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.

Background

Post-traumatic stress disorder (PTSD) is a well recognised psychiatric disorder that can occur following a major traumatic event. Characteristic symptoms include re-experiencing phenomena such as nightmares and recurrent distressing thoughts of the event, avoidance and numbing of general responsiveness such as trying not to talk about or be reminded of the traumatic event, experiencing detachment and estrangement from other people and hyperarousal symptoms including sleep disturbance, increased irritability and hypervigilance. PTSD is a relatively common condition. The National Co-morbidity Survey (Kessler 1995) found that 7.8% of 5,877 American adults had suffered from PTSD at some time in their lives. When data were examined from individuals who had been exposed to a traumatic event rates of PTSD varied according to type of stressor. For example, physical assaults amongst women led to a lifetime prevalence of 29% and combat experience amongst men to a lifetime prevalence of 39%. It is apparent that PTSD causes much suffering and that developing effective interventions is important.

Psychological interventions have been advocated as being effective in the treatment of PTSD since its conception. Various forms of psychological treatment have been used including exposure therapy, cognitive therapy, stress inoculation training, psychodynamic psychotherapy and eye movement desensitisation and reprocessing (EMDR) (Foa 2000). Exposure therapy usually involves asking the subject to relive the trauma imaginally. This is often done by creating a detailed present tense account of exactly what happened, making an audio tape recording of it and asking the individual to listen to this over and over again. Another form of exposure therapy involves exposing subjects to cues associated with the traumatic event (for example graded re-exposure to car travel following a road traffic accident). Trauma-focused cognitive therapy involves helping the individual to identify distorted thinking patterns regarding themselves, the traumatic incident and the world. Individuals are encouraged to challenge their thoughts by weighing up available evidence and through the utilization of various techniques by the therapist including specific questioning that leads the individual to challenge distorted views. EMDR involves the PTSD sufferer focusing on a traumatic image, thought, emotion and a bodily sensation whilst receiving bilateral stimulation most commonly in the form of eye movements. Psychodynamic psychotherapy focuses on integrating the traumatic experience into the life experience of the individual as a whole. Often childhood issues are felt to be important.

The psychological treatments described and a variety of others have their advocates, but much of this advocacy is based on anecdotal evidence only. All the treatments have a theoretical basis as to why they might work, but their true effectiveness in reducing symptoms or their potential adverse consequences is not really known. Solomon 1992 reviewed the treatment literature and concluded that most of the available studies had some methodological shortcomings and that there was a need for further evaluation. A more recently published meta-analysis included more randomised controlled trials (Sherman 1998) and practice guidelines from the International Society for Traumatic Stress Studies (Foa 2000) added to these. However, this topic has not yet been subjected to a systematic review adhering to the Cochrane Collaboration guidelines.

Objectives

To perform a systematic review of randomised controlled trials of psychological treatments for PTSD following the guidelines of the Cochrane Collaboration. The efficacy of psychological treatments in comparison with control conditions and other psychological treatments will be determined using clinician rated symptoms of PTSD as the main outcome measure.

Methods

Criteria for considering studies for this review

Types of studies

Any randomised controlled trial that considered one or more defined psychological treatments to reduce traumatic stress symptoms in comparison with a placebo, other control (e.g. usual care or waiting list control) or alternative psychological treatment condition was included. All studies must have been completed and analysed by October 2004 for inclusion. Sample size, language and publication status was not used to determine whether or not a study should be included.

Types of participants

Any individual suffering from traumatic stress symptoms with a duration of symptoms of three months or more. At least 70% of participants had to be diagnosed as suffering from PTSD according to DSM or ICD criteria This review considered studies of adults only. There was no restriction on the basis of severity of PTSD symptoms, type of traumatic event or comorbidity (including major depressive disorder), however, PTSD had to be considered the primary diagnosis for individuals to be included.

Types of interventions

This review considered any psychological treatment designed to reduce symptoms of PTSD. The review has now been updated to include eye movement desensitisation and reprocessing (EMDR). Other Cochrane Collaboration reviews have considered brief psychological interventions for treating immediate trauma-related symptoms and preventing PTSD (Rose 2004) and pharmacological treatments for the treatment of PTSD (Stein 2004).

The following eligible treatment categories were identified.

a. Trauma focused cognitive behavioural therapy (TFCBT) - Any psychological treatment delivered individually that predominantly used trauma focused cognitive, behavioural or cognitive-behavioural techniques. This category included exposure therapy.
b. Stress management/relaxation - Any psychological treatment delivered individually that predominantly used non-trauma focused cognitive, behavioural or cognitive-behavioural techniques.
c. TFCBT Group Therapy - Any approach delivered in a group setting that predominantly used trauma focused cognitive, behavioural or cognitive-behavioural techniques.
d. Non-trauma focused CBT group therapy - Any approach delivered in a group that predominantly used non-trauma focused cognitive, behavioural or cognitive-behavioural techniques.
e. Other psychological treatment - Any psychological treatment delivered individually that predominantly used non-trauma focused techniques that would not be considered cognitive, behavioural or cognitive-behavioural techniques. This category included non-directive counselling, psychodynamic therapy and hypnotherapy.
f. Eye movement desensitisation and reprocessing (EMDR).
g. Wait list/usual care - These ranged from no intervention at all to undefined psychological input and/or drug treatment that was not fully described.

Types of outcome measures

Categorical and continuous variables were used:

Primary outcome measure:
1. The primary outcome measure was severity of clinician rated traumatic stress symptoms using a standardised measure such as the Clinician Administered PTSD Symptom Scale (Blake 1995).

Secondary outcome measures:
1. Severity of self-reported traumatic stress symptoms using a standardised measure such as the Impact of Event Scale (Horowitz 1979).
2. Severity of depressive symptoms using scales such as the Beck Depression Inventory (Beck 1961).
3. Severity of anxiety symptoms using scales such as the Spielberger State Trait Anxiety Inventory (Spielberger 1973).
4. Dropout rates.
5. PTSD diagnosis after treatment.
6. Any adverse effects, e.g. increased PTSD symptoms.

Search methods for identification of studies

This involved a systematic review of a variety of sources using methods described by the Cochrane Collaboration in August 2005. Computerised databases were searched using the Cochrane optimal RCT search strategy combined with the following key words: PTSD, trauma, cognitive, behavioural, exposure, EMDR, psychological, psychotherapy, psychodynamic, stress inoculation, relaxation, anxiety management.

Databases - Medline, clinpsych, psychlit, Embase, Pilots (a specialized PTSD database maintained by the National PTSD Centre in the USA), Trials Register of the Cochrane Depression, Anxiety and Neurosis Group, lilacs, psynebs, sociofile.

Hand Searches - Journal of Traumatic Stress, ISTSS Treatment Guidelines (Foa 2000)

Reference Lists - Of studies identified in the search

Internet Search - Of known websites and discussion fora

Personal Communication - The main source of personal communication was with the NICE guidelines development group who kindly shared the results of their searches and communications with the following people: Arnoud Arntz & Merel Kindt, Richard Bryant, Willi Butollo, Claude Chemtob, Judith Cohen, Mark Creamer, Jonathan Davidson, Enrique Echeburua, Paul Emmelkamp, Edna Foa, Chris Freeman, Berthold Gersons, Louise Humprheys, Terry Keane, Dean Kilpatrick, Edward Kubany, Brett Litz, Andreas Maercker, Charles Marmar, Sandy McFarlane, Thomas Mellman, Lars-Goran Öst, Michael Otto, Roger Pitman, Mark Pollack, Patti Resick, David Riggs, Sue Rose, Barbara Rothbaum, Joe Ruzek, Patricia White, Paula Schnurr, Matt Friedman, Arieh Shalev, Dan Stein, Nick Tarrier, Agnes van der Minnen, Simon Wessely and Rachel Yehuda.

Abstracts/Dissertations - from meetings of the European and International Societies of Traumatic Stress Studies.

Data collection and analysis

Applying selection criteria - Abstracts of all potential trials identified through the search strategy were independently read by the two reviewers. If an abstract was felt to possibly represent a RCT the full report was fully read by each reviewer independently to determine if the trial met the inclusion criteria.

Extracting data - Spreadsheets were designed to capture data which was then entered using the Review Management software. Information extracted included demographic details of participants, details of the traumatic event, the randomisation process, the interventions used and outcome data.

Assessment of methodological quality - This combined the standard approach described in the Cochrane Handbook which considers randomisation, allocation concealment and intention to treat with a quality score from a predetermined scale (Moncrieff 2001). This scale considers 23 different methodological criteria and assigns scores to them on a 0-2 scale giving a maximum possible total of 46. The criteria included in the scale are objectives and specification of main outcomes a priori, sample size, follow up duration, power calculation, method of allocation, allocation concealment, clear description of treatment and adjunctive treatment, blinding of subjects, representative sample recruitment, use of diagnostic criteria, exclusion criteria and number of exclusions and refusals, description of sample demographics, blinding of assessor, assessment of compliance with treatments, details of side-effects, record of number and reasons for withdrawal by group, outcome measures described clearly or use of validated instruments, information on comparability and adjustment for differences in analysis, inclusion of withdrawals in analysis, presentation of results with inclusion of data for reanalysis of main outcomes, appropriate statistical analysis, conclusions justified and declaration of interests.

The Cochrane criteria and other scale were scored by both reviewers independently. Disagreements were discussed between the reviewers in order to make a final decision regarding the quality score of the study.

Analyses

The following information about the identified trials was presented:
1. Included RCTs and their year of publication.
2. Excluded studies with reason for exclusion.
3. The characteristics of participants.
4. The nature of the psychological treatment and control condition considered.
5. The methodological quality of the RCTs using the methods described above.
6. The pooled effects of the overall effects in individual trials.

The following tables were presented:
1. A table of characteristics of the RCTs included in the review.
2. A table summarising the methodological quality of the RCTs included in the review.

Calculation of treatment effects:
The data were summarised and pooled effects calculated using RevMan 4.1software. Continuous outcomes were analysed as standardised mean differences (SMDs) to allow for ease of comparison across studies. It was decided to use relative risk as the main categorical outcome measure as this is more widely understood than odds ratios in medical practice.

Comparisons:
The following comparisons were used (i) psychological treatment vs waitlist or usual care control; (ii) psychological treatment vs another psychological treatment.

Choice of Method for Pooling Data
Data were pooled from more than one study using a fixed effects meta-analysis, except where heterogeneity was present in which case a random-effects model was used as described below.

Heterogeneity
To check for heterogeneity between studies, both the I squared test of heterogeneity and the chi-squared test of heterogeneity (p < .10), as well as visual inspection of the forest plots were used. An I squared of less than 30% was taken to indicate mild heterogeneity and a fixed effects model was used to synthesise the results. An I squared of more than 50% was taken as notable heterogeneity. In this case, an attempt was made to explain the variation. If studies with heterogeneous results were found to be comparable, a random effects model was used to summarise the results. An I squared of 30% to 50% was taken to indicate moderate heterogeneity. In this case, both the chi-squared test of heterogeneity and a visual inspection of the forest plot were used to decide between a fixed and random effects model.
Clinical heterogeneity subgroup analyses were performed for studies that only included females and studies that did not include Vietnam veterans for the primary outcome comparison of TFCBT vs wait list/usual care. All trials that scored above 25 on the Moncrieff 2001 scale were considered "higher quality studies". Studies that scored below 26 on the Moncrieff 2001 scale were considered "lower quality studies". Sensitivity analyses were performed for higher quality studies and lower quality studies.

Results

Description of studies

See: Characteristics of included studies; Characteristics of excluded studies.

Trials excluded
See excluded trials table.
Studies were excluded if they did not satisfy the inclusion criteria. Other reasons for excluding specific studies were less than three months following trauma and therefore PTSD had not been present for three months or more (Echeburua 1996; Frank 1988), treatment for anger only (Chemtob 1997), relaxation treatments only with no comparison (Walsh) and comparison of two CBT techniques only (Tarrier 1999; Paunovic 2001).

Trials included
See included trials table
Thirty-three different trials fulfilled the inclusion criteria.

Patient selection
See characteristics of trials included.
The study populations were varied and not directly comparable (i.e. there was significant clinical heterogeneity). Six studies included male Vietnam veterans only (Carlson 1998, Cooper 1989, Jensen 1994, Keane 1989, Peniston 1991 and Schnurr 2003), twelve studies considered female assault (mainly sexual assault) survivors (Classen 2001, Cloitre 2002, Echeburua 1997, Foa 1991, Foa 1999, Krakow 2001, Kubany 2003, Kubany 2004, Resick 2002, Rothbaum 1997, Rothbaum 2005 and Zlotnick 1997), two studies included only road traffic accident survivors (Blanchard 2003 and Fecteau 1999), one study was of refugees (Neuner 2004), one of police officers (Gersons 2000) and eleven studies included individuals from various traumas including road traffic accidents, assaults, bereavement and industrial accidents (Brom 1989, Bryant 2003, Devilly 1999, Ehlers 2003, Ironson 2002, Lee 2002, Marcus 1997/2004 (single study with follow-up), Marks 1998, Power 2002, Scheck 1998 and Vaughan 1994). The majority of participants satisfied the criteria for a DSM diagnosis of PTSD although some studies included individuals with traumatic stress symptoms who did not fulfil the full DSM criteria. The Vietnam veteran studies were largely from samples of individuals already in care. Other studies often advertised for their participants or used referrals to an established traumatic stress service.

Cultural Setting:
United States of America (23 studies), Australia (2 studies), United Kingdom (3 studies), The Netherlands (2 studies), Germany (1 study) and Canada (2 studies).

Sample size:
The number of patients randomised to the trials ranged from 16 (Cooper 1989 and Peniston 1991) to 360 (Schnurr 2003). Four studies included sample sizes of over 100 (Schnurr 2003 (360), Resick 2002 (121), Krakow 2001 (114) and Brom 1989 (112)).

Time post Trauma:
All studies included individuals at least three months following the trauma. The range was large , from 3 months to over 30 years. There was often a wide range of times since trauma included in individual studies.

Interventions:

In order to present the results in a meaningful way it was decided to pool data that used a similar theoretical methodology. This resulted in the establishment of seven groups - TFCBT, stress management, trauma focused group CBT, non-trauma focused group CBT, psychodynamic therapy, hypnotherapy and supportive counselling. Because of the existence of only one trial in each of the last three groups it was decided to pool these as "other therapies" for the purposes of this review.

Trauma focused cognitive behavioural therapy - Twenty-two studies considered TFCBT - Blanchard 2003, Brom 1989, Bryant 2003, Cloitre 2002, Cooper 1989, Echeburua 1997, Ehlers 2003, Fecteau 1999, Foa 1991, Foa 1999, Gersons 2000, Keane 1989, Kubany 2003, Kubany 2004, Marks 1998, Neuner 2004, Peniston 1991, Power 2002, Resick 2002, Rothbaum 2005, Taylor 2003 and Vaughan 1994.

Stress management - Seven studies considered stress management - Carlson 1998, Echeburua 1997, Foa 1991, Foa 1999, Marks 1998, Taylor 2003 and Vaughan 1994.

Group trauma focused CBT - Four studies considered group trauma focused CBT - Classen 2001, Krakow 2001, Schnurr 2003 and Zlotnick 1997.

Other therapies - Four studies considered other therapies - Blanchard 2003, Brom 1989, Bryant 2003 and Foa 1991.

Eye Movement Desensitisation and Reprocessing - Twelve studies considered eye movement desensitisation and reprocessing - Carlson 1998, Devilly 1999, Ironson 2002, Jensen 1994, Lee 2002, Marcus 1997/2004, Power 2002, Rothbaum 1997, Rothbaum 2005, Scheck 1998, Taylor 2003 and Vaughan 1994.

Comparisons:

The included trials compared (i) psychological treatment vs waitlist or usual care control (some studies allowed the control group to receive pharmacological treatments and/or psychological treatments that were not being considered specifically); (ii) psychological treatment vs other psychological treatment.

The following specific comparisons were made:

a. TFCBT versus waitlist/usual care - Blanchard 2003, Brom 1989, Cloitre 2002, Cooper 1989, Ehlers 2003, Fecteau 1999, Foa 1991, Foa 1999, Gersons 2000, Keane 1989, Kubany 2003, Kubany 2004, Marks 1998, Peniston 1991, Power 2002, Resick 2002, Rothbaum 2005 and Vaughan 1994.

b. Stress management versus waitlist/usual care - Carlson 1998, Foa 1991, Foa 1999 and Vaughan 1994.

c. Other therapies versus waitlist/usual care - Blanchard 2003, Brom 1989 and Foa 1991.

d. Group CBT versus waitlist/usual care - Classen 2001, Krakow 2001 and Zlotnick 1997.

e. TFCBT versus stress management - Echeburua 1997, Foa 1991, Foa 1999, Marks 1998, Taylor 2003 and Vaughan 1994.

f. TFCBT versus other therapies - Blanchard 2003, Brom 1989, Bryant 2003, Foa 1991 and Neuner 2004.

g. Stress management versus other therapy - Foa 1991.

h. Group TFCBT versus group non trauma focused CBT - Schnurr 2003.

i. EMDR versus waitlist/usual care - Carlson 1998, Jensen 1994, Power 2002, Rothbaum 1997, Rothbaum 2005 and Vaughan 1994.

j. EMDR versus TFCBT - Devilly 1999, Ironson 2002, Lee 2002, Power 2002, Rothbaum 2005, Taylor 2003 and Vaughan 1994.

k. EMDR versus stress management - Carlson 1998, Taylor 2003 and Vaughan 1994.

l. EMDR versus other therapy - Marcus 1997/2004 and Scheck 1998.

Risk of bias in included studies

Randomisation
Most studies did not provide full details of the method of allocation and some bias was believed to be possible from the description in 26 studies. In seven studies the method of allocation was felt to be appropriate with no bias possible (Bryant 2003, Schnurr 2003, Krakow 2001, Marks 1998, Resick 2002, Scheck 1998 and Vaughan 1994).

Allocation concealment
Most studies did not provide full details of the method of randomisation and therefore concealment was unclear in 27 studies (Blanchard 2003, Brom 1989, Bryant 2003, Carlson 1998, Classen 2001, Cloitre 2002, Devilly 1999, Echeburua 1997, Ehlers 2003, Foa 1999, Gersons 2000, Ironson 2002, Jensen 1994, Keane 1989, Kubany 2004, Lee 2002, Marcus 1997/2004, Marks 1998, Peniston 1991, Resick 2002, Rothbaum 1997, Rothbaum 2005, Scheck 1998, Schnurr 2003, Taylor 2003, Vaughan 1994, Zlotnick 1997). There was evidence of adequate concealment in the Power 2002 study. In six studies randomisation concealment was inadequate, for example using the roll of a die or a list of randomised numbers (Cooper 1989, Fecteau 1999, Foa 1991, Krakow 2001, Kubany 2003, Neuner 2004).

Blinding
In common with all studies of psychological treatment a double blind methodology is virtually impossible as it is clear to the subject what treatment they are receiving. However, a well designed study should have ensured blinding of the assessor of outcome measures. This was performed in 20 studies (Blanchard 2003, Bryant 2003, Cloitre 2002, Ehlers 2003, Fecteau 1999, Foa 1999, Gersons 2000, Krakow 2001, Kubany 2003, Kubany 2004, Marks 1998, Neuner 2004, Peniston 1991, Power 2002, Resick 2002, Rothbaum 2005, Scheck 1998, Schnurr 2003, Taylor 2003, Vaughan 1994) but not present in the other studies. In no studies was the blinding complimented by a test for the integrity of it.

Loss to follow-up
This was fully reported with reasons by group in eleven studies (Blanchard 2003, Ehlers 2003, Fecteau 1999, Gersons 2000, Ironson 2002, Krakow 2001, Neuner 2004, Peniston 1991, Rothbaum 1997, Taylor 2003, Vaughan 1994). In three studies this was not recorded (Jensen 1994, Keane 1989, Marcus 1997/2004). In the other studies withdrawals were recorded without reasons by group.

Moncrieff et al (2001) assessment:
The scores for each item and total scores for all the studies are shown in the methodological quality table. It is important to view the items separately as it is likely that some studies with higher scores had significant methodological shortcomings. The overall quality of the studies was variable. Several studies had significant flaws as is illustrated by the table. One trend was that the earlier studies tended to have lower quality scores than the more recent ones. Sixteen studies had a score of 26 or more including 13 of the 15 studies published in the 21st century. Sixteen studies scored below 25 including all four studies published in the 1980s. Only three studies (Krakow 2001, Power 2002, Schnurr 2003) scored over 30.

There was rarely any measure of treatment fidelity and only one study (Taylor 2003) provided details of any side effects of treatment although this was only information regarding worsening of specific symptoms on the main outcome measure. In several studies the conclusions were only partially justified from the results obtained. A strength of the majority of the studies was having clear objectives but sample sizes were small and the follow-up period was limited. Fifteen studies had follow-up periods of six months or more (Bryant 2003, Carlson 1998, Classen 2001, Echeburua 1997, Foa 1999, Krakow 2001, Kubany 2004, Marcus 2004, Marks 1998, Neuner 2004, Peniston 1991, Power 2002, Resick 2002, Rothbaum 2005 and Schnurr 2003). Power calculations were rarely reported and it is apparent that many of the studies were underpowered. The treatments delivered were reasonably well described although there was limited testing of treatment fidelity. The majority of studies used well validated outcome measures although there was considerable variation in the actual measures used.

TFCBT
The TFCBT study scores ranged from 17 (Brom 1989) to 32 (Power 2002). The overall quality was variable and has been further explored in a sensitivity analysis reported in the results section.

There were several specific aspects of individual studies that need to be considered when interpreting the results. Blanchard 2003 included individuals with "severe sub-syndromal PTSD" defined as individuals who did not fully meet either the re-experiencing, avoidance or hyperarousal criteria but did meet all other DSMIV criteria. In the Brom 1989 study, 83 (74%) had experienced bereavement as the trauma and the period between therapeutic sessions was unclear. As part of the assessment interview "confrontation therapy" was used apparently to determine the reaction to the traumatic event. Clearly this may have affected outcome. In the Cooper 1989 study most individuals finishing the imaginal flooding continued to receive both standard individual and group therapies. Both usual care group and treatment group subjects received a standard component treatment (individual and group) designed for PTSD. This comprised weekly sessions of one hour evaluating symptoms and background of PTSD with an educational component. Two hour weekly group sessions focussed on a number of problem areas including PTSD symptoms using group problem-solving, current life problems and group support. Clearly the usual care group received significant treatment in this study.

Foa 1991 excluded assaults by a spouse or family member. Foa 1999 was one of the best studies methodologically although how subjects were recruited was unclear and the number of drop-outs was not specified. Gersons 2000 too was a well designed study but restricted to male police officers. The types of trauma were not specified although all fulfilled Criterion A of the DSMIV classification of PTSD. Keane 1989 did not describe the severity or type of trauma, nor the time between trauma and study. Treatment and waiting list groups continued to receive medication throughout the trial. An unknown number of the usual care/waiting list control group subjects continued to attend programmes for veterans or to see a psychiatrist and there was no data on the degree of involvement or treatment given in this group during the study. This is likely to have reduced the validity of this study and specifically the ability to detect a difference in effectiveness between the two groups. In common with several of the studies of Vietnam veterans this study appears to have been of men with chronic, probably treatment resistant PTSD symptoms with a relatively poor prognosis and compared an active treatment against a usual care control group who were also receiving significant ongoing treatment.

The Marks 1998 study was quite strong methodologically. Exclusions included those who had had past treatment with cognitive therapy, suggesting a bias in favour of those whose symptomatology or illness may have been less severe and clearly in contrast with the methodology employed in several of the Vietnam veteran studies leading to a likely better outcome. Unfortunately there was a high attrition rate and the later follow-up data were often on very small groups. The Peniston 1991 study suffers from low sample size and chronic Vietnam veteran PTSD sufferers - ten of the sixteen were inpatients. There were no drop-outs and no detail on missed sessions. The Resick 2002 study was very strong methodologically with a large sample size. Ehlers 2003 study was strong methodologically but suffered from a small sample size.

Vaughan's study included individuals from a range of traumas of whom 22% did not satisfy the DSM III R criteria for PTSD. No homework was given in the eye movement desensitisation group whereas the applied muscle relaxation and image habituation therapy groups were required to complete homework

Stress management:
The quality scores of these studies varied from 21 (Vaughan 1994) to 29 (Foa 1999). Issues concerning the Foa 1991, Foa 1999, Marks 1998 and Vaughan 1994 studies have been discussed above. The Carlson 1998 study suffered from a small sample size. In the Echeburua 1997 study outcome assessments were performed by the therapists themselves and the treatment was not manualised.

Other therapies
These studies all included TFCBT as an intervention as well as other therapies. The quality scores varied from 17 (Brom 1989) to 29 (Bryant 2003).

Group TFCBT
The studies of group TFCBT included the two of the studies with the highest quality scores (Krakow 2001 31, Schnurr 2003 37) and two of the studies that scored least (Zlotnick 1997 18, Classen 2001 20). The Krakow 2001 treatment focused on nightmares and did not specifically deal with other phenomena of PTSD which may have impacted on the results. In the Zlotnick 1997 study the duration of symptoms was not apparent. All subjects were receiving individual psychotherapy in addition to the group intervention and medication was being prescribed throughout . There were seven (29%) drop-outs in the treatment group with no reasons given for dropping out. However those not completing had higher scores on the pre-treatment PTSD symptom scale and the Dissociative Experience Scale. The presence of PTSD at the end of the study was estimated from the Davidson trauma scale questionnaire as opposed to a structured interview post treatment. Schnurr 2003 had the largest sample size of all the studies but unfortunately there was no wait-list or other non-active treatment control group which makes interpretation very difficult.

EMDR
The quality scores of EMDR studies ranged from 18 (Jensen 1994) to 32 (Power 2002). Unfortunately most studies included only small sample sizes, the maximum number of individuals who had received EMDR in any analysis was 109. Most of the studies assessed fidelity of the EMDR but were less diligant regarding the fidelity of other treatments delivered. There was also great variability between studies with regards to the number of EMDR sessions (from Ironson 2002 - 1-3 to Devilly 1999 - 12).

Effects of interventions

The full results are contained in the tables and are summarised below.

1. TFCBT/Exposure therapy versus waitlist/usual care
Clinician rated PTSD symptoms:
Fourteen studies considered this outcome with a total of 649 individuals. There was significant statistical heterogeneity between these trials (Chi square = 88.89; p<0.00001: I square = 85.4%) and a random effects model was used to pool the data. The TFCBT group did significantly better than the waitlist/usual care group immediately after treatment (SMD (95% CI) = -1.40 (-1.89 to -0.91)).

Self reported PTSD symptoms:
Nine studies considered this outcome with a total of 428 individuals. There was significant statistical heterogeneity between these trials (Chi square = 29.7; p = 0.0002: I square = 73.1%) and a random effects model was used to pool the data. The TFCBT group did significantly better than the waitlist/usual care group immediately after treatment (SMD (95% CI) = -1.68 (-2.14 to -1.22)).

Depression:
Fourteen studies considered this outcome with a total of 625 individuals. There was significant statistical heterogeneity between these trials (Chi square = 69.16; p<0.00001: I square = 81.2%) and a random effects model was used to pool the data. The TFCBT group did significantly better than the waitlist/usual care group immediately after treatment (SMD (95% CI) = -1.26 (-1.69 to -0.82)).

Anxiety:
Eleven studies considered this outcome with a total of 415 individuals. There was no significant statistical heterogeneity between these trials. The TFCBT group did significantly better than the waitlist/usual care group immediately after treatment (SMD (95% CI) = -0.99 (-1.2 to -0.78)).

Adverse effects:
No studies formally considered adverse effects.

Dropouts:
Fifteen studies with a total of 861 individuals recorded whether individuals left the study early for any reason by group. There was no significant statistical heterogeneity between these trials. The TFCBT group did significantly worse than the waitlist/usual care group (RR (95% CI) = 1.42 (1.05, 1.94)).

PTSD diagnosis after treatment:
Fifteen studies with a total of 756 individuals reported this outcome. There was significant statistical heterogeneity between these trials (Chi square = 62.88; p<0.00001: I square = 77.7%) and a random effects model was used to pool the data. The TFCBT group did significantly better than the waitlist/usual care group (RR (95% CI) = 0.44 (0.34, 0.57)).

2. Stress management versus waitlist/usual care:
Clinician rated PTSD symptoms:
Four studies considered this outcome with a total of 86 individuals. There was no significant statistical heterogeneity between these trials. The stress management group did significantly better than the waitlist/usual care group immediately after treatment (SMD (95% CI) = -1.14 (-1.62 to -0.67)).

Self reported PTSD symptoms:
One study considered this outcome with a total of 24 individuals. There was no statistically significant difference between the stress management group and the waitlist/usual care group immediately after treatment (SMD (95% CI) = 0.33 (-0.47 to 1.14)).

Depression:
Four studies considered this outcome with a total of 109 individuals. There was no significant statistical heterogeneity between these trials. The stress management group did significantly better than the waitlist/usual care group immediately after treatment (SMD (95% CI) = -0.73 (-1.12 to -0.33)).

Anxiety:
Three studies considered this outcome with a total of 82 individuals. There was no significant statistical heterogeneity between these trials. The stress management group did significantly better than the waitlist/usual care group immediately after treatment (SMD (95% CI) = -0.77 (-1.23 to -0.31)).

Adverse effects:
No studies formally considered adverse effects.

Dropouts:
Four studies with a total of 121 individuals recorded whether individuals left the study early for any reason by group. There was no significant statistical heterogeneity between these trials. There was no statistically significant difference between the stress management group and the waitlist/usual care group (RR (95% CI) = 2.19 (0.71, 6.73)).

PTSD diagnosis after treatment:
Three studies with a total of 121 individuals reported this outcome. There was significant statistical heterogeneity between these trials (Chi square = 8.63; p = 0.03: I square = 65.2%) and a random effects model was used to pool the data. The stress management group did significantly better than the waitlist/usual care group (RR (95% CI) = 0.64 (0.47, 0.87)).

3. Other therapies versus waitlist/usual care:
Clinician rated PTSD symptoms:
Two studies considered this outcome with a total of 72 individuals. There was no significant statistical heterogeneity between these trials. There was no statistically significant difference between the other therapies group and the waitlist/usual care group immediately after treatment (SMD (95% CI) = -0.43 (-0.9 to 0.04)).

Self reported PTSD symptoms:
Two studies considered this outcome with a total of 132 individuals. There was no significant statistical heterogeneity between these trials. The other therapies group did significantly better than the waitlist/usual care group immediately after treatment (SMD (95% CI) = -0.61 (-0.98 to -0.24)).

Depression:
Two studies considered this outcome with a total of 72 individuals. There was no significant statistical heterogeneity between these trials. There was no statistically significant difference between the other therapies group and the waitlist/usual care group immediately after treatment (SMD (95% CI) = -0.25 (-0.71 to 0.22)).

Anxiety:
Three studies considered this outcome with a total of 153 individuals. There was no significant statistical heterogeneity between these trials. The other therapies group did significantly better than the waitlist/usual care group immediately after treatment (SMD (95% CI) = -0.48 (-0.82 to -0.14)).

Adverse effects:
No studies formally considered adverse effects.

Dropouts:
Three studies with a total of 166 individuals recorded whether individuals left the study early for any reason by group. There was no significant statistical heterogeneity between these trials. The other therapies group did significantly worse than the waitlist/usual care group (RR (95% CI) = 3.82 (1.19, 12.29)).

PTSD diagnosis after treatment:
Three studies with a total of 166 individuals reported this outcome. There was significant statistical heterogeneity between these trials (Chi square = 8.72; p = 0.01: I square = 77.1%) and a random effects model was used to pool the data. There was no difference between the other therapies and the waitlist/usual care group (RR (95% CI) = 0.79 (0.53, 1.18)).

4. Group TFCBT versus waitlist/usual care:
Clinician rated PTSD symptoms:
One study considered this outcome with a total of 45 individuals. The group TFCBT group did significantly better than the waitlist/usual care group immediately after treatment (SMD (95% CI) = -0.72 (-1.14 to -0.31)).

Self reported PTSD symptoms:
Two studies considered this outcome with a total of 71 individuals. There was no significant statistical heterogeneity between these trials. The group TFCBT group did significantly better than the waitlist/usual care group immediately after treatment (SMD (95% CI) = -0.71 (-1.20 to -0.22)).

Depression:
No studies considered this outcome.

Anxiety:
No studies considered this outcome.

Adverse effects:
No studies formally considered adverse effects.

Dropouts:
Three studies with a total of 271 individuals recorded whether individuals left the study early for any reason by group. There was no significant statistical heterogeneity between these trials. There was no statistically significant difference between the group TFCBT group and the waitlist/usual care group (RR (95% CI) = 1.00 (0.64, 1.56)).

PTSD diagnosis after treatment:
One study with a total of 48 individuals reported this outcome. There was no significant difference between the group TFCBT group and the waitlist/usual care group (RR (95% CI) = 0.56 (0.31, 1.01)).

5. TFCBT/Exposure therapy versus stress management:
Clinician rated PTSD symptoms:
Six studies considered this outcome with a total of 239 individuals. There was significant statistical heterogeneity between these trials (Chi square = 11.25; p = 0.05: I square = 55.6%) and a random effects model was used to pool the data. There was no statistically significant difference between the TFCBT group and the stress management group immediately after treatment (SMD (95% CI) = -0.27 (-0.71 to 0.16)). At 2-5 month follow-up five studies considered this outcome with a total of 127 individuals. There was no significant statistical heterogeneity between these trials. The TFCBT group did significantly better than the stress management group at 2-5 month follow-up (SMD (95% CI) = -0.48 (-0.84 to -0.12)).

Self reported PTSD symptoms:
Three studies considered this outcome with a total of 127 individuals. There was no significant statistical heterogeneity between these trials. There was no statistically significant difference between the TFCBT group and the stress management group immediately after treatment (SMD (95% CI) = -0.37 (-0.74 to 0.01)). At 2-5 month follow-up two studies considered this outcome with a total of 54 individuals. The TFCBT group did significantly better than the stress management group at 2-5 month follow-up (SMD (95% CI) = -0.44 (-0.99 to 0.10)).

Depression:
Five studies considered this outcome with a total of 161 individuals. There was no significant statistical heterogeneity between these trials. There was no statistically significant difference between the TFCBT group and the stress management group immediately after treatment (SMD (95% CI) = -0.25 (-0.57 to 0.08)). At 2-5 month follow-up five studies considered this outcome with a total of 147 individuals. There was no significant statistical heterogeneity between these trials. There was no statistically significant difference between the TFCBT group and the stress management group at 2-5 month follow-up (SMD (95% CI) = -0.28 (-0.62 to 0.06)).

Anxiety:
Four studies considered this outcome with a total of 127 individuals. There was no significant statistical heterogeneity between these trials. There was no statistically significant difference between the TFCBT group and the stress management group immediately after treatment (SMD (95% CI) = -0.12 (-0.49 to 0.26)). At 2-5 month follow-up five studies considered this outcome with a total of 117 individuals. There was no significant statistical heterogeneity between these trials. There was no statistically significant difference between the TFCBT group and the stress management group at 2-5 month follow-up (SMD (95% CI) = -0.19 (-0.58 to 0.20)).

Adverse effects:
No studies formally considered adverse effects.

Dropouts:
Six studies with a total of 284 individuals recorded whether individuals left the study early for any reason by group. There was no significant statistical heterogeneity between these trials. There was no statistically significant difference between the TFCBT group and the stress management group (RR (95% CI) = 1.17 (0.69, 2.0)).

PTSD diagnosis after treatment:
Six studies with a total of 284 individuals reported this outcome. There was no significant statistical heterogeneity between these trials. There was a statistically significant difference between the TFCBT group and the stress management group (RR (95% CI) = 0.78 (0.61, 0.99)).

6. TFCBT/Exposure therapy versus other therapies
Clinician rated PTSD symptoms:
Three studies considered this outcome with a total of 120 individuals. There was no significant statistical heterogeneity between these trials. The TFCBT group did significantly better than the other therapies group immediately after treatment (SMD (95% CI) = -0.81 (-1.19 to -0.42)). At 3 month follow-up two studies considered this outcome with a total of 70 individuals. There was no significant statistical heterogeneity between these trials. The TFCBT group did significantly better than the other therapies group at 3 month follow-up (SMD (95% CI) = -0.65 (-1.13 to -0.16)). One trial reported this outcome at 6 to 9 month follow-up and again found that the TFCBT group did significantly better than the other therapies group (SMD (95% CI) = -1.85 (-2.59 to -1.11)).

Self reported PTSD symptoms:
Three studies considered this outcome with a total of 176 individuals. There was significant statistical heterogeneity between these trials (Chi square = 21.90; p<0.0001: I square = 90.9%) and a random effects model was used to pool the data. The TFCBT group did significantly better than the other therapies group immediately after treatment (SMD (95% CI) = -1.18 (-2.32 to -0.03)). At 2-5 month follow-up two studies considered this outcome with a total of 131 individuals. There was significant statistical heterogeneity between these trials (Chi square = 4.43; p = 0.04: I square = 77.4%) and a random effects model was used to pool the data. There was no significant difference between the TFCBT and the other therapies group at 2-5 month follow-up (SMD (95% CI) = -0.28 (-1.04 to 0.48)). One trial reported this outcome at 6 to 9 month follow-up and again found that the TFCBT group did significantly better than the other therapies group (SMD (95% CI) = -1.72 (-2.45 to -1.00)).

Depression:
Three studies considered this outcome with a total of 120 individuals. There was no significant statistical heterogeneity between these trials. The TFCBT group did significantly better than the other therapies group immediately after treatment (SMD (95% CI) = -0.65 (-1.03 to -0.28)). At 2-5 month follow-up two studies considered this outcome with a total of 72 individuals. There was no significant statistical heterogeneity between these trials. The TFCBT group did significantly better than the other therapies group at 2-5 month follow-up (SMD (95% CI) = -0.53 (-1.00 to -0.05)).One trial reported this outcome at 6 to 9 month follow-up and again found that the TFCBT group did significantly better than the other therapies group (SMD (95% CI) = -1.08 (-1.74 to -0.42)).

Anxiety:
Four studies considered this outcome with a total of 197 individuals. There was significant statistical heterogeneity between these trials (Chi square = 12.85; p = 0.005: I square = 76.7%) and a random effects model was used to pool the data. There was no significant difference between the TFCBT and the other therapies group immediately after treatment (SMD (95% CI) = -0.47 (-1.11 to 0.17)). At 2-5 month follow-up three studies considered this outcome with a total of 149 individuals. There was no significant statistical heterogeneity between these trials. There was no significant difference between the TFCBT and the other therapies group at 2-5 month follow-up (SMD (95% CI) = -0.27 (-0.60 to 0.07)). One trial reported this outcome at 6 to 9 month follow-up and again found that the TFCBT group did significantly better than the other therapies group (SMD (95% CI) = -1.18 (-1.85 to -0.51)).

Adverse effects:
No studies formally considered adverse effects.

Dropouts:
Five studies with a total of 290 individuals recorded whether individuals left the study early for any reason by group. There was no significant statistical heterogeneity between these trials. There was no statistically significant difference between the TFCBT group and the other therapies group (RR (95% CI) = 1.14 (0.68, 1.9)).

PTSD diagnosis after treatment:
Five studies with a total of 286 individuals reported this outcome. There was no significant statistical heterogeneity between these trials. There was a statistically significant difference between the between the TFCBT and the other therapies group (RR (95% CI) = 0.71 (0.56, 0.89)).

7. Stress management versus other therapies
Clinician rated PTSD symptoms:
One study considered this outcome with a total of 25 individuals. The stress management group did significantly better than the other therapies group immediately after treatment (SMD (95% CI) = -1.22 (-2.09 to -0.35)). At 3 month follow-up one study considered this outcome with a total of 18 individuals. There was no significant difference between the stress management and the other therapies group at 3 month follow-up (SMD (95% CI) = -0.38 (-1.31 to 0.55)).

Self reported PTSD symptoms:
No studies considered this outcome.

Depression:
One study considered this outcome with a total of 25 individuals. There was no significant difference between the stress management and the other therapies group immediately after treatment (SMD (95% CI) = -0.51 (-1.31 to 0.30)). At 3 month follow-up one study considered this outcome with a total of 18 individuals. There was no significant difference between the stress management and the other therapies group at 3 month follow-up (SMD (95% CI) = -0.48 (-1.42 to 0.46)).

Anxiety:
One study considered this outcome with a total of 25 individuals. There was no significant difference between the stress management and the other therapies group immediately after treatment (SMD (95% CI) = -0.51 (-1.32 to 0.29)). At 3 month follow-up one study considered this outcome with a total of 18 individuals. There was no significant difference between the stress management and the other therapies group at 3 month follow-up (SMD (95% CI) = -0.68 (-1.64 to 0.28)).

Adverse effects:
No studies formally considered adverse effects.

Dropouts:
One study with a total of 31 individuals recorded whether individuals left the study early for any reason by group. There was no statistically significant difference between the stress management group and the waitlist/usual care group (RR (95% CI) = 0.82 (0.20, 3.46)).

PTSD diagnosis after treatment:
One study with a total of 31 individuals reported this outcome. There was no significant statistical heterogeneity between these trials. There was no statistically significant difference between the stress management group and the waitlist/usual care group (RR (95% CI) = 0.58 (0.30, 1.11)).

8. Group TFCBT versus group non-TF CBT
Clinician rated PTSD symptoms:
One study considered this outcome with a total of 325 individuals. There was no significant difference between the group TFCBT and non-trauma-focused CBT groups (SMD (95% CI) = -0.12 (-0.34 to 0.10)).

Self reported PTSD symptoms:
No studies considered this outcome.

Depression:
No studies considered this outcome.

Anxiety:
No studies considered this outcome.

Adverse effects:
No studies formally considered adverse effects.

Dropouts:
One study with a total of 360 individuals recorded whether individuals left the study early for any reason by group. There was no statistically significant difference between the group TFCBT and non-trauma-focused CBT groups (RR (95% CI) = 1.38 (1.0, 1.9)).

PTSD diagnosis after treatment:
One study with a total of 360 individuals reported this outcome. There was no significant statistical heterogeneity between these trials. There was no statistically significant difference between the group TFCBT and non-trauma-focused CBT groups (RR (95% CI) = 0.98 (0.83, 1.16)).

9. EMDR versus waitlist/usual care
Clinician rated PTSD symptoms:
Five studies considered this outcome with a total of 162 individuals. There was no significant statistical heterogeneity between these trials. The EMDR group did significantly better than the waitlist/usual care group immediately after treatment (SMD (95% CI) = -1.51 (-1.87 to -1.15)).

Self reported PTSD symptoms:
Five studies considered this outcome with a total of 156 individuals. There was significant statistical heterogeneity between these trials (Chi square = 27.85; p < 0.0001: I square = 85.6%) and a random effects model was used to pool the data. There was no statistically significant difference between the EMDR and waitlist/usual care groups immediately after treatment (SMD (95% CI) = -1.07 (-2.04 to -.10)).

Depression:
Five studies considered this outcome with a total of 160 individuals. There was no significant statistical heterogeneity between these trials. The EMDR group did significantly better than the waitlist/usual care group immediately after treatment (SMD (95% CI) = -1.48 (-1.84 to -1.12)).

Anxiety:
Five studies considered this outcome with a total of 156 individuals. There was no significant statistical heterogeneity between these trials. The EMDR group did significantly better than the waitlist/usual care group immediately after treatment (SMD (95% CI) = -1.10 (-1.45 to -0.76)).

Adverse effects:
No studies formally considered adverse effects.

Dropouts:
Six studies with a total of 217 individuals recorded whether individuals left the study early for any reason by group. There was no significant statistical heterogeneity between these trials. There was no statistically significant difference between the EMDR and waitlist/usual care groups (OR (95% CI) = 1.33 (0.64 to 2.74)).

PTSD diagnosis after treatment:
Six studies with a total of 209 individuals reported this outcome. There was significant statistical heterogeneity between these trials (Chi square = 52.61; p<0.00001: I square = 90.5%) and a random effects model was used to pool the data. The EMDR group did significantly better than the waitlist/usual care group (RR (95% CI) = 0.47(0.25 to 0.85)).

10. EMDR versus TFCBT/ Exposure therapy:
Clinician rated PTSD symptoms:
Six studies considered this outcome with a total of 187 individuals. There was significant statistical heterogeneity between these trials (Chi square = 16.51; p = 0.006: I square = 69.7%) and a random effects model was used to pool the data. There was no statistically significant difference between the EMDR group and the TFCBT group immediately after treatment (SMD (95% CI) = 0.03 (-0.5 to 0.55)). At 2-5 month follow-up three studies considered this outcome with a total of 76 individuals. There was no statistically significant difference between the EMDR and TFCBT groups at 2-5 month follow-up (SMD (95% CI) = -0.14 (-0.60 to 0.32)).

Self reported PTSD symptoms:
Seven studies considered this outcome with a total of 206 individuals. There was significant statistical heterogeneity between these trials (Chi square = 13.33; p = 0.04: I square = 55%) and a random effects model was used to pool the data. There was no statistically significant difference between the EMDR group and the TFCBT group immediately after treatment (SMD (95% CI) = -0.17 (-0.59 to 0.26)). At 2-5 month follow-up five studies considered this outcome with a total of 111 individuals. There was no statistically significant difference between the EMDR and TFCBT groups at 2-5 month follow-up (SMD (95% CI) = -0.01 (-0.39 to 0.37)).

Depression:
Seven studies considered this outcome with a total of 206 individuals. There was significant statistical heterogeneity between these trials (Chi square = 23.99; p = 0.0005: I square = 75%) and a random effects model was used to pool the data. There was no statistically significant difference between the EMDR group and the TFCBT group immediately after treatment (SMD (95% CI) = -0.32 (-0.90 to 0.26)). At 2-5 month follow-up five studies considered this outcome with a total of 111 individuals. There was no significant statistical heterogeneity between these trials. There was no statistically significant difference between the EMDR group and the TFCBT group at 2-5 month follow-up (SMD (95% CI) = -0.09 (-0.47 to 0.29)).

Anxiety:
Four studies considered this outcome with a total of 136 individuals. There was no significant statistical heterogeneity between these trials. There was no statistically significant difference between the EMDR group and the TFCBT group immediately after treatment (SMD (95% CI) = -0.08 (-0.42 to 0.26)). At 2-5 month follow-up two studies considered this outcome with a total of 48 individuals. There was no significant statistical heterogeneity between these trials. There was no statistically significant difference between the EMDR group and the TFCBT group at 2-5 month follow-up (SMD (95% CI) = 0.24 (-0.33 to 0.81)).

Adverse effects:
No studies formally considered adverse effects.

Dropouts:
Seven studies with a total of 268 individuals recorded whether individuals left the study early for any reason by group. There was no significant statistical heterogeneity between these trials. There was no statistically significant difference between the EMDR group and the TFCBT group (RR (95% CI) = 0.83(0.55 to 1.26 )).

PTSD diagnosis after treatment:
Six studies with a total of 260 individuals reported this outcome. There was significant statistical heterogeneity between these trials (Chi square = 14.38; p = 0.03: I square = 58.3%) and a random effects model was used to pool the data. There was no statistically significant difference between the EMDR group and the TFCBT group (RR (95% CI) = 1.11(0.68 to 1.81)).

11. EMDR versus stress management therapy:
Clinician rated PTSD symptoms:
Two studies considered this outcome with a total of 53 individuals. There was no significant statistical heterogeneity between these trials. There was no statistically significant difference between the EMDR group and the stress management therapy group immediately after treatment (SMD (95% CI) = -0.35 (-0.90 to 0.19)). At 2-5 month follow-up three studies considered this outcome with a total of 71 individuals. The EMDR group did significantly better than the stress management therapy group immediately after treatment (SMD (95% CI) = -0.59 (-1.08 to -0.09)).

Self reported PTSD symptoms:
Three studies considered this outcome with a total of 75 individuals. There was no significant statistical heterogeneity between these trials. There was no statistically significant difference between the EMDR group and the stress management therapy group immediately after treatment (SMD (95% CI) = -0.40 (-0.86 to 0.06)). At 2-5 month follow-up three studies considered this outcome with a total of 75 individuals. The EMDR group did significantly better than the stress management therapy group immediately after treatment (SMD (95% CI) = -0.52 (-0.98 to -0.05)).

Depression:
Three studies considered this outcome with a total of 75 individuals. There was no significant statistical heterogeneity between these trials. The EMDR group did significantly better than the stress management therapy group immediately after treatment (SMD (95% CI) = -0.67 (-1.14 to -0.20)). At 2-5 month follow-up three studies considered this outcome with a total of 75 individuals. There was no statistically significant difference between the EMDR group and the stress management therapy group at 2-5 month follow-up (SMD (95% CI) =
-0.23 (-0.70 to 0.23)).

Anxiety:
Two studies considered this outcome with a total of 45 individuals. There was no significant statistical heterogeneity between these trials. The EMDR group did significantly better than the stress management therapy group immediately after treatment (SMD (95% CI) = -0.75 (-1.36 to -0.13)). At 2-5 month follow-up two studies considered this outcome with a total of 45 individuals. There was no statistically significant difference between the EMDR group and the stress management therapy group at 2-5 month follow-up (SMD (95% CI) =
-0.42 (-2.21 to 1.37)).

Adverse effects:
No studies formally considered adverse effects.

Dropouts:
Three studies with a total of 84 individuals recorded whether individuals left the study early for any reason by group. There was no significant statistical heterogeneity between these trials. There was no statistically significant difference between the EMDR group and the stress mangement therapy group (RR (95% CI) = 1.03 (0.37 to 2.88)).

PTSD diagnosis after treatment:
Three studies with a total of 84 individuals reported this outcome. There was no significant statistical heterogeneity between these trials. There was no statistically significant difference between the EMDR group and the stress management therapy group (RR (95% CI) = 0.69 (0.46 to 1.04)).

12. EMDR versus other therapies:
Clinician rated PTSD symptoms:
No studies formally considered this outcome.

Self reported PTSD symptoms:
Two studies considered this outcome with a total of 124 individuals. There was no significant statistical heterogeneity between these trials. The EMDR group did significantly better than the other therapies group immediately after treatment (SMD (95% CI) = -0.84 (-1.21 to -0.47)).

Depression:
Two studies considered this outcome with a total of 127 individuals. There was no significant statistical heterogeneity between these trials. The EMDR group did significantly better than the other therapies group immediately after treatment (SMD (95% CI) = -0.67 (-1.03 to -0.32)).

Anxiety:
Two studies considered this outcome with a total of 126 individuals. There was no significant statistical heterogeneity between these trials. The EMDR group did significantly better than the other therapies group immediately after treatment (SMD (95% CI) = -0.72 (-1.08 to -0.36)).

Adverse effects:
No studies formally considered adverse effects.

Dropouts:
Two studies with a total of 127 individuals recorded whether individuals left the study early for any reason by group. There was no significant statistical heterogeneity between these trials. There was no statistically significant difference between the EMDR group and the other therapies group (RR (95% CI) = 1.48 (0.26 to 8.54)).

PTSD diagnosis after treatment:
One study with a total of 67 individuals reported this outcome. The EMDR group did significantly better than the other therapies group (RR (95% CI) = 0.40 (0.19 to 0.84)).

Clinical heterogeneity subgroup analyses
In order to explore clinical heterogeneity, two subgroup analyses were performed for the primary outcome measure, i.e. clinician rated PTSD symptoms, for the TFCBT versus waitlist/usual care comparison. Thirteen studies had considered this outcome with a total of 609 individuals and the initial SMD was -1.36 (95% CI = -1.88 to -0.84), suggesting that the TFCBT group did significantly better than the waitlist/usual care group immediately after treatment. There was significant statistical heterogeneity between these trials (Chi square = 86.62; p<0.00001: I square = 86.1%).

Female only studies
Seven studies considered this outcome with a total of 404 females. The TFCBT group did significantly better than the waitlist/usual care group immediately after treatment (SMD (95% CI) = -1.94 (-2.53 to -1.34)), demonstrating a larger difference in favour of TFCBT than in the overall analyses. Seven studies with mixed gender populations and a total of 145 inidividuals reported this outcome. Although the TFCBT group still did significantly better than the waitlist/usual care group immediately after treatment (SMD (95% CI) = -0.83 (-0.61 to -0.41)), the observed difference between groups was much reduced. The observed statistically significant heterogeneity remained following these subgroup analyses, although was much reduced in the mixed gender subgroup (Chi square = 14.52; p = 0.02: I square = 58.7%).

Studies not considering Vietnam veterans
Thirteen studies considered this outcome with a total of 625 individuals. The TFCBT group did significantly better than the waitlist/usual care group immediately after treatment (SMD (95% CI) = -1.49 (-1.99 to -0.99)), demonstrating little difference from the overall analyses. Excluding this one trial made no difference to the observed statistically significant heterogeneity.

Sensitivity analyses
In order to explore the impact of methodological quality, a sensitivity analysis was performed for the primary outcome measure, i.e. clinician rated PTSD symptoms, for the TFCBT versus waitlist/usual care comparison.

Thirteen studies had considered this outcome with a total of 609 individuals and the initial SMD was -1.36 (95% CI = -1.88 to -0.84), suggesting that the TFCBT group did significantly better than the waitlist/usual care group immediately after treatment. The studies were divided into higher and lower quality studies. Nine higher quality studies considered this outcome with a total of 493 individuals. The TFCBT group again did significantly better than the waitlist/usual care group immediately after treatment (SMD (95% CI) = -1.61 (-2.16 to -1.06)). Five lower quality studies considered this outcome with a total of 156 individuals. Once more, the TFCBT group did significantly better than the waitlist/usual care group immediately after treatment (SMD (95% CI) = -1.02 (-1.84 to -0.20)), although in the lower quality studies the observed difference between groups was reduced. The observed statistically significant heterogeneity remained in each of these subgroup analyses.

Publication bias
All the studies identified for this review were published or were accepted for publication, and many of the trials were undertaken relatively recently. The potential effects of publication bias were explored using funnel plots. Two funnel plots were constructed using data from the TFCBT versus waitlist/usual care comparison, one involving continuous data on the primary outcome (clinician-rated PTSD symptoms - see Figure 1), and the second involving dichotomous data on a secondary outcome (PTSD diagnosis after treatment - see Figure 2). These funnel plots both show that the smaller studies may tend to report larger differences between TFCBT and Waitlist/Usual Care, and both suggest an absence of studies demonstrating no difference or a difference in favour of Waitlist/Usual care. It is therefore possible that, due to the greater likelihood of publication of positive studies, the true difference between groups is smaller than is suggested by this review.

Figure 1.

Funnel plot shows that the smaller studies may tend to report larger differences between TFCBT and Waitlist/Usual Care and suggests an absence of studies demonstrating no difference or a difference in favour of Waitlist/Usual care.

Figure 2.

Funnel plot shows that the larger studies demonstrate smaller differences between TFCBT and Waitlist./Usual Care and suggests an absence of smaller studies demonstrating no difference or a difference in favour of Waitlist/Usual care.

Discussion

Trauma focused cognitive behavioural therapy
There was good evidence that TFCBT was better than wait list/usual care in reducing traumatic stress symptoms and additionally associated symptoms of depression and anxiety. It is possible that this may be stronger than suggested by the data, as in several studies the wait list/usual care group received some contact and the expectation that they would be treated which may have been therapeutic. However, there it is also possible that wait list groups do worse than usual care groups because they do not expect to improve until they receive the active intervention. The overall standardised mean difference for traumatic stress symptoms post treatment represents an effect size generally accepted as indicating a strong positive effect. After exploration of heterogeneity this finding remains robust although there is significant heterogeneity present on all analyses. There is not enough evidence to determine if this advantage is maintained over time, but the continuation of improvement of the active treatment groups in the trials with longer follow-ups suggest that this was the case.

There was some evidence that TFCBT was a more effective treatment than non-trauma focused therapies (stress management and other therapies). TFCBT was significantly better than other therapies immediately and than stress management at follow-up.

Stress management
There was evidence that stress management was better than wait list/usual care in reducing traumatic stress symptoms and additionally associated symptoms of depression and anxiety although this was based on only 2 studies with a small sample size. There was some evidence that stress management is a more effective treatment than other non-trauma focused therapies, but this was from the results of one study only.

Other therapies
There was no difference between other therapies and waitlist/usual care on the main outcome measure but it did fare better on the self-report traumatic stress and anxiety measures. As stated above other therapies were significantly worse in terms of the primary outcome measure when directly compared with TFCBT and stress management.

Group TFCBT
There was evidence that group TFCBT was better than waitlist/usual care in reducing traumatic stress symptoms although this was based on only one study with a small sample size. There was no difference between group TFCBT and non-trauma focused group CBT.
Trauma focused cognitive behavioural therapy

Eye Movement Desensitisation and Reprocessing
There was evidence that EMDR was better than wait list/usual care in reducing traumatic stress symptoms and additionally associated symptoms of depression and anxiety. The fact that the studies included only small sample sizes and two lacked randomisation concealment means that the results should be interpreted with caution. However, as was the case with TFCBT it is possible that the results may be stronger than suggested by the data, as in several studies the wait list/usual care group received some contact and the expectation that they would be treated which may have been therapeutic. The overall standardised mean difference for clinician rated traumatic stress symptoms post treatment represents a strong positive effect size although the effect size for self-reported PTSD symptom severity did not reach statistical significance.

EMDR appeared to have similar effectiveness to TFCBT in the studies that compared them directly. There was some evidence that EMDR was a more effective treatment than stress management therapies and other therapies.

Anxiety and Depression
Symptoms of anxiety and depression generally improved in line with improvements in traumatic stress symptoms. For treatments such as cognitive restructuring many of the approaches used for PTSD would also be used for anxiety and depression and might explain the improvement. Other treatments such as exposure therapy may also address depressive symptoms through considering issues such as guilt and reponsibility during the processing and through in vivo homework tasks between sessions. However, the treatments may reduce anxiety and depressive symptoms because they are secondary to the PTSD, and when the PTSD improves these symptoms improve. This would suggest that the anxiety and depressive symptoms found in many PTSD sufferers in these studies were secondary to the PTSD rather than being discrete conditions requiring specific treatment.

Adverse effects
Unfortunately no studies reported adverse effects. It is well recognised that adverse effects may occur such as increased reexperiencing following exposure treatment (e.g. Pitman 1991) and the absence of any reporting of them is of major concern.

Dropouts
Most studies reported on dropouts by group which is likely to be contributed to by adverse effects along with other factors. TFCBT and other therapies both did worse than wait list/usual care on this outcome measure but there were no significant differences in drop-out rates in direct comparisons between active treatments. This may reflect the greater logistic demands of treatment versus wait list but may also be as a result of the active treatments not having always been acceptable to those receiving them. This is an important finding and one that should stimulate research to determine the true explanation. If some interventions are not acceptable to those who receive them, the development of interventions that are should be a priority.

Heterogeneity
The Forest plots of the pooled results demonstrated significant heterogeneity between the studies. For example, heterogeneity levels of p < 0.00001 were observed in several analyses of the primary outcome measure. There are likely to be several factors that contribute to the heterogeneity.

There is clearly considerable clinical diversity within the studies considered. An attempt was made to explore this by performing subgroup analyses on the primary outcome measure of TFCBT versus waitlist/usual care. Those studies including only females, all of whom had been sexually or non-sexually assaulted, produced more positive results than the overall results. Possible explanations include the treatments having been superior, females being more responsive to TFCBT than males, traumatisation by assault being more responsive to TFCBT, a combination of these and/or other factors. Those studies that did not include only Vietnam veterans produced a slightly more positive result than all studies. However there was only one study excluded in this subgroup analysis. Therefore the analysis may lack power to show a real difference and great caution must be exercised in interpreting this.

The separation of different active interventions into groups partially addresses the clinical diversity, although not all trials within the same group used identical interventions. The differences were most marked in the "other treatments" group which had in common the absence of cognitive-behavioural techniques and trauma-focused work. There was also diversity in the TFCBT group which included both exposure only and trauma-focused cognitive therapy interventions.

Another source of heterogeneity was the quality of the studies. Sensitivity analyses of higher quality and lower quality studies were performed for the primary outcome measure comparison of TFCBT versus waitlist/usual care to explore this further. The higher quality studies showed better outcomes than the lower quality studies. This finding contradicts previous research (e.g. Moher 1998) that has found an association between poorer methodology and more favourable results for the intervention. Our finding may reflect the fact that the better studies tended to be more recent and associated with refinement of TFCBT techniques. They also included most of the female only studies.

As with all psychological treatment trials there are issues with the control groups. The development of a "psychological treatment placebo" is very difficult, if not impossible, as is blinding of participants and therapists. This can lead to a bias in favour of the active intervention. If present in these studies it would have resulted in the active treatments being likely to appear better than they actually are.

Summary
Thirty-three studies were included in the review. TFCBT and EMDR did significantly better than waitlist/usual care in reducing clinician assessed PTSD symptoms. There was no significant difference between TFCBT, EMDR and SM, although TFCBT and EMDR did significantly better than other therapies. Stress management did significantly better than waitlist/usual care and than other therapies. There was no significant difference between other therapies and waitlist/usual care control. Group TFCBT was significantly better than waitlist/usual care. 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.

Authors' conclusions

Implications for practice

1. Psychological treatment can reduce traumatic stress symptoms in individuals with PTSD.
2. Trauma focused cognitive behavioural therapy and eye movement desensitisation and reprocessing have the best evidence for efficacy at present and should be made available to PTSD sufferers.
3. There is some limited evidence that stress management is effective.
4. There is more limited evidence that other non trauma focused psychological treatments are effective.
5. Drop-out from treatment is an issue with currently available psychological treatments.

Implications for research

1. Further well-designed trials of psychological treatments are required that consider boundary issues (e.g. predictors for treatment effects).
2. Large EMDR trials are required
2. There is a requirement for further comparison studies of one type of psychological treatment against another.
3. Future trials should consider adverse events and tolerability of treatment in more detail.
4. Future trials should enforce stronger quality control of the interventions and control interventions.
4. The role of psychological treatment in combination and as an alternative to medication is unclear. Further research in this area would be useful.

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.

Acknowledgements

We should like to thank the CCDAN editorial base for their help with searches, helpful comments on the protocol and assistance with the methodology. We should also like to thank the NICE PTSD guideline development group for allowing us access to their datasets.

Data and analyses

Download statistical data

Comparison 1. Trauma Focused CBT/ Exposure Therapy vs Waitlist/Usual Care
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Severity of PTSD symptoms16 Std. Mean Difference (IV, Random, 95% CI)Subtotals only
1.1 Clinician14649Std. Mean Difference (IV, Random, 95% CI)-1.40 [-1.89, -0.91]
1.2 Self-report9428Std. Mean Difference (IV, Random, 95% CI)-1.68 [-2.14, -1.22]
1.3 Clinician PTSD severity higher quality studies only (sensitivity analysis)9493Std. Mean Difference (IV, Random, 95% CI)-1.61 [-2.16, -1.06]
1.4 Clinician PTSD severity lower quality studies only (sensitivity analysis)5156Std. Mean Difference (IV, Random, 95% CI)-1.02 [-1.84, -0.20]
1.5 Clinician PTSD severity female only studies (subgroup analysis)7404Std. Mean Difference (IV, Random, 95% CI)-1.94 [-2.53, -1.34]
1.6 Clinician PTSD severity non-veteran studies (subgroup analysis)13625Std. Mean Difference (IV, Random, 95% CI)-1.49 [-1.99, -0.99]
1.7 Clinician PTSD severity mixed gender studies (subgroup analyses)7245Std. Mean Difference (IV, Random, 95% CI)-0.83 [-1.26, -0.41]
2 Depression14625Std. Mean Difference (IV, Random, 95% CI)-1.26 [-1.69, -0.82]
3 Anxiety11 Std. Mean Difference (IV, Fixed, 95% CI)Subtotals only
3.1 Self report11415Std. Mean Difference (IV, Fixed, 95% CI)-0.99 [-1.20, -0.78]
4 Leaving the study early due to any reason15861Risk Ratio (M-H, Fixed, 95% CI)1.42 [1.05, 1.94]
5 PTSD diagnosis after treatment15756Risk Ratio (M-H, Random, 95% CI)0.45 [0.35, 0.58]
Analysis 1.1.

Comparison 1 Trauma Focused CBT/ Exposure Therapy vs Waitlist/Usual Care, Outcome 1 Severity of PTSD symptoms.

Analysis 1.2.

Comparison 1 Trauma Focused CBT/ Exposure Therapy vs Waitlist/Usual Care, Outcome 2 Depression.

Analysis 1.3.

Comparison 1 Trauma Focused CBT/ Exposure Therapy vs Waitlist/Usual Care, Outcome 3 Anxiety.

Analysis 1.4.

Comparison 1 Trauma Focused CBT/ Exposure Therapy vs Waitlist/Usual Care, Outcome 4 Leaving the study early due to any reason.

Analysis 1.5.

Comparison 1 Trauma Focused CBT/ Exposure Therapy vs Waitlist/Usual Care, Outcome 5 PTSD diagnosis after treatment.

Comparison 2. Stress Management Therapy vs Waitlist/Usual Care
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Severity of PTSD symptoms - Clinician3 Std. Mean Difference (IV, Fixed, 95% CI)Subtotals only
1.1 Clinician386Std. Mean Difference (IV, Fixed, 95% CI)-1.14 [-1.62, -0.67]
2 Severity of PTSD symptoms - Self-report1 Std. Mean Difference (IV, Random, 95% CI)Subtotals only
2.2 Self-report124Std. Mean Difference (IV, Random, 95% CI)0.33 [-0.47, 1.14]
3 Depression4109Std. Mean Difference (IV, Fixed, 95% CI)-0.73 [-1.12, -0.33]
4 Anxiety382Std. Mean Difference (IV, Fixed, 95% CI)-0.77 [-1.23, -0.31]
5 Leaving the study early due to any reason4121Risk Ratio (M-H, Fixed, 95% CI)2.19 [0.71, 6.73]
6 PTSD diagnosis after treatment4121Risk Ratio (M-H, Random, 95% CI)0.65 [0.50, 0.86]
Analysis 2.1.

Comparison 2 Stress Management Therapy vs Waitlist/Usual Care, Outcome 1 Severity of PTSD symptoms - Clinician.

Analysis 2.2.

Comparison 2 Stress Management Therapy vs Waitlist/Usual Care, Outcome 2 Severity of PTSD symptoms - Self-report.

Analysis 2.3.

Comparison 2 Stress Management Therapy vs Waitlist/Usual Care, Outcome 3 Depression.

Analysis 2.4.

Comparison 2 Stress Management Therapy vs Waitlist/Usual Care, Outcome 4 Anxiety.

Analysis 2.5.

Comparison 2 Stress Management Therapy vs Waitlist/Usual Care, Outcome 5 Leaving the study early due to any reason.

Analysis 2.6.

Comparison 2 Stress Management Therapy vs Waitlist/Usual Care, Outcome 6 PTSD diagnosis after treatment.

Comparison 3. Other Therapies vs Waitlist/Usual Care
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Severity of PTSD symptoms - clinician272Std. Mean Difference (IV, Fixed, 95% CI)-0.43 [-0.90, 0.04]
2 Severity of PTSD symptoms - self report2132Std. Mean Difference (IV, Fixed, 95% CI)-0.61 [-0.98, -0.24]
3 Depression2 Std. Mean Difference (IV, Fixed, 95% CI)Subtotals only
3.1 Self report272Std. Mean Difference (IV, Fixed, 95% CI)-0.25 [-0.71, 0.22]
4 Anxiety - Self report3153Std. Mean Difference (IV, Fixed, 95% CI)-0.48 [-0.82, -0.14]
5 Leaving the study early due to any reason3166Risk Ratio (M-H, Fixed, 95% CI)3.82 [1.19, 12.29]
6 PTSD diagnosis after treatment3166Risk Ratio (M-H, Random, 95% CI)0.79 [0.53, 1.18]
Analysis 3.1.

Comparison 3 Other Therapies vs Waitlist/Usual Care, Outcome 1 Severity of PTSD symptoms - clinician.

Analysis 3.2.

Comparison 3 Other Therapies vs Waitlist/Usual Care, Outcome 2 Severity of PTSD symptoms - self report.

Analysis 3.3.

Comparison 3 Other Therapies vs Waitlist/Usual Care, Outcome 3 Depression.

Analysis 3.4.

Comparison 3 Other Therapies vs Waitlist/Usual Care, Outcome 4 Anxiety - Self report.

Analysis 3.5.

Comparison 3 Other Therapies vs Waitlist/Usual Care, Outcome 5 Leaving the study early due to any reason.

Analysis 3.6.

Comparison 3 Other Therapies vs Waitlist/Usual Care, Outcome 6 PTSD diagnosis after treatment.

Comparison 4. Group CBT vs Waitlist/Usual Care
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Severity of PTSD symptoms - clinician1 Std. Mean Difference (IV, Fixed, 95% CI)Subtotals only
2 Severity of PTSD symptoms - self-report271Std. Mean Difference (IV, Fixed, 95% CI)-0.71 [-1.20, -0.22]
3 Leaving the study early due to any reason3271Risk Ratio (M-H, Fixed, 95% CI)1.00 [0.64, 1.56]
4 PTSD diagnosis after treatment148Risk Ratio (M-H, Fixed, 95% CI)0.56 [0.31, 1.01]
Analysis 4.1.

Comparison 4 Group CBT vs Waitlist/Usual Care, Outcome 1 Severity of PTSD symptoms - clinician.

Analysis 4.2.

Comparison 4 Group CBT vs Waitlist/Usual Care, Outcome 2 Severity of PTSD symptoms - self-report.

Analysis 4.3.

Comparison 4 Group CBT vs Waitlist/Usual Care, Outcome 3 Leaving the study early due to any reason.

Analysis 4.4.

Comparison 4 Group CBT vs Waitlist/Usual Care, Outcome 4 PTSD diagnosis after treatment.

Comparison 5. Trauma Focused CBT/ Exposure Therapy vs Stress Management Therapy
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Severity of PTSD Symptoms - clinician6239Std. Mean Difference (IV, Random, 95% CI)-0.27 [-0.71, 0.16]
2 Severity of PTSD symptoms - self report3127Std. Mean Difference (IV, Fixed, 95% CI)-0.37 [-0.74, 0.01]
3 Severity of PTSD symptoms - clinician - follow-up (2-5 months)5127Std. Mean Difference (IV, Fixed, 95% CI)-0.48 [-0.84, -0.12]
4 Severity of PTSD symptoms - self report - follow-up (2-5 months)254Std. Mean Difference (IV, Fixed, 95% CI)-0.44 [-0.99, 0.10]
5 Depression5161Std. Mean Difference (IV, Fixed, 95% CI)-0.25 [-0.57, 0.08]
6 Depression - follow-up (2-5 months)5147Std. Mean Difference (IV, Fixed, 95% CI)-0.28 [-0.62, 0.06]
7 Anxiety4127Std. Mean Difference (IV, Fixed, 95% CI)-0.12 [-0.49, 0.26]
8 Anxiety - Follow-up (2-5 months)4117Std. Mean Difference (IV, Fixed, 95% CI)-0.19 [-0.58, 0.20]
9 Leaving the study early due to any reason6284Risk Ratio (M-H, Fixed, 95% CI)1.17 [0.69, 2.00]
10 PTSD diagnosis after treatment6284Risk Ratio (M-H, Fixed, 95% CI)0.78 [0.61, 0.99]
Analysis 5.1.

Comparison 5 Trauma Focused CBT/ Exposure Therapy vs Stress Management Therapy, Outcome 1 Severity of PTSD Symptoms - clinician.

Analysis 5.2.

Comparison 5 Trauma Focused CBT/ Exposure Therapy vs Stress Management Therapy, Outcome 2 Severity of PTSD symptoms - self report.

Analysis 5.3.

Comparison 5 Trauma Focused CBT/ Exposure Therapy vs Stress Management Therapy, Outcome 3 Severity of PTSD symptoms - clinician - follow-up (2-5 months).

Analysis 5.4.

Comparison 5 Trauma Focused CBT/ Exposure Therapy vs Stress Management Therapy, Outcome 4 Severity of PTSD symptoms - self report - follow-up (2-5 months).

Analysis 5.5.

Comparison 5 Trauma Focused CBT/ Exposure Therapy vs Stress Management Therapy, Outcome 5 Depression.

Analysis 5.6.

Comparison 5 Trauma Focused CBT/ Exposure Therapy vs Stress Management Therapy, Outcome 6 Depression - follow-up (2-5 months).

Analysis 5.7.

Comparison 5 Trauma Focused CBT/ Exposure Therapy vs Stress Management Therapy, Outcome 7 Anxiety.

Analysis 5.8.

Comparison 5 Trauma Focused CBT/ Exposure Therapy vs Stress Management Therapy, Outcome 8 Anxiety - Follow-up (2-5 months).

Analysis 5.9.

Comparison 5 Trauma Focused CBT/ Exposure Therapy vs Stress Management Therapy, Outcome 9 Leaving the study early due to any reason.

Analysis 5.10.

Comparison 5 Trauma Focused CBT/ Exposure Therapy vs Stress Management Therapy, Outcome 10 PTSD diagnosis after treatment.

Comparison 6. Trauma Focused CBT/Exposure Therapy vs Other Therapies (supportive counselling/hypnotherapy/psychodynamic)
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Severity of PTSD symptoms - clinician3120Std. Mean Difference (IV, Fixed, 95% CI)-0.81 [-1.19, -0.42]
2 Severity of PTSD symptoms - clinician - follow-up (3 months)270Std. Mean Difference (IV, Fixed, 95% CI)-0.65 [-1.13, -0.16]
3 Severity of PTSD symptoms - self report3176Std. Mean Difference (IV, Random, 95% CI)-1.18 [-2.32, -0.03]
4 Severity of PTSD symptoms - self report - follow-up (2-5 months)2131Std. Mean Difference (IV, Random, 95% CI)-0.28 [-1.04, 0.48]
5 Depression - self report3120Std. Mean Difference (IV, Fixed, 95% CI)-0.65 [-1.03, -0.28]
6 Anxiety - self report4197Std. Mean Difference (IV, Random, 95% CI)-0.47 [-1.11, 0.17]
7 Depression - self-report - follow-up (2-5 months)272Std. Mean Difference (IV, Fixed, 95% CI)-0.53 [-1.00, -0.05]
8 Anxiety - self-report - follow-up (2-5 months)3149Std. Mean Difference (IV, Fixed, 95% CI)-0.27 [-0.60, 0.07]
9 PTSD diagnosis after treatment5286Risk Ratio (M-H, Fixed, 95% CI)0.71 [0.56, 0.89]
10 Leaving the study early due to any reason5290Risk Ratio (M-H, Fixed, 95% CI)1.14 [0.68, 1.90]
11 Severity of PTSD symptoms - clinician - follow-up (6-9 months)145Std. Mean Difference (IV, Fixed, 95% CI)-1.85 [-2.59, -1.11]
12 Severity of PTSD symptoms - self-report - follow-up (6-9 months)145Std. Mean Difference (IV, Fixed, 95% CI)-1.72 [-2.45, -1.00]
13 Depression - follow-up (6-9 months)145Std. Mean Difference (IV, Fixed, 95% CI)-1.08 [-1.74, -0.42]
14 Anxiety - follow-up (6-9 months)145Std. Mean Difference (IV, Fixed, 95% CI)-1.18 [-1.85, -0.51]
Analysis 6.1.

Comparison 6 Trauma Focused CBT/Exposure Therapy vs Other Therapies (supportive counselling/hypnotherapy/psychodynamic), Outcome 1 Severity of PTSD symptoms - clinician.

Analysis 6.2.

Comparison 6 Trauma Focused CBT/Exposure Therapy vs Other Therapies (supportive counselling/hypnotherapy/psychodynamic), Outcome 2 Severity of PTSD symptoms - clinician - follow-up (3 months).

Analysis 6.3.

Comparison 6 Trauma Focused CBT/Exposure Therapy vs Other Therapies (supportive counselling/hypnotherapy/psychodynamic), Outcome 3 Severity of PTSD symptoms - self report.

Analysis 6.4.

Comparison 6 Trauma Focused CBT/Exposure Therapy vs Other Therapies (supportive counselling/hypnotherapy/psychodynamic), Outcome 4 Severity of PTSD symptoms - self report - follow-up (2-5 months).

Analysis 6.5.

Comparison 6 Trauma Focused CBT/Exposure Therapy vs Other Therapies (supportive counselling/hypnotherapy/psychodynamic), Outcome 5 Depression - self report.

Analysis 6.6.

Comparison 6 Trauma Focused CBT/Exposure Therapy vs Other Therapies (supportive counselling/hypnotherapy/psychodynamic), Outcome 6 Anxiety - self report.

Analysis 6.7.

Comparison 6 Trauma Focused CBT/Exposure Therapy vs Other Therapies (supportive counselling/hypnotherapy/psychodynamic), Outcome 7 Depression - self-report - follow-up (2-5 months).

Analysis 6.8.

Comparison 6 Trauma Focused CBT/Exposure Therapy vs Other Therapies (supportive counselling/hypnotherapy/psychodynamic), Outcome 8 Anxiety - self-report - follow-up (2-5 months).

Analysis 6.9.

Comparison 6 Trauma Focused CBT/Exposure Therapy vs Other Therapies (supportive counselling/hypnotherapy/psychodynamic), Outcome 9 PTSD diagnosis after treatment.

Analysis 6.10.

Comparison 6 Trauma Focused CBT/Exposure Therapy vs Other Therapies (supportive counselling/hypnotherapy/psychodynamic), Outcome 10 Leaving the study early due to any reason.

Analysis 6.11.

Comparison 6 Trauma Focused CBT/Exposure Therapy vs Other Therapies (supportive counselling/hypnotherapy/psychodynamic), Outcome 11 Severity of PTSD symptoms - clinician - follow-up (6-9 months).

Analysis 6.12.

Comparison 6 Trauma Focused CBT/Exposure Therapy vs Other Therapies (supportive counselling/hypnotherapy/psychodynamic), Outcome 12 Severity of PTSD symptoms - self-report - follow-up (6-9 months).

Analysis 6.13.

Comparison 6 Trauma Focused CBT/Exposure Therapy vs Other Therapies (supportive counselling/hypnotherapy/psychodynamic), Outcome 13 Depression - follow-up (6-9 months).

Analysis 6.14.

Comparison 6 Trauma Focused CBT/Exposure Therapy vs Other Therapies (supportive counselling/hypnotherapy/psychodynamic), Outcome 14 Anxiety - follow-up (6-9 months).

Comparison 7. Stress Management Therapy vs Other Therapies
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Severity of PTSD symptoms - Clincian125Std. Mean Difference (IV, Fixed, 95% CI)-1.22 [-2.09, -0.35]
2 Anxiety - Self-report125Std. Mean Difference (IV, Fixed, 95% CI)-0.51 [-1.32, 0.29]
3 Depression - Self-report125Std. Mean Difference (IV, Fixed, 95% CI)-0.51 [-1.31, 0.30]
4 Severity of PTSD symptoms - clinician - follow-up (3 months)118Std. Mean Difference (IV, Fixed, 95% CI)-0.38 [-1.31, 0.55]
5 Anxiety - self-report - follow-up (3 months)118Std. Mean Difference (IV, Fixed, 95% CI)-0.68 [-1.64, 0.28]
6 Depression - self-report - follow-up (3 months)118Std. Mean Difference (IV, Fixed, 95% CI)-0.48 [-1.42, 0.46]
7 PTSD diagnosis after treatment131Risk Ratio (M-H, Fixed, 95% CI)0.58 [0.30, 1.11]
8 Leaving the study early due to any reason131Risk Ratio (M-H, Fixed, 95% CI)0.82 [0.20, 3.46]
Analysis 7.1.

Comparison 7 Stress Management Therapy vs Other Therapies, Outcome 1 Severity of PTSD symptoms - Clincian.

Analysis 7.2.

Comparison 7 Stress Management Therapy vs Other Therapies, Outcome 2 Anxiety - Self-report.

Analysis 7.3.

Comparison 7 Stress Management Therapy vs Other Therapies, Outcome 3 Depression - Self-report.

Analysis 7.4.

Comparison 7 Stress Management Therapy vs Other Therapies, Outcome 4 Severity of PTSD symptoms - clinician - follow-up (3 months).

Analysis 7.5.

Comparison 7 Stress Management Therapy vs Other Therapies, Outcome 5 Anxiety - self-report - follow-up (3 months).

Analysis 7.6.

Comparison 7 Stress Management Therapy vs Other Therapies, Outcome 6 Depression - self-report - follow-up (3 months).

Analysis 7.7.

Comparison 7 Stress Management Therapy vs Other Therapies, Outcome 7 PTSD diagnosis after treatment.

Analysis 7.8.

Comparison 7 Stress Management Therapy vs Other Therapies, Outcome 8 Leaving the study early due to any reason.

Comparison 8. Group CBT (trauma focused) vs Group CBT (non-trauma focused)
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Severity of PTSD symptoms1325Std. Mean Difference (IV, Fixed, 95% CI)-0.12 [-0.34, 0.10]
2 Leaving the study early due to any reason1360Risk Ratio (M-H, Fixed, 95% CI)1.38 [1.00, 1.90]
3 PTSD diagnosis after treatment1360Risk Ratio (M-H, Fixed, 95% CI)0.98 [0.83, 1.16]
Analysis 8.1.

Comparison 8 Group CBT (trauma focused) vs Group CBT (non-trauma focused), Outcome 1 Severity of PTSD symptoms.

Analysis 8.2.

Comparison 8 Group CBT (trauma focused) vs Group CBT (non-trauma focused), Outcome 2 Leaving the study early due to any reason.

Analysis 8.3.

Comparison 8 Group CBT (trauma focused) vs Group CBT (non-trauma focused), Outcome 3 PTSD diagnosis after treatment.

Comparison 9. EMDR vs Waitlist/Usual Care
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Severity of PTSD symptoms - Clinician5162Std. Mean Difference (IV, Fixed, 95% CI)-1.51 [-1.87, -1.15]
2 Severity of PTSD symptoms - self report5156Std. Mean Difference (IV, Random, 95% CI)-1.07 [-2.04, -0.10]
3 Depression5160Std. Mean Difference (IV, Fixed, 95% CI)-1.48 [-1.84, -1.12]
4 Anxiety5156Std. Mean Difference (IV, Fixed, 95% CI)-1.10 [-1.45, -0.76]
5 Leaving study early due to any reason6217Odds Ratio (M-H, Fixed, 95% CI)1.33 [0.64, 2.74]
6 PTSD diagnosis after treatment6209Risk Ratio (M-H, Random, 95% CI)0.47 [0.25, 0.85]
Analysis 9.1.

Comparison 9 EMDR vs Waitlist/Usual Care, Outcome 1 Severity of PTSD symptoms - Clinician.

Analysis 9.2.

Comparison 9 EMDR vs Waitlist/Usual Care, Outcome 2 Severity of PTSD symptoms - self report.

Analysis 9.3.

Comparison 9 EMDR vs Waitlist/Usual Care, Outcome 3 Depression.

Analysis 9.4.

Comparison 9 EMDR vs Waitlist/Usual Care, Outcome 4 Anxiety.

Analysis 9.5.

Comparison 9 EMDR vs Waitlist/Usual Care, Outcome 5 Leaving study early due to any reason.

Analysis 9.6.

Comparison 9 EMDR vs Waitlist/Usual Care, Outcome 6 PTSD diagnosis after treatment.

Comparison 10. EMDR vs Trauma Focused CBT
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Severity of PTSD symptoms - clinician6187Std. Mean Difference (IV, Random, 95% CI)0.03 [-0.50, 0.55]
2 Severity of PTSD symptoms - clinicain - follow-up (2-5 months)376Std. Mean Difference (IV, Fixed, 95% CI)-0.14 [-0.60, 0.32]
3 Severity of PTSD symptoms - self report7206Std. Mean Difference (IV, Random, 95% CI)-0.17 [-0.59, 0.26]
4 Depression7206Std. Mean Difference (IV, Random, 95% CI)-0.32 [-0.90, 0.26]
5 Depression - follow-up (2-5 months)5111Std. Mean Difference (IV, Fixed, 95% CI)-0.09 [-0.47, 0.29]
6 Anxiety4136Std. Mean Difference (IV, Fixed, 95% CI)-0.08 [-0.42, 0.26]
7 Anxiety - follow-up (2-5 months)248Std. Mean Difference (IV, Fixed, 95% CI)0.24 [-0.33, 0.81]
8 Leaving study early due to any reason7268Risk Ratio (M-H, Fixed, 95% CI)0.83 [0.55, 1.26]
9 PTSD diagnosis after treatment7260Odds Ratio (M-H, Fixed, 95% CI)1.01 [0.61, 1.66]
10 Severity of PTSD symptoms - self-report - follow-up (2-5 months)5111Std. Mean Difference (IV, Fixed, 95% CI)-0.01 [-0.39, 0.37]
Analysis 10.1.

Comparison 10 EMDR vs Trauma Focused CBT, Outcome 1 Severity of PTSD symptoms - clinician.

Analysis 10.2.

Comparison 10 EMDR vs Trauma Focused CBT, Outcome 2 Severity of PTSD symptoms - clinicain - follow-up (2-5 months).

Analysis 10.3.

Comparison 10 EMDR vs Trauma Focused CBT, Outcome 3 Severity of PTSD symptoms - self report.

Analysis 10.4.

Comparison 10 EMDR vs Trauma Focused CBT, Outcome 4 Depression.

Analysis 10.5.

Comparison 10 EMDR vs Trauma Focused CBT, Outcome 5 Depression - follow-up (2-5 months).

Analysis 10.6.

Comparison 10 EMDR vs Trauma Focused CBT, Outcome 6 Anxiety.

Analysis 10.7.

Comparison 10 EMDR vs Trauma Focused CBT, Outcome 7 Anxiety - follow-up (2-5 months).

Analysis 10.8.

Comparison 10 EMDR vs Trauma Focused CBT, Outcome 8 Leaving study early due to any reason.

Analysis 10.9.

Comparison 10 EMDR vs Trauma Focused CBT, Outcome 9 PTSD diagnosis after treatment.

Analysis 10.10.

Comparison 10 EMDR vs Trauma Focused CBT, Outcome 10 Severity of PTSD symptoms - self-report - follow-up (2-5 months).

Comparison 11. EMDR vs Stress Management Therapy
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Severity of PTSD symptoms - clinician253Std. Mean Difference (IV, Fixed, 95% CI)-0.35 [-0.90, 0.19]
2 Severity of PTSD symptoms - clinician - follow-up (2-5 months)371Std. Mean Difference (IV, Fixed, 95% CI)-0.59 [-1.08, -0.09]
3 Severity of PTSD symptoms - self report375Std. Mean Difference (IV, Fixed, 95% CI)-0.40 [-0.86, 0.06]
4 Depression375Std. Mean Difference (IV, Fixed, 95% CI)-0.67 [-1.14, -0.20]
5 Depression - follow-up (2-5 months)375Std. Mean Difference (IV, Fixed, 95% CI)-0.23 [-0.70, 0.23]
6 Anxiety245Std. Mean Difference (IV, Fixed, 95% CI)-0.75 [-1.36, -0.13]
7 Anxiety - follow-up (2-5 months)245Std. Mean Difference (IV, Random, 95% CI)-0.42 [-2.21, 1.37]
8 Leaving the study early due to any reason384Risk Ratio (M-H, Fixed, 95% CI)1.03 [0.37, 2.88]
9 PTSD diagnosis after treatment384Risk Ratio (M-H, Fixed, 95% CI)0.69 [0.46, 1.04]
10 Severity of PTSD symptoms - self-report - follow-up (2-5 months)375Std. Mean Difference (IV, Fixed, 95% CI)-0.52 [-0.98, -0.05]
Analysis 11.1.

Comparison 11 EMDR vs Stress Management Therapy, Outcome 1 Severity of PTSD symptoms - clinician.

Analysis 11.2.

Comparison 11 EMDR vs Stress Management Therapy, Outcome 2 Severity of PTSD symptoms - clinician - follow-up (2-5 months).

Analysis 11.3.

Comparison 11 EMDR vs Stress Management Therapy, Outcome 3 Severity of PTSD symptoms - self report.

Analysis 11.4.

Comparison 11 EMDR vs Stress Management Therapy, Outcome 4 Depression.

Analysis 11.5.

Comparison 11 EMDR vs Stress Management Therapy, Outcome 5 Depression - follow-up (2-5 months).

Analysis 11.6.

Comparison 11 EMDR vs Stress Management Therapy, Outcome 6 Anxiety.

Analysis 11.7.

Comparison 11 EMDR vs Stress Management Therapy, Outcome 7 Anxiety - follow-up (2-5 months).

Analysis 11.8.

Comparison 11 EMDR vs Stress Management Therapy, Outcome 8 Leaving the study early due to any reason.

Analysis 11.9.

Comparison 11 EMDR vs Stress Management Therapy, Outcome 9 PTSD diagnosis after treatment.

Analysis 11.10.

Comparison 11 EMDR vs Stress Management Therapy, Outcome 10 Severity of PTSD symptoms - self-report - follow-up (2-5 months).

Comparison 12. EMDR vs Other Therapies
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Severity of PTSD symptoms - self report2124Std. Mean Difference (IV, Fixed, 95% CI)-0.84 [-1.21, -0.47]
2 Depression2127Std. Mean Difference (IV, Fixed, 95% CI)-0.67 [-1.03, -0.32]
3 Anxiety2126Std. Mean Difference (IV, Fixed, 95% CI)-0.72 [-1.08, -0.36]
4 Leaving study early due to any reason2127Risk Ratio (M-H, Fixed, 95% CI)1.48 [0.26, 8.54]
5 PTSD diagnosis after treatment167Risk Ratio (M-H, Fixed, 95% CI)0.40 [0.19, 0.84]
Analysis 12.1.

Comparison 12 EMDR vs Other Therapies, Outcome 1 Severity of PTSD symptoms - self report.

Analysis 12.2.

Comparison 12 EMDR vs Other Therapies, Outcome 2 Depression.

Analysis 12.3.

Comparison 12 EMDR vs Other Therapies, Outcome 3 Anxiety.

Analysis 12.4.

Comparison 12 EMDR vs Other Therapies, Outcome 4 Leaving study early due to any reason.

Analysis 12.5.

Comparison 12 EMDR vs Other Therapies, Outcome 5 PTSD diagnosis after treatment.

What's new

DateEventDescription
5 November 2008AmendedConverted to new review format.

History

Protocol first published: Issue 4, 2001
Review first published: Issue 2, 2005

DateEventDescription
23 May 2007New citation required and conclusions have changedSubstantive amendment

Contributions of authors

JIB has been involved in the identification, quality appraisal, data entry, analysis and writing of the review.
MA has been involved in the identification, quality appraisal and and writing of the review.
JIB has been involved in two randomised trials of early psychological interventions designed to prevent PTSD following traumatic events.

Declarations of interest

Nil.

Notes

Eye movement desensitisation and reprocessing (EMDR) was previously removed from the protocol for this review as it was the focus of a separate Cochrane review, EMDR for PTSD. However, the protocol for EMDR for PTSD has now been withdrawn. Trials of EMDR have now been included in this review.

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Blanchard 2003

MethodsRandomised controlled trial - bias possible
Participants98 road traffic accident survivors
Interventions8-12 sessions TFCBT vs 8-12 sessions supportive psychotherapy vs waiting list
OutcomesAPS, IES,STAI
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear

Blanchard 2003b

MethodsRandomised controlled trial -bias possible
Participants98 road traffic accident survivors
Interventions8-12 sessions TFCBT vs 8-12 sessions supportive psychotherapy vs waiting list
OutcomesAPS, IES,STAI
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear

Brom 1989

MethodsRandomised controlled trial -bias possible
Participants112 outpatients. Various traumas, 89 bereaved.
Interventions14-18 sessions of trauma desensitisatrion, hypnotherapy, psychodynamic therapy or waiting list
Outcomes"trauma symptoms" on SCL-90, STAI
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear

Bryant 2003

MethodsRandomised controlled trial - no bias likely
Participants58 outpatient survivors of non-sexual assaults or road traffic accidents.
Interventions8 weekly 90 minute sessions of imaginal exposure, imaginal exposure/cognitive restructuring or supportive counselling.
OutcomesCAPS, IES, STAI, BDI
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear

Carlson 1998

MethodsRandomised controlled trial - bias possible
Participants35 males with combat-related PTSD
Interventions12 bi-weekly sessions of 60-75 minutes EMDR versus 40 minutes biofeedback assisted relaxation versus routine care
OutcomesMississippi PTSD scale, IES, STAI, BDI
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear

Classen 2001

MethodsRandomised controlled trial -bias possible
Participants52 female child sexual abuse survivors
Interventions24 ninety minute sessions of trauma-focused or present-focused group therapy vs wait list
OutcomesTSC-40
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear

Cloitre 2002

MethodsRandomised controlled trial -bias possible
Participants58 female child sexual abuse survivors
Interventions16 biweekly sessions of 1.5 hours of prolonged exposure and affect regulation versus waiting list
OutcomesCAPS, BDI, STAI
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear

Cooper 1989

MethodsRandomised controlled trial
Participants16 Vietnam veterans. All DSMIIIPTSD
Interventions6-14 90 minute flooding sessions plus standard treatment versus standard treatment
OutcomesSTAI, BDI
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?NoC - Inadequate

Devilly 1999

MethodsRandomised controlled trial
Participants35 combat veterans with PTSD
Interventions12 sessions of EMDR versus biofeedback-assisted relaxation versus routine clinical care
OutcomesMississippi scale, PTSD symptom scale, IES, STAI, BDI
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearD - Not used

Echeburua 1997

MethodsRandomised controlled trial
Participants20 female sexual aggression survivors
Interventions6 weekly sessions of graded self-exposure versus relaxation therapy
OutcomesGlobal PTSD scale, STAI, BDI
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear

Ehlers 2003

MethodsRandomised controlled trial - bias possible
Participants28 survivors of various adulthood discrete traumas. All DSMIV PTSD.
InterventionsUp to 12 weekly trauma focused cognitive therapy sessions versus wait list control.
OutcomesCAPS, BDI, BAI
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear

Fecteau 1999

MethodsRandomised controlled trial - bias possible
ParticipantsRoad traffic accidents
Interventions8-10 hours CBT versus wait list
OutcomesCAPS, IES, BDI, BAI
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?NoC - Inadequate

Foa 1991

MethodsRandomised controlled trial - bias possible
Participants45 female rape victims. All DSMIIIR PTSD
Interventions9 1.5 hour sessions of prolonged exposure versus stress innoculation training versus supportive counselling versus waiting list control
OutcomesPTSD severity, BDI, STAI
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?NoC - Inadequate

Foa 1991b

MethodsRandomised controlled trial - bias possible
Participants45 female rape victims. All DSMIIIR PTSD
Interventions9 1.5 hour sessions of prolonged exposure versus stress innoculation training versus supportive counselling versus waiting list control
OutcomesPTSD severity, BDI, STAI
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?NoC - Inadequate

Foa 1991c

MethodsRandomised controlled trial -bias possible
Participants45 female rape victims. All DSMIIIR PTSD
Interventions9 1.5 hour sessions of prolonged exposure versus stress innoculation training versus supportive counselling versus waiting list control
OutcomesPTSD severity, BDI, STAI
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?NoC - Inadequate

Foa 1999

MethodsRandomised controlled trial - bias possible
Participants96 female sexual assault victims (69 sexual assault)
Interventions9 sessions (2 x 2 hours, 7 x 1.5 hours) prolonged exposure versus stress innoculation training versus combination PIE-SIT versus waiting list
OutcomesPSS-I, BDI, STAI
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?NoC - Inadequate

Foa 1999b

MethodsRandomised controlled trial - bias possible
Participants96 female sexual assault victims (69 sexual assault)
Interventions9 sessions (2 x 2 hours, 7 x 1.5 hours) prolonged exposure versus stress innoculation training versus combination PIE-SIT versus waiting list
OutcomesPSS-I, BDI, STAI
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?NoC - Inadequate

Gersons 2000

MethodsRandomised controlled trial -bias possible
Participants42 police officers. DSMIIIR PTSD. Various workplace traumas.
Interventions16x60 minute sessions of brief eclectic therapy
OutcomesSI-PTSD, SCL-90
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear

Ironson 2002

MethodsRandomised controlled tiral - bias possible
Participants22 victims of various traumas with DSMIIIR PTSD
Interventions3 preparatory sessions fby 1-3 sessions of EMDR or prolonged exposure
OutcomesPSS-SR, BDI
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearD - Not used

Jensen 1994

MethodsRandomised controlled trial - bias possible
Participants25 vietnam veterans with PTSD
Interventions3 sessions of EMDR usually within 10 days or usual care
OutcomesSI-PTSD
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearD - Not used

Keane 1989

MethodsRandomised controlled trial -bias possible
Participants24 Vietnam veterans. DSMIIIR PTSD
Interventions14-16 sessions implosive (flooding) versus waiting list control
OutcomesMMPI - PTSD subscale, BDI, STAI
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear

Krakow 2001

MethodsRandomised controlled trial - no bias likely
Participants169 female sexual assault survivors. 95% DSMIIIR PTSD
Interventions2x3 hours and 1x1 hour sessions of group imagery rehearsal versus waiting list.
OutcomesPSS
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?NoC - Inadequate

Kubany 2003

MethodsRandomised controlled trial - bias possible
Participants42 female survivors of assault.
Interventions8-11 biweekly 90 minute sessions of cognitive trauma therapy vs wait list
OutcomesCAPS, BDI
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?NoC - Inadequate

Kubany 2004

MethodsRandomised controlled trial -bias possible
Participants85 female survivors of assault
Interventions8-11 biweekly 90 minute sessions of cognitive trauma therapy vs wait list
OutcomesCAPS, BDI
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear

Lee 2002

MethodsRandomised controlled trial - bias possible
Participants24 DSMIV PTSD sufferers from various traumas
InterventionsSeven weekly 90 minute sessions of stress innoculation training with prolonged exposure versus EMDR
OutcomesSI-PTSD, IES, BDI
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearD - Not used

Marcus 1997/2004

MethodsRandomised controlled trial - bias possible
Participants67 DSMIIIR PTSD. Various traumas.
InterventionsVariable number of 50 minute sessions of EMDR versus standard care
OutcomesIES, MPTSD, BDI, STAI, SCL-90
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearD - Not used

Marks 1998

MethodsRandomised controlled trial - no bias likely
Participants87 DSMIIIR PTSD. Various traumas
Interventions10 x 90 minute sessions of exposure vs cognitive restructuring vs exposure and cognitive restructuring vs relaxation therapy
OutcomesCAPS, IES, BDI, STAI
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear

Neuner 2004

MethodsRandomised controlled trial - bias possible
Participants43 Sudanese refugees. All diagnosed with PTSD.
Interventions4 sessions of narrative exposure therapy versus 4 sessions of supportive counselling versus one session of psychoeducation
OutcomesPDS
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?NoC - Inadequate

Peniston 1991

MethodsRandomised controlled trial - bias possible
Participants16 Vietnam combat veterans with DSMIII PTSD.
Interventions48 x 30 minute sessions of EMG assisted desensitisation vs no treatment
Outcomesnightmare and flashback frequency
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear

Power 2002

MethodsRandomised controlled trial - bias possible
Participants105 outpatients with DSMIV PTSD. Various traumas.
Interventions10 x 90 minute weekly sessions of EMDR versus exposure plus cognitive restructuring versus wait list.
OutcomesCAPS, HAM-A, MADRS
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?YesA - Adequate

Resick 2002

MethodsRandomised controlled trial - no bias likely
Participants121 female rape victims with DSMIV PTSD
Interventions13 hours of cognitive processing therapy or exposure biweekly over six weeks versus minimal attention.
OutcomesCAPS, PSS, BDI
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear

Resick 2002b

MethodsRandomised controlled trial - no bias likely
Participants121 female rape victims with DSMIV PTSD
Interventions13 hours of cognitive processing therapy or exposure biweekly over six weeks versus minimal attention.
OutcomesCAPS, PSS, BDI
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear

Rothbaum

MethodsRandomised controlled trial - no bias likely
Participants74 female rape victims with DSMIV PTSD
InterventionsNine bi-weekly 90 minute sessions of PE or EMDR versus wait list
OutcomesCAPS, IES, PSS, STAIS, STAIT, BDI
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear

Rothbaum 1997

MethodsRandomised controlled trial - bias possible
Participants21 female sexual assault victims with DSMIIIR PTSD
Interventions3 weekly 90 minute sessions of EMDR versus wait list control
OutcomesPSS, IES, BDI, STAI
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearD - Not used

Scheck 1998

MethodsRandomised controlled trial - no bias likely
Participants60 16-25 year old female victims of various traumas. 77% DSMIV PTSD
InterventionsTwo usually weekly sessions of EMDR versus active listening
Outcomes 
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearD - Not used

Schnurr 2003

MethodsRandomised controlled trial - no bias likely
Participants360 male Vietnam veterans with DSMIV PTSD
InterventionsWeekly present-focused group CBT for 30 weeks versus weekly trauma-ficused CBT group therapy for 30 weeks.
OutcomesCAPS, GHQ, SF36
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear

Taylor 2003

MethodsRandomised controlled trial - bias possible
Participants60 outpatients. Various traumas. DSMIV PTSD.
Interventions8 ninety minute sessions of exposure therapy, EMDR or relaxation training.
OutcomesCAPS, PDS, BDI
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear

Vaughan 1994

MethodsRandomised controlled trial - no bias likely
Participants36 various traumas. 78% DSMIIIR PTSD.
Interventions3-5 50 minute sessions of image habituation training, EMDR or applied muscular relaxation versus waiting list
OutcomesPTSD structured interview, IES, STAI, BDI
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear

Vaughan 1994b

MethodsRandomised controlled trial - no bias likely
Participants36 various traumas. 78% DSMIIIR PTSD.
Interventions3-5 50 minute sessions of image habituation training, EMDR or applied muscular relaxation versus waiting list
OutcomesPTSD structured interview, IES, STAI, BDI
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear

Vaughan 1994c

MethodsRandomised controlled trial - no bias likely
Participants36 various traumas. 78% DSMIIIR PTSD.
Interventions 
Outcomes 
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearD - Not used

Zlotnick 1997

MethodsRandomised controlled trial - bias possible
Participants48 female sexual abuse survivors. All DSMIIIR PTSD.
Interventions15 2-hour sessions of group affective management versus waiting list control
OutcomesDTS
Notesmedication and individual psychological treatment continued during study
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear

Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion
Chemtob 1997Treatment designed for anger versus PTSD with anger measures used as primary outcomes
Echeburua 1996Trauma < 3 months before entry into study
Frank 1988Not a true RCT
Gidron 1996Not psychological treatment
Lange 2003No formal diagnosis of PTSD made
Paunovic 2001TFCBT vs TFCBT
Shapiro 1988Absence of standardised traumatic stress measures
Tarrier 1999Compared trauma focused cognitve therpay with exposure therapy therefore both treatments = TFCBT.
Watson 1997Considered three different types of relaxation training with no other comparison group
Wilson 1995< 50% PTSD at entry to study

Ancillary