Jurnal Reading b.ingris

BackgroundBackground Therelative efficacyofThe relative efficacyof

different psychological treatments fordifferentpsychological treatments for

chronic post-traumatic stress disorderchronic post-traumatic stress disorder

(PTSD) is unclear.(PTSD) is unclear.

AimsAims To determine the efficacyofTo determine the efficacyof

specific psychological treatments forspecific psychological treatments for

chronic PTSD.chronic PTSD.

MethodMethod In a systematic reviewofIn a systematic reviewof

randomised controlled trials, eligiblerandomised controlled trials, eligible

studieswere assessed againststudieswere assessed against

methodological qualitycriteria and datamethodological qualitycriteria and data

were extracted and analysed.were extracted and analysed.

ResultsResults Thirty-eight randomisedThirty-eight randomised

controlled trialswere included in thecontrolled trialswere included inthe

meta-analysis.Trauma-focused cognitive^meta-analysis.Trauma-focused cognitive^

behavioural therapy (TFCBT), eyebehavioural therapy (TFCBT), eye

movementdesensitisation andmovementdesensitisation and

reprocessing (EMDR), stressmanagementreprocessing (EMDR), stressmanagement

andgroup cognitive^behavioural therapyandgroup cognitive^behavioural therapy

improved PTSD symptomsmore thanimproved PTSD symptomsmore than

waiting-listor usual care.Therewaswaiting-listor usual care.Therewas

inconclusive evidence regardingotherinconclusive evidence regardingother

therapies.Therewasno evidence of atherapies.Therewasno evidence of a

difference in efficacybetweenTFCBTanddifference in efficacybetweenTFCBTand

EMDR buttherewas some evidence thatEMDR buttherewas some evidence that

TFCBTand EMDRwere superior to stressTFCBTand EMDRwere superior to stress

management and other therapies, andmanagement and other therapies, and

that stressmanagementwas superior tothat stressmanagementwas superior to

other therapies.other therapies.

ConclusionsConclusions The first-lineThe first-line

psychological treatment for PTSD shouldpsychological treatment for PTSD should

be trauma-focused (TFCBTor EMDR).be trauma-focused (TFCBTor EMDR).

Declaration of interestDeclaration of interest None.None.

Chronic post-traumatic stress disorderChronic post-traumatic stress disorder

(PTSD) is a common disorder that people(PTSD) is a common disorder that people

may develop after exceptionally threateningmay develop after exceptionally threatening

and distressing events. Psychological treat-and distressing events. Psychological treat-

ments from various theoretical perspectivesments from various theoretical perspectives

have been found to be effective for chronichave been found to be effective for chronic

PTSD in previous reviews (Van Etten &PTSD in previous reviews (Van Etten &

Taylor, 1988; BradleyTaylor, 1988; Bradley et alet al, 2005)., 2005). Some ofSome of

the earlier reviews had to rely on un-the earlier reviews had to rely on un-

controlled trials as well as controlled ones,controlled trials as well as controlled ones,

and on uncontrolled effect sizes. There areand on uncontrolled effect sizes. There are

now sufficient numbers of randomised con-now sufficient numbers of randomised con-

trolled trials of psychological treatments oftrolled trials of psychological treatments of

chronic PTSD to allow a meta-analysis of ef-chronic PTSD to allow a meta-analysis of ef-

fect sizes in such trials. We present a compre-fect sizes in such trials. We present a compre-

hensive systematic review and meta-analysishensive systematic review and meta-analysis

of randomised controlled trials assessing theof randomised controlled trials assessing the

efficacy of psychological treatments in redu-efficacy of psychological treatments in redu-

cing symptoms of chronic PTSD, and com-cing symptoms of chronic PTSD, and com-

paring the efficacy of different types ofparing the efficacy of different types of

psychological treatment in reducing symp-psychological treatment in reducing symp-

toms of this disorder.toms of this disorder.

METHODMETHOD

This review and meta-analysis derive fromThis review and meta-analysis derive from

work undertaken in the preparation ofwork undertaken in the preparation of

PTSD treatment guidelines for the NationalPTSD treatment guidelines for the National

Institute for Health and Clinical ExcellenceInstitute for Health and Clinical Excellence

(NICE) in the UK (National Collaborating(NICE) in the UK (National Collaborating

Centre for Mental Health, 2005). FurtherCentre for Mental Health, 2005). Further

details of the protocol are published withindetails of the protocol are published within

the full guideline.the full guideline.

A systematic bibliographic search wasA systematic bibliographic search was

undertaken to find randomised controlledundertaken to find randomised controlled

trials of psychological treatments for PTSDtrials of psychological treatments for PTSD

from databases (EMBASE, Medline,from databases (EMBASE, Medline,

PsycINFO and CINAHL) and the CochranePsycINFO and CINAHL) and the Cochrane

Library, with each database being searchedLibrary, with each database being searched

from inception to August 2004. Additionalfrom inception to August 2004. Additional

papers were found by hand-searching thepapers were found by hand-searching the

references of retrieved articles, previousreferences of retrieved articles, previous

systematic reviews and meta-analyses of psy-systematic reviews and meta-analyses of psy-

chological treatments for PTSD. The searchchological treatments for PTSD. The search

was restricted to papers with English-was restricted to papers with English-

language abstracts. In addition, data fromlanguage abstracts. In addition, data from

unpublished studies or papers in press wereunpublished studies or papers in press were

sought by contacting experts within the field.sought by contacting experts within the field.

SelectionSelection

Studies were only considered if PTSDStudies were only considered if PTSD

symptoms were the main target of treat-symptoms were the main target of treat-

ment, all participants had had PTSD symp-ment, all participants had had PTSD symp-

toms for at least 3 months following atoms for at least 3 months following a

traumatic event, at least 70% of partici-traumatic event, at least 70% of partici-

pants had a diagnosis of PTSD, and PTSDpants had a diagnosis of PTSD, and PTSD

symptoms were measured using a recog-symptoms were measured using a recog-

nised scale. To be included studies had tonised scale. To be included studies had to

be of randomised controlled design, withbe of randomised controlled design, with

adult (adult (4416 years old) participants; the16 years old) participants; the

studies had to report at least pre-treatmentstudies had to report at least pre-treatment

and post-treatment measures, and retain atand post-treatment measures, and retain at

least 50% of the original sample at theleast 50% of the original sample at the

post-treatment assessment. There was nopost-treatment assessment. There was no

restriction regarding type of traumaticrestriction regarding type of traumatic

event. The minimum duration of symptomsevent. The minimum duration of symptoms

was 1 month. Early intervention trials thatwas 1 month. Early intervention trials that

only included participants with recent onsetonly included participants with recent onset

of PTSD were not included and are consid-of PTSD were not included and are consid-

ered in a separate review (further detailsered in a separate review (further details

available from the author upon request).available from the author upon request).

The searching and selection were done byThe searching and selection were done by

a team of systematic reviewers led bya team of systematic reviewers led by

R.M. Any disagreements with regard to in-R.M. Any disagreements with regard to in-

clusion or exclusion of a study were re-clusion or exclusion of a study were re-

solved by discussion with the other authors.solved by discussion with the other authors.

Validity assessmentValidity assessment

All published and unpublished papers wereAll published and unpublished papers were

assessed against the following qualityassessed against the following quality

criteria: random sequence generation,criteria: random sequence generation,

concealment of allocation, masked assess-concealment of allocation, masked assess-

ment of outcomes, number of withdrawals,ment of outcomes, number of withdrawals,

tolerability, adequate reporting of data andtolerability, adequate reporting of data and

intention-to-treat analysis.intention-to-treat analysis.

Data abstractionData abstraction

Study details including the nature of theStudy details including the nature of the

traumatic events, participants’ characteris-traumatic events, participants’ characteris-

tics and type of intervention were enteredtics and type of intervention were entered

into a Microsoft Access database (versioninto a Microsoft Access database (version

2000), the quality criteria were applied2000), the quality criteria were applied

and outcome data for included studies wereand outcome data for included studies were

entered into Review Manager version 4.2.3entered into Review Manager version 4.2.3

for Windows. The application of qualityfor Windows. The application of quality

criteria and the accuracy of outcome datacriteria and the accuracy of outcome data

were double-checked by a second reviewer.were double-checked by a second reviewer.

Study characteristicsStudy characteristics

An initial narrative synthesis was undertakenAn initial narrative synthesis was undertaken

to describe the scope (participants, settings,to describe the scope (participants, settings,

intervention type, comparators, measures ofintervention type, comparators, measures of

effect), quality and outcomes of the studies.effect), quality and outcomes of the studies.

Three main efficacy outcomes were consid-Three main efficacy outcomes were consid-

ered: one dichotomous outcome (retaining aered: one dichotomous outcome (retaining a

diagnosis of PTSD) and two continuous out-diagnosis of PTSD) and two continuous out-

comes (assessor-rated and self-reported sever-comes (assessor-rated and self-reported sever-

ity of PTSD symptoms). Among the mainity of PTSD symptoms). Among the main

9 79 7

BR I T I SH JOURNAL OF P SYCHIATRYBR IT I SH JOURNAL OF P SYCHIATRY ( 2 0 0 7 ) , 1 9 0 , 9 7 ^ 1 0 4 . d o i : 1 0 .11 9 2 / b j p . b p .1 0 6 . 0 21 4 0 2( 2 0 0 7 ) , 1 9 0 , 9 7 ^ 1 0 4 . d o i : 1 0 .11 9 2 / b jp . b p .1 0 6 . 0 214 0 2 R E V I E W A R T I C L ER E V I E W A R T I C L E

Psychological treatments for chronicPsychological treatments for chronic

post-traumatic stress disorderpost-traumatic stress disorder

Systematic review and meta-analysisSystematic review and meta-analysis

JONATHAN I. BISSON, ANKE EHLERS, ROSA MATTHEWS,JONATHAN I. BISSON, ANKE EHLERS, ROSA MATTHEWS,STEPHEN PILLING, DAVID RICHARDS and STUART TURNERSTEPHEN PILLING, DAVID RICHARDS and STUART TURNER

AUTHOR’S PROOFAUTHOR’S PROOF

B IS SON ET ALBIS SON ET AL

outcomes, the primary outcome was clini-outcomes, the primary outcome was clini-

cian-rated severity of PTSD symptoms,cian-rated severity of PTSD symptoms,

although this was not present for all studies.although this was not present for all studies.

Quantitative data synthesisQuantitative data synthesis

Where possible, meta-analysis was used toWhere possible, meta-analysis was used to

synthesise data, including additional meta-synthesise data, including additional meta-

analyses for anxiety and depression mea-analyses for anxiety and depression mea-

sures where available, and numbers leavingsures where available, and numbers leaving

the study early, using Review Manager.the study early, using Review Manager.

Post-treatment data (or change scores ifPost-treatment data (or change scores if

reported instead of post-treatment data)reported instead of post-treatment data)

for the psychological treatment and controlfor the psychological treatment and control

condition were entered in the Reviewcondition were entered in the Review

Manager tables. Dichotomous outcomesManager tables. Dichotomous outcomes

(PTSD diagnosis and leaving the study early(PTSD diagnosis and leaving the study early

for any reason) were analysed as a relativefor any reason) were analysed as a relative

risk number and were calculated on anrisk number and were calculated on an

intention-to-treat basis (i.e. a ‘once ran-intention-to-treat basis (i.e. a ‘once ran-

domised always analyse’ basis). This makesdomised always analyse’ basis). This makes

the conservative assumption that all partici-the conservative assumption that all partici-

pants who ceased to engage in the studypants who ceased to engage in the study

had an unfavourable outcome, e.g. they lefthad an unfavourable outcome, e.g. they left

because the treatment was not acceptablebecause the treatment was not acceptable

and still had a diagnosis of PTSD. Continu-and still had a diagnosis of PTSD. Continu-

ous outcomes were analysed as standardisedous outcomes were analysed as standardised

mean differences (SMDs) to allow for ease ofmean differences (SMDs) to allow for ease of

comparison across studies. It was not poss-comparison across studies. It was not poss-

ible to obtain intention-to-treat data for mostible to obtain intention-to-treat data for most

of the trials, and we therefore used completerof the trials, and we therefore used completer

data for all continuous outcomes.data for all continuous outcomes.

For consistency of presentation all dataFor consistency of presentation all data

were entered into Review Manager in suchwere entered into Review Manager in such

a way that negative effect sizes or relative riska way that negative effect sizes or relative risk

numbers less than 1 represented an effect thatnumbers less than 1 represented an effect that

favoured the active treatment compared withfavoured the active treatment compared with

the waiting-list control. Data were pooledthe waiting-list control. Data were pooled

from more than one study using a fixed-from more than one study using a fixed-

effects meta-analysis except where heteroge-effects meta-analysis except where heteroge-

neity was present, in which case a random-neity was present, in which case a random-

effects model was used as described below.effects model was used as described below.

HeterogeneityHeterogeneity

To check for heterogeneity between studies,To check for heterogeneity between studies,

both theboth the II22-test of heterogeneity and the-test of heterogeneity and the ww22--

test of heterogeneity (test of heterogeneity (PP550.10) as well as0.10) as well as

visual inspection of the forest plots were used.visual inspection of the forest plots were used.

TheThe II22 statistic describes the proportion of to-statistic describes the proportion of to-

tal variation in study estimates that is due total variation in study estimates that is due to

heterogeneity (Higgins & Thompson, 2002).heterogeneity (Higgins & Thompson, 2002).

AnAn II22 of less than 30% was taken to indicateof less than 30% was taken to indicate

mild heterogeneity and a fixed-effects modelmild heterogeneity and a fixed-effects model

was used to synthesise the results. Anwas used to synthesise the results. An II22 ofof

more than 50% was taken as notable hetero-more than 50% was taken as notable hetero-

geneity; in this case an attempt was made togeneity; in this case an attempt was made to

explain the variation. If studies with hetero-explain the variation. If studies with hetero-

geneous results were found to be comparable,geneous results were found to be comparable,

a random-effects model was used to summar-a random-effects model was used to summar-

ise the results (DerSimonian & Laird, 1986).ise the results (DerSimonian & Laird, 1986).

In the random-effects analysis, heterogeneityIn the random-effects analysis, heterogeneity

is accounted for both in the width of confi-is accounted for both in the width of confi-

dence intervals and in the estimate of thedence intervals and in the estimate of the

treatment effect. With decreasing heterogene-treatment effect. With decreasing heterogene-

ity the random-effects approach movesity the random-effects approach moves

asymptotically towards a fixed-effects model.asymptotically towards a fixed-effects model.

AnAn II22 of 30–50% was taken to indicate mod-of 30–50% was taken to indicate mod-

erate heterogeneity. In this case, both theerate heterogeneity. In this case, both the ww22--

test of heterogeneity and a visual inspectiontest of heterogeneity and a visual inspection

of the forest plot were used to decide betweenof the forest plot were used to decide between

a fixed- and random-effects model.a fixed- and random-effects model.

In order to explore heterogeneityIn order to explore heterogeneity

further, sensitivity analyses were performedfurther, sensitivity analyses were performed

to consider the influence of higher-qualityto consider the influence of higher-quality

methodology (this was done by consideringmethodology (this was done by considering

studies that used masked assessment, andstudies that used masked assessment, and

those that used an intention-to-treat analy-those that used an intention-to-treat analy-

sis), studies that only included females andsis), studies that only included females and

those that only included Vietnam veterans.those that only included Vietnam veterans.

Clinical effectivenessClinical effectiveness

Where psychological interventions wereWhere psychological interventions were

compared against waiting-list controlcompared against waiting-list control

groups an effect size (SMD) ofgroups an effect size (SMD) of 770.8 or less0.8 or less

(e.g. a larger negative number) was consid-(e.g. a larger negative number) was consid-

ered clinically meaningful for continuousered clinically meaningful for continuous

variables (a ‘large’ effect size; Cohen,variables (a ‘large’ effect size; Cohen,

1988) and for dichotomous outcomes a re-1988) and for dichotomous outcomes a re-

lative risk of 0.65 or less (or greater thanlative risk of 0.65 or less (or greater than

1.54) was considered clinically meaningful.1.54) was considered clinically meaningful.

Where two active treatments were com-Where two active treatments were com-

pared lower thresholds were set with anpared lower thresholds were set with an

SMD ofSMD of 770.5 or +0.5 for continuous0.5 or +0.5 for continuous

variables (a ‘medium’ effect size), and forvariables (a ‘medium’ effect size), and for

dichotomous outcomes a relative risk ofdichotomous outcomes a relative risk of

0.80 or less or 1.25 or greater was consid-0.80 or less or 1.25 or greater was consid-

ered clinically meaningful. These thresholdsered clinically meaningful. These thresholds

came from discussions in the NICE Guide-came from discussions in the NICE Guide-

line Development Group in advance ofline Development Group in advance of

undertaking the meta-analyses and wereundertaking the meta-analyses and were

based on clinical experience and thresholdsbased on clinical experience and thresholds

used in the literatureused in the literature (Schnurr(Schnurr et alet al, 2003)., 2003).

In order to be considered clinically mean-In order to be considered clinically mean-

ingful the value had to meet the thresholdingful the value had to meet the threshold

criterion and the 95% confidence intervalcriterion and the 95% confidence interval

had to be greater than the threshold. Ifhad to be greater than the threshold. If

the SMD and relative risk met the thresholdthe SMD and relative risk met the threshold

criterion but the 95% CI included values incriterion but the 95% CI included values in

the non-clinically significant range, this wasthe non-clinically significant range, this was

interpreted as limited evidence for an effect.interpreted as limited evidence for an effect.

Similarly, if the SMD or relative risk valueSimilarly, if the SMD or relative risk value

was below the threshold, the 95% CIs werewas below the threshold, the 95% CIs were

examined to determine whether the evidenceexamined to determine whether the evidence

was inconclusive (in case the 95% CI in-was inconclusive (in case the 95% CI in-

cluded numbers greater than the threshold)cluded numbers greater than the threshold)

or whether it could be stated that there wasor whether it could be stated that there was

evidence suggesting that an effect wasevidence suggesting that an effect was

unlikely (where the 95% CI was entirelyunlikely (where the 95% CI was entirely

outside the clinically meaningful range).outside the clinically meaningful range).

Psychological treatment categoriesPsychological treatment categories

Five separate psychological treatment cate-Five separate psychological treatment cate-

gories were defined (see Appendix). Thesegories were defined (see Appendix). These

came from discussions by the NICE Guide-came from discussions by the NICE Guide-

line Development Group in advance ofline Development Group in advance of

undertaking the meta-analyses and wereundertaking the meta-analyses and were

based on clinical experience and categoriesbased on clinical experience and categories

used in the literatureused in the literature (Foa(Foa et alet al, 2000)., 2000).

RESULTSRESULTS

Thirty-eight studies were included in theThirty-eight studies were included in the

meta-analysis. Figure 1 shows the meta-meta-analysis. Figure 1 shows the meta-

analysis profile summarising trial flow.analysis profile summarising trial flow.

9 89 8


Fig. 1Fig. 1 Trial flow (PTSD, post-traumatic stress disorder; RCT, randomised controlled trial).Trial flow (PTSD, post-traumatic stress disorder; RCT, randomised controlled trial).

TREATMENT OF CHRONIC P TSDTREATMENT OF CHRONIC PTSD

9 99 9


Table1

Table1

Summaryof

meta-analysisof

comparisons

ofpsycho

logicaltreatments

Summaryof

meta-analysisof

comparisons

ofpsycho

logicaltreatmentsvv.waitin

glistc

onditio

ns.w

aitin

glistc

onditio

ns

Com

parison

Com

parison

Clinician-rated

Clinician-rated

PTSD

symptom

sPT

SDsymptom

s

PTSD

diagno

sis

PTSD

diagno

sis

(intent-to-treat)

(intent-to-treat)

Self-ratedPT

SDsymptom

sSelf-ratedPT

SDsymptom

sAnx

iety

Anx

iety

Depression

Depression

Withd

rawalrate

Withd

rawalrate

TFCBT

TFCBT

vv.waiting

.waiting

list/usualcare

list/usualcare

TT44WW

14stud

ies

14stud

ies

nn¼649

649

SMD

SMD¼771.40

1.40

(95%

CI

(95%

CI77

1.89

to1.89

to770.91)

0.91)

TT44WW

15stud

ies

15stud

ies

nn¼763

763

RR

RR¼0.44

0.44

(95%

CI0.35to

0.57)

(95%

CI0.35to

0.57)

TT44WW

9stud

ies

9stud

ies

nn¼428

428

SMD

SMD¼771.70

1.70

(95%

CI

(95%

CI77

2.17

to2.17

to771.24)

1.24)

(T(T44W

)W

)

11stud

ies

11stud

ies

nn¼415

415

SMD

SMD¼770.99

0.99

(95%

CI

(95%

CI77

1.20

to1.20

to770.78)

0.78)

TT44

WW

14stud

ies

14stud

ies

nn¼625

625

SMD

SMD¼771.26

1.26

(95%

CI

(95%

CI77

1.69

to1.69

to77

0.82)

0.82)

(W(W44T)

T)

15stud

ies

15stud

ies

nn¼861

861

RR

RR¼1.42

1.42

(95%

CI1.05to

1.94)

(95%

CI1.05to

1.94)

EMDR

EMDRvv.waiting

.waiting

list/usualcare

list/usualcare

EE44WW

5stud

ies

5stud

ies

nn¼162

162

SMD

SMD¼771.51

1.51

(95%

CI

(95%

CI77

1.87

to1.87

to771.15)

1.15)

(E(E44W

)W

)

6stud

ies

6stud

ies

nn¼217

217

RR

RR¼0.49

0.49

(95%

CI0.28to

0.86

)(95%

CI0.28to

0.86

)

(E(E44W

)W

)

5stud

ies

5stud

ies

nn¼156

156

SMD

SMD¼771.13

1.13

(95%

CI

(95%

CI77

2.13

to2.13

to770.13)

0.13)

EE44WW

5stud

ies

5stud

ies

nn¼156

156

SMD

SMD¼771.20

1.20

(95%

CI

(95%

CI77

1.54

to1.54

to770.85)

0.85)

EE44WW

5stud

ies

5stud

ies

nn¼160

160

SMD

SMD¼771.48

1.48

(95%

CI

(95%

CI77

1.84

to^1.12)

1.84

to^1.12)

?? 6stud

ies

6stud

ies

nn¼216

216

RR

RR¼1.21

1.21

(95%

CI0.66to

2.22

)(95%

CI0.66to

2.22

)

Stressmanagem

ent

Stressmanagem

ent

vv.waiting

list/

.waiting

list/

usualcare

usualcare

(S(S44W

)W

)

3stud

ies

3stud

ies

nn¼8686

SMD

SMD¼771.14

1.14

(95%

CI

(95%

CI77

1.62

to1.62

to770.67)

0.67)

(S(S44W

)W

)

4stud

ies

4stud

ies

nn¼121

121

RR

RR¼0.64

0.64

(95%

CI0.47to

0.87)

(95%

CI0.47to

0.87)

?? 1stud

y1stud

y

nn¼2424

SMD

SMD¼0.33

0.33

(95%

CI

(95%

CI77

0.47

to1.14)

0.47

to1.14)

?? 3stud

ies

3stud

ies

nn¼8282

SMD

SMD¼770.77

0.77

(95%

CI

(95%

CI77

1.23

to1.23

to770.31)

0.31)

?? 4stud

ies

4stud

ies

nn¼109

109

SMD

SMD¼770.73

0.73

(95%

CI

(95%

CI77

1.12

to1.12

to770.33)

0.33)

?? 4stud

ies

4stud

ies

nn¼121

121

RR

RR¼2.19

2.19

(95%

CI0.71to

6.73

(95%

CI0.71to

6.73))

Other

therapies

Other

therapiesvv..

waiting

list/usualcare

waiting

list/usualcare

?? 2stud

ies

2stud

ies

nn¼7272

SMD

SMD¼77

0.43

0.43

(95%

CI

(95%

CI77

0.9to

0.04

)0.9to

0.04

)

?? 3stud

ies

3stud

ies

nn¼166

166

RR

RR¼0.79

0.79

(95%

CI0.53to

1.18)

(95%

CI0.53to

1.18)

(O(O44W

)W

)

2stud

ies

2stud

ies

nn¼132

132

SMD

SMD¼770.61

0.61

(95%

CI

(95%

CI77

0.98

to0.98

to770.24)

0.24)

(O(O44W

)W

)

3stud

ies

3stud

ies

nn¼153

153

SMD

SMD¼770.48

0.48

(95%

CI

(95%

CI77

0.82

to0.82

to77

0.14)

0.14)

?? 2stud

ies

2stud

ies

nn¼7272

SMD

SMD¼770.25

0.25

(95%

CI

(95%

CI77

0.71

to0.22

)0.71

to0.22

)

(W(W44O)

O)

3stud

ies

3stud

ies

nn¼166

166

RR

RR¼3.82

3.82

(95%

CI1.19to

12.29)

(95%

CI1.19to

12.29)

Group

CBT

Group

CBT

vv.waiting

.waiting

list/usualcare

list/usualcare

?? 1stud

y1stud

y

nn¼9797

SMD

SMD¼77

0.72

0.72

(95%

CI

(95%

CI77

1.14

to1.14

to770.31)

0.31)

(GC

(GC44W

)W

)

1stud

y1stud

y

nn¼4848

RR

RR¼0.56

0.56

(95%

CI0.31to

1.01

)(95%

CI0.31to

1.01

)

?? 2stud

ies

2stud

ies

nn¼7171

SMD

SMD¼770.71

0.71

(95%

CI

(95%

CI77

1.2to

1.2to

770.22

)0.22

)

Nodata

Nodata

Nodata

Nodata

?? 3stud

ies

3stud

ies

nn¼271

271

RR

RR¼1.00

1.00

(95%

CI0.64to

1.56)

(95%

CI0.64to

1.56)

EMDR

EMDRvv.TF

CBT

.TFC

BT(E(E¼T)

T)

6stud

ies

6stud

ies

nn¼187

187

SMD

SMD¼0.02

0.02

(95%

CI

(95%

CI77

0.5to

0.55)

0.5to

0.55)

?? 7stud

ies

7stud

ies

nn¼267

267

RR

RR¼1.14

1.14

(95%

CI0.70to

1.85)

(95%

CI0.70to

1.85)

(E(E¼T)

T)

7stud

ies

7stud

ies

nn¼20

620

6

SMD

SMD¼770.17

0.17

(95%

CI

(95%

CI77

0.45

to0.11)

0.45

to0.11)

(E(E¼T)

T)

4stud

ies

4stud

ies

nn¼136

136

SMD

SMD¼770.14

0.14

(95%

CI

(95%

CI77

0.48

to0.20

)0.48

to0.20

)

?? 7stud

ies

7stud

ies

nn¼20

620

6

SMD

SMD¼770.32

0.32

(95%

CI

(95%

CI77

0.9to

0.26)

0.9to

0.26)

?? 8stud

ies

8stud

ies

nn¼287

287

RR

RR¼0.87

0.87

(95%

CI0.58to

1.30)

(95%

CI0.58to

1.30) ((Continu

edContinu

ed))


10 010 0

AUTHOR’S PROOFAUTHOR’S PROOFTa

ble1

Table1

((Contin

ued

Contin

ued))

Com

parison

Com

parison

Clin

ician-rated

Clinician-rated

PTSD

symptom

sPT

SDsymptom

s

PTSD

diagno

sis

PTSD

diagno

sis

(intent-to-treat)

(intent-to-treat)

Self-ratedPT

SDsymptom

sSelf-ratedPT

SDsymptom

sAnx

iety

Anx

iety

Depression

Depression

Withd

rawalrate

Withd

rawalrate

TFCBT

TFCBT

vv.stress

.stress

managem

ent

managem

ent

?? 6stud

ies

6stud

ies

nn¼239

239

SMD

SMD¼770.27

0.27

(95%

CI

(95%

CI77

0.71

to0.16)

0.71

to0.16)

(T(T44S)S)

6stud

ies

6stud

ies

nn¼28

428

4

RR

RR¼0.78

0.78

(95%

CI0.61to

0.99

)(95%

CI0.61to

0.99

)

?? 3stud

ies

3stud

ies

nn¼127

127

SMD

SMD¼770.37

0.37

(95%

CI

(95%

CI77

0.74

to0.01

)0.74

to0.01

)

(T(T¼S)S)

4stud

ies

4stud

ies

nn¼127

127

SMD

SMD¼77

0.12

0.12

(95%

CI

(95%

CI77

0.49

to0.26)

0.49

to0.26)

?? 5stud

ies

5stud

ies

nn¼161

161

SMD

SMD¼77

0.25

0.25

(95%

CI

(95%

CI77

0.57

to0.08

)0.57

to0.08

)

?? 6stud

ies

6stud

ies

nn¼28

428

4

RR

RR¼1.17

1.17

(95%

CI0.69to

2.0)

(95%

CI0.69to

2.0)

TFCBT

TFCBT

vv.other

.other

therapies

therapies

(T(T44O)

O)

3stud

ies

3stud

ies

nn¼120

120

SMD

SMD¼770.81

0.81

(95%

CI

(95%

CI77

1.19

to1.19

to770.42)

0.42)

(T(T44O)

O)

5stud

ies

5stud

ies

nn¼28

628

6

RR

RR¼0.71

0.71

(95%

CI0.56to

0.89

)(95%

CI0.56to

0.89

)

(T(T44O)

O)

3stud

ies

3stud

ies

nn¼176

176

SMD

SMD¼771.18

1.18

(95%

CI

(95%

CI77

2.32

to2.32

to770.03)

0.03)

?? 4stud

ies

4stud

ies

nn¼197

197

SMD

SMD¼77

0.47

0.47

(95%

CI

(95%

CI77

1.11

to0.17)

1.11

to0.17)

(T(T44O)

O)

3stud

ies

3stud

ies

nn¼120

120

SMD

SMD¼77

0.65

0.65

(95%

CI

(95%

CI77

1.03

to1.03

to77

0.28

)0.28

)

?? 5stud

ies

5stud

ies

nn¼290

290

RR

RR¼1.14

1.14

(95%

CI0.68to

1.90

)(95%

CI0.68to

1.90

)

EMDR

EMDRvv.stress

.stress

managem

ent

managem

ent

?? 2stud

ies

2stud

ies

nn¼5353

SMD

SMD¼770.35

0.35

(95%

CI

(95%

CI77

0.90

to0.19)

0.90

to0.19)

(E(E44S)S)

3stud

ies

3stud

ies

nn¼8484

RR

RR¼0.69

0.69

(95%

CI0.46to

1.04

)(95%

CI0.46to

1.04

)

?? 3stud

ies

3stud

ies

nn¼7575

SMD

SMD¼770.40

0.40

(95%

CI

(95%

CI77

0.86

to0.06

)0.86

to0.06

)

(E(E44S)S)

2stud

ies

2stud

ies

nn¼4545

SMD

SMD¼77

0.75

0.75

(95%

CI

(95%

CI77

1.36

to1.36

to770.13)

0.13)

(E(E44S)S)

3stud

ies

3stud

ies

nn¼7575

SMD

SMD¼77

0.67

0.67

(95%

CI

(95%

CI77

1.14

to1.14

to770.20

)0.20

)

?? 3stud

ies

3stud

ies

nn¼8484

RR

RR¼1.03

1.03

(95%

CI0.37to

2.88

)(95%

CI0.37to

2.88

)

EMDR

EMDRvv.other

.other

therapies

therapies

Nodata

Nodata

(E(E44O)

O)

1stud

y1stud

y

nn¼6767

RR

RR¼0.4

0.4

(95%

CI0.19to

0.84

)(95%

CI0.19to

0.84

)

(T(T44O)

O)

2stud

ies

2stud

ies

nn¼124

124

SMD

SMD¼770.84

0.84

(95%

CI

(95%

CI77

1.21

to1.21

to770.47)

0.47)

(T(T44

O)

O)

2stud

ies

2stud

ies

nn¼126

126

SMD

SMD¼77

0.72

0.72

(95%

CI

(95%

CI77

1.08

to1.08

to770.36)

0.36)

(T(T44O)

O)

2stud

ies

2stud

ies

nn¼127

127

SMD

SMD¼77

0.67

0.67

(95%

CI

(95%

CI77

1.03

to1.03

to77

0.32)

0.32)

(O(O44T)

T)

2stud

ies

2stud

ies

nn¼127

127

RR

RR¼1.48

1.48

(95%

CI0.26to

8.54)

(95%

CI0.26to

8.54)

Stressmanagem

ent

Stressmanagem

ent

vv.othertherapies

.other

therapies

(S(S44O)

O)

1stud

y1stud

y

nn¼2525

SMD

SMD¼771.22

1.22

(95%

CI

(95%

CI77

2.09

to2.09

to77

0.35)

0.35)

?? 1stud

y1stud

y

nn¼3131

RR

RR¼0.58

0.58

(95%

CI0.30to

1.11)

(95%

CI0.30to

1.11)

Nodata

Nodata

?? 1stud

y1stud

y

nn¼2525

SMD

SMD¼77

0.51

0.51

(95%

CI

(95%

CI77

1.32

to0.29)

1.32

to0.29)

?? 1stud

y1stud

y

nn¼2525

RR

RR¼770.51

0.51

(95%

CI

(95%

CI77

1.31

to0.30)

1.31

to0.30)

?? 1stud

y1stud

y

nn¼3131

RR

RR¼0.82

0.82

(95%

CI0.2to

3.46

)(95%

CI0.2to

3.46

)

Group

TFCBT

Group

TFCBT

vv.grou

pCBT

.group

CBT

(non

-traum

a-focused)

(non

-traum

a-focused)

(GT

(GT¼GC)

GC)

1stud

y1stud

y

nn¼325

325

SMD

SMD¼770.12

0.12

(95%

CI

(95%

CI77

0.34

to0.1)

0.34

to0.1)

(GT

(GT¼GC)

GC)

1stud

y1stud

y

nn¼360

360

RR

RR¼0.98

0.98

(95%

CI0.83to

1.16)

(95%

CI0.83to

1.16)

Nodata

Nodata

Nodata

Nodata

Nodata

Nodata

(GC

(GC44GT)

GT)

1stud

y1stud

y

nn¼360

360

RR

RR¼1.38

1.38

(95%

CI1.00to

1.90

)(95%

CI1.00to

1.90

)

1.Key

tocomparison:

1.Key

tocomparison:

XX44YY,evidence

that

,evidencethat

XXhasclinicallyim

portantadvantages

over

hasclinicallyim

portantadvantages

over

YY;(;(XX44YY),lim

ited

evidence

that

),lim

ited

evidence

that

XXhasclinicallyim

portantadvantages

over

hasclinicallyim

portantadvantages

over

YY;?,evidence

isinconclusiv

eso

itisno

tpossib

leto

determ

inewhe

ther

thereisa

;?,evidenceisinconclusiv

eso

itisno

tpossib

leto

determ

inewhe

ther

thereisa

clinicallyim

portantd

ifference;(

clinicallyim

portantd

ifference;(XX¼YY),thereisevidence

suggestin

gthat

thereisun

likelyto

beaclinicallyim

portantd

ifference.

),thereisevidence

suggestin

gthat

thereisun

likelyto

beaclinicallyim

portantd

ifference.

CBT

,cognitiv

e^b

ehaviouraltherapy;EM

DR,eye

movem

entd

esensitisationandreprocessin

g;GC,group

CBT

,non

-traum

a-focused;

GT,grou

pTF

CBT

;O,o

ther

therapies;PT

SD,p

ost-traumaticstressdisorder;R

R,relativerisk;S,stress

CBT

,cognitiv

e^b

ehaviouraltherapy;EM

DR,eye

movem

entd

esensitisatio

nandreprocessin

g;GC,group

CBT

,non

-traum

a-focused;

GT,grou

pTF

CBT

;O,o

ther

therapies;PT

SD,p

ost-traumaticstressdisorder;R

R,relativerisk;S,stress

managem

ent;SM

D,stand

ardisedmeandifference;TF

CBT

,traum

a-focusedCBT

;W,w

aitin

glist/usualcare.

managem

ent;SM

D,stand

ardisedmeandifference;TF

CBT

,traum

a-focusedCBT

;W,w

aitin

glist/usualcare.


Study characteristicsStudy characteristics

Details of the studies included appear in theDetails of the studies included appear in the

data supplement to the online version ofdata supplement to the online version of

this article. Twenty-five studies comparedthis article. Twenty-five studies compared

trauma-focused cognitive–behaviouraltrauma-focused cognitive–behavioural

therapy (TFCBT) with waiting-list or othertherapy (TFCBT) with waiting-list or other

psychological interventions: Blanchardpsychological interventions: Blanchard et alet al

(2003), Brom(2003), Brom et alet al (1989), Bryant(1989), Bryant et alet al

(2003), Cloitre(2003), Cloitre et alet al (2002), Cooper &(2002), Cooper &

Clum (1989), Devilly & Spence (1999),Clum (1989), Devilly & Spence (1999),

EcheburuaEcheburua et alet al (1997), Ehlers(1997), Ehlers et alet al

(2005), Fecteau & Nicki (1999), Foa(2005), Fecteau & Nicki (1999), Foa et alet al

(1991, 1999), Gersons(1991, 1999), Gersons et alet al (2000), Ironson(2000), Ironson

et alet al (2002), Keane(2002), Keane et alet al (1989), Kubany(1989), Kubany etet

alal (2003), Kubany(2003), Kubany et alet al (2004), Lee(2004), Lee et alet al

(2002), Marks(2002), Marks et alet al (1998), Paunovic &(1998), Paunovic &

Ost (2001), Peniston & Kulkosky (1991),Ost (2001), Peniston & Kulkosky (1991),

PowerPower et alet al (2002), Resick(2002), Resick et alet al (2002),(2002),

RothbaumRothbaum et alet al (2005), Taylor(2005), Taylor et alet al

(2003) and Vaughan(2003) and Vaughan et alet al (1994). Twelve(1994). Twelve

studies compared eye movement desensiti-studies compared eye movement desensiti-

sation and reprocessing (EMDR) withsation and reprocessing (EMDR) with

waiting-list or other psychological inter-waiting-list or other psychological inter-

ventions: Carlsonventions: Carlson et alet al (1998), Devilly &(1998), Devilly &

Spence (1999), IronsonSpence (1999), Ironson et alet al (2002), Jensen(2002), Jensen

(1994), Lee(1994), Lee et alet al (2002), Marcus(2002), Marcus et alet al

(1997), Power(1997), Power et alet al (2002), Rothbaum(2002), Rothbaum

(1997), Rothbaum(1997), Rothbaum et alet al (2005), Scheck(2005), Scheck etet

alal (1998), Taylor(1998), Taylor et alet al (2003) and Vaughan(2003) and Vaughan

et alet al (1994). Seven studies compared stress(1994). Seven studies compared stress

management with waiting-list or othermanagement with waiting-list or other

psychological interventions: Carlsonpsychological interventions: Carlson et alet al

(1998), Echeburua(1998), Echeburua et alet al (1997), Foa(1997), Foa et alet al

(1991, 1999), Marks(1991, 1999), Marks et alet al (1998), Taylor(1998), Taylor

et alet al (2003) and Vaughan(2003) and Vaughan et alet al (1994). Six(1994). Six

studies compared ‘other therapies’ withstudies compared ‘other therapies’ with


ventions: Blanchardventions: Blanchard et alet al (2003), Brom(2003), Brom etet

alal (1989), Bryant(1989), Bryant et alet al (2003), Foa(2003), Foa et alet al

(1991), Marcus(1991), Marcus et alet al (1997) and Scheck(1997) and Scheck

et alet al (1998). Four studies compared group(1998). Four studies compared group

cognitive–behavioural therapy withcognitive–behavioural therapy with


ventions: Classenventions: Classen et alet al (2001), Krakow(2001), Krakow etet

alal (2001), Schnurr(2001), Schnurr et alet al (2003) and Zlotnick(2003) and Zlotnick

et alet al (1997).(1997).

Two additional randomised controlledTwo additional randomised controlled

trials met inclusion criteria but differed intrials met inclusion criteria but differed in

mode of deliverymode of delivery (Lange(Lange et alet al, 2003; Neuner, 2003; Neuner

et alet al, 2004), and one further trial compared, 2004), and one further trial compared

two versions of TFCBT (exposure andtwo versions of TFCBT (exposure and

cognitive therapy) with each othercognitive therapy) with each other (Tarrier(Tarrier

et alet al, 1999, 1999aa,,bb). These studies could not be). These studies could not be

included in the meta-analysis.included in the meta-analysis.

Quantitative data synthesisQuantitative data synthesis

Table 1 provides details of the quantitativeTable 1 provides details of the quantitative

data synthesis. It highlights that TFCBTdata synthesis. It highlights that TFCBT

and EMDR were better than waiting-list/and EMDR were better than waiting-list/

control on most outcome measures. Stresscontrol on most outcome measures. Stress

management was better on some outcomes,management was better on some outcomes,

and ‘other therapies’ appeared to be theand ‘other therapies’ appeared to be the

least effective. Unfortunately none of theleast effective. Unfortunately none of the

studies reported adverse effects andstudies reported adverse effects and

therefore it was not possible to analysetherefore it was not possible to analyse

these. However, most studies did reportthese. However, most studies did report

withdrawal rates and these are included inwithdrawal rates and these are included in

Table 1.Table 1.

Sensitivity analysesSensitivity analyses

Masked assessmentMasked assessment

The EMDR studies using masked assess-The EMDR studies using masked assess-

ment showed evidence favouring EMDRment showed evidence favouring EMDR

over waiting-list on reducing the severityover waiting-list on reducing the severity

of PTSD symptoms (clinician-rated mea-of PTSD symptoms (clinician-rated mea-

sures) (three studies,sures) (three studies, nn¼120; SMD120; SMD¼771.54,1.54,

1.54, 95% CI1.54, 95% CI 771.95 to1.95 to 771.12) similar to1.12) similar to

that in all EMDR studies (see Table 1).that in all EMDR studies (see Table 1).

The TFCBT studies using masked assess-The TFCBT studies using masked assess-

ment showed evidence favouring TFCBTment showed evidence favouring TFCBT

over waiting-list on reducing theover waiting-list on reducing the severity ofseverity of

PTSD symptoms (clinician-PTSD symptoms (clinician-rated measures)rated measures)

(seven studies,(seven studies, nn¼308; SMD308; SMD¼771.70; 95%1.70; 95%

CICI 772.47 to2.47 to 770.93) similar to that in all0.93) similar to that in all

TFCBT studies.TFCBT studies.

Vietnam veteran studiesVietnam veteran studies

One EMDR study considered only VietnamOne EMDR study considered only Vietnam

veterans. This showed less evidenceveterans. This showed less evidence

favouring EMDR over waiting-list onfavouring EMDR over waiting-list on

reducing the severity of PTSD symptomsreducing the severity of PTSD symptoms

(clinician-rated measures) (one study,(clinician-rated measures) (one study,

nn¼25; SMD25; SMD¼770.97, 95% CI0.97, 95% CI 771.81 to1.81 to

770.13) than the other EMDR studies (see0.13) than the other EMDR studies (see

Table 1). One TFCBT study consideredTable 1). One TFCBT study considered

only Vietnam veterans using the primaryonly Vietnam veterans using the primary

outcome measure; this showed less evidenceoutcome measure; this showed less evidence

favouring TFCBT over waiting-list on redu-favouring TFCBT over waiting-list on redu-

cing the severity of PTSD symptoms (clini-cing the severity of PTSD symptoms (clini-

cian-rated measures) (one study,cian-rated measures) (one study, nn¼24;24;

SMDSMD¼770.22, 95% CI0.22, 95% CI 771.03 to 0.58)1.03 to 0.58)

than the other TFCBT studies.than the other TFCBT studies.

Female studiesFemale studies

The EMDR studies including only femaleThe EMDR studies including only female

participants showed evidence favouringparticipants showed evidence favouring

EMDR over waiting-list on reducing theEMDR over waiting-list on reducing the

severity of PTSD symptoms (clinician-ratedseverity of PTSD symptoms (clinician-rated

measures) (two studies,measures) (two studies, nn¼57; SMD57; SMD¼771.67, 95% CI1.67, 95% CI 772.30 to2.30 to 771.04) similar1.04) similar

to that in all EMDR studies. The TFCBTto that in all EMDR studies. The TFCBT

studies including only female participantsstudies including only female participants

showed more evidence favouring TFCBTshowed more evidence favouring TFCBT

over waiting-list on reducing the severityover waiting-list on reducing the severity

of PTSD symptoms (clinician-rated mea-of PTSD symptoms (clinician-rated mea-

sures) (six studies,sures) (six studies, nn¼358; SMD358; SMD¼772.06,2.06,

95% CI95% CI 772.70 to2.70 to 771.42) than all TFCBT1.42) than all TFCBT

studies.studies.

Intention-to-treat analysisIntention-to-treat analysis

None of the EMDR studies reported usingNone of the EMDR studies reported using

an intention-to-treat analysis so this couldan intention-to-treat analysis so this could

not be assessed. The TFCBT studies usingnot be assessed. The TFCBT studies using

an intention-to-treat analysis showed morean intention-to-treat analysis showed more

evidence favouring TFCBT over waiting-listevidence favouring TFCBT over waiting-list

on reducing the severity of PTSD symptomson reducing the severity of PTSD symptoms

(clinician-rated measures) (six studies,(clinician-rated measures) (six studies,

nn¼332; SMD332; SMD¼771.82, 95% CI1.82, 95% CI 772.76 to2.76 to

770.89) than all TFCBT studies.0.89) than all TFCBT studies.

DISCUSSIONDISCUSSION

We identified 38 randomised controlledWe identified 38 randomised controlled

trials of psychological treatments for PTSD.trials of psychological treatments for PTSD.

Trauma-focused cognitive–behaviouralTrauma-focused cognitive–behavioural

therapy showed clinically important bene-therapy showed clinically important bene-

fits over waiting-list or usual care on allfits over waiting-list or usual care on all

measures of PTSD symptoms. In addition,measures of PTSD symptoms. In addition,

there was limited evidence that it also hasthere was limited evidence that it also has

clinically important effects on depressionclinically important effects on depression

and anxiety. The effectiveness of eye move-and anxiety. The effectiveness of eye move-

ment desensitisation and reprocessingment desensitisation and reprocessing

was also generally supported by the meta-was also generally supported by the meta-

analysis, but the evidence base was not asanalysis, but the evidence base was not as

strong as that for TFCBT, both in termsstrong as that for TFCBT, both in terms

of the number of trials available and theof the number of trials available and the

certainty with which clinical benefit was es-certainty with which clinical benefit was es-

tablished. Furthermore, there was limitedtablished. Furthermore, there was limited

evidence that TFCBT and EMDR wereevidence that TFCBT and EMDR were

superior to supportive/non-directive treat-superior to supportive/non-directive treat-

ments, hence it is highly unlikely that theirments, hence it is highly unlikely that their

effectiveness is due to non-specific factorseffectiveness is due to non-specific factors

such as attention. There was limited evi-such as attention. There was limited evi-

dence fordence for stress management and groupstress management and group

cognitive–cognitive–behavioural therapy, but ‘otherbehavioural therapy, but ‘other

therapy’ (supportive/non-directive therapy,therapy’ (supportive/non-directive therapy,

psychodynamic therapies and hypno-psychodynamic therapies and hypno-

therapies) that focused on current or pasttherapies) that focused on current or past

aspects of the patient’s life other than theaspects of the patient’s life other than the

trauma or on general support did not showtrauma or on general support did not show

clinically important effects on PTSD symp-clinically important effects on PTSD symp-

toms, depression or anxiety. However, thistoms, depression or anxiety. However, this

might be due to the limited number ofmight be due to the limited number of

studies available and does not meanstudies available and does not mean

that these treatments were shown to bethat these treatments were shown to be

ineffective.ineffective.

The treatments most supported by theThe treatments most supported by the

review (individually delivered TFCBT andreview (individually delivered TFCBT and

EMDR) are both trauma-focused psycho-EMDR) are both trauma-focused psycho-

logical treatments that specifically addresslogical treatments that specifically address

the patient’s troubling memories of thethe patient’s troubling memories of the

traumatic event and the personal meaningstraumatic event and the personal meanings

of the event and its consequences. Directof the event and its consequences. Direct

comparisons of these two approaches didcomparisons of these two approaches did

not reveal any significant advantages ofnot reveal any significant advantages of

101101



one over the other, with respect to eitherone over the other, with respect to either

treatment outcome or speed of therapeutictreatment outcome or speed of therapeutic

changechange (Taylor(Taylor et alet al, 2003)., 2003).

HeterogeneityHeterogeneity

There is clearly considerable clinicalThere is clearly considerable clinical

diversity within the studies considered.diversity within the studies considered.

The separation of different active inter-The separation of different active inter-

ventions into groups partially addressesventions into groups partially addresses

their impact on clinical diversity, but nottheir impact on clinical diversity, but not

all trials within the same group used identi-all trials within the same group used identi-

cal interventions. The differences werecal interventions. The differences were

most marked in the ‘other therapy’ group,most marked in the ‘other therapy’ group,

which had in common the absence ofwhich had in common the absence of

cognitive–behavioural techniques andcognitive–behavioural techniques and

trauma-focused work. There was alsotrauma-focused work. There was also

diversity in the TFCBT group, whichdiversity in the TFCBT group, which

included both exposure-only and trauma-included both exposure-only and trauma-

focused cognitive therapy interventions.focused cognitive therapy interventions.

Another source of heterogeneity wasAnother source of heterogeneity was

the quality of the studies. Sensitivitythe quality of the studies. Sensitivity

analyses of higher-quality and lower-analyses of higher-quality and lower-

quality studies were performed to explorequality studies were performed to explore

this further. There was some limitedthis further. There was some limited

evidence that higher-quality studies (thoseevidence that higher-quality studies (those

including masked assessment of outcomeincluding masked assessment of outcome

or intention-to-treat analysis) showedor intention-to-treat analysis) showed

better outcomes than the lower-qualitybetter outcomes than the lower-quality

studies. This finding contradicts previousstudies. This finding contradicts previous

researchresearch (Moher(Moher et alet al, 1998) that has found, 1998) that has found

an association between poorer method-an association between poorer method-

ology and more favourable results for theology and more favourable results for the

intervention. It may reflect the fact thatintervention. It may reflect the fact that

the better studies tended to be more recentthe better studies tended to be more recent

and associated with refinement of techni-and associated with refinement of techni-

ques. They also included most of theques. They also included most of the

female-only studies. The fact that female-female-only studies. The fact that female-

only studies showed a better response toonly studies showed a better response to

TFCBT than mixed studies and male-onlyTFCBT than mixed studies and male-only

studies is difficult to interpret. It may bestudies is difficult to interpret. It may be

that the female-only studies used morethat the female-only studies used more

effective interventions, that the trauma ofeffective interventions, that the trauma of

rape is more amenable than other traumasrape is more amenable than other traumas

to effective TFCBT, or that for some unde-to effective TFCBT, or that for some unde-

termined reason women are more respon-termined reason women are more respon-

sive to TFCBT than men. Interestingly, asive to TFCBT than men. Interestingly, a

similar superiority in female response hassimilar superiority in female response has

been found for pharmacological treatmentbeen found for pharmacological treatment

of PTSDof PTSD (National Collaborating Centre(National Collaborating Centre

for Mental Health, 2005). The finding thatfor Mental Health, 2005). The finding that

studies including only Vietnam veteransstudies including only Vietnam veterans

produced worse responses to TFCBT andproduced worse responses to TFCBT and

EMDR might have contributed to theEMDR might have contributed to the

female studies finding and also suggestsfemale studies finding and also suggests

that Vietnam veterans are a particularlythat Vietnam veterans are a particularly

difficult population to treat.difficult population to treat.

As with all psychological treatmentAs with all psychological treatment

trials, there are issues with the controltrials, there are issues with the control

group. The development of a psychologicalgroup. The development of a psychological

treatment placebo is difficult, if not imposs-treatment placebo is difficult, if not imposs-

ible, as is masking of participants andible, as is masking of participants and

therapists. In several of the waiting-list ortherapists. In several of the waiting-list or

usual care conditions it was apparent thatusual care conditions it was apparent that

some (usually poorly defined) treatmentsome (usually poorly defined) treatment

was going on. The main effect of this iswas going on. The main effect of this is

likely to have made it more difficult forlikely to have made it more difficult for

the active intervention to show itself to bethe active intervention to show itself to be

superior to the control condition.superior to the control condition.

TolerabilityTolerability

Unfortunately none of the studies reportedUnfortunately none of the studies reported

adverse effects. It remains unclear whetheradverse effects. It remains unclear whether

no adverse effects occurred, or whetherno adverse effects occurred, or whether

they were not described. This is a key short-they were not described. This is a key short-

coming in the trials identified. Most studiescoming in the trials identified. Most studies

reported withdrawals by group. There arereported withdrawals by group. There are

likely to be several different factors thatlikely to be several different factors that

determine withdrawal rates, including thedetermine withdrawal rates, including the

tolerability of the intervention. There wastolerability of the intervention. There was

limited evidence that TFCBT and otherlimited evidence that TFCBT and other

therapies fared worse than waiting-list ortherapies fared worse than waiting-list or

usual care on this outcome measure, butusual care on this outcome measure, but

there was no significant difference in with-there was no significant difference in with-

drawal rates in direct comparisons betweendrawal rates in direct comparisons between

any of the active treatments. The higher-any of the active treatments. The higher-

quality TFCBT studies showed no differ-quality TFCBT studies showed no differ-

ence in withdrawal rates when comparedence in withdrawal rates when compared

with waiting-list or usual care. Some peoplewith waiting-list or usual care. Some people

find it difficult to fully engage in psycho-find it difficult to fully engage in psycho-

logical treatment because it requires alogical treatment because it requires a

significant commitment of time and emo-significant commitment of time and emo-

tion. For some people with PTSD it maytion. For some people with PTSD it may

initially be difficult and overwhelming toinitially be difficult and overwhelming to

disclose details of their traumatic events.disclose details of their traumatic events.

It is also well recognised that some patientsIt is also well recognised that some patients

may be subject to initial adverse effectsmay be subject to initial adverse effects

such as increased re-experiencing followingsuch as increased re-experiencing following

exposure treatmentexposure treatment (Pitman(Pitman et alet al, 1991; Foa, 1991; Foa

et alet al, 2002; Hackmann, 2002; Hackmann et alet al, 2004). With-, 2004). With-

drawal rates of up to 30% in some studiesdrawal rates of up to 30% in some studies

suggest that the active treatments were notsuggest that the active treatments were not

always acceptable to those receiving them.always acceptable to those receiving them.

It is possible that in these cases devotingIt is possible that in these cases devoting

several sessions to establishing a trustingseveral sessions to establishing a trusting

therapeutic relationship and emotional sta-therapeutic relationship and emotional sta-

bilisation, before addressing the traumaticbilisation, before addressing the traumatic

event, might lead to greater acceptability.event, might lead to greater acceptability.

Limitations of the meta-analysisLimitations of the meta-analysis

Although this meta-analysis provides aAlthough this meta-analysis provides a

systematic and comprehensive comparisonsystematic and comprehensive comparison

of the different psychological treatmentsof the different psychological treatments

of PTSD, it is not without methodologicalof PTSD, it is not without methodological

problems. The randomised controlled trialsproblems. The randomised controlled trials

analysed usually reported unadjustedanalysed usually reported unadjusted

means for the treatment conditions aftermeans for the treatment conditions after

therapy and at follow-uptherapy and at follow-up. Sample sizes. Sample sizes

were usually small, raising the chance thatwere usually small, raising the chance that

baseline differences present before treat-baseline differences present before treat-

ment influenced scores after treatment.ment influenced scores after treatment.

Indeed, some studies showed baselineIndeed, some studies showed baseline

differences between the study conditionsdifferences between the study conditions

that remained uncorrected in our analysis.that remained uncorrected in our analysis.

However, across studies no systematicHowever, across studies no systematic

baseline difference existed, so the conclu-baseline difference existed, so the conclu-

sions remain valid. Furthermore, the Re-sions remain valid. Furthermore, the Re-

view Manager program does not allowview Manager program does not allow

entering a score of 0 for both groups. Thus,entering a score of 0 for both groups. Thus,

the withdrawal rates reported are slightthe withdrawal rates reported are slight

overestimates of the true rates.overestimates of the true rates.

Clinical implicationsClinical implications

Our results suggest that trauma-focusedOur results suggest that trauma-focused

psychological treatments (TFCBT orpsychological treatments (TFCBT or

EMDR) are effective for chronic PTSD.EMDR) are effective for chronic PTSD.

Indeed, the effect sizes compare favourablyIndeed, the effect sizes compare favourably

with those found for cognitive–behaviouralwith those found for cognitive–behavioural

therapy in depressive and anxiety disorderstherapy in depressive and anxiety disorders

(National Collaborating Centre for Mental(National Collaborating Centre for Mental

Health, 2004; National CollaboratingHealth, 2004; National Collaborating

Centre for Primary Care, 2004). TheseCentre for Primary Care, 2004). These

treatments are normally delivered on antreatments are normally delivered on an

individual out-patient basis over 8–12individual out-patient basis over 8–12

sessions. A course of trauma-focusedsessions. A course of trauma-focused

psychological treatment should be offeredpsychological treatment should be offered

to everyone with chronic PTSD. The resultsto everyone with chronic PTSD. The results

also suggest that not all chronic PTSD willalso suggest that not all chronic PTSD will

benefit from these treatments; otherbenefit from these treatments; other

approaches should then be considered,approaches should then be considered,

including extending the number of sessions,including extending the number of sessions,

trying an alternative form of trauma-trying an alternative form of trauma-

focused psychological treatment and thefocused psychological treatment and the

augmentation of trauma-focused psycholo-augmentation of trauma-focused psycholo-

gical treatment with a course of pharmaco-gical treatment with a course of pharmaco-

logical treatment. A recent meta-analysislogical treatment. A recent meta-analysis

has suggested that pharmacologicalhas suggested that pharmacological

interventions are unlikely to be as clinicallyinterventions are unlikely to be as clinically

effective as trauma-focused psychologicaleffective as trauma-focused psychological

interventions and should therefore be usedinterventions and should therefore be used

as a second-line treatmentas a second-line treatment (National(National

Collaborating Centre for Mental Health,Collaborating Centre for Mental Health,

2005).2005).

Future researchFuture research

Further well-designed trials of psycho-Further well-designed trials of psycho-

logical treatments are required, includinglogical treatments are required, including

further comparison studies of one type offurther comparison studies of one type of

psychological treatment against another.psychological treatment against another.

There is a need for large-scale studiesThere is a need for large-scale studies

(phase 4) to find out whether the results(phase 4) to find out whether the results

will survive in real practice. Future trialswill survive in real practice. Future trials

should consider adverse events and toler-should consider adverse events and toler-

ability of treatment in more detail. Our re-ability of treatment in more detail. Our re-

sults suggest that several of the currentlysults suggest that several of the currently

available treatments might benefit fromavailable treatments might benefit from

modifications that would make them moremodifications that would make them more

acceptable to people with chronic PTSDacceptable to people with chronic PTSD

10 210 2



and possibly also more effective. There isand possibly also more effective. There is

also potential for research concerning thealso potential for research concerning the

direct comparison of psychological treat-direct comparison of psychological treat-

ments with pharmacological treatments,ments with pharmacological treatments,

the effectiveness of a combination of thethe effectiveness of a combination of the

two, and the implications of the high degreetwo, and the implications of the high degree

of comorbidity with other disorders for theof comorbidity with other disorders for the

choice of treatment.choice of treatment.

APPENDIXAPPENDIX

Psychological treatment categoriesPsychological treatment categories

Treatments delivered on an individual basisTreatments delivered on an individual basisthat focused on the memory for the traumaticthat focused on the memory for the traumaticevent and its meaningevent and its meaning1. Trauma-focused cognitive^behavioural therapy1. Trauma-focused cognitive^behavioural therapy(TFCBT).(TFCBT).2. Eye movement desensitisation and reprocessing2. Eye movement desensitisation and reprocessing(EMDR).(EMDR).

Treatments delivered on an individual basisTreatments delivered on an individual basisthat do not place the main focus of treatmentthat do not place the main focus of treatmenton the traumaon the trauma3. Stress management and relaxation.3. Stress management and relaxation.4. Other therapies (including supportive therapy/4. Other therapies (including supportive therapy/non-directive counselling, psychodynamic therapiesnon-directive counselling, psychodynamic therapiesand hypnotherapy).and hypnotherapy).

Treatments delivered in groupsTreatments delivered in groups5. Group cognitive^behavioural therapy.5. Group cognitive^behavioural therapy.

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*Tarrier, N., Sommerfield,C., Pilgrim,H.,*Tarrier, N., Sommerfield,C., Pilgrim,H., et alet al(1999(1999bb)) Cognitive therapy or imaginal exposure in theCognitive therapy or imaginal exposure in thetreatment of post-traumatic stress disorder.Twelvetreatment of post-traumatic stress disorder.Twelvemonth follow-up.month follow-up. British Journal of PsychiatryBritish Journal of Psychiatry,, 175175,,571^575.571^575.

*Taylor, S.,Thordarson, D. S., Maxfield, L.,*Taylor, S.,Thordarson, D. S., Maxfield, L., et alet al(2003)(2003) Comparative efficacy, speed, and adverse effectsComparative efficacy, speed, and adverse effectsof three PTSD treatments: exposure therapy, EMDRof three PTSD treatments: exposure therapy, EMDRand relaxation training.and relaxation training. Journal of Consulting and ClinicalJournal of Consulting and ClinicalPsychologyPsychology,, 7171, 330^338., 330^338.

Van Etten, M. L. & Taylor, S. (1988)Van Etten, M. L. & Taylor, S. (1988) ComparativeComparativeefficacy of treatments for post-traumatic stressefficacy of treatments for post-traumatic stress

disorder: a meta-analysis.disorder: a meta-analysis. Clinical Psychology andClinical Psychology andPsychotherapyPsychotherapy,, 55, 126^145., 126^145.

*Vaughan, K., Armstrong, M. S., Gold, R.,*Vaughan, K., Armstrong, M. S.,Gold, R., et alet al(1994)(1994) A trial of eye movement desensitizationA trial of eye movement desensitizationcompared to image habituation training and appliedcompared to image habituation training and appliedmuscle relaxation in post-traumatic stress disorder.muscle relaxation in post-traumatic stress disorder.Journal of BehaviorTherapy and Experimental PsychiatryJournal of BehaviorTherapy and Experimental Psychiatry,,2525, 283^291., 283^291.

*Zlotnick,C., Shea,T. M., Rosen, K.,*Zlotnick,C., Shea,T. M., Rosen, K., et alet al (1997)(1997) AnAnaffect-management group for women withaffect-management group for women withposttraumatic stress disorder and histories of childhoodposttraumatic stress disorder and histories of childhoodsexual abuse.sexual abuse. Journal of Traumatic StressJournal of Traumatic Stress,, 1010, 425^436., 425^436.

*Studies that were part of the meta-analysis.*Studies that were part of the meta-analysis.

10 410 4


JONATHAN I.BISSONJONATHAN I.BISSON,Department of Psychological Medicine,Cardiff University;,Department of Psychological Medicine,Cardiff University; ANKE EHLERSANKE EHLERS, Institute of, Institute ofPsychiatry,King’s College London;Psychiatry,King’s College London; ROSAMATTHEWS, STEPHEN PILLINGROSAMATTHEWS, STEPHEN PILLING,National Collaborating Centre for,National Collaborating Centre forMental Health, London;Mental Health, London; DAVID RICHARDSDAVID RICHARDS,Department of Mental Health,University of York;,Department of Mental Health,University of York; STUARTSTUARTTURNERTURNER,University College London, London,UK,University College London, London,UK

Correspondence:Dr Jonathan Bisson,Department of Psychological Medicine,Monmouth House,Correspondence:Dr Jonathan Bisson,Department of Psychological Medicine,Monmouth House,University Hospital of Wales,Heath Park,Cardiff CF14 4XN,UK.Email: bissonjiUniversity Hospital of Wales,Heath Park,Cardiff CF14 4XN,UK.Email: bissonji@@cf.ac.ukcf.ac.uk

(First received 5 January 2006, final revision 27 April 2006, accepted 2 June 2006)(First received 5 January 2006, final revision 27 April 2006, accepted 2 June 2006)

Table DS1Table DS1 Studies included in themeta-analysisStudies included in themeta-analysis

Study referenceStudy reference

and countryand country

Participants ran-Participants ran-

domised/domised/

in post-in post-

treatmenttreatment

analysis,analysis, nn

Age, yearsAge, years

mean (s.d.)mean (s.d.)11FemaleFemale

%%

TraumaticTraumatic

eventsevents

Mean durationMean duration

of symptoms/of symptoms/

time sincetime since

traumatrauma

Types ofTypes of

treatmenttreatment

and controland control

DurationDuration

ofof

treatmenttreatment

PTSDPTSD

outcomeoutcome

measuresmeasures

Follow-upFollow-up

periodperiod

Randomis-Randomis-

ationation

concealmentconcealment

ITTITT

analysisanalysis

MaskingMasking

ofof

assessorassessor

BromBrom et alet al, 1989, 1989

(The Netherlands)(The Netherlands)

112112

100 completed100 completed

(12 drop-outs(12 drop-outs

reported)reported)

42 (14.3)42 (14.3) 7979 MixedMixed Less thanLess than

5 years5 years

OT1 (psycho-OT1 (psycho-

dynamicdynamic

therapy)therapy)

OT2OT2

(hypnotherapy)(hypnotherapy)

TFCBT (trauma de-TFCBT (trauma de-

sensitisation)sensitisation)

Waiting listWaiting list

Mean 14^19Mean 14^19

sessionssessions

SCL^90 (traumaSCL^90 (trauma

symptoms)symptoms)

IESIES

(intrusion and(intrusion and

avoidance)avoidance)

Post-Post-

treatment,treatment,

3MFU3MFU

Not givenNot given CompletersCompleters

onlyonly

Not givenNot given

Cooper & ClumCooper & Clum

1989 (USA)1989 (USA)

22 randomised22 randomised

14 included in14 included in

analysis (8 didanalysis (8 did

not complete)not complete)

3737 00 CombatCombat

(Vietnam)(Vietnam)

Not givenNot given TFCBTTFCBT

(imaginal(imaginal

flooding)flooding)

Standard careStandard care

(psychological(psychological

and pharma-and pharma-

cological)cological)

Six to fourteenSix to fourteen

1.5h sessions1.5 h sessions

includingincluding

introductionintroduction

and assess-and assess-

mentment

(maximum 9(maximum 9

active floodingactive flooding

sessions)sessions)

Self-monitoringSelf-monitoring

ofof

re-experiencingre-experiencing

symptoms andsymptoms and

sleepsleep

Modified VietnamModified Vietnam

Experiences Ques-Experiences Ques-

tionnaire (non-vali-tionnaire (non-vali-

dated)dated)

BehaviouralBehavioural

avoidance testavoidance test

SUDSSUDS

Post-Post-

treatmenttreatment

3 MFU3MFU


onlyonly

Not givenNot given

KeaneKeane et alet al, 1989, 1989

(USA)(USA)

2424


34.6 (4.3)34.6 (4.3) 00 CombatCombat

(Vietnam)(Vietnam)

Not givenNot given TFCBTTFCBT

(implosive(implosive

flooding)flooding)


Fourteen toFourteen to

sixteen 90minsixteen 90min

sessionssessions

PTSD symptomPTSD symptom

checklistchecklist

(Jackson(Jackson

StructuredStructured

Interview)Interview)

MMPI (PTSDMMPI (PTSD

sub-scale)sub-scale)

Post-Post-

treatmenttreatment

6MFU (CBT),6MFU (CBT),

4.5 MFU4.5 MFU

(waiting list)(waiting list)

Not givenNot given YesYes NoNo

FoaFoa et alet al, 1991, 1991

(USA)(USA)

4545

3535

31.8 (8.2)31.8 (8.2) 100100 RapeRape 6.2 (6.7)6.2 (6.7)

yearsyears

SM (stressSM (stress

inoculation)inoculation)

TFCBT (prolongedTFCBT (prolonged

exposure)exposure)

OT (supportiveOT (supportive

counselling)counselling)


13.5 h13.5h Clinician-ratedClinician-rated

PTSD severityPTSD severity

Post-Post-


3MFU3MFU


onlyonly

Not givenNot given

(Continued)(Continued)

DATA

SU

PPLEM

EN

TTO

DATA

SU

PPLEM

EN

TTO

BRIT

ISH

JOURNALOFPSYCHIA

TRY

BRIT

ISH

JOURNALOFPSYCHIA

TRY(2007),1

90,97^104

(2007),1

90,97^104

Peniston &Peniston &

Kulkosky, 1991Kulkosky, 1991

(USA)(USA)

2929

2929

36.6 (2.82)36.6 (2.82) 00 CombatCombat

(Vietnam)(Vietnam)

12^15 years12^15 years TFCBT (neuro-TFCBT (neuro-

feedbackfeedback

training)training)

Usual careUsual care

4h pre-4h pre-

training+training+

15h active15h active

interventionintervention

MMPI^RMMPI^R Post-Post-


30MFU30MFU

Not givenNot given YesYes MaskedMasked

evaluationevaluation

of MMPIof MMPI

datadata

Jensen, 1994Jensen, 1994

(USA)(USA)

2929

2525

41.3 (2.84)41.3 (2.84) 00 CombatCombat

(Vietnam)(Vietnam)

Not givenNot given EMDRControlEMDRControl Not givenNot given

(3 sessions in all)(3 sessions in all)


Interview forInterview for

PTSDPTSD

Post-Post-

treatmenttreatment

onlyonly


onlyonly

Not givenNot given

VaughanVaughan et alet al,,

1994 (Australia)1994 (Australia)

3636

3636

32 (14.7)32 (14.7) 6464 MixedMixed Not givenNot given EMDREMDR

TFCBT (imageTFCBT (image

habituationhabituation

training)training)

SM (appliedSM (applied

musclemuscle

relaxation)relaxation)

Four 50minFour 50min

sessions (allsessions (all

conditions)conditions)

PTSDPTSD


InterviewInterview

IESIES

Post-Post-


3MFU3MFU

Not givenNot given YesYes YesYes

Echeburua eEcheburua et alt al,,

1997 (Spain)1997 (Spain)

2020 20 (7.09)20 (7.09) 100100 SexualSexual

aggressionaggression

(childhood and(childhood and

adult)adult)

Not givenNot given TFCBT (gradualTFCBT (gradual

self-exposureself-exposure

and cognitiveand cognitive

restructuring)restructuring)

SM (progressiveSM (progressive

relaxation training)relaxation training)

Six 70min self-Six 70min self-

exposure sessionsexposure sessions

Six 45minSix 45min

relaxation sessionsrelaxation sessions


interviewinterview

(scored on(scored on

Scale of SeverityScale of Severity

of PTSDof PTSD

Symptoms)Symptoms)

Post-Post-


1MFU, 3MFU,1MFU, 3MFU,

6MFU, 12MFU6MFU, 12MFU

Not givenNot given YesYes NoNo

MarcusMarcus et alet al,,

1997 (USA)1997 (USA)

6767

66 completed (166 completed (1

drop-outdrop-out

reported)reported)

41.0 (range41.0 (range

18^73)18^73)

7979 MixedMixed Not givenNot given EMDREMDR

Standard careStandard care

(including(including

psychological andpsychological and

pharmacological)pharmacological)

No set duration;No set duration;

at least threeat least three

50min sessions50min sessions

Modified PTSDModified PTSD

scalescale

IESIES

SCL^90SCL^90

SUDSSUDS

Mid-therapyMid-therapy

(after 3(after 3

sessions),sessions),

post-treatmentpost-treatment

Not givenNot given UnclearUnclear NoNo

Rothbaum, 1997Rothbaum, 1997

(USA)(USA)

2121

18 completed (318 completed (3

drop-outsdrop-outs

reported)reported)

34.2 (11.1)34.2 (11.1) 100100 RapeRape

(adulthood)(adulthood)

Not givenNot given

Mean 104Mean 104

monthsmonths

since rapesince rape

(s.d.(s.d.¼106.6)106.6)

EMDREMDR


OneOne

information-information-

gatheringgathering

session thensession then

three 90minthree 90min

active EMDRactive EMDR

sessionssessions


interview (PSS)interview (PSS)

IESIES

Rape AftermathRape Aftermath

SymptomTestSymptomTest

Post-Post-


3MFU3MFU


onlyonly

No (inde-No (inde-

pendentpendent

but notbut not

masked)masked)

ZlotnickZlotnick et alet al,,

1997 (USA)1997 (USA)

4848



reported;reported;

2 unaccounted2 unaccounted

for)for)

39 (9.59)39 (9.59) 100100 ChildhoodChildhood

sexual abusesexual abuse

Not givenNot given

Mean age ofMean age of

first abusefirst abuse

6.86 years6.86 years

(s.d.(s.d.¼2.36)2.36)

Group CBTGroup CBT

(affectmanage-(affect manage-

ment group)ment group)


One 2h sessionOne 2h session

per week forper week for

15 weeks15 weeks

CAPS^1CAPS^1

DavidsonDavidson

Trauma ScaleTrauma Scale

SCL^90^RSCL^90^R

Post-Post-

treatmenttreatment


onlyonly

Not givenNot given

((ContinuedContinued))

DATA

SU

PPLEM

EN

TTO

DATA

SU

PPLEM

EN

TTO

BRIT

ISH

JOURNALOFPSYCHIA

TRY

BRIT

ISH

JOURNALOFPSYCHIA

TRY(2007),1

90,97^104

(2007),1

90,97^104

CarlsonCarlson et alet al,,1998 (USA)1998 (USA)

353534 completed34 completed(1 drop-out(1 drop-out upupto post-to post-treatmenttreatmentassessment,assessment,30 at 3MFU,30 at 3MFU,12 at 9MFU)12 at 9MFU)

48 (8.6)48 (8.6) 00 CombatCombat Not givenNot given EMDREMDRSMSM(biofeedback-(biofeedback-assisted relaxa-assisted relaxa-tion)Waiting listtion)Waiting list

EMDR: twelveEMDR: twelve60^75 min60^75 minsessions oversessions over6 weeks6 weeksRelaxation:Relaxation:twelve 40mintwelve 40minsessions oversessions over6 weeks6 weeks

CAPS^1CAPS^1PTSD SymptomPTSD SymptomScaleScaleIESIESMississippi ScaleMississippi Scalefor Combat-for Combat-Related PTSDRelated PTSD

Post-Post-treatment (all)treatment (all)3MFU, 9MFU3MFU, 9MFU(intervention(interventiongroups only)groups only)

Not givenNot given CompletersCompletersonlyonly

Post-Post-treatment/treatment/3MFU3MFUmask-mask-inging unclearunclearMaskedMaskedassessmentassessmentreported atreported at9MFU9MFU

MarksMarks et alet al,,

1998 (UK)1998 (UK)

878777 completed77 completed(10 drop-outs(10 drop-outsreported)reported)

38 (10)38 (10) 3636 VariousVarious At least 6At least 6months,months,mean 46mean 46monthsmonths(s.d.(s.d.¼58)58)

TFCBT1TFCBT1(prolonged(prolongedimaginal andimaginal andlive exposurelive exposuretherapy)therapy)TFCBT 2 (cognitiveTFCBT 2 (cognitiverestructuring)restructuring)TFCBT 3TFCBT 3(combined(combinedprolongedprolongedexposure andexposure andcognitivecognitiverestructuring)restructuring)SM (relaxation)SM (relaxation)

All conditions,All conditions,ten 90min sess-ten 90min sess-ions (105min forions (105min forcombined group)combined group)

CAPS^2CAPS^2IESIESPSSPSS

Post-Post-treatment,treatment,1MFU, 3MFU,1MFU, 3MFU,6MFU6MFU

Not givenNot given Com-Com-pleterspletersonlyonly

YesYes

ScheckScheck et alet al,,1998 (USA)1998 (USA)

676760 completed (760 completed (7drop-outsdrop-outs re-re-ported)ported)

20.920.9(range 16^25)(range 16^25)

100100 Mixed: 50%Mixed: 50%sexual traumasexual trauma

Not givenNot given EMDREMDROT (activeOT (activelistening)listening)

Two 90minTwo 90minsessions (bothsessions (bothconditions)conditions)

Penn InventoryPenn Inventoryfor PTSDfor PTSDIESIES

Post-Post-treatment,treatment,3MFU3MFU


Masked ad-Masked ad-ministrationministrationat end-point,at end-point,masking ofmasking ofassessmentassessmentunclearunclear3MFU not3MFU notmaskedmasked

Devilly & Spence,Devilly & Spence,1999 (Australia)1999 (Australia)

323223 completed (923 completed (9drop-outs re-drop-outs re-ported)ported)

37.96 (12.82)37.96 (12.82) 6565(of completers)(of completers)

Not givenNot given Not givenNot given TFCBTTFCBT(CBT ^ trauma(CBT ^ traumatreatmenttreatmentprotocol)protocol)EMDREMDR

CBT: nineCBT: ninesessions (6sessions (6�90min90min+3+3�120min)120min)EMDR: up toEMDR: up toeighteight90^120min90^120minsessionssessions

SCL^90^RSCL^90^RSUDSSUDSCivilianCivilianMississippi ScaleMississippi Scalefor PTSDfor PTSDIESIESPSS^SRPSS^SRPTSD InterviewPTSD Interview

Post-Post-treatment,treatment,2 weeks,2 weeks,3 months3 months


Not givenNot given

Fecteau &Nicki,Fecteau &Nicki,1999 (Canada)1999 (Canada)

23232020

41.341.3(range 25^63)(range 25^63)

7070 RTARTA 18.8 months18.8 months(mean)(mean)

TFCBTTFCBTWaiting listWaiting list

8 h8happroximatelyapproximately

CAPSCAPSIESIES

6MFU6MFU Not givenNot given CompletersCompletersonlyonly

Not givenNot given

FoaFoa et alet al, 1999, 1999(USA)(USA)

96967979

34.9 (10.6)34.9 (10.6) 100100 Assault ofAssault ofwhich 72%which 72%sexual assaultsexual assault

Not givenNot given TFCBT (exposureTFCBT (exposuretherapy) SM (stresstherapy) SM (stressinoculation train-inoculation train-ing) TFCBT+SMing) TFCBT+SM(combination ex-(combination ex-posure and stressposure and stressinoculation)inoculation)Waiting listWaiting list

10.5h10.5h PSS^IPSS^I 12MFU12MFU Not givenNot given CompletersCompletersonlyonly

Not givenNot given

(Continued)(Continued)

DATA

SU

PPLEM

EN

TTO

DATA

SU

PPLEM

EN

TTO

BRIT

ISH

JOURNALOFPSYCHIA

TRY

BRIT

ISH

JOURNALOFPSYCHIA

TRY(2007),1

90,97^104

(2007),1

90,97^104

TarrierTarrier et alet al,,

19991999aa (UK)(UK)

7272

62 completed;62 completed;

57 at 6MFU,57 at 6MFU,

54 at 12MFU54 at 12MFU

37.9 (11.8)37.9 (11.8) 4141 MixedMixed Not givenNot given TFCBT1TFCBT1

(imaginal(imaginal

exposure)exposure)

TFCBT 2 (cogni-TFCBT 2 (cogni-

tive therapy)tive therapy)

Sixteen 60minSixteen 60min

sessions in bothsessions in both

conditionsconditions

(mean(mean

attendanceattendance

11.2 sessions,11.2 sessions,

s.d.s.d.¼4.5)4.5)

IESIES

CAPSCAPS

Penn Inventory forPenn Inventory for

PTSDPTSD

Post-Post-


12MFU12MFU


onlyonly

YesYes

TarrierTarrier et alet al,,

19991999bb (UK)(UK)

7272


57 at 6MFU57 at 6MFU

8.6 (11.6)8.6 (11.6) 4242 MixedMixed

(non-CSA)(non-CSA)

34%34%551212

monthsmonths

40%40%

1^2 years1^2 years

26%26%

2^10 years2^10 years

TFCBT1TFCBT1

(imaginal(imaginal

exposure)exposure)

TFCBT 2 (cognitiveTFCBT 2 (cognitive

therapy)therapy)

Sixteen sessionsSixteen sessions

60min in both60min in both

conditionsconditions

IESIES

CAPSCAPS

Penn Inventory forPenn Inventory for

PTSDPTSD

6MFU6MFU Not givenNot given CompletersCompleters

onlyonly

YesYes

GersonsGersons et alet al,,

20002000


4242


(1 drop-out(1 drop-out

included inincluded in

analysis)analysis)

36.5 (7)36.5 (7) 2222 TraumaticTraumatic

event at workevent at work

(all police(all police

officers)officers)

3 years3 years TFCBT (briefTFCBT (brief

eclectic psy-eclectic psy-

chotherapy)chotherapy)


16h16h Clinician-ratedClinician-rated

PTSD symptomsPTSD symptoms

3MFU3MFU Not givenNot given YesYes YesYes

ClassenClassen et alet al,,

2002001 (USA)1 (USA)

5555

5252

Not givenNot given 100100 AdultAdult

survivorssurvivors

of CSAof CSA

Not givenNot given GroupTFCBTGroupTFCBT

(trauma-focused(trauma-focused

group therapy)group therapy)

Group CBTGroup CBT

(present-centred(present-centred

group therapy)group therapy)


36h36h TraumaTrauma

SymptomSymptom

Checklist^40Checklist^40


onlyonly

Not givenNot given

KrakowKrakow et alet al,,

2002001 (USA)1 (USA)

168168

114 (end-point)114 (end-point)

96 (3MFU)96 (3MFU)

99 (6MFU)99 (6MFU)

36.9 (12.7)36.9 (12.7) 100100 Sexual assaultSexual assault

(adult and(adult and

CSA)CSA)

Not givenNot given Group CBT (groupGroup CBT (group

imagery rehearsal)imagery rehearsal)


Three 3hThree 3h

sessionssessions

DSSDSS

CAPSCAPS

Post-Post-

treatmemt,treatmemt,

3MFU, 6MFU3MFU, 6MFU


Paunovic &Ost,Paunovic &Ost,

2002001 (Sweden)1 (Sweden)

2020



reported)reported)

37.9 (7.6)37.9 (7.6) 1919 MixedMixed

(refugee(refugee

population)population)

7.8 years7.8 years

(s.d.(s.d.¼7.0)7.0)

TFCBT1TFCBT1

(trauma-(trauma-

focused CBT)focused CBT)

TFCBT 2 (expo-TFCBT 2 (expo-

sure therapy)sure therapy)

Sixteen toSixteen to

twentytwenty

60^120min60^120min

(both(both

conditions)conditions)

CAPS^IVCAPS^IV

IES^RIES^R

PSSPSS

Post-Post-


6MFU6MFU


onlyonly

NoNo

CloitreCloitre et alet al,,

2002 (USA)2002 (USA)

5858

4646

34 (7.22)34 (7.22) 100100 AdultAdult

survivorssurvivors

of CSAof CSA

Not givenNot given TFCBT (CBTTFCBT (CBT

andmodifiedandmodified

prolongedprolonged

exposure)exposure)


20h20h CAPSCAPS

ModifiedModified

PSS^SRPSS^SR


onlyonly

Not givenNot given

((ContinuedContinued))

DATA

SU

PPLEM

EN

TTO

DATA

SU

PPLEM

EN

TTO

BRIT

ISH

JOURNALOFPSYCHIA

TRY

BRIT

ISH

JOURNALOFPSYCHIA

TRY(2007),1

90,97^104

(2007),1

90,97^104

IIronsonronson et alet al,,2002 (USA)2002 (USA)

222219 completed19 completed(3 drop-outs re-(3 drop-outs re-ported)ported)12 at 3MFU12 at 3MFU

Limited dataLimited datagiven (range 16^given (range 16^

62 years)62 years)

7777 MixedMixed Not givenNot given EMDREMDRTFCBT (pro-TFCBT (pro-longed exposure)longed exposure)

In bothIn bothconditionsconditions3 non-active3 non-activesessions, 3 activesessions, 3 activesessions withsessions withhomeworkhomework

SUDSSUDSPSS^SRPSS^SR



NoNo

LeeLee et alet al, 2002, 2002(USA)(USA)

242421 completed21 completed(3 drop-outs re-(3 drop-outs re-ported)ported)

35.3 (17.16)35.3 (17.16) 4646 MixedMixed Time since trau-Time since trau-ma: mean 14.9ma: mean 14.9monthsmonths(s.d.(s.d.¼15.71)15.71)

EMDREMDRSM+TFCBTSM+TFCBT(stress inoculation(stress inoculationtraining withtraining withprolongedprolongedexposure)exposure)

Seven 90minSeven 90minsessionssessions

SI^PTSDSI^PTSDIESIESKeane’s PTSD scaleKeane’s PTSD scalefrom the MMPIfrom the MMPI



NoNo

PowerPower et alet al,,2002 (UK)2002 (UK)


Completers:Completers:39.2 (11.8)39.2 (11.8)

58 (of58 (ofcompleters)completers)

MixedMixed Time sinceTime sincetraumatrauma(completers):(completers):mean 199.3mean 199.3weeksweeks(s.d.(s.d.¼426)426)

EMDREMDRTFCBTTFCBT(cognitive(cognitiverestructuringrestructuringand exposureand exposuretherapy)therapy)Waiting listWaiting list

Maximum ofMaximum often 90min sessionsten 90min sessions

CAPSCAPSIESIESSI^PTSD (self-SI^PTSD (self-report version)report version)



YesYes

ResickResick et alet al, 2002, 2002(USA)(USA)


32 (9.9)32 (9.9) 100100 Rape (duringRape (duringchildhoodchildhoodand/orand/oradulthood)adulthood)

At least 3At least 3months sincemonths sincetrauma, meantrauma, mean8.5 years8.5 years(s.d.(s.d.¼8.5)8.5)

TFCBT1 (cogni-TFCBT1 (cogni-tive processingtive processingtherapy)therapy)TFCBT 2TFCBT 2(prolonged(prolongedexposure)exposure)Minimal attentionMinimal attention

Total 13h activeTotal 13h activetreatment overtreatment over6 weeks, plus6 weeks, plushomeworkhomework(TFCBT1mean(TFCBT1mean22.6h, TFCBT 222.6h, TFCBT 2mean 44.8h)mean 44.8h)

CAPSCAPSPSSPSS

Post-Post-treatment,treatment,3MFU, 9MFU3MFU, 9MFU

Not givenNot given YesYes Not givenNot given

BlanchardBlanchard et alet al, 2003, 2003(USA)(USA)

73735353

41 (13.1)41 (13.1) 7373 RTARTA 9.8^15.1months9.8^15.1monthsaverageaveragedurationdurationacross treat-across treat-ment groupsment groups

TFCBTTFCBTOT (supportiveOT (supportivepsychotherapy)psychotherapy)Waiting listWaiting list

8^12 sessions8^12 sessions(length(lengthunspecified)unspecified)

CAPSCAPSIESIES

3MFU3MFU Not givenNot given CompletersCompletersonlyonly

YesYes

BryantBryant et alet al,,2003 (Australia)2003 (Australia)


35.2 (12.31)35.2 (12.31) 5252 MixedMixed(excluding(excludingsexual assault)sexual assault)

MininumMininum3months3 months

TFCBT1TFCBT1(prolonged(prolongedimaginalimaginalexposure andexposure andcognitivecognitiverestructuring)restructuring)TFCBT 2 (pro-TFCBT 2 (pro-longed imaginal ex-longed imaginal ex-posure)posure)OT (supportiveOT (supportivecounselling)counselling)

All conditions:All conditions:eight 90mineight 90minsessionssessions

CAPS^2CAPS^2IESIES



KubanyKubany et alet al,,2003 (USA)2003 (USA)

373732 completed (532 completed (5drop-outs re-drop-outs re-ported)ported)25 at 3MFU25 at 3MFU

36.4 (9.1)36.4 (9.1) 100100 MixedMixedtraumaswithin atraumaswithin apopulation ofpopulation of‘battered‘batteredwomen’women’

Not givenNot given TFCBTTFCBT(cognitive(cognitivetrauma therapytrauma therapyfor batteredfor batteredwomen)women)Waiting listWaiting list

Mean 8.5 (range 7^Mean 8.5 (range 7^11) sessions11) sessions(90min)(90min)

CAPSCAPS Post-Post-treatment,treatment,3MFU3MFU


DATA

SU

PPLEM

EN

TTO

DATA

SU

PPLEM

EN

TTO

BRIT

ISH

JOURNALOFPSYCHIA

TRY

BRIT

ISH

JOURNALOFPSYCHIA

TRY(2007),1

90,97^104

(2007),1

90,97^104

LangeLange et alet al, 2003, 2003


184184

10101 at post-1 at post-

treatmenttreatment


reported)reported)

57 at 6 weeks57 at 6 weeks

Completers:Completers:

39.0 (10.5)39.0 (10.5)

8080 MixedMixed At least 3At least 3

months sincemonths since

trauma, meantrauma, mean

9.0 years9.0 years

(s.d.(s.d.¼11.6)11.6)

InterapyInterapy


Ten 45minwritingTen 45min writing

exercisesexercises

SCL^90SCL^90

IESIES

Post-Post-


6 weeks FU6 weeks FU


onlyonly

Not givenNot given

TaylorTaylor et alet al, 2003, 2003

(Canada)(Canada)

6060


37 (10)37 (10) 7575 MixedMixed MeanMean

durationduration

8.7 years8.7 years

(s.d.(s.d.¼10.8)10.8)

EMDREMDR

TFCBTTFCBT

(exposure(exposure

therapy)therapy)

SM (relaxation)SM (relaxation)

All conditions:All conditions:

eight 90mineight 90min

sessionssessions

CAPSCAPS

PSSPSS

Post-Post-


3MFU3MFU

Not givenNot given BothBoth

completer andcompleter and

(limited) ITT(limited) ITT

analyses re-analyses re-

portedported

YesYes

SchnurrSchnurr et alet al,,2003 (USA)2003 (USA)

360360253 completed253 completed(325 partici-(325 partici-pated inpated infollow-up)follow-up)

50.7 (3.7)50.7 (3.7) 00 CombatCombat(Vietnam)(Vietnam)

Not givenNot given GroupTFCBTGroupTFCBTGroup CBTGroup CBT(present-(present-centredcentredgroupgrouptherapy)therapy)

Both conditions:Both conditions:thirty 90^thirty 90^120min sessions,120min sessions,then five 90minthen five 90min‘booster’ sessions‘booster’ sessions

CAPSCAPSPTSDPTSDChecklistChecklistSF^36SF^36

Post-Post-treatment,treatment,12 months12 months(end of booster(end of boosterperiod) 18MFU,period) 18MFU,24MFU24MFU


EhlersEhlers et alet al,,2005 (UK)2005 (UK)

28282828

36.6 (11.2)36.6 (11.2) 53.553.5 MixedMixed 11.5 months11.5 months(median)(median)

TFCBTTFCBT(trauma-(trauma-focusedfocusedcognitivecognitivetherapy)therapy)Waiting listWaiting list

Up to 15Up to 15sessionssessions(mean 12.4)(mean 12.4)

CAPSCAPSPDSPDS

6MFU6MFU Not givenNot given YesYes YesYes

KubanyKubany et alet al,,2004 (USA)2004 (USA)

12512585 analysed85 analysedpost-treatmentpost-treatment

42.2 (10.1)42.2 (10.1) 100100 MixedMixedtraumastraumaswithin awithin apopulationpopulationof ‘batteredof ‘batteredwomen’women’

WhereWheretraumawastraumawaspartnerpartnerabuse,abuse,mean 5.0mean 5.0years sinceyears sincelast abuselast abuse(s.d.(s.d.¼7.4)7.4)

TFCBT (immediateTFCBT (immediatecognitivecognitivetrauma therapy)trauma therapy)Waiting listWaiting list

8^11 sessions8^11 sessionsof 90minof 90min

CAPSCAPSDistressingDistressingEventEventQuestionnaireQuestionnaire


Not givenNot given Both com-Both com-pleter andpleter andITTanalysesITTanalysesreportedreported

YesYes

NeunerNeuner et alet al,,2004 (Germany)2004 (Germany)

434340 analysed40 analysedpost-post-treatment,treatment,38 at 12MFU38 at 12MFU

33.1 (7.9)33.1 (7.9) 6060 RefugeeRefugeepopulationpopulation(Sudanese(Sudanesecivil war)civil war)

Mean 7.5 yearsMean 7.5 yearssince ‘worst’since ‘worst’traumatrauma(s.d.(s.d.¼3.3)3.3)

TFCBTTFCBT(narrative(narrativeexposureexposuretherapy)therapy)OT1OT1(supportive(supportivecounselling)counselling)PsychoeducationPsychoeducation

TFCBTandTFCBTandOT1: fourOT1: four90^120min90^120minsessionssessionsPsychoeducation:Psychoeducation:oneone90^120min90^120minsessionsession

PDSPDSCIDI^PTSDCIDI^PTSDpartpart



YesYes

RothbaumRothbaum et alet al,,2005 (USA)2005 (USA)


Completers:Completers:33.77 (11.03)33.77 (11.03)

100100 Rape inRape inadulthood (adulthood (441212yearsyearsold)old)

More thanMore than3 months3 monthssince traumasince trauma

TFCBT (prolongedTFCBT (prolongedexposure)exposure)EMDREMDRWaiting listWaiting list

Both conditions:Both conditions:nine 90minnine 90minsessionssessions

CAPSCAPSSCIDSCIDPSS^SRPSS^SRIES^RIES^R

Post-treatment,Post-treatment,6MFU, 12MFU6MFU, 12MFU


YesYes

CAPS,Clinician Administered PTSD Scale; CBT, cognitive^behavioural therapy; CIDI,Composite International Diagnostic Interview; CSA, childhood sexual abuse; DSS,Depression Symptom Scale; EMDR, eyemovement desensitisation and reprocessing;CAPS,Clinician Administered PTSD Scale; CBT, cognitive^behavioural therapy; CIDI,Composite International Diagnostic Interview; CSA, childhood sexual abuse; DSS, Depression Symptom Scale; EMDR, eyemovement desensitisation and reprocessing;IES(^R), Impact of Events Scale (Revised); ITT, intention-to-treat; MFU,months of follow-up; MMPI(^R),MinnesotaMultiphasic Personality Interview (Revised); OT, other therapies; PDS, PTSDDiagnostic Scale; PSS(I, SR), PTSD Symptom Scale (Interview,IES(^R), Impact of Events Scale (Revised); ITT, intention-to-treat; MFU,months of follow-up; MMPI(^R),Minnesota Multiphasic Personality Interview (Revised); OT, other therapies; PDS, PTSDDiagnostic Scale; PSS(I, SR), PTSD Symptom Scale (Interview,Self-Report); PTSD, post-traumatic stress disorder; RTA, road traffic accident; SCID, Structured Clinical Interview for DSM^IV; SCL^90^R, Symptom Checklist 90 ^ Revised; SI^PTSD, Structured Interview for PTSD; SM, stressmanagement; SUDS,Self-Report); PTSD, post-traumatic stress disorder; RTA, road traffic accident; SCID, Structured Clinical Interview for DSM^IV; SCL^90^R, Symptom Checklist 90 ^ Revised; SI^PTSD, Structured Interview for PTSD; SM, stress management; SUDS,Subjective Units of Distress Scale; TFCBT, trauma-focused cognitive^behavioural therapy.Subjective Units of Distress Scale; TFCBT, trauma-focused cognitive^behavioural therapy.1. Where standard deviations are given for each treatment group separately, the highest across treatment groups is reported.1. Where standard deviations are given for each treatment group separately, the highest across treatment groups is reported.

DATA

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DATA

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BRIT

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JOURNALOFPSYCHIA

TRY(2007),1

90,97^104

(2007),1

90,97^104

10.1192/bjp.bp.106.021402Access the most recent version at DOI: 2007, 190:97-104.BJP

and STUART TURNERJONATHAN I. BISSON, ANKE EHLERS, ROSA MATTHEWS, STEPHEN PILLING, DAVID RICHARDSdisorder: Systematic review and meta-analysisPsychological treatments for chronic post-traumatic stress

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