Clinical Evidence Concise

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Post-traumatic Stress Disorder



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What are the effects of preventive intervention?

LIKELY TO BE BENEFICIAL

Multiple-session CBT in People with Acute Stress Disorder (Reduced PTSD Compared with Supportive Counseling)

Two small randomized controlled trials (RCTs) in people with acute stress disorder after a traumatic event (e.g., motor vehicle crash, nonsexual assault) found that five sessions of cognitive behavior therapy (CBT) reduced the proportion of people with post-traumatic stress disorder (PTSD) after six months compared with supportive counseling.

UNLIKELY TO BE BENEFICIAL

Single-session Individual Debriefing

One systematic review of RCTs in people who had been exposed to a traumatic event in the previous month found no significant difference between a single session of individual psychological debriefing and no debriefing in the rate of PTSD at three to six months. The review found that individual psychological debriefing increased the rate of PTSD compared with no debriefing at 13 months.

Supportive Counseling

Two RCTs in people with acute stress disorder after a traumatic event (e.g., motor vehicle crash, nonsexual assault) found that supportive counseling was less effective than five sessions of CBT in reducing the proportion of people with PTSD after six months.

UNKNOWN EFFECTIVENESS

Single-session Group Debriefing

One systematic review identified no RCTs comparing single-session group debriefing with no debriefing. One RCT found that early group debriefing (within 10 hours of the traumatic event) reduced PTSD compared with delayed group debriefing (after 48 hours) at two weeks.

Multiple-session CBT in All People Exposed to a Traumatic Event

One RCT found that four sessions of CBT reduced post-traumatic stress symptoms at 13 months in people with psychological distress following physical injury compared with no psychological intervention. However, it found no significant difference in the proportion of people meeting the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) criteria for PTSD. Another RCT in bus drivers who had been attacked in the previous five months found that CBT improved measures of anxiety and intrusive symptoms at six months compared with standard care. However, it found no significant difference in measures of depression or avoidance symptoms. One RCT provided insufficient evidence to assess CBT plus education techniques in preventing PTSD in motor vehicle crash survivors. Another small RCT provided insufficient evidence to compare memory structuring with supportive listening in motor vehicle crash survivors.

Multiple-session Collaborative Trauma Support

Two RCTs provided insufficient evidence to assess multiple-session collaborative trauma support interventions involving emotional, social, and practical support in people exposed to a traumatic event in the previous 24 hours to one week.

Multiple-session Education

No systematic review or RCTs assessing the effects of multiple-session education alone were found. One RCT provided insufficient evidence to assess education techniques plus CBT in preventing PTSD in motor vehicle crash survivors.

Hydrocortisone

One small RCT involving people in intensive care with septic shock provided insufficient evidence to assess hydrocortisone in preventing PTSD.

Propranolol

One small RCT provided insufficient evidence to assess propranolol in preventing PTSD in people with early symptoms of PTSD after a traumatic event.

Temazepam

One small RCT provided insufficient evidence to assess temazepam in preventing PTSD in people with acute stress disorder or early symptoms of PTSD after a motor vehicle crash, industrial accident, or nonsexual assault.

What are the effects of treatment?

BENEFICIAL

CBT

One systematic review found that CBT reduced rates of PTSD compared with no treatment, stress management, supportive psychotherapy, psychodynamic psychotherapy, supportive counseling, or hypnotherapy. The review found no significant difference in rates of PTSD between CBT and eye movement desensitization and reprocessing.

Eye Movement Desensitization and Reprocessing

One systematic review found that eye movement desensitization and reprocessing improved symptoms compared with no treatment or usual treatment. The review found no significant difference in rates of PTSD between eye movement desensitization and reprocessing and stress management or CBT.

LIKELY TO BE BENEFICIAL

Fluoxetine

One systematic review found that fluoxetine reduced symptoms of PTSD compared with placebo at three months.

Paroxetine

One systematic review found that paroxetine improved symptoms compared with placebo at three months in people with PTSD.

Sertraline

One systematic review found that sertraline improved symptoms of PTSD at three to seven months compared with placebo.

UNLIKELY TO BE BENEFICIAL

Venlafaxine

One large RCT identified by a systematic review found no significant difference in symptom severity at 12 weeks between venlafaxine and placebo in people with PTSD.

UNKNOWN EFFECTIVENESS

Affect Management

One RCT provided insufficient evidence about the effects of affect management in improving symptoms in people with PTSD.

Drama Therapy

We found no systematic review or RCT investigating the effects of drama therapy in improving symptoms of PTSD.

Group Therapy

RCTs identified by a systematic review provided insufficient evidence about the effects of group therapy in improving symptoms of PTSD.

Hypnotherapy

One RCT identified by a systematic review provided insufficient evidence about the effects of hypnotherapy in improving symptoms of PTSD.

Inpatient Treatment Programs

We found no systematic review or RCT investigating the effects of inpatient treatment programs in improving symptoms of PTSD.

Internet-based Psychotherapy

One RCT provided insufficient evidence about the effects of Internet-based psychotherapy in improving symptoms of PTSD.

Psychodynamic Psychotherapy

One RCT identified by a systematic review provided insufficient evidence about the effects of psychodynamic psychotherapy in improving symptoms of PTSD.

Supportive Psychotherapy

One RCT provided insufficient evidence about the effects of supportive psychotherapy in improving symptoms in people with PTSD.

Mirtazapine

One RCT identified by a systematic review provided insufficient evidence about the effects of mirtazapine in improving symptoms of PTSD.

Nefazodone

We found insufficient evidence about the effects of nefazodone in improving symptoms of PTSD.

Tricyclic Antidepressants

RCTs identified by a systematic review provided insufficient evidence to assess imipramine or amitriptyline in people with PTSD.

Phenelzine

One RCT identified by a systematic review provided insufficient evidence about the effects of phenelzine in improving symptoms of PTSD.

Brofaromine

One RCT identified by a systematic review provided insufficient evidence about the effects of brofaromine in improving symptoms of PTSD.

Carbamazepine

We found no systematic review or RCT of carbamazepine in people with PTSD.

Risperidone

One RCT identified by a systematic review provided insufficient evidence about the effects of risperidone in improving the symptoms of PTSD.

Benzodiazepines

One systematic review identified no RCT of sufficient quality that assessed benzodiazepines in people with PTSD.

Propranolol

We found no systematic review or RCT that assessed propranolol in people with PTSD.

Olanzapine

One systematic review identified no good quality RCTs that assessed olanzapine in people with PTSD.

Definition

PTSD can occur after any major traumatic event. Symptoms include upsetting thoughts and nightmares about the traumatic event, avoidance behavior, numbing of general responsiveness, increased irritability, and hypervigilance.1 To fulfill the DSM-IV criteria for PTSD, an individual must have been exposed to a traumatic event; have at least one reexperiencing, three avoidance, and two hyperarousal phenomena; have had the symptoms for at least one month; and the symptoms must cause clinically important distress or reduced day-to-day functioning.1 People with subsyndrome PTSD meet the criteria for PTSD except one of the reexperiencing, avoidance, or hyperarousal phenomena. Acute stress disorder occurs within the first month after a major traumatic event and requires the presence of symptoms for at least two days. It is similar to PTSD, but dissociative symptoms are required to make the diagnosis. Treatments for PTSD may have similar effects, regardless of the traumatic event that precipitated PTSD. However, caution should be applied when generalizing among types of trauma.

Incidence

One large cross-sectional study in the United States found that one in 10 women (10 percent) and one in 20 men (5 percent) experience PTSD at some stage in their lives.2

Etiology

Risk factors for PTSD include major trauma (e.g., rape), a history of psychiatric disorders, acute distress and depression after the trauma, lack of social support, and personality factors.3

Prognosis

One large cross-sectional study in the United States found that more than one third of people with previous PTSD continued to satisfy the criteria for PTSD six years after initial diagnosis.2 However, cross-sectional studies provide weak evidence about prognosis.

search date: December 2004

Adapted with permission from Bisson J. Post-traumatic stress disorder. Clin Evid Concise 2005;13:306–9.

editor’s note: Brofaromine is not available in the United States.

 

REFERENCES

1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed. Washington, D.C.: American Psychiatric Association, 1994.

2. Kessler RC, Sonnega A, Bromet E, et al. Posttraumatic stress disorder in the national comorbidity survey. Arch Gen Psychiatry. 1995;52:1048–60.

3. O’Brien S. Traumatic events and mental health. Cambridge: Cambridge University Press, 1998.

This is one in a series of chapters excerpted from Clinical Evidence Concise, published by the BMJ Publishing Group, Tavistock Square, London, United Kingdom. Clinical Evidence Concise is published in print twice a year and is updated monthly online. Each topic is revised every 12 months, and subscribers should view the most up-to-date version at http://www.clinicalevidence.com. If you are interested in contributing to Clinical Evidence, please send an e-mail to CEcommissioning@bmj.com.


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