 8-week waiting period. Two further blind assessments were conducted at posttreatment and 3-months follow-up. Overall, the results indicated that both interventions produced significant therapeutic gains at posttreatment and follow-up in an equal number of sessions. Similar treatment effect sizes were observed in both treatment groups. Regarding clinical significant changes, a slightly higher proportion of patients in the EMDR group produced substantial clinical changes compared with the EFT group. Given the speculative nature of the theoretical basis of EFT, a dismantling study on the active ingredients of EFT should be subject to future research.
Introduction:
This is an overall review on mindfulness-based interventions (MBIs).
Sources of data:
We identified studies in PubMed, EMBASE, CINAHL, PsycINFO, AMED, Web of Science and Google Scholar using keywords including 'mindfulness', 'meditation', and 'review', 'meta-analysis' or their variations.
Areas of agreement:
MBIs are effective for improving many biopsychosocial conditions, including depression, anxiety, stress, insomnia, addiction, psychosis, pain, hypertension, weight control, cancer-related symptoms and prosocial behaviours. It is found to be beneficial in the healthcare settings, in schools and workplace but further research is warranted to look into its efficacy on different problems. MBIs are relatively safe, but ethical aspects should be considered. Mechanisms are suggested in both empirical and neurophysiological findings. Cost-effectiveness is found in treating some health conditions.
Areas of controversy:
Inconclusive or only preliminary evidence on the effects of MBIs on PTSD, ADHD, ASD, eating disorders, loneliness and physical symptoms of cardiovascular diseases, diabetes, and respiratory conditions. Furthermore, some beneficial effects are not confirmed in subgroup populations. Cost-effectiveness is yet to confirm for many health conditions and populations.
Growing points:
Many mindfulness systematic reviews and meta-analyses indicate low quality of included studies, hence high-quality studies with adequate sample size and longer follow-up period are needed.
Areas timely for developing research:
More research is needed on online mindfulness trainings and interventions to improve biopsychosocial health during the COVID-19 pandemic; Deeper understanding of the mechanisms of MBIs integrating both empirical and neurophysiological findings; Long-term compliance and effects of MBIs; and development of mindfulness plus (mindfulness+) or personalized mindfulness programs to elevate the effectiveness for different purposes.
Post-traumatic stress disorder (PTSD) is a common trauma and stressor-related disorder. Trauma-focused psychotherapies and selective serotonin reuptake inhibitors represent current state of the art treatment for PTSD, with current evidence favouring psychotherapy as first-line treatment. Much room remains for development of more effective therapeutics. This article give a brief update on diagnosis and treatment of PTSD.
Introduction
Sleep problems are common in post-traumatic stress disorder (PTSD). Exercise can improve sleep quality but whether this occurs among those with PTSD is unclear. We conducted a systematic review and meta-analysis to estimate the magnitude of the effect of exercise training on overall sleep quality in patients with PTSD. Secondarily, the impact of exercise training on symptoms of PTSD, anxiety and depression were evaluated.
Methods
Articles published before April 1, 2020, were located through PubMed, Web of Science, PsycINFO, and Google Scholar. Exercise training interventions that measured sleep quality in patients with PTSD were evaluated for inclusion. In total, 1948 articles were screened, 40 were further appraised, and four were analyzed. Hedges’ d effect sizes were calculated for sleep quality. Due to the relationship between poor sleep and symptoms of PTSD, anxiety, and depression, symptom changes with exercise training were analyzed.
Results
The four studies involved a total of 149 participants (61% males) with a mean (SD) age of 44.7 (16.3) years. The exercise intervention duration ranged from 3 to 12 weeks. All 5 effect sizes for overall sleep quality supported a favorable effect of exercise training; the mean Hedges'd (95% CI) was −0.47 (−0.18, −0.75), p < 0.05. Exercise training was consistently associated with small or moderate improvements in PTSD, anxiety, and depression symptoms.
Conclusions
The small body of evidence suggests that exercise training has promise for improving overall sleep quality and PTSD, anxiety, and depression symptoms among those with PTSD.
Background
Mental health problems are becoming increasingly prevalent among students and adequate support should be provided to prevent and treat mental health disorders in those at risk.
Methods
This systematic review and meta-analysis examined the efficacy of psychological interventions for students, with consideration of how adaptions to intervention content and delivery could improve outcomes. We searched for randomised controlled trials (RCTs) of interventions in students with or at risk of mental health problems and extracted data for study characteristics, symptom severity, wellbeing, educational outcomes, and attrition. Eighty-four studies were included.
Results
Promising effects were found for indicated and selective interventions to treat anxiety disorders, depression and eating disorders. PTSD and self-harm data was limited, and did not demonstrate significant effects. Relatively few trials adapted intervention delivery to student-specific concerns, and overall adapted interventions showed no benefit over non-adapted interventions. There was some suggestion that adaptions based on empirical evidence and provision of additional sessions, and transdiagnostic models may yield some benefits.
Limitations
The review is limited by the often poor quality of the literature and exclusion of non-published data.
Conclusions
Interventions for students show benefit though uncertainty remains around how best to optimise treatment delivery and content for students. Additional research into content targeting specific underlying mechanisms of problems and transdiagnostic approaches to provision could be promising avenues for further research.
Aim: To review the literature on psychological interventions for post-traumatic stress following childbirth (PTSDFC) and determine clinical effectiveness. To synthesise the qualitative literature on the facilitators and barriers to uptake of care for PTSDFC.
Background: The context of childbirth trauma differs from that of other events perceived as traumatic. Current guidance on treatment for PTSDFC requires further clarification.
Method: Web of Knowledge, CINAHL, MEDLINE, PSYCINFO, the Cochrane Central Register of Controlled Trials (CENTRAL), Open Grey, UKCTG, and the ISRCTN were consulted to include journal articles published in English.. Articles were segregated according to methodology and appraised using the Mixed Methods Appraisal Tool.
Results: A total of 5355 papers were identified with five quantitative and 13 qualitative included in the review. Four types of interventions were identified: eye movement desensitisation and reprocessing, trauma focussed CBT, debriefing and expressive writing. All showed some effectiveness in treating PTSDFC. Themes emerging from the meta-synthesis included women finding it difficult to recognise having a problem, needing validation and only seeking help ‘at breaking point’. Women wanted health professionals actively asking in a non-judgemental way at different time points and providing support and listening, ideally with continuity of carer to make sense of their experiences.
Limitations: Quantitative studies were not disaggregated by intervention timing or follow-up duration. A single independent reviewer with team discussion was utilised.
Conclusion: There is little definitive evidence assessing the effectiveness of psychological interventions for PTSDFC. There are psychological barriers for women accessing help for traumatic childbirth which services can mitigate.
The link between interpersonal trauma and negative biopsychosocial outcomes has been well-documented. Integrated treatments that address trauma, mental health, and substance use among women with trauma histories have been found to be more effective than treatments that focus separately on these concerns. Since the early 2000s, the Trauma Recovery and Empowerment Model (TREM) has been described as a “promising” integrated trauma group therapy for women. Despite widespread recognition and implementation of TREM, its effectiveness has not been clearly established. The present scoping review is the first systematic effort to describe the extant literature on TREM and aims to provide an understanding of TREM’s effectiveness by organizing and synthesizing the available empirical data. Guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews, a systematic search was conducted using PubMed, PsycINFO, SW Abstracts, Scopus, Embase, and Web of Science. Quantitative dissertation findings not published elsewhere and peer-reviewed journal articles published in English that reported outcomes from TREM intervention research with adult women were included. Twelve of the initial 385 publications identified met the inclusion criteria and reported data from nine studies. TREM demonstrated statistically significant effects on posttraumatic stress disorder, anxiety, psychological/psychosomatic distress, and substance use. A more limited set of findings suggests that TREM may also be associated with additional gains, including self-esteem, relationship power, social support, attachment, and spiritual well-being. Future research should replicate findings, use random assignment to groups, involve larger sample sizes and more representative samples, examine optimal duration, and identify components that facilitate change.