Which psychological therapies are most effective for chronic posttraumatic stress disorder (PTSD) in adults?
Trauma-focused cognitive behavior therapy (CBT) and eye movement desensitization and reprocessing (EMDR) are more effective than other therapies in reducing PTSD symptom severity up to four months after treatment, but more robust studies are needed to evaluate the long-term effectiveness. (Strength of Recommendation: B, based on inconsistent or limited-quality patient-oriented evidence.)
PTSD can develop after a major traumatic event and is characterized by at least one month of recurrent nightmares or distressing thoughts about the event; mood and thought alterations; and hyperarousal symptoms, including sleep disturbance, irritability, and hypervigilance. PTSD can be considered chronic after three months of symptoms. Overall, 7.8% of American adults have PTSD at some point, but the prevalence varies by type of stressor. Women who have been physically assaulted have a lifetime prevalence of PTSD of 29%, whereas combat experience in men leads to a lifetime prevalence of 39%.1
Different therapies have been used to treat PTSD in adults. Previous Cochrane reviews in 2005 and 2007 reported that trauma-focused therapies were more effective than other types. Trauma-focused CBT is a variant of CBT that incorporates exposure to memories of the event to change thought processes and behavioral response. EMDR is a psychological therapy that uses guided eye movements while the patient recalls distressing images, beliefs, and sensations. This Cochrane review updates the evidence for the treatment of chronic PTSD in adults.
The researchers identified 70 randomized controlled trials (RCTs) of psychological therapies for chronic PTSD with 4,761 participants. About one-half of the trials were conducted in North America (37 trials), with the remainder from Europe (20 trials), Australia (seven trials), Asia (four trials), and Africa (two trials). The majority of the trials involved trauma-focused CBT or EMDR. The authors compared individual trauma-focused CBT and EMDR with each other, and with usual care (wait-listed participants who may have been receiving medications and/or other supports), non–trauma-focused CBT, group trauma-focused CBT, and other therapies. Fewer studies compared group trauma-focused CBT, non–trauma-focused CBT, and other therapies with usual care and with each other. The primary outcomes were clinician-rated PTSD symptoms and drop-out rates. Secondary outcomes included self-reported PTSD symptoms, depression, anxiety, PTSD diagnosis after treatment, and adverse effects.
Individual trauma-focused CBT and EMDR appear to be similarly effective when compared directly. They are also the most effective compared with wait-list/usual care, non–trauma-focused CBT, group trauma-focused CBT, and other therapies in reducing clinician-rated PTSD symptoms and associated depression and anxiety. Some evidence shows the benefits of trauma-focused CBT and EMDR extending one to four months after treatment compared with other therapies. Drop-out rates were much higher in trauma-based therapies compared with others, perhaps because of reexposure to traumatic thoughts.
The authors caution that many factors limit the strength of these findings. Significant heterogeneity in most of the comparisons, small sample sizes, and unclear risk of bias contribute to an overall low quality of evidence assessment. None of the studies reported on adverse effects of treatment.
The National Institute for Health and Care Excellence guidelines recommend trauma-focused CBT and EMDR as treatments of choice.2 Although this Cochrane review reinforces these recommendations, additional large, well-designed trials that compare psychological therapies and better assess drop-out rates and adverse effects are needed.