Psychological therapies for chronic post-traumatic stress disorder (PTSD) in adults

  • Review
  • Intervention

Authors


Abstract

Background

Post-traumatic stress disorder (PTSD) is a distressing condition, which is often treated with psychological therapies. Earlier versions of this review, and other meta-analyses, have found these to be effective, with trauma-focused treatments being more effective than non-trauma-focused treatments. This is an update of a Cochrane review first published in 2005 and updated in 2007.

Objectives

To assess the effects of psychological therapies for the treatment of adults with chronic post-traumatic stress disorder (PTSD).

Search methods

For this update, we searched the Cochrane Depression, Anxiety and Neurosis Group's Specialised Register (CCDANCTR-Studies and CCDANCTR-References) all years to 12th April 2013. This register contains relevant randomised controlled trials from: The Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). In addition, we handsearched the Journal of Traumatic Stress, contacted experts in the field, searched bibliographies of included studies, and performed citation searches of identified articles.

Selection criteria

Randomised controlled trials of individual trauma-focused cognitive behavioural therapy (TFCBT), eye movement desensitisation and reprocessing (EMDR), non-trauma-focused CBT (non-TFCBT), other therapies (supportive therapy, non-directive counselling, psychodynamic therapy and present-centred therapy), group TFCBT, or group non-TFCBT, compared to one another or to a waitlist or usual care group for the treatment of chronic PTSD. The primary outcome measure was the severity of clinician-rated traumatic-stress symptoms.

Data collection and analysis

We extracted data and entered them into Review Manager 5 software. We contacted authors to obtain missing data. Two review authors independently performed 'Risk of bias' assessments. We pooled the data where appropriate, and analysed for summary effects.

Main results

We include 70 studies involving a total of 4761 participants in the review. The first primary outcome for this review was reduction in the severity of PTSD symptoms, using a standardised measure rated by a clinician. For this outcome, individual TFCBT and EMDR were more effective than waitlist/usual care (standardised mean difference (SMD) -1.62; 95% CI -2.03 to -1.21; 28 studies; n = 1256 and SMD -1.17; 95% CI -2.04 to -0.30; 6 studies; n = 183 respectively). There was no statistically significant difference between individual TFCBT, EMDR and Stress Management (SM) immediately post-treatment although there was some evidence that individual TFCBT and EMDR were superior to non-TFCBT at follow-up, and that individual TFCBT, EMDR and non-TFCBT were more effective than other therapies. Non-TFCBT was more effective than waitlist/usual care and other therapies. Other therapies were superior to waitlist/usual care control as was group TFCBT. There was some evidence of greater drop-out (the second primary outcome for this review) in active treatment groups. Many of the studies were rated as being at 'high' or 'unclear' risk of bias in multiple domains, and there was considerable unexplained heterogeneity; in addition, we assessed the quality of the evidence for each comparison as very low. As such, the findings of this review should be interpreted with caution.

Authors' conclusions

The evidence for each of the comparisons made in this review was assessed as very low quality. This evidence showed that individual TFCBT and EMDR did better than waitlist/usual care in reducing clinician-assessed PTSD symptoms. There was evidence that individual TFCBT, EMDR and non-TFCBT are equally effective immediately post-treatment in the treatment of PTSD. There was some evidence that TFCBT and EMDR are superior to non-TFCBT between one to four months following treatment, and also that individual TFCBT, EMDR and non-TFCBT are more effective than other therapies. There was evidence of greater drop-out in active treatment groups. Although a substantial number of studies were included in the review, the conclusions are compromised by methodological issues evident in some. Sample sizes were small, and it is apparent that many of the studies were underpowered. There were limited follow-up data, which compromises conclusions regarding the long-term effects of psychological treatment.

Plain language summary

Psychological therapies for chronic post-traumatic stress disorder (PTSD) in adults

Background: Post-traumatic stress disorder (PTSD) can occur following a traumatic event. It is characterised by symptoms of re-experiencing the trauma (in the form of nightmares, flashbacks and distressing thoughts), avoiding reminders of the traumatic event, negative alterations in thoughts and mood, and symptoms of hyper-arousal (feeling on edge, being easily startled, feeling angry, having difficulties sleeping, and problems concentrating).

Previous reviews have supported the use of individual trauma-focused cognitive behavioural therapy (TFCBT) and eye movement desensitisation and reprocessing (EMDR) in the treatment of PTSD. TFCBT is a variant of cognitive behavioural therapy (CBT), which includes a number of techniques to help a person overcome a traumatic event. It is a combination of cognitive therapy aimed at changing the way a person thinks, and behavioural therapy, which aims to change the way a person acts. TFCBT helps an individual come to terms with a trauma through exposure to memories of the event. EMDR is a psychological therapy, which aims to help a person reprocess their memories of a traumatic event. The therapy involves bringing distressing trauma-related images, beliefs, and bodily sensations to mind, whilst the therapist guides eye movements from side to side. More positive views of the trauma memories are identified, with the aim of replacing the ones that are causing problems.

TFCBT and EMDR are currently recommended as the treatments of choice by guidelines such as those published by the United Kingdom's National Institute of Health and Clinical Excellence (NICE).

Study characteristics: This review draws together up-to-date evidence from 70 studies including a total of 4761 people.

Key findings: There is continued support for the efficacy of individual TFCBT, EMDR, non-TFCBT and group TFCBT in the treatment of chronic PTSD in adults. Other non-trauma-focused psychological therapies did not reduce PTSD symptoms as significantly. There was evidence that individual TFCBT, EMDR and non-TFCBT are equally effective immediately post-treatment in the treatment of PTSD. There was some evidence that TFCBT and EMDR are superior to non-TFCBT between one to four months following treatment, and also that individual TFCBT, EMDR and non-TFCBT are more effective than other therapies. No specific conflicts of interest were identified.

Quality of the evidence: Although we included a substantial number of studies in this review, each only included small numbers of people and some were poorly designed. We assessed the overall quality of the studies as very low and so the findings of this review should be interpreted with caution. There is insufficient evidence to show whether or not psychological therapy is harmful.

Резюме на простом языке

Психологические методы лечения хронического пост-травматического стрессового расстройства (ПТСР) у взрослых

Актуальность: Пост-травматическое стрессовое расстройство (ПТСР) может развиться вслед за травмирующим событием. Оно характеризуется повторным переживанием травмы (в виде ночных кошмаров, воспоминаний и мучительных мыслей), избеганием напоминания о травмирующем событии, негативным изменением мыслей и настроения, и симптомами гипер-возбуждения (чувство пребывания на краю, повышенная пугливость, чувство гнева, трудности со сном, и проблемы с концентрацией внимания).

Предыдущие обзоры поддерживали использование индивидуальной когнитивной поведенческой терапии, фокусированной на травме, (КПТФТ) и десенситизации с репроцессингом движениями глаз (ДРДГ) в лечении пост-травматического стрессового расстройства. КПТФТ является вариантом когнитивной поведенческой терапии (КПТ), который включает в себя ряд методов, чтобы помочь человеку преодолеть травмирующее событие. Она представляет собой комбинацию когнитивной терапии, направленной на изменение способа думать (как человек думает), и поведенческой терапии, направленной на изменение того, как человек действует. КПТФТ помогает человеку примириться с травмой через воспоминания об этом событии. ДРДГ - это психологическая терапия, которая ставит целью помочь человеку переработать (репроцессинг) свои воспоминания о травмирующем событии. Эта терапия включает в себя актуализацию в памяти связанных с травмой образов, представлений и телесных ощущений, в то время как терапевт направляет движения глаз из стороны в сторону. При этом идентифицируются более позитивные представления о травмирующих воспоминаниях с целью замены ими тех, которые вызывают проблемы.

КПТФТ и ДРДГ в настоящее время рекомендуются в качестве лечения выбора клиническими руководствами, такими как руководства, публикуемые Национальным Институтом Здоровья и Клинического Совершенства Соединенного Королевства Великобритании (NICE).

Характеристика исследований: Этот обзор объединяет последние доказательства из 70 исследований, включающих в общей сложности 4761 человек.

Основные результаты: Подтверждается поддержка доказательствами эффективности индивидуальной КПТФТ, ДРДГ, КПТ-не-ФТ и групповой КПТФТ в лечении хронического пост-травматического стрессового расстройства у взрослых. Другие, не фокусированные на травме психологические методы лечения (КПТ-не-ФТ), не уменьшали симптомы пост-травматического стрессового расстройства столь же значимо. Имелись доказательств того, что индивидуальная КПТФТ, ДРДГ и КПТ-не-ФТ одинаково эффективны сразу после события в лечении пост-травматического стрессового расстройства (ПТСР). Был ряд доказательств, что КПТФТ и ДРДГ превосходят КПТ-не-ФТ на сроках от одного до четырех месяцев после лечения, а также, что индивидуальная КПТФТ, ДРДГ и КПТ-не-ФТ более эффективны, чем другие виды терапии. Не было выявлено каких-либо конкретных конфликтов интересов.

Качество доказательств: Хотя мы включили значительное число исследований в этот обзор, каждое из них включало лишь малое число людей, а некоторые были плохо разработаны. Мы оценили общее качество исследований как очень низкое, и поэтому результаты этого обзора следует интерпретировать с осторожностью. Доказательств недостаточно, чтобы показать, вредна ли психологическая терапия или нет.

Заметки по переводу

Перевод: Рыбакова Светлана Викторовна. Редактирование: Зиганшина Лилия Евгеньевна. Координация проекта по переводу на русский язык: Казанский федеральный университет. По вопросам, связанным с этим переводом, пожалуйста, свяжитесь с нами по адресу: lezign@gmail.com

Laički sažetak

Psihološke terapije za kronični posttraumatski stresni poremećaj (PTSP) u odraslih

Uvod: Posttraumatski stresni poremećaj (PTSP) može se pojaviti nakon traumatičnog događaja. Obilježavaju ga simptomi ponovnog proživljavanja traume (u obliku noćnih mora, prisjećanja na traumatični događaj i uznemirujućih misli), izbjegavanja svega što podsjeća na traumatični događaj, negativnih promjena misli i raspoloženja te simptomi pretjerane pobuđenosti (osjećaj kao da si na rubu, poteškoće sa spavanjem i koncentriranjem, razdražljivost i osjećaj ljutnje).

Prethodna istraživanja su podržala upotrebu individualnih kognitivno-bihevioralnih terapija usmjerenih na traumu (TFCBT) te desenzibilizacije pomoću pokreta očiju i reprocesiranja (EDMR) u liječenju PTSP-a. TFCBT je oblik kognitivno-bihevioralne terapije (CBT) koji uključuje brojne tehnike za pomaganje osobi u savladavanju traumatičnog događaja. To je kombinacija kognitivne terapije usmjerene na mijenjanje načina na koji osoba razmišlja i bihevioralne terapije koja nastoji promijeniti način na koji osoba postupa. TFCBT pomaže osobi doći do uvjeta traume kroz izlaganje sjećanjima tog događaja. EDMR je psihološka terapija koja nastoji pomoći osobi u ponovnom obrađivanju (reprocesiranju) sjećanja na traumatični događaj. Terapija uključuje prizivanje uznemirujućih traumatičnih slika, vjerovanja i tjelesnih senzacija u misli, pri čemu terapeut usmjerava očne pokrete osobe s jedne strane na drugu. Identificiraju se pozitivniji pogledi na traumatična sjećanja s ciljem zamjenjivanja onih koja izazivaju probleme.

TFCBT i EDMR se trenutno preporučuju kao terapije izbora po smjernicama kao što su one koje objavljuje Nacionalni institut za zdravlje i kliničku izvrsnost Ujedinjenog Kraljevstva (NICE).

Značajke istraživanja: Ovaj Cochrane sustavni pregled predstavlja najnovije dokaze iz 70 studija koje uključuju ukupno 4761 osobu.

Zaključci: Dokazi iz studija kontinuirano potvrđuju djelotvornost individualne kognitivno-bihevioralne terapije usmjerene na traumu (TFCBT), EDMR, non-TFCBT i grupne TFCBT u liječenju kroničnog PTSP-a kod odraslih. Ostale psihološke terapije neusmjerene na traumu nisu značajno smanjivale simptome PTSP-a. Postoje dokazi da su individualna TFCBT, EDMR i non-TFCBT podjednako učinkovite neposredno nakon tretmana u liječenju PTSP-a. Neki dokazi pokazuju da su TFCBT i EDMR uspješnije od non-TFCBT u razdoblju od jednog do četiri mjeseca nakon tretmana, ali da su individualna TFCBT, EDMR i non-TFCBT učinkovitije od ostalih terapija. Nije pronađen neki poseban sukob interesa u uključenim studijama.

Kvaliteta dokaza: Iako je uključen pozamašan broj studija u ovom pregledu, svaka od njih uključila je mali broj ispitanika dok su neke od njih i loše osmišljene. Procjenjuje se da je ukupna kvaliteta navedenih studija vrlo niska te bi se i rezultati ovog sustavnog pregleda trebali protumačit is oprezom. Nedovoljno je dokaza koji pokazuju jesu li psihološke terapije štetne ili ne.

Bilješke prijevoda

Hrvatski Cochrane
Prevela: Kristina Ajduković
Ovaj sažetak preveden je u okviru volonterskog projekta prevođenja Cochrane sažetaka. Uključite se u projekt i pomozite nam u prevođenju brojnih preostalih Cochrane sažetaka koji su još uvijek dostupni samo na engleskom jeziku. Kontakt: cochrane_croatia@mefst.hr

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