Psychological treatment of post-traumatic stress disorder (PTSD)

  • Review
  • Intervention

Authors


Abstract

Background

Psychological interventions are widely used in the treatment of post-traumatic stress disorder (PTSD).

Objectives

To perform a systematic review of randomised controlled trials of all psychological treatments following the guidelines of The Cochrane Collaboration.

Search methods

Systematic searches of computerised databases, hand search of the Journal of Traumatic Stress, searches of reference lists, known websites and discussion fora, and personal communication with key workers.

Selection criteria

Types of studies - Any randomised controlled trial of a psychological treatment.

Types of participants - Adults suffering from traumatic stress symptoms for three months or more.

Types of interventions - Trauma-focused cognitive behavioural therapy/exposure therapy (TFCBT); stress management (SM); other therapies (supportive therapy, non-directive counselling, psychodynamic therapy and hypnotherapy); group cognitive behavioural therapy (group CBT); eye movement desensitisation and reprocessing (EMDR).

Types of outcomes - Severity of clinician rated traumatic stress symptoms. Secondary measures included self-reported traumatic stress symptoms, depressive symptoms, anxiety symptoms, adverse effects and dropouts.

Data collection and analysis

Data were entered using Review Manager software. Quality assessments were performed. Data were analysed for summary effects using Review Manager 4.2.

Main results

Thirty-three studies were included in the review. With regards to reduction of clinician assessed PTSD symptoms measured immediately after treatment TFCBT did significantly better than waitlist/usual care (standardised mean difference (SMD) = -1.40; 95% CI, -1.89 to -0.91; 14 studies; n = 649). There was no significant difference between TFCBT and SM (SMD = -0.27; 95% CI, -0.71 to 0.16; 6 studies; n = 239). TFCBT did significantly better than other therapies (SMD = -0.81; 95% CI, -1.19 to -0.42; 3 studies; n = 120). Stress management did significantly better than waitlist/usual care (SMD = -1.14; 95% CI, -1.62 to -0.67; 3 studies; n = 86) and than other therapies (SMD = -1.22; 95% CI, -2.09 to -0.35; 1 study; n = 25). There was no significant difference between other therapies and waitlist/usual care control (SMD = -0.43; 95% CI, -0.90 to 0.04; 2 studies; n = 72). Group TFCBT was significantly better than waitlist/usual care (SMD = -0.72; 95% CI, -1.14 to -0.31). EMDR did significantly better than waitlist/usual care (SMD = -1.51; 95% CI, -1.87 to -1.15; 5 studies; n = 162). There was no significant difference between EMDR and TFCBT (SMD = 0.02; 95% CI, -0.28 to 0.31; 6 studies; n = 187). There was no significant difference between EMDR and SM (SMD = -0.35; 95% CI, -0.90 to 0.19; 2 studies; n = 53). EMDR did significantly better than other therapies (self-report) (SMD = -0.84; 95% CI, -1.21 to -0.47; 2 studies; n = 124).

Authors' conclusions

There was evidence individual TFCBT, EMDR, stress management and group TFCBT are effective in the treatment of PTSD. Other non-trauma focused psychological treatments did not reduce PTSD symptoms as significantly. There was some evidence that individual TFCBT and EMDR are superior to stress management in the treatment of PTSD at between 2 and 5 months following treatment, and also that TFCBT, EMDR and stress management were more effective than other therapies. There was insufficient evidence to determine whether psychological treatment is harmful. There was some evidence of greater drop-out in active treatment groups. The considerable unexplained heterogeneity observed in these comparisons, and the potential impact of publication bias on these data, suggest the need for caution in interpreting the results of this review.

摘要

背景

創傷後壓力症候群(PTSD)的心理處置

心理處置廣泛的運用在治療創傷後壓力症候群的患者身上(PTSD).

目標

根據Cochrane Collaboration的指導方針來系統性的回顧有關心理處置的所有隨機對照試驗研究

搜尋策略

系統性地搜尋有關創傷壓力的電子資料庫及紙本期刊,同時搜尋參考文獻、知名的網站、討論論壇以及主要研究人員的通訊討論資料。

選擇標準

研究的形式 – 有關心理處置的任何隨機對照試驗。受試者的類型 – 持續3個月或以上受苦於創傷壓力的成人。處置的形式 – 以創傷為焦點的認知行為治療/暴露治療(TFCBT); 壓力管理(SM); 其他治療(支持性治療、非指導性諮商、精神分析治療、催眠);團體認知行為治療(group CBT);眼動減敏及重整(EMDR). 結果的形式 – 臨床者評估創傷壓力症狀的嚴重程度。第二種測量包括自我報告創傷壓力症狀,憂鬱、焦慮、不利影響及退出率。

資料收集與分析

使用Review Manager software來整理資料,同時對於品質也加以評估。使用Review Manager 4.2.來分析綜合效果。

主要結論

本篇文獻回顧共包含33篇研究。就治療後臨床醫師立即評估PTSD症狀減輕程度而言,相較於等候名單/一般照顧的個案,使用TFCBT治療的個案確實有較好的結果(standardised mean difference (SMD) = −1.40; 95% CI, −1.89 to −0.91; 14 studies; n = 649)。至於TFCB和SM這兩種治療方式彼此間並無明顯差異(SMD = −0.27; 95% CI, −0.71 to 0.16; 6 studies; n = 239)。TFCBT顯著地優於其他治療(SMD = −0.81; 95% CI, −1.19 to −0.42; 3 studies; n = 120)。壓力管理顯著優於等候名單/一般照顧組的個案(SMD = −1.14; 95% CI, −1.62 to −0.67; 3 studies; n = 86),也優於其他治療(SMD = −1.22; 95% CI, −2.09 to −0.35; 1 study; n = 25)。其他治療和等候名單/一般照顧組並無顯著差異(SMD = −0.43; 95% CI, −0.90 to 0.04; 2 studies; n = 72)。團體的TFCBT顯著地優於等候名單/一般照顧組(SMD = −0.72; 95% CI, −1.14 to −0.31)。EMDR顯著地優於等候名單/一般照顧組(SMD = −1.51; 95% CI, −1.87 to −1.15; 5 studies; n = 162)。EMDR和TFCBT則無顯著差異(SMD = 0.02; 95% CI, −0.28 to 0.31; 6 studies; n = 187)。EMDR 和 SM也同樣沒有顯著差異(SMD = −0.35; 95% CI, −0.90 to 0.19; 2 studies; n = 53)。EMDR則顯著地優於其他治療(selfreport) (SMD = −0.84; 95% CI, −1.21 to −0.47; 2 studies; n = 124).

作者結論

證據指出個別的TFCBT、EMDR、壓力管理和團體TFCBT在治療PTSD上都有療效。其他以非創傷為焦點的心理處置則無法顯著地降低PTSD的症狀。一些證據指出在治療PTSD後的2 – 5個月間,發現個別的TFCBT 和 EMDR都優於壓力管理,同時TFCBT、EMDR和壓力管理也比其他治療方式有效。目前沒有足夠的證據顯示心理處置是否有害,但是在主動治療組中卻有較明顯的退出率。由於在這些比較當中存在著相當程度無法解釋的異質性,同時受到潛在發表偏誤的影響,導致在詮釋這篇文獻回顧的結果時需要謹慎小心。

翻譯人

本摘要由彰化基督教醫院胡淑惠翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

心理處置能降低創傷後壓力症候群的症狀。以創傷為焦點的治療方式比起不是以創傷為焦點的治療方式來得有效。這篇回顧文獻著眼於心理處置在治療創傷後壓力症候群患者的有效性。證據指出以創傷為焦點的個別認知行為治療(TFCBT)、眼動心身重建法的治療(EMDR)、壓力管理和團體TFCBT在治療創傷後壓力症候群都有療效。其他不是以創傷為焦點的治療方式則無法顯著地降低PTSD的症狀。一些證據指出在治療PTSD後的2 – 5個月間,發現個別TFCBT 和 EMDR 都優於壓力管理,同時,TFCBT 、 EMDR和壓力管理也比其他治療方式來得有效。目前沒有足夠的證據顯示心理處置是否有害。以創傷為焦點的認知行為治療或者眼動心身重建法的治療可以考慮使用在PTSD的患者身上。

Plain language summary

Psychological treatment of post traumatic stress disorder (PTSD)

This review concerns the efficacy of psychological treatment in the treatment of PTSD. There is evidence that individual trauma focused cognitive-behavioural therapy (TFCBT), eye movement desensitisation and reprocessing (EMDR), stress management and group TFCBT are effective in the treatment of PTSD. Other non-trauma focused psychological treatments did not reduce PTSD symptoms as significantly. There is some evidence that individual TFCBT and EMDR are superior to stress management in the treatment of PTSD at between 2 and 5 months following treatment, and also that TFCBT, EMDR and stress management are more effective than other therapies. There is insufficient evidence to show whether or not psychological treatment is harmful. Trauma focused cognitive behavioural therapy or eye movement desensitisation and reprocessing should be considered in individuals with PTSD. Psychological treatments can reduce symptoms of post traumatic stress disorder (PTSD). Trauma focused treatments are more effective than non-trauma focused treatments.