Implementing AHRQ Effective Health Care Reviews

Helping Clinicians Make Better Treatment Choices

Psychological and Pharmacologic Treatments for Adults with PTSD

 

Am Fam Physician. 2019 May 1;99(9):577-583.

Author disclosure: No relevant financial affiliations.

Key Clinical Issue

What are the benefits and harms of psychotherapies and pharmacologic agents for the treatment of adults with posttraumatic stress disorder (PTSD)?

Evidence-Based Answer

Cognitive behavior therapy (CBT) and CBT-mixed treatments had high strength of evidence for benefit in improving PTSD-related outcomes, such as reduced PTSD symptoms, reduced depression symptoms, and resolution of PTSD diagnosis. (Strength of Recommendation [SOR]: A, based on consistent, good-quality patient-oriented evidence.) Cognitive processing therapy, cognitive therapy, eye movement desensitization and reprocessing (EMDR), and narrative exposure therapy had moderate strength of evidence for benefit. (SOR: B, based on inconsistent or limited-quality patient-oriented evidence.) Fluoxetine, paroxetine, and venlafaxine had moderate strength of evidence for reducing PTSD symptoms. (SOR: B, based on inconsistent or limited-quality patient-oriented evidence.) There was insufficient evidence to compare psychotherapy with pharmacotherapy and to compare serious adverse events among treatments.1

Practice Pointers

Family physicians regularly diagnose and treat PTSD, which affects 8% of men and 20% of women in the general population.2 Similarly, 16% of female veterans receiving care in Veterans Health Administration facilities have PTSD.3 Male veterans have higher rates of PTSD than the general population; PTSD has been diagnosed in one out of four male combat veterans serving in Operation Enduring Freedom or Operation Iraqi Freedom.3 Untreated, PTSD can lead to substance abuse and suicide.2

This Agency for Healthcare Research and Quality (AHRQ) systematic review updates a 2013 report and includes 193 studies. Because several different outcome scales were used across trials (e.g., the Clinician-Administered PTSD Scale, which measures the presence and intensity of PTSD-related symptoms), the authors interpreted a standardized mean difference (SMD) of 0.5 (a medium effect size) as being clinically significant, although definitive thresholds for clinical significance have not been established.

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CLINICAL BOTTOM LINE

Summary of Efficacy and Strength of Evidence of PTSD Psychological Treatments

TreatmentSymptomNo. of trials (no. of participants)FindingsStrength of evidence

Cognitive processing therapy

PTSD symptoms*

5 (399)

Reduced PTSD symptoms SMD = −1.35 (95% CI, −1.77 to −0.94)

● ● ○

Loss of PTSD diagnosis

4 (299)

Greater loss of PTSD diagnosis RD = 0.44 (95% CI, 0.26 to 0.62)

● ● ○

Depression symptoms†

5 (399)

Reduced depression symptoms SMD = –1.09 (95% CI, –1.52 to –0.65)

● ● ○

Cognitive therapy

PTSD symptoms*

4 (283)

Reduced PTSD symptoms SMD of individual studies ranged from –2.0 to –0.3 All studies favored treatment (all studies P < .05)

● ● ○

Loss of PTSD diagnosis

4 (283)

Greater loss of PTSD diagnosis RD = 0.55 (95% CI, 0.28 to 0.82) All studies favored treatment (3 of 4 studies P < .05)

● ● ○

Depression symptoms†

4 (283)

Reduced depression symptoms Between-group mean differences of individual trials ranged from –11.1 to –8.3 All studies favored treatment (4 of 4 studies P < .05)

● ● ○

Cognitive behavior therapy (exposure)

PTSD symptoms*

Reduced PTSD symptoms

● ● ●

13 (885)

SMD = –1.23 (95% CI, –1.50 to –0.97)

8 (689)

SMD for the Clinician-Administered PTSD Scale = –1.12 (95% CI, –1.42 to –0.82)

Loss of PTSD diagnosis

6 (409)

Greater loss of PTSD diagnosis RD = 0.56 (95% CI, 0.35 to 0.78)

● ● ●‡

Depression symptoms†

10 (715)

Reduced depression symptoms SMD = –0.76 (95% CI, –0.91 to –0.60)

● ● ●

Cognitive behavior therapy (mixed)

PTSD symptoms*

Reduced PTSD symptoms

● ● ●‡

21 (1,349)

SMD = –1.01 (95% CI, –1.28 to –0.74)

11 (709)

SMD = –1.24 (95% CI, –1.67 to –0.81)

Loss of PTSD diagnosis

9 (474)

Greater loss of PTSD diagnosis RD = 0.29 (95% CI, 0.11 to 0.41)

● ● ●‡

Depression symptoms†

15 (929)

Reduced depression symptoms SMD = –0.87 (95% CI, –1.14 to –0.61)

● ● ●‡

Eye movement desensitization and reprocessing

PTSD symptoms*

8 (449)

Reduced PTSD symptoms SMD = –1.08 (95% CI, –1.82 to –0.35)

● ● ○§

Loss of PTSD diagnosis

7 (427)

Greater loss of PTSD diagnosis RD = 0.43 (95% CI, 0.25 to 0.61)

● ● ○

Depression symptoms†

7 (347)

Reduced depression symptoms SMD = –0.91 (95% CI, –1.58 to –0.24)

● ● ○

Brief eclectic psychotherapy

Loss of PTSD diagnosis

3 (96)

Greater loss of PTSD diagnosis RD of individual studies ranged from 0.13 to 0.58 All studies favored treatment (P < .05)

● ○ ○

Depression symptoms†

3 (96)

Reduced depression symptoms Different depression scales used; all 3 studies favored treatment (3 of 3 studies P < .05)

● ○ ○

Imagery rehearsal therapy

PTSD symptoms*

1 (168)

Reduced PTSD symptoms Between-group mean difference = –21.0

Author disclosure: No relevant financial affiliations.

Address correspondence to Aaron Saguil, MD, MPH, FAAFP, at aaron.saguil@usuhs.edu. Reprints are not available from the author.

References

1. Agency for Healthcare Research and Quality. Effective Healthcare Program. Psychological and pharmacological treatments for adults with posttraumatic stress disorder: a systematic review update. Rockville, Md.: Agency for Healthcare Research and Quality; May 2018. https://effectivehealthcare.ahrq.gov/topics/ptsd-adult-treatment-update/research-2018. Accessed October 8, 2018.

2. Warner CH, Warner CM, Appenzeller GN, Hoge CW. Identifying and managing posttraumatic stress disorder [published correction appears in Am Fam Physician. 2014;89(6):424]. Am Fam Physician. 2013;88(12):827–834.

3. U.S. Department of Veterans Affairs, U.S. Department of Defense. VA/DoD clinical practice guidelines. Management of posttraumatic stress disorder and acute stress reaction 2017. https://www.healthquality.va.gov/guidelines/MH/ptsd/VADoDPTSDCPGFinal012418.pdf. Accessed October 8, 2018.

The Agency for Healthcare Research and Quality (AHRQ) conducts the Effective Health Care Program as part of its mission to produce evidence to improve health care and to make sure the evidence is understood and used. A key clinical question based on the AHRQ Effective Health Care Program systematic review of the literature is presented, followed by an evidence-based answer based upon the review. AHRQ’s summary is accompanied by an interpretation by an AFP author that will help guide clinicians in making treatment decisions. For the full review, clinician summary, and consumer summary, go to https://effectivehealthcare.ahrq.gov/topics/ptsd-adult-treatment-update/research-2018.

This series is coordinated by Kenny Lin, MD, MPH, Deputy Editor.

A collection of Implementing AHRQ Effective Health Care Reviews published in AFP is available at https://www.aafp.org/afp/ahrq.

 

 

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