ArticleLiterature Review

Psychological interventions for adult PTSD are effective irrespective of concurrent psychotropic medication intake: A meta- analysis of randomized controlled trials

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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.

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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.
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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).
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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.
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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.
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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).
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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.
Article
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.
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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.
Article
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.
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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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
Article
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.
Article
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).
Article
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.
Article
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.
Article
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.
Article
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.